This is an excellent post written by Sam Watson, a blogger on the Academic Health Economists’ Blog posted on 16 February 2012 entitled ‘The Ethics of Doing Nothing’. In the post, Sam reflects about the ethics of non-action in health care provision. Though the arguments put forward mostly relate to physical health care, there are some relevant issues to consider in reference to mental health treatment. An example of this would be the justification often put forward to funding commissioners regarding the funding of expensive treatments and services such as Children and Adolescent Mental Health and Early Intervention. As many health care providers will argue, provision at early stages of mental distress may not only prevent future (and more substantial) problems but also can contribute to a better quality of life. This, ultimately, can also provide savings in the longer term (e.g. less service use in adulthood) and in other areas of social care (e.g. dependence of the welfare state). But the problem always comes back to this: with limited amount of funds and resources, how can you justify putting money into services that offer benefits well outside the time cycle of short-term budget reviews, as well as in areas which may have no direct bearing on health care? Conversely perhaps, how can you quantify quality of life and is this something you can even put a price tag on? Yet is doing nothing the better alternative? Have a read of the post and let us know your thoughts!
Can we reasonably consider ‘doing nothing’ as an alternative course of action? In many cost-effectiveness analyses the intervention under consideration is compared against a ‘doing nothing’ scenario, although frequently the next best alternative is used. Ultimately the health technology assessment carried out by NICE is an informative effort and the final decision is made by the budget holder. However, NICE makes each assessment in isolation of each other and so prioritising treatments is left to the budget holder. But can the budget holder choose a ‘do nothing’ option, and should this option be considered at all in cost-effectiveness analysis?
This may come down to an issue on the role of the health care system in general. One of the principle tenets of NICE and the NHS is justice (the others being beneficence, non-maleficence, and autonomy). This NHS justice, it seems, is a sense of justice as described by John Rawls – justice as fairness. Justice as fairness is founded on two points – liberty and equality, that everyone should have the same right to basic liberties, and that inequalities should be arranged to benefit the worst off in society to ensure distributive justice. Both of these principles are satisfied by the idea of access to health care based on need and regardless of ability to pay.
We use cost-effectiveness analysis to best allocate resources, so that we all get the greatest gain for our limited resources, but that does not necessarily ensure that the worst off get priority.
In the end it comes down to a deontologism versus consequentialism debate. Deontologism dictates that there are certain moral rules that must be followed, or as Kant described them ‘categorical imperatives’, and these rules can be reached through logical reasoning and must be universal. In this case, for example, if doing nothing were universally permissible for health care professionals then it would be permissible for no-one to be treated which would negate the existence of the health care professional in the first place. So, if we say that all those with needs must be treated, this may be a deontological stance. However, we do not provide services for all those with needs, and it may be practically impossible to do so. Health care provision is proportional to need, but those with the least needs generally have to pay for their own services, unless they are sufficiently poor, for example, dentistry.
Now, if we consider health care provision to be philosophically consequentialist, can we allow a ‘do nothing’ option? Many thought experiments exist to exercise consequentialist ethics. Consider a runaway train, it’s careering down the track towards a station in which there are ten people who will die if the train gets there, you are on the train and have the option to switch tracks to divert the train away from the station. However, there are three men working on the line on the other track who will die if you pull the lever. Do you pull the lever? One argument, the utilitarian one, would say yes. The total loss would be smaller on the other track, we would therefore be maximising the total utility from the situation. Another argument may say though that not pulling the lever is the only option since if you did the deaths of the three men would be your responsibility but in doing nothing you would be morally neutral. This is a form of egoistic consequentialism. Under both these arguments a health care provider could do nothing, in the first case if utility was maximised by treating others and in the second case because the health care provider is not morally responsible for a person’s health care state in the first place.
There are objections to this line of reasoning. Peter Singer describes a situation to illustrate an objection to this. Imagine you are walking home one day. As you walk you pass a pond in which a child is drowning. The pond is not very deep and you could walk in and save the child, bearing no tangible risk to your own life. In this case the choice of inaction would lead to the child’s death, and you surely could be held responsible for that. The choice of doing nothing, then, does not negate responsibility. Moreover, if the budget holder is the government, there are certainly arguments which may attribute to them a certain responsibility for poor health in the population (consider the relationship between the macroeconomy and health).
The key issue that remains is opportunity cost. The only reasonable argument for doing nothing is that the time and resources could be better spent elsewhere, and cost-effectiveness analysis provides us with the information to know where it is best spent. However, in reality, no patient would be left to die if they turned up to a hospital and could be saved, and many adult intensive care units intervene in ways that are not cost-effective as per the NICE definition. The end of life is the most difficult to deal with, research has shown that people value a change from 0.2-0.4 QALYs more than they value a change from 0.6-0.8 QALYs. Many expensive life prolonging cancer drugs are not funded by the NHS, but there are cases of successful lobbying to have these drugs reimbursed despite their lack of cost-effectiveness. This could lead us to conclude that doing nothing is fine as long as it does not kill the patient (or allow the patient to die, depending on your stance) in which case we should always intervene. It is unfair to ask a health care professional not to act, since, as detailed, it is their responsibility if their patient dies through inaction.
For the most part, everybody is provided with the necessary treatment when they are in need. It’s really only at the end of life the problem of opportunity cost is apparent due to the high cost of interventions. Perhaps the answer lies in allowing NICE to negotiate the price of drugs, although this would not necessarily lead to price reductions since companies would be incentivised to pitch drugs at an even higher price knowing that they will be negotiated down to their acceptable price. To the contrary though it may be argued that this constitutes inaction on the part of NICE, and by negotiating (or at least trying to) they could allow more people to survive. Another issue is that the few months that are gained by (usually expensive) end of life treatment are usually in very poor quality. From an Aristotelian perspective this would not be a virtuous choice, as we would not be achieving ‘the good life’, and what’s more, Aristotle says, no-one would actually choose this state of suffering unless they were defending a philosophical position.
In the end we may defend ‘doing nothing’ as a choice as it may be necessary in the face of opportunity cost, and it is always better to know the outcomes from as many scenarios as possible when modelling it in simulation based studies. However, in practice ‘doing nothing’ may not be realisable, since the fear of death may prohibit people from accepting this option. Perhaps there is a case for allocating more resources to health care from other areas of public spending, which there certainly is a case for. What would be ideal would be a quantifiable way of measuring the benefit from all government spending and then choosing the health care budget based on this. But this is definitely a long way from reality.
University of Warwick
Originally posted in the Academic Health Economists’ Blog on 16 Feb 2012