rationing health care - three rules for applying quality measures

In trying to figure out how to apply quality measures in a nondiscriminatory fashion, the FCEO standard turns out to be of great help, by immediately suggesting three rules for applying quality measures within a rationing system.

According to the FCEO standard, an injustice arises when we factor in a quality of life adjustment for a condition that is unrelated to the treatment being considered. For instance, the fact that a patient in a wheelchair has cancer in no way relates to the fact that he is in a wheelchair. Nor is his likelihood of responding to therapy related to the fact that he is in a wheelchair. Thus, the fact that he is wheelchair-bound is merely a constraint imposed on him by nature. It is irrelevant to whether he should receive chemotherapy.

Thus, a new rule derives from the FCEO principle:

Rule 1: A quality of life adjustment should not be made for a condition that is unrelated in any way to the treatment being considered.

On the other hand, according to the FCEO standard, quality adjustments are relevant for diseases or disabilities that impact on the effect of the treatment being considered. For instance, the presence of severe heart failure or severe chronic lung disease significantly impacts on the outcome of coronary artery bypass surgery, both in terms of the risk of dying from surgery, and in the risk of long-term disability after surgery. In terms of the FCEO standard, these risks clearly affect an individual’s chance of gaining in the opportunity to enjoy the fruits of life as a result of such surgery, and therefore they need to be factored in to the prioritization scheme.

Another new rule is thus derived:

Rule 2: A quality of life adjustment should be made for a condition that is clearly related to the treatment being considered.

Finally, there are conditions that are so severe and so pervasive that they will impact on the results of virtually any therapy that might be considered. Such conditions might include patients in a chronic vegetative state (i.e., completely unresponsive to external stimuli but not “brain dead,”) or a patient in the end-stages of an irreversibly terminal illness. We ought to apply quality adjustments in deciding on therapy for these patients, for two reasons. First, not doing so would tend to cause us to systematically divert resources to conditions for which it would be difficult or impossible to substantially improve quality. Second, applying quality adjustments in such patients is entirely consistent with the FCEO standard since, in these cases, nothing we can do will result in a “fair chance” to enjoy equal opportunities. A third rule would then be:

Rule 3: A quality of life adjustment should be made for a condition that is so severe and so pervasive that it will impact on the outcome of any treatment that might be considered.

It should be noted that this third rule allows us to integrate the problem of “futile health care” into the more general construct of rationing under the FCEO standard. This rule does not attempt to define futile care or to disallow it. Instead, it allows for certain conditions (defined by their severity and irreversibility) in which it is permissible to take quality of life calculations into account when deciding whether to offer therapy. Quality of life measures for these severe, irreversible conditions will likely indicate that, once appropriate cost-effectiveness calculations are performed, spending expensive resources to, say, prolong life for a short while will not receive a high priority score in relation to other potential therapies for other patients.

These three rules for applying quality measures, all of which directly derive from the FCEO ethical standard, ought to guide us as we prioritize health care services. These rules recognize the fact that it is not the quality measures themselves that produce systematic discrimination, it is how we apply those quality measures. They also recognize that avoiding the use of quality measures altogether (because they are felt to be inherently unjust) would make it difficult or impossible for us to optimize the good we obtain with our health care resources. Therefore, these rules should help us to a) guarantee that no systematic discrimination occurs on account of disease or disability, b) guarantee that beneficence is maximized within the constraints of fairness, and c) integrate the concept of “futile care” within the more general construct of “fairly” rationing health care.

Next: A general scheme for prioritizing health services

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