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

6

Question?

Given resource constraints and substantial budget is needed to spend on dialysis programme, is the programme justifiable on ethical and moral grounds?

7

Options

Fund the dialysis programmeNot fund the dialysis

programme but spend on other cost-effective programme

8

Options

Fund the dialysis programmeNot fund the dialysis

programme but spend on other cost-effective programme

Saving lives regardless its cost

9

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

11

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

12

We should not let some people in our society suffered without help!

13

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)

14

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 %

15

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)

16

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

18

19

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

20

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

21

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!

22

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

23

24

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?

25

Utilitarianism vs. Kant’s moral theory

26

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.

27

Checking utilitarianism

• A case of Somsri and her rich uncle

28

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’

29

Checking Kant’s moral theory

• A case of Somchai and a hiding would-be victim for a pursuing criminal

30

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.