Lancet: Principles for allocation of scarce medical interventions

Department of Ethics
The Lancet, Volume 373, Issue 9661, Pages 423 - 431, 31 January 2009
Principles for allocation of scarce medical interventions

Govind Persad BS a, Alan Wertheimer PhD a, Ezekiel J Emanuel MD a
Summary

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.

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UPDATE: Article on end of life care from Alternet -

Obamacare: "Do they really want to croak Granny? - Yes, sometimes"

"While the imposition of this new ethos of death is justly alarming, the more present problem of medical rationing is likely to impact granny much more gravely and much sooner. The rationing of medical treatment for the elderly is marbled throughout the Obama bill in so many places that we will have to address this issue in more detail in a future installment. For example, cancer treatment, much of which is skewed toward an older demographic, will be limited ("adjusted" in Obama-speak, "rationed" in actual English), if it becomes too costly in a particular hospital. (Section 1145) Another example: services to be provided under many plans are quite limited, i.e. rationing. A more attenuated but relevant problem is that hospitals are actually prohibited from expanding, and are limited to their size as of the date of the enactment of the bill, unless a medical politburo, answerable to no one, gives the OK to expand. Thus, treatment options become further limited.

Dr. Ezekiel J. Emanuel, a key medical ethics adviser to the president, and brother of Obama's chief-of-staff Rahm Emanuel, has set forth in writing a deadly formula for allocating care. In a January 31, 2009 article in a prestigious British medical journal, The Lancet, he and two co-authors offer a theory they call, "the complete lives system," as a means to decide who gets care and who dies.

In a complex web of interlocking principles for allocating medical treatment, in an environment where rationing is assumed, Dr. Emanuel opines that teenagers should have priority over infants, because they have received more resources from society. Older people, however, are "objectively less valuable," so, yes, granny does have to die. Under this system, using utilitarian and amoral criteria like "distributive justice," young healthy people from ages 15-40 get priority, and the rest, including grandma, may not.

One can infer that this premise will undergird the implementation of the Obama healthcare regime, including the assumption of rationing of care. While the self-anointed messiah Obama brazenly proclaims throughout the land that his deadly healthcare bill will be good for society, the Hebrew prophet Isaiah rightly saw that such thinking reflects that "the dust of death" has settled over a culture.

The Obama bill reflects the ethos of amoral "utility" throughout. For example, in Section 1177, many plans will not be allowed to enroll "special needs" people. No explanation is given as to the rationale behind this cruel mandate."

Link

The Human Rights of Older People in Healthcare

From the UK
Eighteenth Report of Session 2006-07

HL Paper 156-I HC 378-I Published on 14 August 2007 by authority of the House of Commons London:
The Human Rights of Older People in Healthcare 3 Summary In addition to its scrutiny of parliamentary Bills and policy documents for human rights implications, the Committee examines areas where human rights concerns arise, such as the treatment of older persons in health care. In this Report the Committee examines how human rights principles can be applied toensure that older people in hospitals and care homes are treated with greater dignity andrespect (paragraphs 1 - 8).The Committee heard that, while some older people receive excellent care, there are concerns about poor treatment, neglect, abuse, discrimination and ill-considered discharge.It considers that an entire culture change is needed. It also recommends legislative changesand a role for the new Commission for Equality and Human Rights (paragraphs 9 - 65).In the Committee’s view there is a significant distinction between a “duty to provide” undercare standards legislation and a “right to receive” under human rights legislation. It recommends that the Government and other public bodies should champion understandingof how human rights principles can help transform health and social care services (paragraphs 66 - 95).While welcoming the recent acceptance at senior levels in the Department of Health of theimportance of human rights in healthcare, the Committee recommends adoption of astrategy to make the Human Rights Act integral to policy-making and social care across the Department (paragraphs 96 - 124)

Excerpt

26. A number of witnesses expressed concern about the inappropriate use of medication
on older people, including the over or under-use of medication and the use of medication
as a means of controlling patients and residents. Action on Elder Abuse cited the misuse of
medication as one type of abuse which frequently comes to its attention.47 This is a
particular issue in care homes.
27. Again, witnesses accepted that there was good practice in this area,48 but that this was
not universally implemented. Witnesses raised a particular issue of medication being
inappropriately used to keep residents docile.49 As the Alzheimer’s Society’s said:
The response to aggression in dementia is often to prescribe powerful sedative
neuroleptic drugs that can help to calm the person However, these treatments have
very damaging side effects. Medications such Haliperidol, Risperidone and
Olanzipine are being routinely prescribed to people with dementia in hospitals and
care homes. A recent study found that 40% of people with dementia in care homes
are being prescribed neuroleptic drugs.50 Neuroleptics are not licensed for use in
dementia care but have become a convenient staple as part of routine treatment,
despite known evidence on the risks which such ‘treatments’ pose to quality of life
and the increased risk of death.51
28. The concerns of witnesses accord with the findings of the Health Committee that
medication was “in many cases, being used simply as a tool for the easier management of
residents”.52 The National Service Framework for Older People requires that all people over
75 years should normally have their medicines reviewed at least annually and those taking
four or more medicines should have a review every six months.53 In 2006, Living Well in
Later Life noted that “the management of medicines needs to be addressed, as many older
people taking more than four medications are still not receiving a review every six
months”.54 CSCI found that, in 2005-06, only 59% of care homes met the National
Minimum Standard (Standard 9) for medication.55 The Alzheimer’s Society agreed that
there is a very poor record of medication in care homes.56

