Ethical dilemmas with resource constraints in aged care

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Ethical dilemmas with resource constraints in
aged care

• Dr John I Fleming
• Director, Southern Cross Bioethics Institute

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Must we ration in healthcare?

• Healthcare is unsuited to the free market.
• Healthcare is about the flourishing and
  well-being of people.
• Healthcare has a voracious appetite for funding.
• There are many other worthy social pursuits to
  fund.
• Therefore rationing in healthcare is unavoidable.

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We need an ethical framework for rationing

• Rationing implies systematic decisionmaking.
• Rationing decisions should be transparent and
  morally justified.
• Which approaches to rationing are unacceptable,
  and why?
• What is a morally appropriate system of rationing?

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Ageist rationing

• The clinical argument
• (capacity to benefit)
• The philosophical argument
• (a fair innings)

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Objections to ageist rationing

• Age is a poor surrogate for prognosis
• Aggravated ageing
• A typical or reasonable lifespan?
• Who judges quality of life?
• The eugenic impulse

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Objections to ageist rationing

• Spending on the elderly is not disproportionate
• Social contributions over a lifetime
• The fundamental objection It breaches the
  principles of non-discrimination, equal access to
  the satisfaction of needs, social solidarity and
  respect for the elderly.

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Healthworkers should not be gatekeepers.

• Their concern must be for the individual patient.
• They lack the information to make rationing
  decisions.
• Their involvement in rationing may cause a breach
  of trust.
• Instead, they should do all that is truly
  possible, both practically and morally.

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Inappropriate philosophies for rationing

• Liberal-welfarism
• Utilitarianism

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The liberal-welfarist philosophy

• Committed to liberty, equality and fraternity,
  but also neutrality about the human good.
• Liberty/autonomy
• Equality of opportunity
• Fraternity
• Many questions remain unanswered, leaving an
  inadequate basis for healthcare allocation.

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The utilitarian philosophy

• A calculation of costs and benefits
• QALYs are the most common application
• QALYs are systematically biased against the
  elderly
• Utilitarianism is seriously flawed

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Utilitarianism a brief critique

• People are not reducible to numbers
• Comparing the incommensurable
• Human rights are ignored
• What is cost and what is benefit?
• It requires moral luck
• No justice or charity

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Inappropriate principles for rationing

• Neutral principles
• Majority principles
• Arbitrary principles

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Neutral principles

• For a liberal, pluralistic society?
• Avoid choosing one conception of the good
• Assumes the separation of public and private
  life
• Ultimately precludes state involvement in
  healthcare
• Favours the status quo

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Majority principles

• Opinion polls
• Confirm majority prejudices
• Methodological flaws
• Marginalises the vulnerable and inarticulate
  minority
• We always need to critique the views of the
  majority
• We need responsible leadership

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Arbitrary principles

• Rules or standards with no coherent basis.
• Principlism autonomy, beneficence,
  nonmaleficence, justice.
• Principles must be balanced and compromised.
• Ultimately autonomy trumps all.
• Social justice is an also-ran.

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What are appropriate principles for rationing?

• What is healthcare about?
• What are our basic values?
• A conception of the human good
• Justice
• Human needs

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Justice

• Part of morality
• Right relations between people
• Commonality of life and interests
• The common good
• Giving to others their due
• Distributive justice

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A conception of the human good

• We desire life and health
• The ultimate goals behind our choices
• Fundamental to rational deliberation
• We do not choose what they will be
• They are given in our very nature

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Life and health

• Human personal existence is a bodily existence.
• Life and health are sought for their own sake.
• They are intrinsically valuable.
• But they are not the only goods.
• What is integral to our flourishing gives rise to
  our basic needs.

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Human needs

• Not all healthcare meets genuine needs.
• Healthcare needs do not create absolute duties.
• Not all ways of satisfying needs are morally
  warranted.
• We must seek what we need, but only in morally
  reasonable ways
• Not all needs are equal.