Allocation of Resources: Social and Political Factors

Two patients in the emergency department require admission to the intensive care unit (ICU). At this time only one bed is open, so one of the patients must be transferred to another hospital. The first patient, who is on the hospital's board of directors, came to the emergency department complaining of chest pains. He is now in an apparently stable condition with no indications of myocardial infarction, although he continues to require intensive care monitoring facilities.

The other patient is a "wino" with pneu­mococcal pneumonia and sepsis; he is a very sick individual. Major intervention with both fluids and vasopressors is being used to keep him stable during the acute illness, but his blood pressure is 85 palpable systolic (normal is usually 120 mm Hg). The only other hospital with an available intensive care unit bed is ten miles away. Who should be transferred? What if the board member had arrived first and was told that he had the bed, but he was still in the emergency department when the second patient arrived?


Commentary

The board member in this case has no claim to hospital services or to consideration of his interests over and above those of any other hospital patient, including the wino. That he is a board member does not entitle him to any special treatment. Whether he should be admitted to the intensive care unit's available bed or transferred must depend on other factors, none of which places any weight on his membership on the board. Indeed, if anyone should understand this, a board member should.

Such membership is not an additional piece of medical insurance to protect holders against the sort of eventuality illustrated by this case. Board members exist to serve the interests of the hospital, not vice versa. If this particular board member does not understand this, claiming that his position gives him certain medical privileges, he obviously is not fit to serve on the board.

This initial part of an answer to the questions posed in this case can be defended in a variety of ways. The one sketched here involves appeals to considerations about equality of opportunity. Other things being equal, it would, perhaps, be reasonable and fair to give extra weight to those who are board members over those who are not, assuming that all who are likely to need the services of a hospital, including emergency services, have had an equal opportunity to serve on the board.


Yonder wino, however, is one who lacks this opportunity, given any realistic interpretation of the idea of equal opportunity. Hospital boards of directors tend to a very considerable extent to be com­prised of an elite within our society. Wealthy, well-educated persons with the "right" sorts of background, family names, and political connections are likely to predominate.

Minorities, the poor, the uneducated, and "winos" are, we may assume, underrepresented. So long as our society does not provide its citizens an equal opportunity to secure those advantages (wealth and education, for example) that enable individuals to gain access to the world of boards of directors, it cannot be equitable to count service on such a board as a reason for giving preferential treatment to its members.


In the case before us, then, who gets the available bed and who gets transferred must depend — subject to the qualifications set out below — on whose health needs are such that he needs access to an intensive care unit most quickly or, stated more simply, on who is sicker and at greatest risk. In the case described, this is the wino.

PROMISING BEDS — MEDICALLY AND MORALLY INAPPROPRIATE


Would it make any difference if the board member had arrived first and had been "told he had the bed" (that is, had in effect been promised the bed)? Though this makes the case more complicated, I do not think it strengthens the board member's claim to the available bed.

If we assume that the hospital has a practice of promising beds, so that it is not unusual that the board member has been promised one, the board member himself must understand that (a) such a promise is overridable in the face of someone else's much greater immediate health needs and (b) the wino has, in fact, such needs. Such a practice of promising beds cannot make either medical or moral sense unless the promises are understood as presumptive and not absolute guarantees, to the effect that this person will get this bed unless another person arrives whose condition is much worse and whose immediate need for health care is proportionately much greater.


At the same time, because promises normally are made to be believed and because, in a hospital context, it is both important in fact and desirable in principle to promote confidence, it is advisable not to encourage practices that involve making promises which may be overridden. The board member, who should know what is common practice in the hospital, should have been among the first to advise that the practice in question, assuming it is standard procedure, should be curtailed. Certainly he has no title now to be counted among its beneficiaries.

RELEVANCE OF AN INDIVIDUAL'S RESPONSIBILITY FOR HIS HEALTH


If the preceding were all we had to consider, the case would be relatively simple: The wino stays; the board member gets transferred. In fact, however, we need to ask not only how bad off each of the two patients is, from a medical point of view, whatever may have been "promised," but also why the patients are as bad off as they are.


This is a crucially relevant though a very difficult and controversial question, (a) because people are sometimes responsible for their ill health and (b) because when they are, it is unfair that other patients, whose ill health is not a result of their own decisions, should be denied treatment or put at greater risk in order to serve the needs of those who are responsible for their ill health. People whose life-style is known by them to put them at increased risk of serious ill health and who voluntarily continue to engage in this life-style — such people, I believe, have less of a claim on scarce medical resources than those who do not knowingly and voluntarily take large risks of serious ill health.

The­ oretically, therefore, it is possible that a patient whose medical needs are less ought to be given quicker attention than one whose needs are greater, because the latter patient is in the condition he is in as a result of his knowingly and voluntarily running risks he could have chosen not to run. Stated in simpler terms, one of the risks persons who take serious health risks run is that they will not get the medical treatment they need when they need it. In the case before us, therefore, it is possible that, though the wino's need is greater, he should be transferred and the board member should be given the available bed.


To make the general position I am recommending clearer, let us suppose that the board member is a pillar of health consciousness, a man who practices what he preaches: no smoking, regular exercise, an informed diet (very low fat, high fiber), maybe an occasional glass of white wine. He arrives at the hospital in the condition described in the case. Soon after his arrival, another patient is wheeled in — a race car driver, let us suppose, who is much worse off than the board member.

