Healthcare Rationing

June 12, 2013

It is a sad reality of any publically-funded heath service that there is always more that could be done if only there were sufficient finances. This short video by Medical students at the University of Leicester, raises some of the different tensions facing those who need to make decisions about the allocation of resources.

Headline Bioethics: Too NICE to Push? Ethical issues surrounding a woman’s decision for elective caesarean section

January 7, 2013

[A printable version of this Headline Bioethics Commentary is available via this link]

Author: Matthew Taylor

Clip: Women can choose caesarean birth

Date of story: 23rd November 2011

Summary of story: In November 2011, The National Institute of Health and Clinical Excellence (NICE) updated its clinical guidance to health care professionals regarding caesarean sections. This update helps ensure “every mum-to-be in England and Wales can request [a caesarean birth].” The story examines the case of Leigh East, who had concerns over a vaginal birth due to a pre-existing back injury. She was initially refused a caesarean section (CS), but was allowed the treatment after her own research persuaded her midwife to allow it. East said, “There was a great deal of pressure initially to not plan a caesarean”.

The report continues by covering how women who have had a traumatic experience with natural childbirth in the past should be treated. This includes offering counselling and, ultimately, the option for a caesarean birth if the woman is not reassured. Jenny Clery, Head of Midwifery at Whittington Hospital, said “you shouldn’t force anything on anybody, i.e. go into labour and we’ll see what happens.” The report finishes by stating the new guidelines are there to help women make an inform decision regarding mode of birth (BBC, 2011a).

Discussion of ethical issues: There are many ethical issues surrounding a woman’s choice regarding the mechanism of delivery for her unborn child. Doctors are faced with decisions requiring them to take each case individually, taking a consequentialist approach to each mode of birth, whilst also considering patient autonomy. The Changing Childbirth report (Expert Maternity Group & Cumberlege J., 1993) makes it an explicit right for a woman to be involved in decisions regarding all aspects of her pregnancy and childbirth. Read the rest of this entry »

Headline Bioethics: Cut out by the NHS

January 4, 2013

[A printable version of this Headline Bioethics Commentary is available via this link]

Author: Arnold GangaidzoNHSrationingmedium

Clip: NHS obesity surgery court bid lost

Date of story: 27th July 2011

Summary of story: In July 2011 Tom Condliff, a 22-stone man lost his Court of Appeal case for a life-saving gastric bypass operation which had a detrimental impact on his family life and mental well-being (BBC, 2011a). The North Staffordshire primary care trust (PCT) refused to fund the procedure arguing that he failed to fulfil their IFR (individual funding response) policy and his body mass index (BMI) of 43 was below their threshold. He claimed the main reason he gained weight stemmed from drugs that he took for long term diabetes and the procedure was the best solution in order to prolong his life. In August 2011, subsequent to the events in this story, the PCT reviewed his case again and decided to fund his procedure as they now saw his case as an exceptional circumstance (BBC, 2011b). After having the operation, Condliff was reported to have lost six stone (Doward, 2012).

Discussion of ethical issues: The ‘four principles’ of autonomy, beneficence, non-maleficence and justice are widely recognised as the cornerstones of biomedical ethics. In this case, the principle of justice is brought into question. Chadwick (2008) says ‘justice in allocation’ is a bioethical issue since resources can be unfairly distributed and people can be discriminated against. Article 2 of The European Convention on Human Rights (ECHR, 1950) state “everyone’s right to life shall be protected by law…” but also notes that this must not be interpreted in a way as to put an impossible burden upon the authorities (Foster, 2007). Tom Condliff, a man seeking a gastric bypass, had to battle against his PCT to have them fund the operation. He argued that it was a breach of his rights under Article 8 of the ECHR (right to a family life) for the PCT to restrict their decision to clinical factors, and Article 6 (right to a fair trial) for not giving him sufficient details regarding their reasoning (Alexander Thomas Condliff v North Staffordshire Primary Care Trust, 2011). The Court found against Mr Condliff (though, as noted above, the PCT eventually relented). Read the rest of this entry »

Holby City – Resource allocation UPDATE

March 30, 2009
The most recent episode of Holby City, Feet of Clay, is available to view of download on via the BBC iPlayer until March 17 2009.

The most recent episode of Holby City is available to view of download on via the BBC iPlayer.

Following on from the recent BioethicsBytes post Holby City – “If you can’t look after yourself, then why should we?” (published on January 21 2009; updated February 4th 2009), which concerned ethical issues in NHS resource allocation as highlighted by two episodes of the BBC1 drama Holby City, this update post covers events in more recent episodes of Holby City – including the denouement to the storyline, as depicted in Feet of Clay.

