Transcript palliativ care in general practice

ETHICAL DILEMMAS
IN THE INTERFACE BETWEEN
PERSONAL AND SOCIETAL NEEDS
Manfred Maier
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
OBJECTIVES
Participants should be able to
• identify various reasons which cause ethical
dilemmas
• discuss the rational of different approaches
when faced with ethical dilemmas
• compare arguments for individual and public
health priorities
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
ETHICAL DILEMMAS
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Bled 2006
demanding patients
patients in need
guideline requirements
genetic diagnostics
screening procedures – prevention – medicalisation
palliative care
defensive medicine
to many duties in GP / FM – time limited
public health care – private insurance
economic forces – ethical principles
overuse – misuse – underuse of resources
inpatient – outpatient interface
Abtg. Allgemeinmedizin
Medizinische Universität Wien
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
ALLOCATION OF RESOURCES –
RAISING NEEDS IN HEALTH CARE
• demographic developments
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Bled 2006
increased life expectancy
increased elderly population
increase in chronic diseases
new diseases
increase in multi - morbid patients
new epidemics
reduction in birth rate
increased risks due to leisure time
activities
Abtg. Allgemeinmedizin
Medizinische Universität Wien
RAISING NEEDS
• biomedical developments
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Bled 2006
technical developments (PET,…)
diagnostic / therapeutic improvements
Increased requirement for resources
new medications
screening – prevention – health promotion
palliative care
guidelines
quality improvement measures
information technology
individualized treatment
(pharmacogenomics)
Abtg. Allgemeinmedizin
Medizinische Universität Wien
LIMITED RESOURCES
• financial resources
– reimbursement system
• structural resources
– Health insurance, HC - systems, group
practices, facilities
• personnel resources
– imbalance of health care professionals,
– generalists - specialists,
– health care teams
not all goals can be reached at the same time
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
NEW DEVELOPMENTS
• health insurance companies have the right to
look into individual medical data
• physicians are obliged to provide documentation
• the health insurance system system has the
right to collect and process individual data
• patient management has to follow guidelines
established by public health authorities –
sanctions ?
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
EXAMPLE: PATIENT
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Chol > 300, LDL > 200, hypertension
Bezafibrate medication no effect
Simvastatin sample effective
Prescription not accepted by insurance company
(high risk, PVAD, CAD, diabetes, ...)
• Pharmacist: indication ?
• Private prescription not possible for patient
• How would you react ?
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
ETHICAL PRINCIPLES
• Primacy of patient welfare
• Patient autonomy
• Social justice
Hippocrates
(460-380 bc)
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
PUBLIC VERSUS PERSONAL INTEREST
• cost effectivness – individual health data
- control mechanisms
- steering instruments
• legislation – privileges of physician
- loss of autonomy
• electronic records and data processing
- negative outcome for vulnerable populations
• confidentiality = right of privacy
- exemptions restricted to defined epidemic diseases
- sanctions for physicians violating this code of ethics
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
ECONOMIC RESOURCES
Education
Prevention
accidents
immunization
health checks
Health Care
Curative Medicine
diagnostics
therapy
emergency care
Environment
Rehabilitation
medical
social
occupational
nursing
Safety
continued
payment
of wages
inpatient
sickness
advising
handicapped
psychosocial
Patient – oriented health care
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
HEALTH PROMOTION
AND HEALTH CARE SPENDING
• NEJM 2003;349:1048
• goal:
to estimate the relation of health status to life
expectancy and cumulative health care
expenditures
• methods:
- assessment of functional status and health
- calculation of life expectancy
- annual health care expenditures
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
HEALTH PROMOTION
AND HEALTH CARE SPENDING
• results:
– life expectancy longer for people in good health
– similar cumulative health expenditures until death
– institutionalization increases costs
• interpretation:
health promotion may improve health and
longevity without increasing health expenditures
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
QUESTIONS
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individual or public health priorities ?
economic savings for patient or society ?
management for patients or society / system ?
vulnerable populations ?
confidentiality ?
who is sanctioned ?
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien
Bled 2006
Abtg. Allgemeinmedizin
Medizinische Universität Wien