Rationing Scenario

[Guest InspectorKewl]

You're an Aid Worker in Africa.

There are 100s of people waiting for you to supply

then with food, as they haven't eaten anything

for days.

The food shipment you have just received is

contaminated with an unknown organism.

So, you only have a limited amount of food -

not nearly enough to go around.

What do you do?

[Guest aberza]

Interesting Scenario... did you get this in an interview?

 

The situation you describe would force me, the aid worker, to make some difficult decisions about who would receive food and who would continue to starve.

 

The first thing I would do is identify those among the group who are at highest risk for death due to malnutrition (e.g. the very young, sick and old). I would ration a majority of the food among this portion of the population first and if there is anything left, I would distribute it equally to the rest.

 

Obviously those who do not fall into the "high risk" group may not agree with this decision because they will continue to starve until more food arrives. Unfortunately, I would be left with no choice but to try and manage a disastrous situation from becoming even worse, i.e. an increase in the number of deaths due to starvation. If we are able to save those who are at highest risk for death, hopefully we can buy some time before more food arrives.

[Guest wattyjl]

of course the other option is to give food to the people who will have the best chance of making something of it, i.e. the relatively healthy for which even a little food will sustain them. i'm not necessarily saying this is something i would do at all, but i guess this speaks to the bigger question that with *extremely* limited resources do you risk potentially 'wasting' them on those who may not recover or help those that have a better chance?

i guess this is somewhat analogous to organ donation? and indeed, in that situation, as i understand it, it is people that are considered likely to live a healthy 'responsible' lifestyle (and make use of the organ) that are generally considered to receive the transplant first... any thoughts?

[Guest UWOMED2005]

You get realistic and give the food to those who a) need most BUT are most likely to survive until the next shipment.

 

Interesting question/scenario. It also applies extremely well to rationing of medical care. I was in rural South Africa for two months in the fall. South Africa is much better off than its neighbours, but still has a shortage of resources. As a result, they do somethings rationing wise you'd never dream of in Canada. ALL HIV patients had automatic "Do Not Resuscitate" orders - you're not allowed sending them to an ICU. As well babies less doctors are not allowed to resuscitate babies born less than 1 kg. . . because survival for such kids is so dismal and there aren't the resources to care for every baby under 1 kg.

[Guest canmic]

The odd thing is, in the Canadian healthcare system, we are in a similar position in that there is not enough money and resources in the system to give everyone everything they need.

 

Many provinces have actually stopped paying for routine annual examinations of people who are healthy to catch problems quickly before they become serious at a cost of about $50 per year per person.

 

But, we routinely spend a million dollars on a single patient who has less than a 1% chance of living a week regardless of the care they get. Not a year, not a month, but a week.

 

It's all about politics, and which cases get the most attention from the media.

 

If you don't believe me, ask any doctor who works, or has worked, in a NICU or who has done patient transport.

[Guest wattyjl]

my feeling on this is that people/society doesn't understand the merit of prevention. we are a society that recognizes health only when we're sick. we work a lot, and play a lot, but don't do the obvious things (like eat well and exercise) that help maintain health. we expect to be treated for our illness, and not to have to worry ourselves about things we could do to prevent it. maybe success with programs like flu vaccination (when it works) will help argue in favour of early detection/prevention, who knows.

 

i don't really have anything to add to the other part of your comment, dealing with spending so many reasources on one individual. it's amazing to think what would happen if the hundreds of thousands that are spent to keep people hanging on by a thread were instead invested in programs to help the impoverished, etc. it must go deeper than politics, as politics only reflect aspects of our society that already exist - that said, the media could probably convince us that anything is important... we are a bizarre society.

[Guest UWOMED2005]

Canmic and wattyjrl - in many ways, you both are SO correct. I was in a rush with my last post. . . I wanted to say something similar, but didn't have the time to figure out how to word things.

