Critical care decisions in fetal and neonatal medicine: ethical issues
Economic issues
3.36 No healthcare system provides unlimited resources. The resources available for healthcare are limited compared with demand, if not need. All healthcare systems, regardless of their financing and organisation, employ mechanisms to set priorities for finite resources. Increases in funding or the removal of inefficiencies in the healthcare system which improve access to treatment are likely be counterbalanced by other pressures on resources. Such pressures could, for example, arise from the introduction of new and more costly interventions resulting from medical advances, or from patients expecting healthcare services to do more to alleviate suffering.57 While some commentators consider that the main economic issues concern improving expenditure on healthcare, or removing inefficiencies from the way in which it is delivered,58the need for setting priorities is generally perceived to be self-evident by those who have to allocate resources.
3.37 Given that decisions about the prioritisation of healthcare resources are unavoidable, how should we allocate finite healthcare resources in fetal and neonatal medicine? How should the lifetime costs of caring for a seriously ill newborn baby be taken into account when devising policies on whether to institute resuscitation or whether to continue treatment? Is it appropriate to invest heavily in caring for babies with poor prognoses when the resources might be directed to babies with better prognoses or elsewhere within the healthcare system? These questions are difficult to answer because there appears to be no consensus between philosophers, health economists and public health physicians about the moral basis for decisions on resource allocation.59
3.38 Economic evaluation offers an explicit framework for addressing many of these divisive issues. Health economists attempt to identify the human and material inputs that combine to maximise health benefits or other measures of social welfare. Cost utility analysis is a tool, developed by health economists, that allows all health interventions to be compared in terms of their costs and the health improvements they procure. This permits healthcare resources to be allocated on a ‘cost per quality-adjusted life year (QALY) gained’ basis (see Appendix 8). However, numerous problems may be encountered when allocating finite resources in fetal and neonatal medicine by this method. Most notably, there is a well recognised paucity of adequate data on the effects of fetal and neonatal interventions on survival and health-related quality of life for many conditions. In many cases, this information will also prove to be technically difficult and expensive to generate. Thus information on costs and health outcomes may be available for only a few of the range of interventions competing for priority. Moreover, little attempt has been made to test the validity, reliability, responsiveness and interpretability of the health attributes incorporated into the QALY measure in fetal and neonatal medicine. Crucially, however, allocating finite resources in fetal and neonatal medicine on a ‘cost per QALY gained’ basis raises a number of ethical issues. Important principles of justice may be ignored, for example if a treatment is available in one neonatal unit but not another. In addition, because neither ill health nor the distribution of healthcare resources are distributed randomly, a strategy aimed at maximising health outcomes within a limited budget may perpetuate inequalities or make them worse, and at best ignores them. In principle, this problem could be addressed by weighting the relevant data using agreed criteria for equity.
3.39 Broadly speaking, there are three levels at which economic issues could operate to influence decision making in healthcare. These may be described as the macroeconomic, the mesoeconomic
Overview of the organisation of the NHS in England
and the microeconomic levels (see Figure3.4; further details are provided in Appendix 7). Government agencies take decisions at the macroeconomic level, for example on the level of resource to be allocated to a particular area of clinical practice or on whether a particular treatment should be available within the NHS. The mesoeconomic level concerns regional and local decision making, such as whether or where a specialist service will be offered and the number of cots to be made available on a neonatal ward. Decisions made by healthcare professionals about a particular patient they are treating are at the microeconomic level. In practice, decision making in healthcare in the UK is affected by economic considerations at the macroeconomic and mesoeconomic levels. In our fact-finding meetings we consistently found that healthcare professionals took account only of ‘the patient in front of them’, although they could be frustrated by the difficulty, for example, of locating an intensive care bed for a very ill child. We reach some conclusions in relation to economic considerations in Chapter 2 and discuss their influence further, including the costs to families, in Chapters 4–7.
Footnotes57 Mooney G (1992) Economics, Medicine and Healthcare(London: Harvester Wheatsheaf).
58 Frankel S (1991) Health needs, health-care requirements, and the myth of infinite demand Lancet337: 1588–90.
59 We do not discuss the moral basis of resource allocation in this Report, but see, for example: Harvey I (1996) Philosophical perspectives on priority setting, in Priority Setting: The health care debate, Coast J, Donovan J and Frankel S (Editors) (Chichester: Wiley), pp 83–110.