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Ethics & Decision Making a case of providing RRT in Thailand. Yot Teerawattananon International Health Policy Program Journal club, 17 March 2006. Background. Introduction of universal health insurance (NHS-like system) in 2001 - PowerPoint PPT Presentation
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1
Ethics & Decision MakingEthics & Decision Making
a case of providing RRT in Thailanda case of providing RRT in Thailand
Yot Teerawattananon
International Health Policy Program
Journal club, 17 March 2006
2
Background
• Introduction of universal health
insurance (NHS-like system) in 2001
• Dialysis for chronic renal disease
(CRD) was excluded from the health
service package
• Disease incidence is 10,000
patients/year. Only 5% of patients with
CRD can afford for dialysis (~ £6,000
per year)
3
VS.
Age (years) Life years gained
20 17.65
30 15.32
40 12.96
50 10.60
60 8.45
70 6.53
Estimated programme output
Saving 9,500 lives each yearSaving 9,500 lives each year
4
Cost effectiveness analysis– Renal Replacement Therapy (RRT)
• Cost per life year saved (Teerawattananon et al 2005)– Peritoneal dialysis 10,170 US$
– Hemodialysis 10,490 US$
– Anti Retroviral Therapy - ART • Cost per life year saved (Lertiendumrong et al 2005)
– Antiretroviral Therapy 590 US$
– GNI Thailand • US$ 2,540 per capita (2006 WDR)
– RRT is not cost-effective, as cost per life year saved is • 4 times of GNI per capita,
• 18 times as expensive as the current national ART program.
5
Budget impact analysis
2005
(year 1)
2009
(year 5)
2014
(year 10)
2019
(year 15)
Universal access to RRT (million Baht)
3,994 18,058 32,255 43,804
As % of UC budget 5.5 18.4 23.7 23.6
As % of THE 1.7 5.9 7.7 7.7
RRT for KT eligible (mil Baht)
1,981 8,944 15,966 21,625
As % of UC budget 2.7 9.1 11.7 11.7
As % of THE 0.9 2.9 3.8 3.8
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Question?
Given resource constraints and substantial budget is needed to spend on dialysis programme, is the programme justifiable on ethical and moral grounds?
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Options
Fund the dialysis programmeNot fund the dialysis
programme but spend on other cost-effective programme
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Options
Fund the dialysis programmeNot fund the dialysis
programme but spend on other cost-effective programme
Saving lives regardless its cost
10
Options
Fund the dialysis programmeNot fund the dialysis
programme but spend on other cost-effective programme
Saving lives regardless its cost
Equity—not let the poor die
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Options
Fund the dialysis programmeNot fund the dialysis
programme but spend on other cost-effective programme
Saving lives regardless its cost
Equity—not let the poor die
Share risks and benefits
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Options
Fund the dialysis programmeNot fund the dialysis
programme but spend on other cost-effective programme
Saving lives regardless its cost
Equity—not let the poor die
Share risks and benefits
More benefits could be obtained(Utilitarianism)
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Statins: underused by those who would benefit
More people would benefit from prevention of coronary heart disease!
Lipid lowering drugs e.g. statins reduces the odds of a coronary heart
disease event by 30% e.g. reduce risk of cardiac death by 0.000X %
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Options
Fund the dialysis programmeNot fund the dialysis
programme but spend on other cost-effective programme
Saving lives regardless its cost
Equity—not let the poor die
Share risks and benefits
More benefits could be obtained(Utilitarianism)
Distribution problem (Fair-inning)
17
Options
Fund the dialysis programmeNot fund the dialysis
programme but spend on other cost-effective programme
Saving lives regardless its cost
Equity—not let the poor die
Share risks and benefits
More benefits could be obtained(Utilitarianism)
Distribution problem (Fair-inning)
Equity—patients with other diseases
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Options
Fund the dialysis programmeNot fund the dialysis
programme but spend on other cost-effective programme
Saving lives regardless its cost
Equity—not let the poor die
Share risks and benefits
More benefits could be obtained(Utilitarianism)
Distribution problem (Fair-inning)
Equity—patients with other diseases
Rule of rescue
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The rule of rescue
• There is an identified person whose life is
at risk
• There exists an intervention which has a
good change of saving the person’s life
• It is justified to save this person’s life
rather than others who cannot be identified
e.g. a case of lipid lowering drugs
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For• Death is a very
significant harm but a very small chance of death is by no mean a great harm
• In our lives, all of us trades small increase in the chance of death against really quite small benefits!
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AgainstA women trapped in a house-fired. Without rescue she will die. She
can be saved if a large number of people doing a rescue. Do you
think you will join/support?
-If you face 1:1000 risk of death in doing so
-if 3,000 people joining the rescue
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Options
Fund the dialysis programmeNot fund the dialysis
programme but spend on other cost-effective programme
Saving lives regardless its cost
Equity—not let the poor die
Share risks and benefits
More benefits could be obtained(Utilitarianism)
Distribution problem (Fair-inning)
Equity—patients with other diseases
Rule of rescue
Your turn! What do you support? And why?
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Utilitarianism
• The conversion of all things is to
happiness or pleasure or utility
• Everything has a common denominator—
ready-made formula for assessing of what
one should do morally
• It downplays respect, human dignity,
individual rights etc.
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Kant’s moral theory
• The will to do the right thing only for the sake of doing the right thing regardless of its consequences
• The moral principle should be ‘universalizable’ and ‘categorical imperative’
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Checking Kant’s moral theory
• A case of Somchai and a hiding would-be victim for a pursuing criminal
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Reference1. Thomson A. Critical reasoning in ethics: a practical introduction.
London: Routledge, 1999.
2. Hope T. Medical ethics: a very short introduction. Oxford: Oxford
University Press, 2004.
3. Cookson R, Dolan P. Principles of justice in health care rationing. J
Med Ethics 2000;26(5):323-9.
4. Pinkerton SD, Johnson-Masotti AP, Derse A, Layde PM. Ethical issues
in cost-effectiveness analysis. Evaluation and Program Planning
2002;25(1):71-83.
5. Pignone M, Phillips C, Mulrow C. Use of lipid lowering drugs for
primary prevention of coronary heart disease: meta-analysis of
randomised trials 10.1136/bmj.321.7267.983. BMJ
2000;321(7267):983-986.