Paul T. Menzel

The moral relevance of personal characteristics in setting health care priorities

This paper discusses the moral relevance of accounting for various personal characteristics when prioritising between groups of patients. After a review of the results from empirical studies, we discuss the ethical reasons which might explain-and justify-the views expressed in these studies. The paper develops a general framework based upon the causes of ill health and the consequences of treatment. It then turns to the question of the extent to which a personal characteristic-and the eventual underlying ethical justification of its relevance-could have any relationships to these causes and consequences. We attempt to disentangle those characteristics that may reflect a potentially relevant justification from those which violate widely accepted principles of social justice.

Improving value measurement in cost-effectiveness analysis.

Objective.Before cost-effectiveness analysis (CEA) can fulfill its promise as a tool to guide health care allocation decisions, the method of incorporating societal values into CEA may need to be improved. Design.The study design was a declarative exposition of potential fallacies in the theoretical underpinnings of CEA. Two values held by many people—preferences for giving priority to severely ill patients and preferences to avoid discrimination against people who have limited treatment potential because of disability or chronic illness—that are not currently incorporated into CEA are discussed. Conclusions.Traditional CEA, through the measurement of quality-adjusted life years (QALYs), is constrained because of a “QALY trap.” If, for example, saving the life of a person with paraplegia is equally valuable as saving the life of a person without paraplegia, then current QALY methods force us to conclude that curing paraplegia brings no benefit. Basing cost-effectiveness measurement on societal values rather than QALYs may allow us to better capture public rationing preferences, thereby escaping the QALY trap. CEA can accommodate a wider range of such societal values about fairness in its measurements by amending its methodology.

Advance directives, dementia, and physician-assisted death.

Physician-assisted suicide laws in Oregon and Washington require the persons current competency and a prognosis of terminal illness. In The Netherlands voluntariness and unbearable suffering are required for euthanasia. Many people are more concerned about the loss of autonomy and independence in years of severe dementia than about pain and suffering in their last months. To address this concern, people could write advance directives for physician-assisted death in dementia. Should such directives be implemented even though, at the time, the person is no longer competent and would not be either terminally ill or suffering unbearably? We argue that in many cases they should be, and that a sliding scale which considers both autonomy and the capacity for enjoyment provides the best justification for determining when: when written by a previously well-informed and competent person, such a directive gains in authority as the later persons capacities to generate new critical interests and to enjoy life decrease. Such an extension of legalized death assistance is grounded in the same central value of voluntariness that undergirds the current more limited legalization.

Advance Directives, Dementia, and Withholding Food and Water by Mouth

People with dementia who are no longer competent have limited control over how their lives end. But an advance directive to withhold food and water by mouth could be used to ensure that one does not live for years in severe dementia. Such directives are arguably already legal.

A Conservative Case for Universal Access to Health Care

Universal access to health care has historically faced strident opposition from political conservatives in the United States, although it has long been accepted by most conservatives in the rest of the industrialized world. Now, in a global economy where American business is crippled by the rising cost of market-based health care, the time may be ripe for change. The key to fostering a new mindset among American conservatives is to show why universal access fulfills many of the basic values that all conservatives hold.

Some ethical costs of rationing.

