Last chance therapies and managed care. Pluralism, fair procedures, and legitimacy

How can health plans make fair determinations about when "experimental" (and costly) treatments such as high dose chemotherapy with autologous bone marrow transplantation should be covered despite lack of clear clinical consensus about their benefits? Different models for managing "last chance" therapies evolving in some health plans offer promising examples of how issues of fairness and legitimacy in decision-making can be addressed.

Negative and positive genetic interventions: is there a moral boundary?

Some have claimed that negative genetic interventions are morally permissible while positive ones are not, but the distinction cannot be used to draw this moral boundary. Underlying the negative/positive distinction is a distinction between treatment and enhancement. The treatment/enhancement distinction at best provides an imperfect guide to which health care services we are obliged to provide and which we are not. It offers only some "warning flags" to help us think about what is permissible or not.

Dialogue. Resource allocation: to those in the greatest need or those who will benefit most?

The behavioral healthcare community seeks universal coverage for mental health and addiction treatment services at parity with coverage for other medical conditions. To achieve this goal, our field must accept and work within realistic financial limits. The time has come to establish a framework for "rational rationing" of behavioral healthcare resources. What are the priorities? How should resources be equitably shared? Should we sacrifice people with mild and moderate disabilities and illness in order to spend most of our dollars on people who are severely impaired? Our first writer, Dr. Daniels, warns us that there are no moral tenets upon which we can easily or comfortably hang our hats, as he shares the current perspective of medical bio-ethics. Dr. Sabin is a practicing psychiatrist at Harvard Pilgrim Health Care. He highlights the Oregon health Plan as one example of political fortitude and wisdom in resolving healthcare resource allocation challenges. Mac Crawford, chairman of the board and chief operating officer of Magellan Health Services, is in one of the most influential positions in private sector integrated behavioral services delivery. He stresses the importance of managed care and clinical process standardization as fundamental requirements for the rational allocation of resources. One additional note: The lack of a consumer voice in this Dialogue is an unfortunate consequence of the mismatch between submissions received and our publication deadlines. It was our intention to present the perspective of a prominent individual from the growing field of consumer and family advocacy. We apologize for the lack of this perspective, which may have extended this discussion to the practical implications of this abstract question of resource allocation.

The yin and yang of health care system reform. Professional and political strategies for setting limits

President Clinton's proposed Health Security Act would establish a National Health Board (NHB) with three key functions. The NHB would (1) decide which services are "medically necessary or appropriate" (Title I, Subtitle B, Section 1154), (2) "recommend ... appropriate revisions (to the benefit package) ... to reflect changes in technology, health care needs, health care costs, and methods of service delivery" (Title I, Subtitle F, Section 1503, [a] [2]), and (3) "determine a national per capita baseline premium target" (Title VI, Subtitle A, Section 6002, [a]), thereby establishing a national health care budget. To date, including the work of Mrs Clinton's Task Force on Health Care System Reform, there has been little discussion of how the NHB would carry out these responsibilities. Critics claim that a budget cap would require rationing. Advocates counter that eliminating waste would make rationing unnecessary. In the imagined "testimony" that follows, we recommend two strategies to the NHB for carrying out its three key functions and for addressing the controversy about whether it should consider rationing.

The articulation of values and principles involved in health care reform

The Ethics Working Group of Clinton's Health Care Task Force developed a list of principles and values that should govern health care reform. These principles and values are compatible with central moral and political traditions, as well as with more rigorous theoretical accounts of justice and health care, but they are "freestanding" points of agreement, not presupposing any particular theoretical background. Though imprecise and not ranked by priorities, the principles guide thinking about the fairness of alternative reform proposals. Their use is illustrated by comparing alternatives on universality of access, phase-in period, the creation of unequal tiers, and the provision for wise allocation and rationing.

