Læknablaðið - 15.10.1989, Blaðsíða 47

LÆKNABLAÐIÐ
309
circumstances. Cost Effectiveness Analysis
(CEA) should incorporate the best available
scientific information about the results of the
therapies being considered and all appropriate
medical and non-medical costs and benefits -
including an assessment of foreseeable changes in
the patient’s quality of life as a result of the
proposed therapies. Although CEA is an
invaluable and indispensible tool in making
ethical decisions, it is not a simple formula and
must not be naively applied. Several caveats are
noteworthy. CEA, like all analytical frameworks,
requires accurate data which may be extremely
difficult and expensive to obtain. Care must be
taken to be sure that the interpretation of the data
is free from unwarranted extrapolations. Finally
CEA must be tempered by sensitivity to human
differences and case by case application, based on
the assessment of particular benefits and burdens
for individual patients.
4. CEA-based information, guidelines, and
limitations should be quickly and widely
distributed.
5. Society must be willing to adjust its
expectations so that its selected limits become
accepted practice and/or legal norms.
6. Both ethical and effective policy require that
institutions conspicuously publicize any
restrictive or prescriptive policy rules in advance
of patient admission.
7. If institutional limits imply that physicians
must deny care to some patients, they have an
especially strict obligation to weigh burdens and
benefits in selecting care and treatment.
8. Patients do not have a right to treatment which
has no reasonable expectation of benefit.
9. If treatment is denied on the basis of a social
decision, such denial must not be disguised as a
medical decision.
10. When physicians believe that care is being
withheld improperly, the are obliged to protest on
behalf of their patients.
11. Private purchase of health care necessarily
produces inequities. When the private purchase of
health care significantly impinges of the fair
distribution of available medical resources (as in
the availability of organs for transplant) or on a
society’s ability to provide an acceptable, decent
minimum of basic health care, such private
purchase could be restricted.
DISSENTS
Part I.
1. Requests for euthanasia by competent patients
severely and irremediably suffering as a result of
incurable disease may be understandable, but are
not morally justified. Statutory legalization of the
intetional killing of patients by doctors is against
basic morality as well as against the public
interest.
Shimon Glick, M.D., Beer-Sheva, Israel
Arnold Rosin, M.B., Ch.B., F.R.C.P.,
Jerusalem, Israel
Avraham Steinberg, M.D., Jerusalem, Israel.
Part II.
Persistent vegetative state
1. While it may be true that the patient with PVS
has no »self-regarding interests,» it is not so
obvious that no other moral interests are at stake;
for example, the inherent value of life. Since
patients with PVS clearly do not suffer from their
state, their quality of life cannot be characterized
as »harmful« to themselves. We, therefore,
cannot accept a categorial statement which rules
out life-sustaining treatments.
Shimon Glick, M.D., Beer-Sheva, Israel
Thomas Murray, Ph.D., Cleveland, Ohio
Arnold Rosin, M.B., Ch.B., F.R.C.P.,
Jerusalem, Israel
Avraham Steinberg, M.D., Jerusalem, Israel
Susan Wolf, J.D., Briarcliff Manor, New York
NOTES
1. Despite the wide variety of medical cultures
represented, the delegates want to acknowledge
that the perspective included in the conference
represented only a small fraction of the world
population and did not include perspectives from
Eastern Europe, the Orient, the Third World, and
several other »western« nations, both European
and American. It is our hope that the discussion
provoked by the publication of these guidelines
will lead to contributions from many of those
perspectives.
2. The new delegates are indicated on the list of
delegates, Table I.
3. The membership of the working groups is also
indicated in Table I.
4. These four principles, though individually
ancient, were rearticulated in the bioethics
literature in the late seventies by the philosopher