Just Caring: Parsimonious Care in Certain Uncertain Circumstances

Uncertainty is a Hydra-headed phenomenon in health care. From a physician’s perspective there often is uncertainty (many degrees) with respect to diagnosis (and the reliability of the technologies needed to establish a diagnosis), prognosis (and the infinite variety of genetic, physiological, pharmacological, behavioral, technological, economic, and cultural factors that affect the outcome of prognostic judgments), the appropriateness of a therapeutic intervention (perhaps related to medical disagreement), the likely effectiveness of a therapeutic intervention, the risk/ benefit ratio of a therapeutic intervention (potentially complicated by co-morbid conditions), the likelihood of a patient complying with the behaviors needed to maximize the likelihood of a therapeutic outcome, the applicability of a clinical guideline to this patient in the clinic, the reliability of the evidence and research behind that guideline, and, finally, the sheer randomness of natural events at various levels in the health care encounter. That is the background for this presentation. Our question, however, is this: How should all this uncertainty be addressed in the economic/ political context of having to do health care rationing, and in the ethical context of having to do that rationing justly? Today there is an increasing emphasis on the obligation of physicians to provide parsimonious care, i.e., the prudent and cost-effective use of health care resources in caring for individual patients. To focus discussion I offer several common examples, such as $100,000 precision cancer drugs,$40,000 implantable cardiac defibrillators, PCSK9s for lowering “bad” cholesterol, access to ICU beds---- all of which represent uncertain benefit at very great cost. DRGs as a hospital payment mechanism are part of the same problem since they can motivate “premature” discharge of a patient, thereby putting them at uncertain risk for an otherwise avoidable bad health outcome. If physicians cooperate with the intent of DRGs (or other care protocols intended to promote parsimonious care), are they treating their patients unjustly? Must physicians be virtually certain that no harm will come to their patients in order to be just and justified in carrying out parsimonious protocols? “No” is the response I will defend. If a patient does not have a just claim to some health care resource, then the harm that “might” befall them as a result of that denial is properly regarded as being unfortunate but not unjust. Access to health care resources is about access to a limited common good. This is what makes such access a matter of justice rather than a matter of informed consent wherein a patient weighs from their point of view the risks and benefits (and related uncertainty) they are willing to trade off. Matters of justice require social decisions. Patients do not have a presumptive just claim to a $100,000 cancer drug if there is only a small chance that drug would yield an extra six months of life. What level of certainty would generate such a just claim? There is no objectively correct answer to that question. It needs to be resolved, I will argue, through a process of rational democratic deliberation, the results of which will be just and legitimate for all in the relevant clinical circumstances

Last Chance Therapies: Can a Just and Caring Society Do Health Care Rationing When Life Itself Is at Stake?

What does it mean to be a just and caring society (or a just and caring hospital or managed care plan) when we have only limited resources to meet virtually unlimited health care needs, and the need before us now is a person faced with death in the near future unless she or he has access to a very expensive medical intervention that offers only a relatively small chance of a relatively small gain in life expectancy? Such medical interventions are what Norman Daniels and James Sabin refer to as last chance therapies because patients who need them have no other medical options to forestall death in the foreseeable future. It is difficult to imagine a more psychologically and morally burdensome decision than whether to offer a last chance therapy. This Article attempts to determine how such last chance therapy rationing decisions should be made within the broad structure of the U.S. health care system-a very fragmented, public-private system for financing health care that is dominated by a variety of managed care options intended to control h~alth care costs more effectively than the indemnity insurance system. The focus of this Article can be interpreted in two ways: First, what moral norms should be used in making these last chance rationing decisions? Given all of the health care needs that exist in our society, and given limited resources to meet those needs (limits ultimately determined by taxpayers or members of a managed care plan), what priority should access to various last chance therapies have relative to all other health needs that make presumptively just claims on health resources? Second, what should be the political-philosophical framework of managed care plans responsible for making these last chance rationing decisions? That is, would we be more likely to get morally defensible last chance rationing decisions if the political philosophy that shaped the functioning of our managed care plan were libertarian, communitarian (Ezekiel Emanuel\u27s vision), or liberal (in the Rawlsian sense)

Healthcare Priority-Setting: Chat-Ting Is Not Enough; Comment on “Swiss-CHAT: Citizens Discuss Priorities for Swiss Health Insurance Coverage”

CHAT has its limits. It is a three-hour exercise. However, the real world problems of healthcare rationing and priority-setting are too complex for a three-hour exercise. What is needed, as a supplement, are sustained processes of rational democratic deliberation that can address the challenges to healthcare justice posed by costly emerging medical technologies, such as these targeted cancer therapies

Healthcare Priority-Setting: Chat-Ting Is Not Enough Comment on “Swiss-CHAT: Citizens Discuss Priorities for Swiss Health Insurance Coverage”

Abstract CHAT has its limits. It is a three-hour exercise. However, the real world problems of healthcare rationing and priority-setting are too complex for a three-hour exercise. What is needed, as a supplement, are sustained processes of rational democratic deliberation that can address the challenges to healthcare justice posed by costly emerging medical technologies, such as these targeted cancer therapies

Cancer Biomarkers: Ethics, Economics and Society

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The challenges of implementing packaged hospital electronic prescribing and medicine administration systems in UK hospitals: premature purchase of immature solutions?

The UK National Health Service is making major efforts to implement Hospital Electronic Prescribing and Medicine Administration (HEPMA) to improve patient safety and quality of care. Substantial public investments have attracted a wide range of UK and overseas suppliers offering Commercial-Off –The-Shelf (COTS) solutions. A lack of (UK) implementation experience and weak supplier-user relationships are reflected in systems with limited configurability, poorly matched to the needs and practices of English hospitals. This situation echoes the history of comparable corporate information infrastructures - Enterprise Resource Planning systems - in the 1980s/1990s. UK government intervention prompted a similar swarming of immature, often unfinished, products into the market. This resulted, in both cases, in protracted and difficult implementation processes as vendors and adopters struggled to get the systems to work and match the circumstances of the adopting organisations. An analysis of the influence of the Installed Base on Information Infrastructures should explore how the evolution of COTS solutions is conditioned by the structure of adopter and vendor ‘communities’

Mereotopological Connection

The paper outlines a model-theoretic framework for investigating and comparing a variety of mereotopological theories. In the first part we consider different ways of characterizing a mereotopology with respect to (i) the intended interpretation of the connection primitive, and (ii) the composition of the admissible domains of quantification (e.g., whether or not they include boundary elements). The second part extends this study by considering two further dimensions along which different patterns of topological connection can be classified—the strength of the connection and its multiplicity