The escalating cost of health care has forced people to confront the possibility of rationing-forgoing beneficial care for patients so that the resources might be used either for other current or prospective patients or for entirely different things in life than health care. Rationing of some sort makes eminent sense, not just economically; only those who are fanatics about health and medicine would urge that everything possible be spent on health care for even the slightest marginal benefit. Yet actual rationing of health care is usually thought to exact high, or at least disturbing, ethical costs. I will examine four of these costs here: (I) the sacrifice of physician loyalty to patients, (2) the substitution of misleading and discriminatory numerical measurements of medicine’s human benefit for more sensitive qualitative judgments, ( 3 ) the unfair bite that rationing is likely to take first out of poor people’s care before it affects wealthier patients, and (4) the general Substitution of public, group standards about life and health for the values and decisions of individuals. In m y discussion of the second and third costs, especially, I will refer to the state of Oregon’s concrete attempt at rationing. Throughout I will not just elaborate these moral costs hut assess them, estimating in particular the extent to which they can be minimized by certain forms of rationing and hy certain ways of conceiving of the values that rationing either represents or appears to threaten. Taken together, these four ethical costs portray rationing as preserving or enhancing the welfare of the larger society, at the cost of attending to the needs of each individual patient. Though to some extent these four ethical costs will affect any actual rationing of health care, I will argue that generally they are not as high as is commonly supposed. To the extent that this claim is correct, rationing’s conflict with full respect for individual patients can be significantly diminished. Another way of stating this general line of argument is to propose a reconception of what rationing represents. Rationing is commonly thought to reflect the “welfare of society”-the needs of people other than the patient whose care gets rationed out. If that indeed is the value that limiting medically beneficial care because of its expense essentially represents, it will (and probably should) be a long time indeed before American society comes to any kind of reasonably secure, ethical satisfaction with rationing. It will be accused, plausibly, of assaulting our most vulnerable citizens, the sick and disabled, so others can retain their desired level of amenities. As I have argued elsewhere,’ however, there is a different way of seeing the whole business. Rationing, properly formed, should represent people’s own hard judgment about the kind of society in which on balance, in the long term, and considering all the realities of cost and scarcity, they wish to live. Concomitantly, commitment to individual patients should involve much more than maximizing their welfare us pntients. Then respect for individual patients can be reconciled with rationing: if, beforehand, inclividual patients have consented, or clearly would have consented,‘ to substantive and procedural policies for rationing out care of relatively high expense per benefit, those policies’ ethical appeal will rest not merely on the morally controversial goal of increasing aggregate societal welfare but on respect for patients’ own values. I will apply this line of argument, with less success in some cases than in others, to each of the four ethical costs of rationing mentioned above.

The Nature, Scope, and Implications of a Personal Moral Duty to Die

In the relevant circumstance of both relatively high burden or cost to others and low prospective gain for themselves, people have a prima facie duty to die sooner rather than later. This duty is a personal moral duty, not a “societal” duty, and thus, it in no way implies that others may demand that it be exercised. It is literally a duty to let death come, not a more general duty to die that encompasses active measures to ensure death. A person can owe this duty not only to close family and loved ones when they are heavily burdened, but in the right circumstances also to more distant persons, even to “society”; the fundamental reason is fairness to others in the society or insurance pool, given one’s own evaluative preferences about trade-offs involving expensive, low-chance-of-benefit care. This personal moral duty to die does not extend to incompetent patients, at least not in any literal sense. The duty to die also does not jeopardize the marital vow, “for better or worse, in sickness and in health”; the creative and mutual relationship envisioned in a marital promise does not bar people from ever coming to think that they may be obligated to accept death because of effects on a spouse. Finally, although this duty is rooted in sensitivity to considerations of quality of life, it need not threaten the “special” value of individual life and lifesaving.

Risk perception, addiction, and costs to others: an assessment of cigarette taxes and other anti-smoking policies.

This paper offers a relatively comprehensive assessment of government anti-smoking policies (both taxation and other regulatory measures). I conclude that interventions to engender in smokers and prospective smokers an accurate perception of tobaccos health risks are justified, that except in the case of adolescents addiction by itself does not justify intervention beyond providing adequate information, that the proper goal of tobacco taxation policy should be to recoup only the extra costs that smokers place on others (at most a

Utilities for Health States: Whom to Ask

1/pack tax on cigarettes), and that passive smokes imposition of harm on unconsenting others strongly supports at least the development of a safe-to-others smokeless cigarette, if not direct intervention.

Complete Lives, Short Lives, and the Challenge of Legitimacy

Health state utilities elicited from actual patients are generally higher than those elicited from hypothetical patients. Thus, whose ratings to use in cost-effectiveness analysis (CEA) is an issue of practical importance. The issue is also complex, with numerous conceptual and normative elements. One promising comprehensive answer carefully distinguishes between individual utilities and social values. Cogent conflicting arguments, however, render the matter unresolved, and some elements in the discussion continue to pose fundamental challenges for CEA.