What does fairness mean? Prof. Samia Hurst Institute for Ethics, History, and the Humanities Geneva University Medical School

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1 What does fairness mean? Prof. Samia Hurst Institute for Ethics, History, and the Humanities Geneva University Medical School

2 Doctors must be fair US study Physicians face resource constraints and make decisions to limit their use. They are conflicted about this. They do not view these decisions as yes/no cases European study Physicians face resource constraints and make decisions to limit their use. Most rationed interventions are not life/death choices Some countries limit by rules, others by pressure on physicians. Switzerland limits by pressure on physicians Tilburt et al.: Conflicted and Divided: US Physicians Views on Addressing Health Care Costs. JAMA ;310(4) :380-8 Hurst et al.: Prevalence and Determinants of Physician Bedside Rationing: Data from Europe. JGIM 2006; 21(11):

3 Different circumstances Triage Locally available resources are in obvious and immediate short supply. Example: last isolation bed, transplantation Comparison to other potential patients Locally available resources are strained or subject to fixed limits. Example: limited blood supply Using a threshold The cost-effectiveness analysis ratio for an intervention shows a small benefit, but this is judged to be too small in this specific case. Example: non-ionic contrast material

4 We are pluralists and have more than one moral principle Reasonable persons can disagree We nevertheless have to decide : non-decision is also a decision

5 Goodness What will help patients? What fits with their life goals? What is the balance of burdens and benefits to them for various interventions? Evidence-based assessment, respect for autonomy Fairness Who has access to what interventions? Who pays for what, and what about those who cannot pay for interventions? What is the distribution of resources, efforts, innovation? Fair access for all, equity in health

6 Be fair «Treat similar cases similarly; dissimilar cases dissimilarly» Aristotle, Nichomachean ethics Equitable access based on need alone to all effective care society can reasonably afford Churchill, Rationing Health Care in America, 1987

7 Be fair Who has access to What and How do we decide?

8 Vaccarino et al. Sex and racial differences in he management of acute myocardial infarction, 1994 through NEJM.2005;353(7):671-82? Escher M, Perneger TV, Chevrolet JC. National Questionnaire survey on what influences doctors decisions about admission to intensive care. BMJ 2004;329:425 12% reported being more likely to use an expensive intervention if the patient had an important position in society. Hurst S., Slowther A., et al.: Prevalence and Determinants of Physician Bedside Rationing: Data from Europe. Journal of General Internal Medicine. 2006;21(11): Hurst S., Forde R., et al.: Physicians Views on Resource Availability and Equity in Four European Health Care Systems. BMC Health Services Research. 2007;7:137

9 We are right to be wary of our intuitions in prioritizing Despite the importance we attach to fair distribution, we have a tendency to be biased These biases are often unconscious They sometimes correlate with differences in behaviour

10 Be fair 1) Avoid discrimination and give equal value to the same interests in everyone

11 Views of Swiss doctors on clinical fairness Give the same treatment Give access to care Give the same contact Priority to the greatest need Do not consider insurance status Do not give more to those who ask louder Act against gender-based health inequalities Give care which equalizes chances. Act against social devaluing of the sick Act against inequalities based on affects generated by patients Hurst S., Clinical Fairness Improving bedside rationing. Faculté de médecine, Genève, 2010.

12 Views of Swiss doctors on clinical fairness Distribute fairly Give the same treatment Give access to care Give the same contact Priority to the greatest need Do not consider insurance status Do not give more to those who ask louder Act against your own biases Resist the mixture Give care of social which inequalities into equalizes disease and medicine chances. Act against gender-based health inequalities Act against social devaluing of the sick Act against inequalities based on affects generated by patients Hurst S., Clinical Fairness Improving bedside rationing. Faculté de médecine, Genève, 2010.

13 Resisting our own biases ( ) understanding but, but it s sometimes diff because we are still human beings like all the others and we are much more motivated to help people who are nice to us, than people who aren t nice, so I think that the alcoholic, alcoholised in acute phase and who s agressive hem it s important to still consider him as someone who has a health problem, even if we calls us a bastard ( ) [11;internal med;hosp] Hurst S., Clinical Fairness Improving bedside rationing. Faculté de médecine, Genève, 2010.

14 Resisting social inequalities I m thinking of an African patient at the airport who was in a corner, hem in a drowsy state like that and who the security only approached with his foot, didn t talk to him, ask him what is happening, because he only spoke English and then the paramedics finally came, with about the same attitude, that is without trying to understand what was really happening and then finally someone called us, we arrived, I talked to the patient, I ended up realizing that, so, he had a myocardial infarction, well? His heart was blowing itself up and we took him on much too late because of hem all these barriers there ( ) Hurst S., Clinical Fairness Improving bedside rationing. Faculté de médecine, Genève, 2010.

15 Resisting social inequalities So I came and established the diagnosis, we, we left for the hospital right away and then everything ended very well, he could have ended very very badly, so there I know it s not me personnally who was hem who was involved in, in the negligence of the problem because of barriers, it was others but it could have been me in another context, easily. [11; internal med; hosp] Hurst S., Clinical Fairness Improving bedside rationing. Faculté de médecine, Genève, 2010.

16 Be fair 1) Avoid discrimination and give equal value to the same interests in everyone 2) Resist the mixture of social status and clinical care

17 Dimensions of fairness Equality in coverage Priority to the worse off Priority to large benefit and low cost

18 Goodness Fairness Evidence-based assessment, respect for autonomy Fair access for all, equity in health equal access to the means of medicine towards one s own goals in life

19 The measure of efficiency Less effective As effective More effective Less costly Value judgment Use Use For the same disease only As costly Do not use Indifferent Use More costly Do not use Do not use Value judgment Donaldson, Currie et Mitton, BMJ 2002;

20 Those marginalized and clearly discriminated against Those living far from health services Those with the worst lifetime health Those with the lowest socioeconomic status Those with uneconomic diseases

21 Be fair 1) Avoid discrimination and give equal value to the same interests in everyone 2) Resist the mixture of social status and clinical care 3) Remember that cost-effectiveness is only half the story 4) Be particularly careful of marginalized groups

22 How to decide? A proposed approach, Accountability for reasonableness is a proposal based on the following criteria Publicity condition Relevance condition Revision and Appeals condition Regulative condition Daniels and Sabin, Setting limits fairly, 2002

23 Publicity condition Decisions regarding both direct and indirect limits to care and their rationales must be publicly accessible

24 Relevance condition A rationale will be reasonable if it appeals to evidence, reasons, and principles that are accepted as relevant by fair-minded people who are disposed to finding mutually justifiable terms of cooperation

25 Revision and Appeals condition There must be mechanisms for challenge and dispute resolution regarding limitsetting decisions, and, more broadly, opportunities for revision and improvement of policies in the light of new evidence or arguments

26 Regulative condition There is either voluntary or public regulation of the process to ensure that conditions 1-3 are met.

27 Be fair 1) Avoid discrimination and give equal value to the same interests in everyone 2) Resist the mixture of social status and clinical care 3) Remember that cost-effectiveness is only half the story 4) Be particularly careful of marginalized groups 5) Be ready to open your reasoning to scrutiny and revision

28 Be fair Give equal value to the interests of everyone to have access to the means of medicine towards their own goals in life. How you do this should be visible, and open to scrutiny and revision.