What Factors Need To Be Considered And Prioritised In Creating A Just Health Care System?

What factors need to be considered and prioritised in creating a just health care system?

Justice is one of the 4 pillars of medical ethics originally formulated by two American philosophers called Beachump and Childress. These are justice, beneficence, non-maleficence, and respect to autonomy (Ref. 1). Within a just health care system initially it is important that there is equal access to all. This will help ensure health care treatment is fair for two different individuals with the same health problems. Example of barrier to this include not being able to pay for health care and medicine, not being able to physically attend a health care setting due to no public transport or inability to drive, and finally not feeling comfortable to attend due to previous discrimination or risk of discrimination. Alongside ensuring equal health care needs are dealt with equally, it is also important to consider which interventions to fund when there is a limited pot of money to spend, within a world where many people who die each year due to a lack of funding for their health problem.

What factors create an equal access health care system

The economic aspect to health care and medication

There is a clear positive impact that health insurance has on an individuals health (Ref 2). There are better screening services provided, this includes screening for blood pressure, cardiovascular disease, and breast cancer screening. Diseases therefore can be found earlier, more easily and with a greater end result (both for quality of life and mortality). This can be due to different reasons, specifically for hypertension it could be due to the fact that these individuals will have a greater incentive to change certain lifestyle choices (Ref 3). For example, changing what they are eating, to reduce further risks strokes and heart attacks. Screening for breast cancer shows significant reduction in mortality, unto 61% (Ref 4). A lack of health insurance is something that is seen much more heavily of those of a lower socioeconomic class in society (Ref 5). The need for paid health insurance is therefore something that would reduce fairness within a health system.

Transport barrier to health

Transport barriers can come in many different forms, such as cost, safety on public transport and a lack of public transport all together (Ref 6). These barriers disproportionately impact the vulnerable within our society, directly reducing the fairness of the healthcare system. One specific example of the cause of transport barrier can be as a result of drivers licences being taken away from elderly people. This could be due to reduced reaction time or eyesight which is no longer sufficient for safe driving. Feeling safe and actually being safe on public transport are also important factors in allow individuals to access public transport (Ref 7). For some, (e.g. individuals with dementia) it would not be safe to take a bus alone, as the new setting would cause confusion and lead to negative outcomes. If this is not compensated for through the provision different services, it would again decreases fairness within access to the health system.

Discrimination as a barrier to health

Within health services across the world, and here in the UK there is discrimination towards certain subsections of the population. One example of this is direct and indirect discrimination of people with intellectual disability (Ref 8). These intellectual disabilities included Down syndrome, cerebral palsy and autism. There were difficulties in communication for these individuals. This lead to some patients feeling unheard by the doctors and others feeling like they ‘were talked over’ by the doctor when their carer was present. Medical staff also are sometimes unable to adapt questions in a way that is understandable for these individuals, and their answers failed to recognise that information can not be taken on as quickly for these individuals, so speaking at a normal speed can feel much too fast. This is just one example of discrimination, but it highlights that certain areas of the population will be less likely to attend appointments, given it is a much more challenging experience for them.

Ways in which this equal access health care system can be achieved

The economic aspect to healthcare and medication

In the UK, the NHS was founded on several key principles, one of the most significant being the promise for health care to be based upon clinical need not an individuals ability to pay (Ref 9). This has meant health care free at the point of access. On the whole, this has been a large improvement in the access to health care seen compared to other systems which require payment for the treatment, or health insurance systems which are not the same for all such as in the US (Ref 10). However other steps to improve access to health care would include payments for medicine and dental care. In the UK there is a charge for prescri ption medication for some within the population. There are several exemption categories, and these charges are heavily subsidised, but there are still certain individuals within the population who do not feel like they can afford these prescri ptions so therefore don’t get them, leading to worse health outcomes for them (Ref 11). So in the perfectly fair health care system, these charges would be abolished, alongside charges for health related dental care, as some individuals don`t get regular checkups due to the cost of seeing a dentist (Ref 12).

