By Christian Munthe, Davide Fumagalli and Erik Malmqvist
Most countries with publicly funded healthcare systems have ethically informed priority setting schemes to decide how to allocate scarce resources. Established principles in such schemes recognise patients’ need of care, the effects of interventions, and background requirements of equal consideration and cost-effectiveness. However, the typical use of such schemes is alarmingly short-sighted, systematically allowing the future resource base of healthcare to be undermined. In short: our way of helping current patients is systematically exposing future patients to serious harm and risk.
Currently, we can see this effect in the severe challenges of care systems to handle the Covid-19 pandemic due to shortages of important equipment. But fragile delivery pathways for vital drugs, such as antibiotics, have long been a problem. In spite of this, such fragility is not considered when investment decisions for drugs and equipment are made. This allows companies with poor delivery pipelines to beat those with more sustainable operations, as the former can charge less for the same commodity. But the price is paid by future patients who may be harmed due to lack of access to effective treatment or protective equipment to shield them from dangerous infection.
Another well-known example is drug pricing policies that allow less and less effective drugs to be bought at increasingly higher prices. It may seem ethically called for to give severely ill people access even to drugs with minimal or very uncertain effect, such as in schemes like the UK cancer fund, special rare (or “orphan”) disease pathways or so-called compassionate use programmes. However, the dynamics of all these schemes increasingly deplete the resources available for future patients. What looks like proper ethical compassion for people in dire need and vulnerable positions, may in fact be a cold-hearted and unjustified lack of concern for other, less visible, patients downstream.
Less well known is the vast environmental pollution of drugs, for instance, resistance driving antibiotics emitted in large quantities from factories. Companies ignoring to manage this aspect can charge lower prices and win procurement competitions based on cost-effectiveness. Thereby our systems systematically move scarce healthcare resources to support practices that seriously undermine the future effectiveness of healthcare. As antimicrobial resistance is increasingly recognised as a major structural challenge for health systems, this environmental aspect must be given priority, as a recent joint brief from three major global health organizations emphasises.
In a new Feature Article in the Journal of Medical Ethics, we propose that healthcare resource allocation schemes incorporate an additional principle of sustainability. This principle can take different institutional forms, and be given varying weight, but at least it gives the ethically valid concern for future patients a firm place in healthcare resource allocation. We describe possible variations of the principle in some detail and provide support for it, drawing on established resource allocation principles and ethical theory.
As background, we present a more general analysis of the problem of lack of concern for future patients in healthcare systems. The cases above are all examples of a generic phenomenon we call negative dynamics. Such dynamics may also be present in other cases of health policy decisions regarding the use of scarce public resources, such as (controversially) whether or not to subcontract key public services to private businesses. Other examples include more general environmental health effects of healthcare, as well as the production of materials and installations for its practice.
Resisting our proposal by arguing that healthcare systems should ignore future patients and their needs would be inconsistent on several levels. First, already today, positive dynamics (such as a future absence of health needs) are being considered in allocation of resources to primary prevention measures, such as vaccines. Second, the basic ethical rationale of healthcare is future oriented: what makes the enterprise worth pursuing is its prospective health effects. Third, already established principles for healthcare priority setting implicitly support considering the needs of future people on equal terms as those of present people.
Public healthcare systems must stop ignoring future patients! Our proposed sustainability principle can help in making that possible.
Authors: Christian Munthe, Davide Fumagalli, Erik Malmqvist
Affiliations: Centre for antibiotic resistance research (CARe) and the Department of philosophy, linguistics and theory of science, University of Gothenburg
Competing interests: None
Social media accounts of post author(s): @christianmunthe