Ethics & Decision Making a case of providing RRT in Thailand

1. Ethics & Decision Makinga 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. Estimated programme output Saving 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

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

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

14. 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 % Statins: underused by those who would benefit More people would benefit from prevention of coronary heart disease!

19. 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. Against • A 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

24. Your turn! What do you support? And why? Rule of rescue

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. Reference 1. 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.