The storyline concerns the “zero tolerance” policy implemented by Head of Surgery, Dr Ric Griffin (Hugh Quarshie), who is refusing to authorise surgical procedures for patients whose lifestyle choices may have contributed to their illness. Previous posts have covered the instigation of this policy in the episode Just (first broadcast on BBC1 on January 20 2009, at 20.00; TRILT Identifier: 00D15A4E),  and the events and debates this creates between the characters in Tough Love (first broadcast on BBC1 on February 3 2009, at 20.00; TRILT Identifier: 00D8E505). This post notes relevant events in the subsequent episodes Trust, Truth and Mercy, and Take Her Breath Away, and the closure of the storyline in Feet of Clay.

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Holby City – “If you can’t…look after yourself, then why should we?”

January 21, 2009
Watch this episode via the BBC iPlayer (available until January 27th 2009)

Watch this episode via the BBC iPlayer (available until January 27th 2009)

The issue of resource allocation in the NHS has cropped up several times in recent programmes (see, for example, Dom’s on the Case regarding the “postcode lottery”. The present post examines the ethical issues implicit in a different aspect of resource allocation in healthcare: the potential for conflict between traditional medical ethics and core NHS values and increasingly prominent views of the individual as both responsible and accountable for their own health status. This tension came to the fore in Just, a recent episode of the BBC drama Holby City (first broadcast on BBC1 at 8.00pm on 20th January 2009), and is captured nicely in one particular quote from the programme in which surgeon Ric Griffin challenges his patient, an obese smoker, “if you can’t be bothered to look after yourself, then why should we?” (00:38:07)

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Beating the NHS postcode lottery – Dom’s on the Case

September 25, 2008
Visit the Dom's on the Case hompage at BBC iPlayer

Visit the "Dom's on the Case" homepage at BBC iPlayer

2008 marks the 60th anniversary of the establishment of the National Health Service (the NHS) in the UK. While it has undoubtedly served the British public well in that time, the five part BBC1 series Dom’s on the Case continues the current trend for documentary programming which investigates inequalities with the NHS system, specifically geographical inequalities which arise from the so called ‘postcode lottery’.

Previous BioethicsBytes posts have highlighted resources which have examined this issue in detail (including The NHS Postcode Lottery: It Could Be You – Panorama and Herceptin: Wanting the wonder drug – Panorama), so here we highlight some additional issues raised within the third episode of Dom’s on the Case, which was first broadcast on BBC1 on Wednesday 24th September 2008, at 09.15. In this 45 minute programme, reporter Dom Littlewood highlights some of the inequalities which arise from differential prescription charging and access to drugs across the UK. While the programme’s tone may seem excessively negative – insofar as it presents only the perspectives of aggrieved patients and members of the public – it offers a number of short clips which provide concise descriptions of the various sources of inequality. Further it highlights the extreme measures that some patients feel forced to take in order to “beat the postcode lottery” (00:10:05) and access the drugs and treatment they feel they deserve.

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The NHS Postcode Lottery: It Could Be You – Panorama

September 5, 2008
It Could Be You" online at the Panorama homepage

Watch "The NHS Postcode Lottery: It Could Be You" online at the BBC's Panorama homepage

In this edition of Panorama (first broadcast in the UK on BBC1 at 20.30 on the August 18th 2008), reporter Shelly Jofre investigates the “postcode lottery”, an expression that has come into usage to describe differences in the availability of medicines and other treatments dependent upon where you live, and hence under the authority of which Primary Care Trust (PCT) your provision falls. This thirty minute episode focussed on discrepancies in the guidelines for prescribing three medications: Avastin, Lucentis and Aricept, which are used in the treatment of bowel cancer, wet age-related macular degeneration (wet AMD) and Alzheimer’s Disease, respectively. What all three drugs have in common is that they are licensed as safe and effective for use in the UK, but have not been approved for unrestricted provision on the NHS by the National Institute of Clinical Excellence (NICE).

Using the stories of patients – including the author Terry Pratchett – and their doctors, The NHS Postcode Lottery explores the various agencies who have a role in deciding whether or not these drugs could or should be provided at the point of NHS care, and to whom they should go.

This is an engaging, if a little sensational, introduction to some of the ethical issues raised by current resource allocation practices within the UK healthcare system, and – insofar as it is organised around three ‘case studies’ of approximately ten minutes in length – it could form the basis for discussion of resource allocation within a GCSE science or biology lesson (see the BioethicsBytes “Bioethics in the UK Curriculum” website for details of curricula requirements in this area). This post highlights the framework into which these cases fit and, based on the information presented in this episode of Panorama, it addresses two questions: How does the ‘postcode lottery’ arise? and What are the consequences of it? It also provides a rough guide to how the programme might be used in teaching.

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