 

On my ICU rotation, I saw hundreds of thousands of dollars spent on individual patients when the medical care team knew there was essentially no chance the patient would leave the ICU alive. The money spent was like a 'Hail Mary' pass in football. . . essentially no chance, but essentially no chance isn't really NO chance.

 

Here's a question for you - if this was the scenario and you were the patient, would you want the system to take that chance?

 

You guys are very right on the issue of prevention. . . when it comes to the population as a whole. There's no question decreasing the overall number of smokers is going to decrease the prevalence of heart attacks, lung cancer, and a whole host of other problems. There's very little question getting people to stop eating fast food would decrease obesity, diabetes and MIs. There's some but little question incresing fiber would decrease colon cancer. There's little question increasing exercise would. . . you get my point.

 

The problem is that we can say the above is 100% true for the population as a whole, you really CAN NOT say that the INDIVIDUAL will get lung cancer from smoking (there are lots of smokers who die of other things, often even not smoking related.) Or that you will develop colon cancer because you didn't eat All Bran. You can't say someone is going to have an early MI just because they eat a lot of McDonald's. Or have an because they sit on the couch and play too much PS/2.

 

The classic example for me would be my grandmother and a neighbour of mine growing up. My grandmother smoked 2 packs/day for her entire life. . . she did die of Lung Cancer, but that was at the age of 80. . . above the average life expectancy for her generation and gender. In contrast, my neighbour was the fitest person on the block. . . ate right, ran every day, saw his GP every year for a physical. He died in his early 40s from colorectal cancer - a huge shock to all his friends and family.

 

I think that's a large factor in why it's so hard to get the general population to completely buy into preventitive medicine. It's not a guarantee. . . it just sways the stats when you look at the country as a whole.

 

In general preventative is the best sort of medicine for what we're talking about.*

 

But I have to admit, while I do buy into the whole preventitive medicine approach, if I develop leukemia in my 30s you can be sure I'll want a sytem that is willing to pay for the bone marrow transplant. That's an extremly expensive procedure. But it has a solid chance of outright giving me a cure, and if I've been paying my taxes into our healthcare system and the leukemia is no fault of my own. . . isn't this exactly the sort of thing that is the justification for having medical insurance (which is what government sponsored health care in Canada basically is)? I think that's a great use of medical resources. . .

 

Same thing if I get to be 58 and end up in Emerg with an MI, despite living healthily. . . I'm going to want the system to pay for PTCA.

 

Rationing. . . You are correct - we do ration medical services in Canada. There is the fact Ontario has delisted services like optometry and physio. There is the point the gov't has never paid for home care or drugs. But we also ration in hospital procedures and tests - thing is, it's often not by coming up with new rationing protocols/rules (ie South Africa). . . it's by screening how we provide new technologies. . .

 

And ironically, this approach demonstrates the tricky balance between rationing AND trying to give the really sick patient that hail mary chance. . .

 

For example, in 2002 the PROWESS trial showed "Activated Protein C" (APC) did have a significant effect on decreasing mortality in Sepsis patients. For every 16 patients you treated, you would prevent 1 death. Problem is, APC costs roughly $10,000 for the 96 hour course! You wouldn't believe how common Sepsis is in the ICU - treating every patient with ICU would mean several patients at any one time would be receiving APC. What they're currently doing in London is reserving APC for only the sickest of the sick sepsis patients. . . the ironic thing is, we're only using it on patients who are sicker than they were in the PROWESS trial. . . so there's not even really any evidence the stuff works in the patients we're using it on!

 

Another good example is Ischemic Cardiac Defibrillators (ICDs.) These devices (shaped and placed like a pacemaker, but basically give a shock if a patient goes into an arrhythmia ie 'heart stops') have been shown time and again to decrease mortality in patients suceptible to arrhythmias. Anti-arrythmic drugs have been shown to either have no effect on or increase mortality in patients with arrhythmias. But we can't afford ICDs for every patient with an arrhythmia. . . last I heard most cardiology services were rationed a certain number of ICDs per year, and had to sort out who got them on their own.

 

Just some things to think about. . .

