1 Ethics & Decision Making a case of providing RRT in Thailand Yot Teerawattananon International...

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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

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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)

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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

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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.

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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



Saving lives regardless its cost

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Options




Equity—not let the poor die

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Options





Share risks and benefits

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

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Options






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







Distribution problem (Fair-inning)

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Options








Equity—patients with other diseases

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Options









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









Rule of rescue

Your turn! What do you support? And why?

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Utilitarianism vs. Kant’s moral theory

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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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Checking utilitarianism

• A case of Somsri and her rich uncle

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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.

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