On the view recommended here, the fact that the race car driver is in greater need of immediate medical assistance does not mean that he should get the available bed and the board member should be transferred across town. For the competitive racer knowingly and voluntarily has chosen to engage in a life-style that adds to his risks of injury and ill health, whereas the board member has embarked on a life-style that lowers these risks. As such, it cannot be fair automatically to give first treatment to the racer.

If the board member's condition is such that he does need prompt medical treatment, of the sort that can only be provided by an intensive care unit — and that is what I am assuming is true in this imaginary case as well as in the case under discussion — I see no good reason to support transferring him and giving the available bed to the racer. And if he (the driver) or someone rep­resenting his interests were to protest, insisting that he is at greater risk of very serious harm, perhaps even death, we should reply that his not getting the medical attention he needs, when he needs it, is one of the risks he chooses to run when he engages in the life-style he has chosen.


Those of us who do not choose to add such risks to our lives, who, on the contrary, choose to live in ways that reduce the health risks we run, ought not be made to run new risks so that the race car driver can get the medical attention he needs, before we receive the medical attention we need. We come first, or we should, in cases where we are in genuine need of immediate health care, else we face increased chances of serious harm.

Before we attempt to apply the preceding to the case before us, it is important to emphasize that the people who should receive treatment first are always assumed to face genuine risks of serious harm. There is a degree of unavoidable and ineliminable vagueness in both these ideas (in both "genuine risks" and "serious harm"). The best we can do, I think, is operate with paradigms of each. Thus, an untimely death is a very serious harm, but so are paralysis, loss of sight, severe burns, and other cases of long-term incapacity or protracted pain.


As for "genuine risks," the operative basis for making such judgments must be the informed opinion of the attending physician(s); there must not only be a possibility of serious harm, but there must also be a good medical reason to believe that one's chances of significant harm are substantially increased, the longer emergency or intensive care is delayed. If, then, the health conscious board member were to enter the hospital simultaneously with the race car driver, and if the latter was in very serious condition whereas the former had a nasty splinter or a thorn in his foot, the driver should receive the available bed. Obviously.

But if the health-conscious board member arrives at the same time as the driver, and if the former is in a condition which standardly calls for treatment in an intensive care unit, his chances of significant harm increasing the longer such treatment is delayed, he, not the driver, should get the available bed, and the driver, not the board member, should be transferred.

IMPLICATIONS FOR THIS CASE


Concerning this case, then, the situation appears to be this. The wino has the greater need for immediate admission to the ICU. Neither the board member's formal association with the hospital, nor his having arrived first and been "promised" the available bed should be used to justify sending the wino across town.


Since he (the wino) is the sicker of the two, facing greater risk of serious harm than the board member, it is he (the wino) who has the stronger presumptive claim to the one available bed. However, as was just illustrated by the case involving the race car driver, this sort of presumptive claim can be defeated if (a) both patients run genuine risks of serious harm if they are not given prompt ICU treatment and (b) the one whose need is greater is in that condition as a result of knowingly and voluntarily engaging in a life-style that includes this condition as one of its risks. Our question, accordingly, is whether this latter requirement, the one set out in (b), is true of the wino, assuming that the requirement set out in (a) is fulfilled.

That the life-style of the wino is fraught with health risks, is, I assume, not open to serious dispute. But does the wino know this? It is hard to imagine how he could not. Probably he himself has been frequently ill. Probably he knows, either firsthand or orally from others on the streets, that some (and these not a few) of his peers have fallen desperately ill or died. There is, I believe, no serious grounds for doubting that the wino knows that he is embarked on a life-style that carries genuine risks of serious illness. To deny him even this knowledge would be to patronize him in the extreme.


But does the wino voluntarily choose to run these risks? Superficially, at least, it appears that he does. A wino is not a wino because somebody else habitually holds a gun to his head, threatening to shoot if the wino refuses to drink. Still, the casual nexus of human psychology is not simple, and even if we assume that some people can help being and doing what they are or do, it does not follow that the wino can help being a wino or taking his next drink.

If, as many informed persons believe, alcoholism is a disease, not a character defect, not a moral failing, it seems grossly unreasonable to blame the wino for his condition or to think that he himself has chosen to become what he is. Whatever the casual geneology of his disease, whether it is wholly genetic, wholly environmental, or (more likely) a combination of the two, we ought, on this view, to regard him as doubly sick: sick not only because of the conditions set forth in the case before us but also at a deeper, more sinister level — at the level of his "winoism" itself.


If this is the correct view to take of the wino's circumstances, the case for giving him the available bed and transferring the board member is overwhelming. The one remaining factor that would reverse that verdict — namely, that the wino has knowingly and voluntarily brought his desperate condition on himself — is nullified if the underlying alcoholism itself is a disease. I believe this is the verdict we should reach, even if we do so reluctantly.

And I do so with more than a little reluctance. If, as seems likely, the alcoholism that has the wino in its grip is not a purely hereditary disease, so that environmental factors can contribute to its development, I think we must be mindful that our decisions and policies do not themselves help contribute to its incidence in the general population.


To the extent that hospital policies themselves are part of the larger casual environment, these policies themselves play a casual role in creating and sus­taining conditions favorable to the development of alcoholism in the general population. Perhaps by giving the wino the available bed we encourage him and others in their illness. I do not think we should take this possibility lightly. As things stand, however, I do not think we should penalize the wino for our ignorance.

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