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The Ethics of Aggressive Discharge Planning

Published online by Cambridge University Press:  22 December 2009

Extract

In any healthcare system in which demand exceeds supply—which means any typical public healthcare system—patients cannot always get the care they want or need when they want or need it. It is also unrealistic to suppose that it will ever be otherwise. There have been such advances in medicine and growth in the population that even if we forgot about all other goods such as education, roads, social services, and so forth and put the entire budget into healthcare, there would still be a gap between supply and demand. Moreover, even if we could by that expedient make them match and had eyes only for health, we still should not. For it is now understood that healthcare is the least important determinant of health, lining up well behind poverty and social status. But if suboptimal care is to be our destiny, we must plan how it is to be delivered.

Type
Special Section: Open Forum
Copyright
Copyright © Cambridge University Press 2010

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References

1. Brock DW. Broadening the bioethics agenda. Kennedy Institute of Ethics Journal 2000;10(1):21–38, esp. pp. 31–6.

2. Rawls J. A Theory of Justice. Cambridge, Mass.: Harvard University Press; 1971.

3. This extension is also made by Childress JF. Who shall live when not all can live? In Mappes TA, Zembaty JS. Biomedical Ethics. New York: McGraw-Hill; 1981:578–87, esp. p. 583. Footnote 21 (pp. 585–6) addresses the question of whether Rawls would approve of this use of the Original Position.

4. Even if withholding Burgundy Codes and leaving mortality, morbidity, and discomfort unreduced now would guarantee resources in the future that would reduce those things to an even greater extent, it still will not follow that those Codes should be withheld. A maximizing utilitarian would say that they should be, but that just underlines what is most odious about that species of utilitarianism, namely, the willingness to put burdens on some to swell average or total utility. A Rawlsian would look at the matter in a different and, I think, preferable way, like this. Suppose that there are two possible worlds, W1 and W2. In W1 at time T1 hospitals have a significant degree of mortality, morbidity, and discomfort due to long wait-lists, but at T2, because they allowed this to occur, the hospital has resources that significantly reduce those things. In W2, hospitals have introduced Burgundy Codes with the result that there is a significant reduction of suffering from that attached to hospitals in W1 at T1, but not as great a reduction as that attached to hospitals at T2. For a Rawlsian, whether Burgundy Codes should be withheld or initiated (assuming that the former will bring about the state of affairs in W1 and the latter W2), will depend on whether Rawlsian decision makers would choose to be in W1 if they did not know whether they will exist at T1 or T2, or in W2, and Burgundy Codes should be withheld if and only if they would choose to be in W1. But that is far from an automatic choice and will depend on the various degrees of mortality, morbidity, and discomfort in the three states in question. If those things are very high in W1 at T1 but are not so very bad in W2, then however low they are in W1 at T2, a Rawlsian decision maker will arguably not choose W1.

5. For the contrary view see Slote MA. Beyond Optimizing: A Study of Rational Choice. Cambridge, MA: Harvard University Press; 1989. It is not, however, clear that Slote would count it rational to satisfice rather than optimize in the selection of Burgundy Codes.

6. In game-theoretic terms the logic here is that of the Folk Theorem, according to which “every contract on which rational players might agree in the presence of external enforcement is available as an equilibrium outcome in an infinitely repeated game,” where “infinitely” is weakened to “indefinitely,” and it is assumed that the players care enough about the future that it is worth their while to value long-term relationships. See Binmore K. Natural Justice. New York: Oxford University Press; 2005:79–82 at 81.

7. Daniels N, Sabin JE. Setting Limits Fairly: Can We Learn to Share Medical Resources? New York: Oxford University Press; 2002:174. See further Pearson SD. Caring and cost: The challenge for physician advocacy. Annals of Internal Medicine 2000;133:148–53.

8. McAfee A, CityPlan Team. Vancouver's CityPlan: People participating in planning. Plan Canada May 1995;15–6.

9. The classic statement of the relationship between publicity and democracy is Meiklejohn A. Political Freedom. Part One: Free Speech and Its Relation to Self-Government. New York: Oxford University Press; 1965:3–28. For an application of these ideas to healthcare policy see note 7, Daniels, Sabin 2002:46–51, 169–74.

10. For a sketch of how such a democracy could be practically possible, see Wolff RP. In Defense of Anarchism. New York: Harper & Row; 1970:34–7.

11. For an application of Rawlsian ideas to the question of how to make reductions (or additions) to patient services, see Browne A, Anderson T, Brown D, Cooledge C, Leal B, McDonald D, Saxe-Braithwaite M. How to make allocation decisions: A theory and test questions. Healthcare Management Forum 2005;18(1):32–3.