 

* One caveat. . . I believe (can't remember the exact study) that it has been shown that routine physical examinations in people under 40. . . there aren't many things you can pick up in a physical exam that will affect someone less than 40 and that the patient won't notice themselves. . .

[Guest wattyjl]

UWOMED - i of course agree with your statement regarding prevention working primariliy at a population level - nonetheless we are a society of individuals that don't like to be held responsible for anything (including our own health) but that's not really the point here.

 

and of course i agree that our system should be designed and used for the life-saving measures you describe. i guess i am more concerned about situations like the recently much-reported on one with an individual receiving what must have amounted to hundreds of thousands (if not more) of dollars worth of care, for what... and i'm not saying i necessarily disagree with it, it just has to be considered. of course, where do you draw the line? when do you give it everything you have and when do you give up?

 

the more i think about and become aware of these types of issues (both the theory and practical manifestations that so many of you guys (clerks, residents, etc.) describe) the more i appreciate the significance of health policy makers and bioethics in general.

[Guest canmic]

A few comments.

 

A 1 in 16 or even a 1 in 50 chance is still a pretty good chance. I was referring to the patients that are basically dead but no one wants to admit it (think the recent case in florida, basically by any sane definition she was dead and wasn't coming back, but the parents wanted millions spent on 'therapy'...)

 

As far as the 'if I was the patient', well, I've already got a fully signed and registered living will, does that answer the question, at least partly?

 

For the 'routine exam picking up stuff' well, the first thing that comes to mind is diabetes (type II in particular) and the second is breast cancer (something like 90% of women don't do self exams or don't do them properly). Another biggie is cervical cancer (ie: pap smear). If you push the 'under 40' to be 'under 50' then you've also got prostate cancer in there.

 

When I say a routine annual physical, I am adding in all the common sense tests that a good family doc would do.

 

Also as far as the prevention argument, there is a HUGE difference between someone who choses to smoke and gets lung cancer and dies and someone who dies of prostate cancer because the government wouldn't pay for the annual physical...

[Guest CalicoKal]

I just want to say that the previous posts are very well written and thought out. Interesting points were made and they were supported by some great evidence and examples.

 

I continue to be impressed by the people who post on this board--as a country we have some amazing up and coming physicians!

 

CK

[Guest InspectorKewl]

I don't know if you can compare the scenario I posted with "rationing" organs. It just seems to me that the concepts

and ethical/moral underpinnings differ drastically. For instance, with food rationing, there may be a finite amount

of food available at the moment, but there are always subsequent shipments forthcoming - so, the decisions here must be based on the short-term. This is in stark contrast to organ availability - a decision to be made over the long-term with the knowing that only a finite amount of organs are available (and the supply is generally stable, that is, there is no supposition that you may suddenly get a surge of organ donation). I hope I'm making sense. I just view the two scenarios as fundamentally dissimilar!!?! I'd like to hear some of your thoughts....

[Guest wattyjl]

ah - i see, i guess i didn't really pick up on that reading your original post. obviously, if one expects another "full" shipment within a few weeks then the healthiest people would be able to survive on very minimal rations until that time.

 

so now you're saying, out of a group of people (children, elderly, sick) that likely won't survive without rations NOW, who do allocate to? children over elderly? sick-but-likely-to-recover adults? also, do you spread the rations thin with the hopes of helping more people survive, but at the risk of the reverse than if the rations were concentrated on less people?

 

tough question, i don't really know how to approach it... other than 'save those you think you have the best chance of saving', but i'm not sure if that applies here in quite the same way.

[Guest UWOMED2005]

I don't know if you can compare the scenario I posted with "rationing" organs. It just seems to me that the concepts

 

No sorry - we're got side tracked by a tangent.

[Guest canmic]

I think the analogy of the 'rationing' of healthcare dollars works for this example.

 

Do you take the 'political' solution or do you take the pragmatic solution?