Running economy of elite male and elite female runners

Twenty female and 45 male middle and long-distance runners, in training for the U.S. Olympic Trials, served as subjects. Ninety percent of both men and women subjects reached the Trials; eight women and 12 men qualified for the Olympic Games and five won medals. Each subject completed a VO2max and a series of submax treadmill runs, for the purpose of comparing heart rate (HR), VO2, and blood lactate (HLa) among men and women and among runners of various event specialties. Results showed the men to be taller, heavier, to have a lower six-site skinfold sum and a higher VO2max, than the women (P less than 0.05); there was no difference in age. When compared in running economy, men used less oxygen (ml.min-1.kg-1) at common absolute velocities, but VO2 (ml.km-1.kg-1) was not different between men and women at equal relative intensities (%VO2max). When men and women of equal VO2max were compared, the men were significantly more economical, using any method of comparison. Also, when comparisons of men and women of equal economy were made, it was found that the men had an even greater advantage over the "matched" women subjects than the mean VO2max comparison using all subjects. In looking at the SD (800-/1500-m runners), MD (3-K/5-K/10-K runners) and LD (marathon runners), it was found that the SD runners used the least oxygen (ml.min-1.kg-1) at speeds of marathon race pace and faster, but not at slower speeds. Men and women responded similarly in this regard. Running economy data for speeds slower than typical race paces, tended to show the LD runners to be most economical, suggesting that the speeds over which runners are tested plays an important part in determining which subjects are the most economical. It was concluded that at absolute running velocities, men are more economical than women, but when expressed in ml.km-1.kg-1 there are no gender differences at similar relative intensities of running. Also, when men and women of equal VO2max or equal economy are matched, the men show a better aerobic profile. It is recommended that economy data be collected up to speeds equal to over 90% VO2max.

HIV-infected professionals, patient rights, and the 'switching dilemma'

The ethical issues surrounding the Centers for Disease Control and American Medical Association guidelines for health professionals infected with the human immunodeficiency virus are examined and discussed. Although human immunodeficiency virus transmission risks during surgery are lower than many risks we routinely face, it is not irrational for a patient to want to switch from an infected professional to an uninfected one. The American Medical Association claim that physicians have a duty to avoid imposing any identifiable risks is implausible. Knowing the Centers for Disease Control estimate of risks gives us no way to decide whether the rights of patients or those of handicapped (infected) workers should be given priority. Granting priority to patient rights, either by giving patients the opportunity to know the risks they face and to switch to another provider, or by removing infected providers (compulsory switching), makes us all worse off. This gives us reason to reject these guidelines and emphasize other infection control measures.

The nutritional habits of young adolescent swimmers

Dietary food records from adolescent male and female swimmers participating in a national developmental training camp were analyzed for nutrient density. The mean caloric intake was 5,221.6 kcal for males and 3,572.6 kcal for females. The distribution of calories between carbohydrates, protein, and fat was not ideal for athletes trying to optimize performance. These young swimmers consumed too much fat and not enough carbohydrate. They consumed more than the RDA of vitamins A and C, and thiamine, riboflavin, and niacin; however, some concern is expressed for females who did not meet the RDA for calcium and iron. This study shows that although a group of adolescent swimmers may be consuming enough nutrients, individual swimmers may have very poor dietary habits and thus may not be providing adequate fuel or nutrients for optimal training or performance.

Duty to treat or right to refuse?

By entering the medical profession, physicians have consented to accept a standard level of risk of infection. In most instances, the risk of contracting HIV does not exceed this level.

Chronic Vietnam PTSD and acute civilian PTSD. A comparison of treatment experiences

Many types of external trauma have been linked to the genesis of posttraumatic stress disorder (PTSD) and yet recent reports have focused almost exclusively on PTSD occurring in the Vietnam veteran (PTSD/veteran). The extent to which treatment experiences with PTSD/veteran can be generalized to other traumatized patients, for example, acute civilian populations, has not been investigated. Clinical observations comparing PTSD precipitated by a motor vehicle accident with PTSD/veteran suggested there were major differences between these two groups on the following variables: source of referral, age, sex, socioeconomic level, nature of stressor, timing of the stressor, character of the intrusive and avoidance symptoms, and treatment noncompliance behavior. These differences were of sufficient magnitude to call into question the feasibility, at this time, of constructing generalizations regarding PTSD utilizing only the PTSD/veteran population.

Family responsibility initiatives and justice between age groups

Only one of the Ten Commandments offers a reward. We should honor our parents, we are told, so that our days may be long. When the federal or state governments appeal to traditional religious and family values, however, we should look to the costs and not the benefits. In Hawaii, House Resolution 54 would seek to reinstate a relative responsibility law that was repealed in 1965; the immediate concern is to correct a $30 million shortfall in Medicaid. In Massachusetts, a pending bill, House Bill 1753, would make each “responsible relative” of a Medicaid recipient residing in a nursing home accountable for up to 25 percent of the amount paid, although the total collected from all responsible relatives must not exceed 100 percent of Medicaid payments. According to the bill, responsible relatives are spouses, natural and adoptive children, or natural or adoptive parents of blind or disabled children under 18.