You have one liver but three patients awaiting a liver transplant.
Who should get the liver? What criteria should be used to select the
recipient? Is it fair to give it to an alcoholic? These are some of the
questions that arise in the context of rationing and allocating scarce
health care resources among particular individuals, and concern what are
called micro-allocation decisions. But trade-offs also need to be made
at the meso- and macro-level. Budgets of public payers of healthcare,
such as governments, and of private ones, such as health plans, are
limited: they cannot cover all drugs and services that appear beneficial
to patients or physicians. So what services should they provide? Is
there a core set of benefits that everyone should be entitled to? How
can we make fair decisions, if we know from the outset than not all
needs can be met? Using the cases of organs for transplantation, the
rationing for vaccines in a flu pandemic, and drug shortages, the course
will critically examine alternative theories for allocating scarce
resources among individuals, while also exploring the principles and
values that underlie those theories.
Logistics and Grading
This class is seven weeks long. Each week, students will watch approximate
30 - 40 minutes of lectures by Dr. Emanuel. Students should expect to spend
2 - 5 hours per week reading related materials from the reading list, all
of which are freely accessible online.
Students taking the course for a grade will complete one quiz (also referred to throughout the course as a peer assessment) per week, which will be
peer-graded based on a detailed answer key provided after the due date.
Of the seven scores earned for assignments, the lowest two scores will
be dropped in calculating the final grade. The remaining five scores will
be weighted equally. As a result, students who miss a homework assignment
can still earn full credit in the course. There are no exams or final projects
in this course. Students not taking the course for a grade may choose not
to complete the assignments.
The details of these logistics are subject to change; if changes are made,
students will be notified via an announcement and this page will be updated.
Week 1: "Who Gets the Liver?" & History of Rationing
We begin the course with a hypothetical case. We have one liver and three
patients who will die if they don't get a transplant. We will discuss some
of the potential approaches for making life and death decisions in the
context of absolute scarcity. Next we will explore the history of rationing
in medicine. Absolute scarcity has always been a problem. How have we dealt
with this problem in the past? We'll take a look at what happened in the
cases of three major 20th century medial advances: insulin, penicillin,
Week 2: Conceptual Distinctions
The study of rationing was borne out of the concept of absolute scarcity
in medicine--cases in which the demand for medical care far exceeds the
resources existing to meet that need. Because demand will inevitably exceed
supply--no matter what--choices must be made about which patients receive
treatment, and which don't. But what do we really mean when we use the
term 'rationing?' Is there a difference between the terms rationing, resource
allocation, and priority-setting? In this lecture, we will attempt to explain
the conceptual distinctions that give meaning to the terms we use in this
Week 3: Organs for Transplantation
Kidneys, livers, hearts, and lungs are among the most discussed absolutely
scarce medical resources. And their allocation poses some of the most vexing
ethical dilemmas. The lecture for this week will break down the process
by which organs for transplantation are allocated in the United States
through the United Network for Organ Sharing (UNOS). We will discuss some
of the values and principles that are implicitly favored in the UNOS rules
and grapple with a few particularly difficult cases. Should alcoholics
with cirrhosis be eligible to receive a liver transplant, if their receiving
a liver means a person with a "blameless" liver disease will die as a result?
What role should socioeconomic or legal status play in organ transplantation?
Do you agree with the UNOS policies as written?
Week 4: Theories
This week, we will explore some of the moral schools of thought that have
shaped the modern-day study of bioethics, and have a tremendous impact
on health policy. Deontology regards morality as the driving guide behind
our choices of what we ought to do. Utilitarianism, on the other hand,
views the proper course of action as the one that maximizes utility. The
tension between these two ethical theories highlights the ethical dilemmas
that bioethicists face in determining how to ration scarce medical resources.
Week 5: Values & Principles
Value judgments are inescapable in rationing decisions. But what are the
competing values and principles that are inherently at play? How can one
choose among them? This week's lecture explores 4 key values and 8 guiding
principles that ethicists and policymakers must consider when confronting
rationing decisions. We'll look at the distinctions between the values
and principles, and discuss the advantages and disadvantages of each. Additionally,
we'll examine the Complete Lives System, which is a theoretical framework
designed to draw upon multiple principles and values.
Week 6: Flu Emergency
This week, we will explore another real life example of rationing in action.
What should we do if there is a major flu pandemic and there isn't enough
vaccine to go around? Who should get the limited vaccine and who should
not? We'll examine the U.S. Government's actual policy for major health
crises. For example, we will look at Department of Health and Human Services
(HHS) briefs that deal with allocation protocols in the event of an influenza
pandemic. We will also look into historical examples of flu crises, and
analyze the ethical approaches taken in specific case studies.
Week 7: From Micro to Macro
For the final week of the course, we'll examine the difference between
micro rationing decisions and meso/macro decisions. We'll look at the case
of Shep Glazer, whose testimony before Congress fundamentally changed the
way dialysis treatment was allocated in the United States. We'll also look
briefly at cost effectiveness analysis and the Quality Adjusted Life Year
(QALY) as tools for macro level decisions. What paradoxes arise when using
these tools? Do they favor some people over others? What values are implicit
in policies that draw upon cost-effectiveness and QALYs?