24.10.09

ALLOCATING SCARCE RESOURCES. Albert Camus's The Plague considers the way a community can be overwhelmed when almost everybody gets sick. That's not a classroom situation for philosophers only, as Florida officials are discovering.

Florida health officials are drawing up guidelines that recommend barring patients with incurable cancer, end-stage multiple sclerosis and other conditions from being admitted to hospitals if the state is overwhelmed by flu cases.

The plan, which would guide Florida hospitals on how to ration scarce medical care during a severe flu outbreak, also calls for doctors to remove patients with poor prognoses from ventilators to treat those who have better chances of surviving. That decision would be made by the hospital.

The story prompts Charlie Sykes to quip, "Whatever you do, don't call these 'death panels'." The arguments over whether "death panel" is Inappropriate Language, or misleading, or wrong miss the point. Where resources are scarce and have competing uses, somebody has to make do with less or with none. And where incentives to convert resources from some other use to the use in question are missing, making do is more constrained than otherwise.

Here's Patrick McIlheran on that point.

"The problem is that there are enough people running the show who have said some human life is worth more than others," said Cynthia Jones-Nosacek, a Milwaukee family doctor who's spoken out on ethics. The cure is to say all human lives have value.

Even ones likely to end soon. Jones-Nosacek is particularly troubled by the idea of pushing patients toward their end, as in Oregon, which offers suicide pills but not necessarily chemo, or as in Britain, where patients deemed terminal now can be sedated and starved.

She's got patients with terminal diseases, and with the advent of hospice care, if "their needs are being cared for, they don't ask for death." She's had patients go on breathing tubes to overcome pneumonia and then live for happy, bonus months. The dying need to be adequately helped, not rushed.

"Adequate," however, does not make the underlying problem of allocating resources subject to constraints go away. Britain's National Institute for Health and Clinical Excellence faces that reality head-on.
The Government's rationing body said lapatinib is too expensive even though its makers will provide the first three months' treatment free of charge.
I'm not sure that mau-mauing the institute as a death panel changes the underlying reality of allocating resources under constraint, although the strategy has been used previously.

NICE will issue guidance shortly that in effect bans the drug, which is used in 18 other European countries.

It comes despite a pledge by NICE to be more flexible in giving life-extending drugs to terminally ill cancer patients after a public outcry last year over 'death sentence' decisions.

NICE was forced to apply this end-of-life criteria to lapatinib by its own appeals panel.

The acronym is infelicitous, especially given the difference in the British use of "nice" from the North American. The flexibility the institute applies, however, must mean that some other treatments, perhaps less obviously life-extending, are reduced to release resources for cancer patients.

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