[Guest InspectorKewl]

I think the "only" way to consider this scenario (one which Aid workers face on a daily basis worldwide) is to consider NEED (I don't think benefit is necessarily applicable to the rationing of food). I think it is grossly insensitive and unethical to state that one would simply not give food to the ill/elderly simply given their "status" - the only fair thing to do is allocate according to need, so that children/pregnant women/elderly/ill get the first "share" and whatever is left over will be equally distributed among the remainder of the so-called "healthy" individuals. As long as all these individuals have an adequate supply of clean drinking water, they should be able to "manage" until the next shipment arrives.

I don't see how you could draw an analogy between organ donation or rationing of health-care dollars, for that matter? Isn't the McGuinty government applying a similar algorithm in the decision to provide optometry & physiotherapy services to only the elderly and children?

I don't think rationing should, or is (at least theoretically!), based solely on financial considerations - the primary concern for physicians (& obligation) is one of CARE.

It's a whole different scenario when one considers extremely scarce "resources" (e.g. organs), which are "allocated" based on need & benefit, along with incorporating consideration of only "morally-relevant" criteria. For example, if a physician is faced with two patients, but only one organ, the way this decision would be made is based on a consideration of need & benefit (i.e. survival over the long-term, risk of rejection, etc.) - whichever patient outweighs the other would receive the organ, BUT they must be "equal" in all other respects....

At least this is how I see things!

Rationing involves making difficult judgment calls - perhaps I'm just having a hard time reconciling...I don't know! I'd appreciate any further input! :rolleyes

[Guest CalicoKal]

BUT--what if you have two patients who need the organ just as much and have an equal chance of benefiting from it and they differ in their age: one is 20 and the other is 70. Do you give it to the 20 year old in the hopes of ensuring a normal life span or do you give it to the 70 year old?

[Guest Lactic Folly]

Whoever got on the list first..

[Guest studentz]

This scenario is on Interview Feedback for UWO.

[Guest canmic]

Uh...

 

How could healthcare rationing not be based on financial considerations?

 

Apart from organ donation and blood transfusion, how could it be based on anything else?

 

The healthcare 'pot' is NOT bottomless, when all the money is gone, there is no more there.

 

The governments are deciding what they will and will not pay for based on the amount of money they want to spend, plain and simple.

 

It would be great to live in a world where money isn't a consideration, and everything is free... but... that's not the case.

 

Also, we can't just point the finger at the government and say "Bad!" when they do not pay for a given service under medicare. Think of it this way, if EVERY service that everyone wanted or thought they needed was covered by medicare, the healthcare budget would be larger than the total current budget for each province. In some cases, the healthcare budget would be larger than the GNP of the province, obviously that won't work. Hence, we have rationing of healthcare dollars.

 

The case of the BC families that want Lovaas babysitters paid for under medicare is a case in point. The cost of providing them would increase the healthcare budget for the province by about 25%, just for that one item. Apart from the fact that the research evidence is clearly heavily weighted against this 'therapy', the cost of providing it just isn't sustainable.

 

Back to the point of this thread, the basic reasoning behind asking a question of this type (think Kobiyashi Maru (sp)) is to see if you freeze up and become useless when put in a situation where you must make difficult decisions.

 

In a more medical context, consider this alternative form of basically the same question:

 

Suppose you are alone in an ER and there is no one to help you. You have the following 4 patients, all of whom are coding. What do you do?

 

1) A 30 year old bank robber with 2 children who was shot by police while robbing a bank. He has no previous criminal record.

 

2) One of the policeman from the robbery, who was shot by the bank robber. He is 55 years old and single with no children.

 

3) A 65 year old priest who spent his life helping lepers in africa

 

4) A 10 year old girl who was in a car accident, but is healthy apart from her injuries and will fully recover if she lives.

 

 

Any answer which tries to avoid making the decision, or tries to save more than one person will be the wrong answer, as it would result in all of them dying. What they are looking for is to see if you can make the tough decisions under pressure. There is no 'right' or 'wrong' choice of who to save, really, as any one of the 4 can be justified, BUT, avoiding the question or the decision is the wrong answer..

