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Ethical Considerations in Managing Weighting Lists

As I have blogged before, the scarce availability of access to evidence-based treatments for obesity within the public health care system is resulting in ever increasing “weighting” lists for bariatric services.

Thus, as in other cases, where the demand for medical and/or surgical interventions seriously outstrips the availability of services, the ethical dilemma of distributing these limited services in the most equitable and acceptable fashion is clearly evident.

In this context, a recent article by Govind Persad and colleagues from the Department of Bioethics at the US National Institutes of Health, published in a recent issue of The Lancet is a very worthwhile read.

As Persad and colleagues discuss, there are eight commonly used ethical principles for allocation of scarce resources, which can be divided into four categories based on their core ethical values:

1) Treating people equally (lottery, first-come-first-served)

2) Favouring the worst-off (sickest first, youngest first)

3) Maximising total benefits (save the most lives, prognosis or life years)

4) Promoting and rewarding social usefulness (instrumental value, reciprocity)

As discussed in the article, none of these principles satisfy all ethical requirements in that they are either insufficient (i.e. ignore some morally relevant considerations) or fundamentally flawed (by recognizing irrelevant considerations).

Thus, for example, a simple lottery may result in the chance allocation of a scarce resource to someone who has only 4 months of life to gain vs. someone who may gain 40 years.

Similarly, first-come-first-served principles ignores relevant differences between individuals and tends to favour people who are wealthier, better informed, or better connected (e.g. to their referring physician).

Treating the sickest first may result in allocation of treatments to people, who have the worst prognosis and therefore the least long-term benefit.

Treating the youngest first would divert all of the resource to infants and young children, when most people may agree that saving the life of a young mother may be more important than saving the life of a 2 year-old.

If the focus is on saving most lives, how would you rate saving the life of one 20 year-old, who may gain 60 years vs. saving the life of five 70 year-olds, who may gain 10 additional years of life each?

Prioritization of people who have a high instrumental value (e.g. health care workers) or reciprocity for people who have “paid their dues” (e.g. veterans) also raises inherent ethical issues.

Thus, according to Persad and colleagues, none of these commonly used principles are fully adequate. In their paper, they propose a “complete lives system”, which incorporates five ethical principles: youngest first, prognosis, save the most lives, lottery and instrumental value.

As laid out in their paper, this system would prioritise adolescents and young adults over infants but also takes into account prognosis, in cases where the worst-off can benefit a little, but better-off people can benefit substantially more from the same intervention. It would enable more people to live complete lives whereby introducing a lottery for roughly equal recipients ensures that no individuals – irrespective of age or prognosis is fully abandoned.

Based on this concept, individuals between roughly 15 and 40 years of age, who have yet to live “complete” lives, get the most substantial level of care, whereas the youngest and oldest have a lower chance of getting that care.

For various reasons described in the paper, this system is least vulnerable to corruption and provides a disincentive for referrers to misrepresent the actual health of their patients.

Obviously, even this system is not perfect and can draw objections from some. Nevertheless, the authors argue, that this system of “complete lives” is theoretically the best framework that balances widely held values: giving priority to the worst off, maximising benefits and treating people equally.

Certainly a topic that will continue to be hotly debated as we continue wondering how to best manage an ever growing waiting list for bariatric care.

Winnipeg, Manitoba

1 Comment

  1. I have been suffering with my stomach and weight issues since I was a teenager, I have ALWAYS had PCOS but there was no diagnosis for it until I was 19. Now I am trying to get approved for gastric by pass in a town, where there is NO bariatric department in ANY of the hospitals from what research I have done. The dr my children see wants to refer me to a endocronologist, instead of sending a letter of referal directly to a hospital and dr of my choice through the research I have done for the gastric bypass procedure to be done. The endo’s was trying to figure what purpose would there be for me to see one if all I need is a letter referring me to a hospital that does the procedures, my health issues speak for themselves for how many years they have been going on. What I am wondering is can the dr the Gyncologist that did ovarian drilling on me, who knows my history with PCOS and weight can HE give me a letter of referral to a bariatrics department in a hospital that does the gastric by pass procedures? I can get in to see that dr in 2 wks… that’s alot shorter a wait time.. then the endocronologist who I have never seen and don’t know. I just know I am suffering every day and I can’t take myself to an emergency room and demand the procedure be done.. my acid reflux issues, indigestion, my inability to enjoy, food, and my inability to eat until I am full because of the size and weight I am… so there is a CONSTANT hunger the size of a football field in my stomach when I eat the normal portion of food a skinny person would eat. I don’t breathe well at night, and haven’t slept good in years! What can I do besides seeing that gyncologist who does know me and my history to help speed up the process? I don’t think I can go another year like this, I am so uncomfortable most of the time! Please I look forward to your response.

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