Medical School Interviews: Medical Ethics Justice
What is Justice
Justice considers the concept of fairness between different people within the population.
Organ allocation MMI Stations
MMI stations frequently present students with scenarios where they are asked to select an individual, from series of patient descriptions, who is most worthy of receiving an organ donation. In order to act justly doctors must not discriminate. The 2010 Equality Act outlines a number of grounds on which doctors cannot discriminate including: employment status, family circumstances, lifestyle, learning disability, age, race and sex. There are several morally relevant differences which can be considered when deciding which patient to prioritise.
Within your answer there are a series of factors which ARE important to consider in order to make a fair and just decision:
- Biological match – certain patients may be more appropriate organ recipients due to their physiology. When matching patients and donors we should consider the blood type and body size of the individuals. When kidneys are matched the process of tissue typing allows us to compare the number of HLA antigens in common between the donor and recipient.
- Patient need –The urgency of a candidates need for a transplant is an important consideration. Consider the prognosis of the patient and the likelihood of prolonged survival following the transplant. Consider whether there could be alternative treatments which haven’t already been tried and how long the patient has been on the waiting list for.
- Patients’ current health status – The patient must be available for the transplant with no current infections. Certain patients will be ineligible for transplantation where the pathology of their disease will lead to reinfection of the new organ. Patients with comorbidities may be inappropriate candidates to receive a transplant as other medications and illness’ may affect their ability to safely engage with the surgery and recovery. We cannot discriminate against a patient because of their age as age is a protected characteristic under the 2010 Equality Act. However, we must consider a patients physiological fitness/ age and ability to recover from the transplant. It can be useful to calculate the number of years someone will live after a transplant – this involves calculating Quality Adjusted life year.
- Wider implications – Consider whether the individual has a dependable such as a child and what their capacity to contribute to the tax base and gain employment.
- Lifestyle status – a patient’s profile may indicate that their illness is “self-induced.” It is important to avoid being judgemental in your answer and avoid stating that patients with self-inflicted diseases don’t deserve organs. Consider how the patient’s social history may impact their recovery. If they are an alcohol is there a chance of relapse and what rehabilitative support has the individual received.
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Rationing – Distributive Justice
Within any health care system there will be resource constraints. Funding limitations mean that there has to be restrictions on the endorsement of certain treatments in the NHS. As a doctor a major challenge is balancing the needs of an individual patient with the needs of the wider population. Doctors are advocates for their patients and should make their patients their first concern, despite this it is still necessary to consider the choices and resources available for others. It can be challenging when you feel you cannot provide the best standard of care to a patient due to resource restraints. Due to financial constraints within the NHS, there is increasingly the need to ration investigations and treatments. There are growing restrictions in the UK where treatments such as speech therapy, operations to remove varicose veins and botox to help with movement in children with cerebral palsy. On a local level CCGs make decisions on which treatments to fund or withdraw.
Rationing – MMI Station
MMI ethical stations may require you to decide which services, from a list of options, should be commissioned or rationed considering the needs of the diverse local population being served. Consider the following factors in your answer:
- The service type:
- Treatment – A treatment service is a service created for those already diagnosed with an illness such as an elective surgery hip replacement. Consider the current suffering of the individual and whether they would have other treatment options if this treatment was withdrawn. Consider the outcomes of the treatment to the individual – What is the chance of treatment success and to what extent will the individual benefit i.e., how will the service delivery effect the quality of life of its users?
- Preventative – Preventative health measures help to greatly reduce future health care costs and increase patient’s health. However, the benefit seen by each individual is minimal. Funding preventative services supports the ethical theory of consequentialism when we consider which treatment/ investigation is maximally effective and brings the best overall health outcome, for the most people, for the least cost?
- Cost – some services may be more costly than others. Consider the cost saving potential of a treatment. This is particularly important when deciding to fund preventative services. The term opportunity cost refers to the value lost when you choose from two or more alternatives.
It can be useful to have an idea of how prioritisation decisions are made within the NHS. Clinical ethics committee have been created to ethically debate and analyse situations regarding an individual’s care. Decisions affecting multiple individuals or the whole population will be made by Primary Care Trusts. Committees and panels will use ethical frameworks to make fair transparent decisions.
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