Thursday, 19 July 2012

Liverpool Care Pathway - A Utilitarian Pathway


The Nuremberg Code emphasized the primacy of the informed, voluntary consent of the patient in governing physician behaviour.

The Nuremberg Code rejected the utilitarian argument that the few may be involuntarily sacrificed for the benefit of the many.

These precepts, carved in the moral stone of the Code and in the very fibre of what we know to be right and wrong are today being questioned and brought into ridicule.

Here is the New York Post -


DEADLY DOCTORS

O ADVISERS WANT TO RATION CARE

Last Updated: 1:13 AM, July 24, 2009
Posted: 1:03 AM, July 24, 2009

THE health bills coming out of Congress would put the decisions about your care in the hands of presidential appointees. They'd decide what plans cover, how much leeway your doctor will have and what seniors get under Medicare.


Yet at least two of President Obama's top health advisers should never be trusted with that power.

Start with Dr. Ezekiel Emanuel, the brother of White House Chief of Staff Rahm Emanuel. He has already been appointed to two key positions: health-policy adviser at the Office of Management and Budget and a member of Federal Council on Comparative Effectiveness Research.

Emanuel bluntly admits that the cuts will not be pain-free. "Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality are merely 'lipstick' cost control, more for show and public relations than for true change," he wrote last year (Health Affairs Feb. 27, 2008).

Savings, he writes, will require changing how doctors think about their patients: Doctors take the Hippocratic Oath too seriously, "as an imperative to do everything for the patient regardless of the cost or effects on others" (Journal of the American Medical Association, June 18, 2008).

Yes, that's what patients want their doctors to do. But Emanuel wants doctors to look beyond the needs of their patients and consider social justice, such as whether the money could be better spent on somebody else.

Many doctors are horrified by this notion; they'll tell you that a doctor's job is to achieve social justice one patient at a time.

Emanuel, however, believes that "communitarianism" should guide decisions on who gets care. He says medical care should be reserved for the non-disabled, not given to those "who are irreversibly prevented from being or becoming participating citizens . . . An obvious example is not guaranteeing health services to patients with dementia" (Hastings Center Report, Nov.-Dec. '96).

Translation: Don't give much care to a grandmother with Parkinson's or a child with cerebral palsy.

He explicitly defends discrimination against older patients: "Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years" (Lancet, Jan. 31).

The bills being rushed through Congress will be paid for largely by a $500 billion-plus cut in Medicare over 10 years. Knowing how unpopular the cuts will be, the president's budget director, Peter Orszag, urged Congress this week to delegate its own authority over Medicare to a new, presidentially-appointed bureaucracy that wouldn't be accountable to the public.

Since Medicare was founded in 1965, seniors' lives have been transformed by new medical treatments such as angioplasty, bypass surgery and hip and knee replacements. These innovations allow the elderly to lead active lives. But Emanuel criticizes Americans for being too "enamored with technology" and is determined to reduce access to it.

Dr. David Blumenthal, another key Obama adviser, agrees. He recommends slowing medical innovation to control health spending.

Blumenthal has long advocated government health-spending controls, though he concedes they're "associated with longer waits" and "reduced availability of new and expensive treatments and devices" (New England Journal of Medicine, March 8, 2001). But he calls it "debatable" whether the timely care Americans get is worth the cost. (Ask a cancer patient, and you'll get a different answer. Delay lowers your chances of survival.)

Obama appointed Blumenthal as national coordinator of health-information technology, a job that involves making sure doctors obey electronically deivered guidelines about what care the government deems appropriate and cost effective.

In the April 9 New England Journal of Medicine, Blumenthal predicted that many doctors would resist "embedded clinical decision support" -- a euphemism for computers telling doctors what to do.

Americans need to know what the president's health advisers have in mind for them. Emanuel sees even basic amenities as luxuries and says Americans expect too much: "Hospital rooms in the United States offer more privacy . . . physicians' offices are typically more conveniently located and have parking nearby and more attractive waiting rooms" (JAMA, June 18, 2008).

No one has leveled with the public about these dangerous views. Nor have most people heard about the arm-twisting, Chicago-style tactics being used to force support. In a Nov. 16, 2008, Health Care Watch column, Emanuel explained how business should be done: "Every favor to a constituency should be linked to support for the health-care reform agenda. If the automakers want a bailout, then they and their suppliers have to agree to support and lobby for the administration's health-reform effort."

Do we want a "reform" that empowers people like this to decide for us?

Betsy McCaughey is founder of the Committee to Reduce Infec tion Deaths and a former New York lieutenant governor.


Dr. Ezekiel Emanuel, co-author of this paper which appears in The Lancet, is chief health-care policy adviser to President Barack Obama, and the brother of President Obama's chief of staff, Rahm Emanuel. 






The Lancet, Volume 373, Issue 9661, Pages 423 - 431, 31 January 2009

Principles for allocation of scarce medical interventions

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.


The paper is also published by the National Institutes of Health in Bethesda.




Principles for allocation of scarce medical interventions

Department of Bioethics, 
The Clinical Center, National 
Institutes of Health, Bethesda, 
Maryland, USA (G Persad BS, 
A Wertheimer PhD, 
E J Emanuel MD)
Correspondence to:
Ezekiel J Emanuel, 
Department of Bioethics, 
The Clinical Center, National 
Institutes of Health, Bethesda, 
MD 20892-1156, USA
eemanuel@nih.gov

Govind Persad, Alan Wertheimer, Ezekiel J Emanuel


Extracts follow -

Strict youngest-first allocation directs scarce resources predominantly to infants. This approach seems incorrect. The death of a 20-year-old woman is intuitively worse than that of a 2-month-old girl, even though the baby has had less life. The 20-year-old has a much more developed personality than the infant, and has drawn upon the investment of others to begin as-yet-unfulfilled projects.... Adolescents have received substantial substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments.... It is terrible when an infant dies, but worse, most people think, when a three-year-old child dies, and worse still when an adolescent does.

Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

Ultimately, the complete lives system does not create 'classes of Untermenschen whose lives and well being are deemed not worth spending money on,' but rather empowers us to decide fairly whom to save when genuine scarcity makes saving everyone impossible.

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated

The fact is that the “communitarianism” (complete lives system) advocated by Emanuel is only Utilitarianism by another name. 

This table is extracted from the Paper. It indicates the prioritisation of medical intervention which the authors favour.

Emanuel has defended himself by saying he has been quoted out of context from an academic work. However that is or is not the case, he is still responsible for floating the idea and thus advancing the invidious trend.

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