Læknablaðið - 15.10.1989, Blaðsíða 46

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LÆKNABLAÐIÐ
the conclusions made about management. Such
patterns of careful thinking and careful
documentation constitute good clinical practice.
How often audit occurs and by whom may be a
matter of considerable difference among various
countries. Adding extra layers of mandatory
audit may compromise the quality of patient care
without helping to avoid the occasional bad
decision.
6. When patients lack a surrogate, little difficulty
arises when the benefit-burden ratio clearly favors
administration and continuation of
life-prolonging treatment. When the
benefit-burden ratio is less certain or reversed, a
wide variety of mechanisms have been proposed
to aid or to review the physician’s decision
making.
7. The physician may appropriately withdraw or
withhold life-prolonging treatment when, in the
view of the informed surrogate and physician,
continued treatment would lead to unacceptable
burdens without sufficient compensating
benefits. What counts as a benefit and a burden
and the relative ratio between them depend on
specific situational factors, and therefore, good
decisions in this category of patients demand
individual discretion. While these patients possess
a vulnerability which makes them frequently
subject to social discrimination and
stigmatization, their interests are not protected by
the elimination of decisional discretion. On the
contrary, a trustworthy physician and the
processes of appropriate audit are better means of
protecting the interests of vulnerable patients.
PART IV: SCARCITY (17)
Growing needs and demands, a growing range of
increasingly costly medical options, and
diminishing resources compel us to recognize that
it is not feasible to offer all beneficial treatments
that are medically possible to all patients.
Necessarily, all communities face scarcities. Some
instances of scarcity can be addressed by a
particular allocation of funds. Others, such as a
shortage of organs for transplant, may involve
absolute limitations which may not be resolved
easily within the apparently acceptable range of
ethical choices. Scarcity, by definition, requires
choice, and any choice in the context of scarcity
requires forgoing alternative choices. Societies
may deny that they make such choices or disguise
the ones they make, but they do so at the price of
honesty, justice and efficiency. Honest responses
to situations which require choice may, on the
other hand, yield long-term advantages. Scarcity
forces societies and institutions to establish
priorities which may give rise to more efficient
resource use, such as devoting more resources to
those medical circumstances where the returns in
terms of health outcomes are likely to be the
greatest. In determining priorities, given the
scarcity of health resources, the following
concepts play critical roles:
1. The principle of justice requires universal
access to an acceptable, decent minimum of basic
health care.
2. What constitutes this acceptable, decent
minimum of basic health care will depend on the
particular society’s general level of affluence and
other priorities and hence will vary not only from
culture to culture but from time to time (18). The
principal task is to assess other competing values
and to make judgments about which health care
needs are most pressing and which responses to
those needs are reasonable and proportional.
3. When a society decides to declare a right to
certain health services for all, it must incorporate
into that decision a willingness to give up
alternative uses of those resources necessary to
deliver such care.
4. If medical decision making emphasizes
cost-effective therapies, the burdens of satisfying
the desired universal access will be markedly
reduced.
5. Sometimes relatively unfettered market
transactions can do a good job of delivering
cost-effective health care products and services,
but, even when market processes deliver
efficiency, they do so at the cost of equitable
access; thus, the market place cannot be the sole
determinant of access and priorities.
Guidelines
With these notions in mind, the following
guidelines should be considered:
1. Society must establish the limits and the
priorities for lifesustaining treatment options.
2. Processes used to establish such limits must be,
and be perceived to be, open and fair.
3. Cost effectiveness should be used whenever
feasible to inform decisions about appropriate
life-prolonging treatments in particular