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Toronto journalist Judy Steed has been writing about social issues for 30 years. Last fall, she embarked on a one-year project to document the most pressing policy implications of our aging society as part of the 2008 Atkinson Fellowship in Public Policy.
She has visited dozens of nursing homes and interviewed hundreds of health-care workers, policy-makers and seniors to present this weeklong portrait.

Day 4 of an eight-day Atkinson Fellowship series
Drugged-out seniors a prescription for disaster
November 11, 2008
JUDY STEED
SPECIAL TO THE STAR

They are the drugged-out generation, and they're not who you think they are.

They're 80. And 85 and 90 and 95 – overmedicated seniors clogging emergency departments, blocking hospital beds and sicker than they have any reason to be.

The Number 1 drug users in North America, outside of patients in long-term care facilities, are women over the age of 65. Twelve per cent are on 10 or more meds, sometimes up to 20 or more drugs; 23 per cent take at least five drugs. In long-term care, seniors are on six to eight medications, on average. Fifteen per cent of seniors admitted to hospital are suffering drug side effects. It's not uncommon to find seniors dizzy and dotty from being prescribed so many drugs.

"You'd fall down, too, if you were on so many drugs," says Dr. William Dalziel, a prominent Ottawa geriatrician.

Typically, overmedicated seniors have been seen by numerous specialists who have prescribed various medications to treat a host of chronic ailments – high blood pressure, hypertension, diabetes, osteoporosis, arthritis, heart disease, cancer – but there hasn't been any oversight by a geriatrician skilled in looking at the big picture and assessing contra-indications and side effects. Ask any doctor with expertise in seniors what their top health concerns are and they all cite overmedication.

Article on drugging of seniors from the Toronto STAR
Link

When Medicine Went Mad

Bioethics issues from the Holocaust. Are they still relevant today? Mature content. Link to Google books

Vortex of Mental Illness Map and Kitbag

Detail - From International Futures Forum an update on the old game of Snakes and Ladders. Kudos for this outstanding graphic design, which really help us think about these problems in a new way - to get inside them. Image
See more MacroVu diagrams here
http://www.macrovu.com/
MacroVu/Stanford's map re mental health care mess here
http://web.archive.org/web/20011129070448/www.stanford.edu/~rhorn/images/PortlandDynamics.pdf

"Vortex of mental illness
December 4th, 2008

You might wonder why Kitbag was first tested at Cornton Vale women’s prison in Scotland.

This came about following a meeting between the governor and me in response to work I had done on improving services for adult survivors of sexual abuse. The prison population has a high percentage of women survivors and the governor was wondering whether there was anything more she could be doing to help them recover from their trauma.

I showed her work the IFF had done in Fife which examined the systemic behaviours that drive people ever deeper into care and custodial services as they slip out of the support of family, friends and community. Bob Horn, an expert in visual language, helped us illustrate our thinking with a mural called the Vortex of Mental Illness. You can link through to it from this post: I would be interested in your views.

When I had a prototype Kitbag to show her, it seemed sensible to return to the prison to see if they woudl be interested in using it with their women. The Head of Care and governor were both keen. They liked its holistic/wellness perspective. With modifications for the prison environment and agreement with mental health nursing staff, we gave three women the kits and worked through each pocket over a year.

We are now planning to expand this work to include more women, using a peer education model.

Margaret Hannah"

Kitbag - what is it?


We think massage, lighting candles and drawing divination cards are fine. However, what people need first to shake their "psychological problems" and "addictions" is correct diagnosis and treatment of their nutritional and other underlying health problems. When we checked we found only one link on nutrition at International Futures Forum.

Here's an earlier post on using nutrition to
get through heroin withdrawal.

Secrecy shields medical mishaps from public view

Almost 200,000 people a year die from preventable medical errors and hospital acquired infections. More people die from preventable medical errors and hospital-acquired infections than from alcohol-related auto accidents, murder, illegal drugs and suicide combined.
Link

DSM: Once APA's Fundraiser, Now Drives the Psych Industry

What's wrong with the DSM?

Plenty.

DSM authors in bed with Big Pharma

"Soaring ambition and remarkably weak methodology" - pdf

Slate weighs the evidence against the APA and DSM

DSM Funding/Finances (2005)