Transport as a barrier to health

One way in which transport as a barrier can be elevated is through the use of home visits by GPs. Although there is some debate around the number of home visits in the NHS currently there is clear evidence to show that visiting people’s home is a beneficial thing, and improves health outcomes for certain individuals. (Ref 13) These individuals may be bed ridden in a care home or may have mental health reasons such as Alzheimer’s which would mean that they would be negatively effected by travelling to a new place such as the doctors surgery.

Discrimination as a barrier to health

One way in which the NHS tries to improve itself to elevate discrimination which would act as a barrier to access of health care is through the training of staff to be able to understand and best cope with the extra needs presented by groups such as those with an intellectual disability, (Ref 14). There are also other ways in which health care staff can be educated and trained more effectively in these areas to reduce cases of discrimination (Ref 15).

The next section of my essay focuses on the the question of which health care treatments to fund within a just health care system.

Maximisation view

In order to try and quantify the benefit of different interventions and compare them, a principle which assesses benefit via quality adjusted life years (QALYs) can be used (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1376052/). Often it is argued that more QALYs will be produced through the following of good ethical principles so doctors shouldn’t need to continually consult the principle, though it can sometimes be useful to do so. In a perfectly just health care system it may seem intuitive to suggest that the best way to allocate resources would be to increase QALYs by the maximal amount for the budget available. This would involve finding treatments with the lowest cost per single QALY, and spending increased money on these. In the following arguments I will suggest problems which may put a strain upon the idea that this perfectly just health care system would purely aim to increase the most amount of QALYs for the least amount of money spent.

The distribution problem

One problem facing this above approach is the distribution problem. Take an example of making a decision between 3 different treatments which all cost the same, but we can only afford one:

Intervention 1 - benefits 10 people with a total life gain of 35 QALYs, between 2-4 QALYs per patient.

Intervention 2 - benefits 15 people with a total life gain of 30 QALYs, between 1-3 QALYs per patient.

Intervention 3 - benefits 2 people with a total life gain of 28 QALYs, between 12-16 QALYs per patient.

It would seem from the maximisation view that this would be a clear decision to go for intervention 1 which would increase the amount of QALYs the most. However some may argue that the most just option would be to go for intervention 2 which would help the most amount of people even if it is only for a shorter amount of time. Moreover other people may argue that intervention 3 would be the best option as the two individuals benefitted will have a really significant gain in life (minimum of 12 QALYs) rather than in the other two options where the maximum gain would only be 4 QALYs per individual. So the question would remain whether the distribution of extra QALYs should make a difference, and if it does make a difference then it would be at the cost of QALYs in other areas, as with the arguments to chose intervention 2 or 3 over intervention 1.

(Ref 17)

Rule of rescue

Another objection to the maximisation view is the rule of rescue, first coined by Jonsen in 1986 (Ref 18). This is relevant in situations where there is an intervention (rescue) which has a high chance of saving the person’s life who otherwise would have died. However this intervention is expensive, and if the same money was placed into other treatments there may be a greater increase in number of QALYs. So the main principle of this argument is is that it is normally justified to spend more per QALYs in a situation where the individual can be identified compared to situations where they can’t be identified.

Interventions A and B which show the difference between anonymous ‘statistical’ lives and rescues of an identified person

Intervention A saves anonymous ‘statistical’ lives by reducing the risk of death by a small amount, from a value that is already small, for a large amount of people. For example out of 5000 people in a group, 200 may die if intervention A is not given, but 195 people may die if intervention A is give. Therefore we know that intervention A will saves 5 lives per 5000 people who take the drug, but we can’t identify who within the group has been saved, as most people within this group of 5000 would be saved anyway (96%). A real world example of this would be a treatment which lowers moderately raised blood pressure, statins. Lowering blood pressure and lowering cholesterol would reduce risk of heart attack and stroke which can both lead to premature death. This treatment is cheap and would only cost £10,000 per QALY. (Ref 17)

To contrast this, intervention B rescues the life of an identifiable person. This would be if an individual would face a greater than 90% chance of death over the next year if not given the specific expensive intervention B. In this case the cost per QALY is £50,000. An example of this sort of treatment would be kidney dialysis if there is no availability for a kidney transplant. (Ref 17)

