Budgetary constraints and healthcare in hospitals : an ethical

point of viewSadek Beloucif, M.D, Ph.D.

Paris 13 University & Avicenne Hospital, AP-HP

Le Monde, Apr 1, 2009

Land Area (worldmapper.org)

Often Preventable Deaths (worldmapper.org)

Physicians Working (worldmapper.org)

Lessons from developing nations on improving health care Berwick, BMJ 2004

1. Simplify.

- Complexity is waste2. Teamwork

- Uncoperativeness is waste3. Be pragmatic for the evaluation

- Too much counting is waste4. Limit organisational aspects

- Dependency is waste5. Consider political aspects

- Naivety is waste6. Empower patients

- Keeping patients silent is waste7. Start now

- Delay is waste8. Continuously expand

- Isolation is waste9. And don’t complain !

- Complaint is waste

NBC News, Aug 7, 2009

QuickTime™ et undécompresseur

sont requis pour visionner cette image.

NBC News, Aug 9, 2009

QuickTime™ et undécompresseur

sont requis pour visionner cette image.

Why We Must Ration Health CareBy PETER SINGER

Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse.

If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend.

When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable.

Then we can ask, What is the best way to do it?.

“France's woes provide grist to critics of Mr. Obama and the Democrats' vision of a new public health plan to compete with private health insurers. Republicans argue that tens of millions of Americans would leave their employer-provided coverage for the cheaper, public option, bankrupting the federal government.”

“With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects.”

August 12, 2007EDITORIAL

World’s Best Medical Care?• Insurance coverage. • Access. • Fairness. • Healthy lives. • Quality. • Life and death. • Patient satisfaction. • Use of information technology. • Top-of-the-line care.

4

Neither of the AboveThe health systems in the UK and the US have different virtues and different vicesIn the battle over which country, the UK or the US, has the better health system, it is a shame that either side has to win. The answer to the question is probably France.

There is no doubt that the healthcare system that is being so vigorously defended at town hall meetings across America has glaring flaws. America spends 16 per cent of its national income, more than any country in the world, on health. To spend $2.2 trillion per annum and still fail to insure more than 40 million citizens is quite something. Administrative costs are a third of the bill, hospital costs are high and employer-provided insurance is a serious reduction of labour market flexibility. President Obama has a point when he suggests that the NHS provides universal cover for half the cost.

That said, the American critics of the NHS have a point too. The deficiencies of what the Americans call “socialised medicine” are amply exhibited by the NHS. Four-month waits for treatment and limited patient choice are no great cause for British patriotism. The problems with the NHS are all the more stark when they are contrasted with the best of American healthcare. The better insurance plans provide an unmatched rapidity of response and quality of care. The teaching hospitals at American universities lead the world in research and development.

The sophisticated question is not which one of these two flawed systems is the better but is it feasible to combine the virtues of both, without busting the bank? France has a system of universal healthcare financed by compulsory national insurance. Premiums are charged as a percentage of income and paid to insurers that are non-government, non-profit agencies. The French have a choice of doctor whose fee they usually pay and then claim back 75-80 per cent of the cost. The poor are exempt from payment. All patients, whether exempt from co-payments or not, may go directly to a specialist.

CCNE Opinion #101: Health, ethics and money: ethical issues as a result of budgetary constraints on public health expenditure in hospitals http://www.ccne-ethique.fr

• What criteria should be used to arrive at an equitable decision when a choice has to be made between two frequently contradictory imperatives: preserving the health of an individual versus the responsible management of a community's health care? – Decisions must lead to rationalisation of expenditure to avoid what

in effect would be rationing of care.

• A balance in pure accounting terms, – taking only into consideration the liabilities (the cost of services) – without relating them to the assets which are their counterpart (the

benefits for the community or those that can reasonably be expected from the adoption of a new system of calculation)

would not be acceptable.

Further, there are 2 possible responses: “utilitarian” (“distributive justice”) vs. “equalitarian” (so-called "deontological") ethics

• In practice, existing tension between person-centred ethics and utilitarian ethics leads to choosing between two contradictory demands: – on the one hand achieving effectiveness in a competitive

environment, – on the other accepting a public service mission assigned

specifically to hospitals by the code of public health.

• The ethical and economic constraints of the hospital system —which is also true for the more general context of democracy— in fact reside in the opposition between two apparently mutually exclusive concepts: the "unconditional value" of an individual and "satisfying the greatest number".

Therefore,

• The limited nature of financial resources allocated to the hospital system requires ethical choices to be made by the community which should be made public.

• The ethical dimension of these decision-making processes should be clearly identified and integrated in the evaluation methods. Evaluation methods including only quantifiable criteria but neither qualitative criteria nor the ethical dimension would put hospitals in grave danger of dehumanisation and furthermore would lead in practice to increased costs.

• Clinically speaking, the notion of sober medicine, as opposed to redundant medicine should be given prominence. Redundancy disguised as precaution is only too often a mask for intellectual laziness and for reluctance to shoulder the responsibility of difficult decisions.

In conclusion, guaranteeing fair access to quality health care

is not incompatible with economic orthodoxy.

• The constant need to adjust health care to demographic requirements, epidemiological changes and technological advances is ample justification, more so than for any other human activity, for clear and courageous choices, which must be explicit in the eyes of citizens. Such decisions must be kept under constant review without ever losing sight of the central core objective: helping the most vulnerable.

• The ethical issue raised by an examination of the economic dimensions of health care is an exploration of the tension between autonomy and solidarity, between individual liberty and the public good. Such tension can only be relieved by seeking equity, in other words, justice.