 

So, back to the africa famine, if you try to change the parameters of the question, you will not be giving them what they are looking to see.

 

If you try to save everyone, you will kill everyone.

 

Indecisiveness or a failure to accept harsh realities is deadly in medicine. Remember that.

[Guest Malikar]

Canmic's example of the Lovaas babysitters made me think of the parents of autistic children who are lobbying the government to pay for this and other types of therapies for autism.

 

I heard of this one therapy (could have been Lovaas, or something else) that costs around $40,000 a year. Now if there are over 100,000 autistic people (not just children, as I would suggest both children and adults could benefit) in Canada... multiplied by $40,000 each is around four billion dollars.

 

Four billion dollars a year spent on autism exclusively. That would certainly impact our healthcare budget, not to mention set precedent for others to lobby for coverage of expensive therapies for other conditions. Realistically with an "economies of scale" effect the cost for the service could probably be reduced dramatically. I postulate the price would still be high. High but justifiable? Depends who you ask...

[Guest CalicoKal]

If the therapy will create high-functioning citizens--who will subsequently be less of a burden on the social-support system over the course of their life--then maybe it is a net reduction in overall spending on these children though. The parents who took the case to court in Ontario had a health economist figure that it would save millions in the long-run. At least that's what they said... I don't think they had any real evidence to support the benefit though, in which case it is a lot of money spent on what could be called "experimental" treatment...

[Guest InspectorKewl]

CanMic: I don't think I'm being indecisive - I proposed my allocation algorithm, and it's not something that everyone may agree with, but I think that's a given with resource allocation. That is, more than likely, many people will find fault with a given/proposed way of rationing ... This is precisely why entire committees of doctors/ethicists/case managers/etc. agonize over stuff like this on an ongoing basis...often coming up with less-than-ideal "solutions"...but the fact is, we don't live in an ideal world!

And I never said that financial considerations are not part of rationing - that's ridiculous - health care, like anything else, must operate within budgetary constraints and be "fiscally responsible" BUT, it should not be the primary guiding factor/decisive factor in determing the course of treatment for a patient ... that's why we do spend hundreds of thousands of dollars on life-sustaining treatments for likely-futile cases (whether we should do so is an entirely separate issue)!!!

[Guest canmic]

As far as Lovaas (which is the stuff they went to court over in Ontario) goes, for every paper that says it works (written by Lovaas himself) there are about 10 papers written by various other researchers pointing out why his research was totally flawed and his conclusions incorrect. Currently both the CMA and the AMA, along with various other medical bodies (CCNS for example) have taken the stance that it is NOT considered to be an effective treatment.

 

The cost is closer to $60k/year, and it can't really be 'saved' on with economy of scale, because it requires full time 1 on 1 therapy.

 

I've worked with autistic kids, and believe me, the idea of any of those who are at the low end of the spectrum becoming 'functional adults not requiring full time care' is absurd. It's a cold hard reality for some parents, and they don't want to face it. That's why they fight for quackery treatment such as Lovaas. Everyone else has told them that there is no hope, but the 'therapists' (who usually have very little in the way of professional credentials) promise them unrealistic improvement and so they find themselves in a position of having to believe. The alternative is just too hard for them to face.

 

I feel sorry for the parents, but I don't think that it's right to bankrupt the healthcare system to help them to stay in denial.

 

As far as the rationing not being based on financial considerations. Well, actually it SHOULD be based more on financial considerations. Suppose that every time a doctor was faced with a decision about attempting a futile treatment, or transport, he was presented with the cost. Not in dollars, but in other treatments that there would be no money for. Ie: Yes you can transport this dying patient and put them on full support in an ICU for a week and have them die anyway, but by doing so, you are increasing the waiting time for cardiac stress tests by a day for the entire province, and by doing that, you've just killed two people. Ooops..

 

Unfortunately, it's never that obvious, even if that basically IS the result.