Differences between these inventions

There are 2 main differences between these two cases. The first is that B saves lives within the next year whereas the benefits of A are not realised for many years. This will mean that some of the individuals who may have benefitted from A will die from an independent cause before gaining any benefit from A. There may also be a case to be made for the fact that increased QALYs in the future may have a different value rather than an increase in QALYs now, as the cost per increase in one QALY may go down in the future with increased medical research. (Ref 17)

The second difference is that intervention B benefits identifiable people rather than intervention A which will benefit a proportion of people within a group, but we can’t know who within the group will benefit (but we do know the likely proportion that will benefit). According to the rule of rescue this may mean that intervention B is taken despite it being more costly per QALY. This is seen in the NHS where dialysis is still offered to patients. This is despite the fact that investing the money it costs for one person to have dialysis into a different treatments such as statins may save the lives of 3 or 4 people compared to this one patient who is saved through dialysis. However it is felt that removing dialysis treatment would be the wrong thing to do as we are condemning the person to death. Whereas with the case of statins we are slightly lowering an already small chance of death. (Ref 17)

Thought experiments

Thought experiment in favour of the rule of rescue

Premature death is something that will cause harm to both the individual and those effected in the immediate family and friends, this harm is significant. However increasing the chance of premature death by a very small amount is something which doesn’t bring about great harm. All of us trade small increases in the chance of death for quite small benefits. An example of this would be driving across the country to watch a sports match or concert if free tickets were offered. This would increase the chance of death by a small amount as there is a risk of accident which could lead to death. However the enjoyment of the sports game or concert around outweighs this small increase in risk premature death. There seems nothing irrational in this. (Ref 17)

Take the example that a friend must hand in a job application for a job they really want, and their car is currently in the garage, most of us would also be happy to take this application letter and drive it to where it need to be. This is despite it having no specific benefit to us, but it would help and friend, and it does lead to a small increase in the chance of premature death, due to a car accident. With this in mind it would seem better to go against intervention A, as it shows that we readily risk a small increase in premature death for other people, to allow them to hand in a job application. So how much more would we be willing to risk for something that would save that persons life. Therefore, not getting A would marginally increase our chance of premature death, but putting this money towards B would lead to those who need dialysis to be saved. (Ref 17)

Thought experiment against the rule of rescue

If you consider the case that there is a lost miner trapped and you have to work out whether to join the rescue party. If nobody goes this miner will definitely die. However there is a risk to each member who goes out to rescue this miner, and the greater the size of the rescue part the smaller the size of the risk. If there were 100 rescuers there would be a 1:1,000 chance of death for each rescuer. For 1,000 rescuers just 1:2000 and for 10,0000 rescuers just 1:5,000, and finally with 100,000 rescuers the risk of death for each rescuer is just 1:10,000. This is a huge rescue party but this can be acceptable and useful as this is a thought experiment to test a theoretical point. (Ref 17)

The larger the size of the party, the smaller the individual risk, but there is a greater increase in risk for the whole party. With the rescue party of 100,000, each member of the rescue party would face a risk which was very low, and a level of risk they would be prepared to take for something much less important than saving a life. However for this party, we would expect 10 people to die for the sake of just one person. (Ref 17)

If we assume that most people are altruistic at least to a small extent, then it is fair to assume that most people would be prepared to take a small risk to save another life (which could line up with giving up intervention A which was the statin). However as we’ve seen this could easily lead to more overall death and in this situation the commanding officer of the rescue operation would be criticised for the lost of life, despite each member of the rescue party voluntarily signing up. (Ref 17)

When looking back at health and intervention A it is not clear that everyone who could receive the small decrease in risk of premature death, would volunteer themselves to save the miner (and provide their part of the money for intervention B). Moreover by donating their money to intervention B with the aim to reduce death, they would actually be causing further death. (Ref 17)

To conclude, a health care system will never be considered fully just, partly because the needs of citizens within a large health care system changes daily, and party due to the fact that some ethical theories such as the rule of rescue are subjective and bring up questions which can only be answered personally. Such as whether being non-identifiable is a good enough reason to discriminated against as a point against the rule of rescue (Ref 18), or whether you could ever quantify the increase in quality of life and trust in the state which is built up by knowing that if you got into trouble the equivalent of a large search party would be willing to give up so much to save you.

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