Cost-effectiveness analysis of health care services, and concepts of distributive justice

Ethical Issues in Consultation-Liaison Psychiatry

This article contextualizes several key ethical issues in consultation-liaison (C-L) psychiatry within historical and principlist frameworks. After summarizing the history of the field, it focuses on 3 main areas of ethical import in C-L psychiatry: decisional capacity assessment, psychosocial evaluations for transplant, and treating mental illness in pregnant patients.

Unstable Ethical Plateaus and Disaster Triage

Disasters are defined medically as mass casualty incidents in which the number of patients presenting during a given time period exceeds the capacity of the responders to render effective care in a timely manner. During such circumstances, triage is instituted to allocate scarce medical resources. Current disaster triage attempts to do the most for the most, with the least amount of resources. This article reviews the nature of disasters from the standpoint of immediate medical need, and places into an ethics framework currently proposed utilitarian triage schema for prioritizing medical care of surviving disaster victims. Specific questions include whether resources truly are limited, whether specific numbers should dictate disaster response, and whether triage decisions should be based on age or social worth. The primary question the authors pose is whether disaster triage, as currently advocated and practiced in the western world, is actually ethical.

Priority setting for new technologies in medicine: a transdisciplinary study

BACKGROUND

Decision makers in health care organizations struggle with how to set priorities for new technologies in medicine. Traditional approaches to priority setting for new technologies in medicine are insufficient and there is no widely accepted model that can guide decision makers.

DISCUSSION

Daniels and Sabin have developed an ethically based account about how priority setting decisions should be made. We have developed an empirically based account of how priority setting decisions are made. In this paper, we integrate these two accounts into a transdisciplinary model of priority setting for new technologies in medicine that is both ethically and empirically based.

SUMMARY

We have developed a transdisciplinary model of priority setting that provides guidance to decision makers that they can operationalize to help address priority setting problems in their institution.

The which-hunt: assembling health technologies for assessment and rationing

To rationalize and restrict health care spending, policy, makers in many jurisdictions have withdrawn insurance or funding for selected health care technologies. Numerous analytic frameworks and applied exercises have emerged to guide decisions about "which" services to cut. But in their focus on choice-making processes, these efforts have paid little attention to the problem of defining and dividing the set of technologies to choose among. If technology assessment refers to methods for weighing services for their relative value, the term technology assembly might be used to refer to methods for framing the technological trade-offs to enroll in such contests. This article examines technology assemblies found in several types of theoretical and applied rationing exercises (including Oregon's Medicaid rationing process, economic evaluation literature, citizen "values" surveys, and Canadian provincial deinsurance policies). Based on this review, some key conceptual conventions and problems in technology assembly can be identified. The boundaries between health technologies are fuzzy, interlocked, layered, and continuously moving. Consequently, the defining features of technological trade-offs are inevitably socially constructed and negotiated. Trade-offs can be arranged along numerous dimensions, and the divisions typically correspond to broader political, administrative, and ethical dilemmas in health policy. Examples include equity among demographic classes, concepts of need, legitimacy of therapeutic goals, and so forth. Insights into the process of constructing technological trade-offs may help policy makers better question what technologies they are looking at and why, before moving on to the task of determining which ones to cover.