 

Back to the scenario, as I said, there is no 'wrong' answer, really, but the question is: Are you able to sacrifice some to save others, and when put in the position of having to choose, will you be paralyzed and lose everyone.

 

If they say that you only have enough food for 1/4 of the people to survive, for example, don't try to 'fiddle' with the numbers by saying that you can put some on part rations and do some fancy math and have more than 1/4 survive. They have told you that 1/4 live and 3/4 die. You have to show that you can make that hard decision. Avoiding it only works for Kirk...

 

I'm not commenting specifically on anyone's answer by the way, this is basically what I was told by some friends who interview for med school and residency. If they ask that sort of question, they want to know if you can face the hard decisions, or if you try to 'run away' by changing the terms of the question. They aren't really looking at who you will save and who you will allow to die, they are looking at your ability to make that decision.

 

By the way, for the above example, the answer "Shoot 1/4 of the people and feed them to another 1/4 and that way you save 1/2 the people instead of 1/4 of the people" isn't going to work, unless it's a military interview...

[Guest Malikar]

"Soilent Green is people!!!!"

 

Please tell me I'm not the only one that just though of that... look it up if you don't know what Soilent Green refers to.

 

You bring up an interesting point about medicine Canmic. I've been told many times the paradigm is basically "save the person who is in front of you now, even if it means sacrificing many later".

 

A good example of this could be HIV treatments. A professor of mine once went over this in class, over-simplified for the sake of teaching, of course.

 

Basically if one anti-HIV drug is effective at stopping the virus, but the mutation rate for resistance is 1 in a million, then after one million virions are produced you'd have one that is resistant. Recall that these mutations often preceed the treatment as mutations are constantly occuring. Take another drug that has a different target, the mutation rate for resistance is also 1 in a million. Combine the two and the mutation rate for resitance to your drug-cocktail is 1 in a trillion, effectively enough to prevent mutation for resistance. Clearly the cocktail would be much more effective at treating HIV. Indeed, this is what is done nowadays.

 

But, back when the first anti-HIV drugs were coming out, instead of holding these back and waiting for other drugs to come out, which would have been inevitiable, the drugs were administered as soon as they came out. Unfortunately this resulted in resistant strains of HIV quickly developing. Though he never said it right out, my professor favoured sacrificing some to save more.

 

I should say I didn't agree with his arguement for a number of reasons. After all, it was over-simplified and didn't take a number of things into account.

 

For one, I think we should always try to save the person in front of us with the hope that better treatments will come out in the future to help save those we may be putting at risk.

 

There was also no guarantee that the drugs in the R&D pipeline would have passed clinical trials, as 99% seem to fail...

 

I think at the time, doctors didn't think resistance could develop so quickly. In retrospect, this should have been obvious as retroviruses mutate quickly and patients who don't strictly follow their therapeutic regimens increase risk of resistance developing.

 

Anyways, just food for thought.

 

Mal

[Guest canmic]

Soylent green With a 'y'

 

I think that you have to remember that back in the 80's when AIDS first appeared, the word 'retrovirus' barely existed.

 

I remember reading the journal articles as they were coming out back then, and believe me, for several years no one had a clue what was going on, then they started to think they knew something, but they still had no idea.

 

It has been almost 25 years since AIDS hit north america, and while it's easy to armchair quarterback with hindsight, I think that it is hard to really have an appreciation for how little information they had to go on back then, and how impossible the struggle seemed to be.

 

AZT was considered to be a veritable 'cure' for AIDS when it came out, no one expected the virus to mutate as quickly as it did back then.

 

Actually, just about every anti-viral drug we currently have was developed after AIDS started spreading in north america. (not vaccines, anti-virals) Zovirax (the old herpes drug) is about the only one I can think of that was around back then, and it was JUST getting approved.

 

It amazes me that when I was in high school, I was reading about research that was done decades or even centuries earlier and it was considered 'state of the art' but now, anything more than 10-20 years old is 'ancient history'. What's being taught, even at the high school level, now is mostly stuff that was figured out after I finished my first undergrad degree.