Rationing and Allocating Scarce Medical Resources

课程简介

This course will explore the complex challenges of allocating scarce medical resources at both the micro and macro level. Students will learn the theories behind allocation and use modern examples to explore how society makes the difficult decisions that arise when there is not enough to go around.

课程大纲

This class is seven weeks long. Each week, students will watch
approximate 30 - 40 minutes of lectures by Dr. Emanuel. Students should
expect to spend 2 - 5 hours per week reading related materials from the
reading list, all of which are freely accessible online.

Students taking the course for a grade will complete one to three
short essay questions (totaling approximately 1 page) per week, which
will be peer-graded based on a detailed answer key provided after the
due date. Of the eight scores earned for assignments, the lowest two
scores will be dropped in calculating the final grade. The remaining
five scores will be weighted equally. As a result, students who miss a
homework assignment can still earn full credit in the course. There are
no exams or final projects in this course. Students not taking the
course for a grade may choose not to complete the assignments.

The details of these logistics are subject to change; if changes are
made, students will be notified via an announcement and this page will
be updated.

We begin the course with a hypothetical case. We have one liver and
three patients who will die if they don't get a transplant. We will
discuss some of the potential approaches for making life and death
decisions in the context of absolute scarcity. Next we will explore the
history of rationing in medicine. Absolute scarcity has always been a
problem. How have we dealt with this problem in the past? We'll take a
look at what happened in the cases of three major 20th century medial
advances: insulin, penicillin, and dialysis.

The study of rationing was borne out of the concept of absolute
scarcity in medicine--cases in which the demand for medical care far
exceeds the resources existing to meet that need. Because demand will
inevitably exceed supply--no matter what--choices must be made about
which patients receive treatment, and which don't. But what do we really mean when we use the term 'rationing?' Is there a difference between the terms rationing, resource allocation, and priority-setting? In this lecture, we will attempt to explain the conceptual distinctions that give meaning to the terms we use in this course.

Kidneys, livers, hearts, and lungs are among the most discussed
absolutely scarce medical resources. And their allocation poses some of
the most vexing ethical dilemmas. The lecture for this week will break
down the process by which organs for transplantation are allocated in
the United States through the United Network for Organ Sharing (UNOS).
We will discuss some of the values and principles that are implicitly
favored in the UNOS rules and grapple with a few particularly difficult
cases. Should alcoholics with cirrhosis be eligible to receive a liver
transplant, if their receiving a liver means a person with a "blameless"
liver disease will die as a result? What role should socioeconomic or
legal status play in organ transplantation? Do you agree with the UNOS
policies as written?

This week, we will explore some of the moral schools of thought that
have shaped the modern-day study of bioethics, and have a tremendous
impact on health policy. Deontology regards morality as the driving
guide behind our choices of what we ought to do. Utilitarianism, on the
other hand, views the proper course of action as the one that maximizes
utility. The tension between these two ethical theories highlights the
ethical dilemmas that bioethicists face in determining how to ration
scarce medical resources.

Value judgments are inescapable in rationing decisions. But what are
the competing values and principles that are inherently at play? How can
one choose among them? This week's lecture explores 4 key values and 8
guiding principles that ethicists and policymakers must consider when
confronting rationing decisions. We'll look at the distinctions between
the values and principles, and discuss the advantages and disadvantages
of each. Additionally, we'll examine the Complete Lives System, which is
a theoretical framework designed to draw upon multiple principles and
values.

This week, we will explore another real life example of rationing in
action. What should we do if there is a major flu pandemic and there
isn't enough vaccine to go around? Who should get the limited vaccine
and who should not? We'll examine the U.S. Government's actual policy
for major health crises. For example, we will look at Department of
Health and Human Services (HHS) briefs that deal with allocation
protocols in the event of an influenza pandemic. We will also look into
historical examples of flu crises, and analyze the ethical approaches
taken in specific case studies.

For the final week of the course, we'll examine the difference
between micro rationing decisions and meso/macro decisions. We'll look
at the case of Shep Glazer, whose testimony before Congress
fundamentally changed the way dialysis treatment was allocated in the
United States. We'll also look briefly at cost effectiveness analysis
and the Quality Adjusted Life Year (QALY) as tools for macro level
decisions. What paradoxes arise when using these tools? Do they favor
some people over others? What values are implicit in policies that draw
upon cost-effectiveness and QALYs?

课程详情

You have one liver but three patients awaiting a liver transplant.
Who should get the liver? What criteria should be used to select the
recipient? Is it fair to give it to an alcoholic? These are some of the
questions that arise in the context of rationing and allocating scarce
health care resources among particular individuals, and concern what are
called micro-allocation decisions. But trade-offs also need to be made
at the meso- and macro-level. Budgets of public payers of healthcare,
such as governments, and of private ones, such as health plans, are
limited: they cannot cover all drugs and services that appear beneficial
to patients or physicians. So what services should they provide? Is
there a core set of benefits that everyone should be entitled to? How
can we make fair decisions, if we know from the outset than not all
needs can be met? Using the cases of organs for transplantation, the
rationing for vaccines in a flu pandemic, and drug shortages, the course
will critically examine alternative theories for allocating scarce
resources among individuals, while also exploring the principles and
values that underlie those theories.