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Ethical and economic consequences of the limitation of resources for health care

Creación: Comité permanente de médicos europeos (Comité Permanent des Médecins Européens, Standing Committee of European Doctors, CPME)
Fuente: Comité permanente de médicos europeos
Lengua original: Inglés.
Copyright del original inglés: No
Adopción: 1994
Traducción castellana: No
Comprobado el 16 de mayo de 2002


Ethical and economic consequences of the limitation of resources for health care

Recognising that the problems raised by an increase in health expenditure at a rate which exceeds that of the GNP are a challenge not only for governments and the citizen, but also for the medical profession.

Recognising that it is difficult to reconcile the need to guarantee the citizen the enjoyment of the best health care available with the most recent developments in the world of medicine and the desire by the various governments to control increases in expenditure.

The Standing Committee hereby expresses the following opinion:

I. The Problem

Although it appears to be a legitimate desire on the part of governments to contain expenditure, it must nevertheless be emphasised that:

1. that part of the nation's wealth which is devoted to health care is a function of choices made by society.

2. public health also constitutes an investment, and the potential benefits for the health of the citizen of an increase in the share of GNP allocated to health care have not been given sufficient consideration.

3. the health care sector constitutes a source of employment for a not inconsiderable proportion of the active population at a time when the problems of unemployment and employment are among the principal concerns of the majority of Governments and trade unions;

4. an important proportion of the expenditure in this area returns to the state in the form of taxation; 5. the health care sector also has productive aspects to it if account is taken of the pharmaceutical industry, biomedical equipment, computer technology, construction, etc.

It is therefore clear that the health care sector is not only a source of expenditure but also a source of benefit for public health and the state.

It is therefore appropriate to consider it in terms of its positive economic aspects, and not only in terms of expenditure.

II. The causes

The increase in expenditure results from a number of medical and social and economic factors which need to be identified in order to establish which proportion of it is unchangeable and, of that which is changeable, which it is acceptable to change and which it is not.

Certain causes have their origin in natural developments and are difficult to avoid.

1. medical progress which make available to patients increasingly effective diagnostic and therapeutic techniques;

2. more effective but also more expensive medicinal products;

3. the increased use of organ transplants as a routine procedure;

4. an increase in the number of physically and mentally handicapped people, due to an increase in their life expectancy;

5. an increase in the longevity of the chronically sick;

6. an increase in the average age of the population, while the incidence of chronic afflictions and of cancer is higher for aged persons.

7. the emergence of new illnesses such as AIDS;

8. the need experienced by medical teams to have at their disposal for the benefit of patients in­

creased numbers of better qualified staff, who are by that very fact more costly;

9. an increase in the insurance premiums for professional negligence, caused by medical techniques which are more effective but which at the same time carry greater risks.

This increase in medical liability also affects the attitude adopted by medical practitioners, who feel obliged cover themselves by means of increased levels of professional guarantees, particularly by multiplying their procedures;

10. increasing public pressure for progress in preventive medicine which, even though it gives rise to certain savings, is nevertheless very costly.

Certain causes have their origin in society itself, and could become the subject-matter of preventative action on the part of the governments:

1. increasing levels of severity in road traffic accidents;

2. an increase in illnesses caused by pollution and the working environment;

3. an increase in the number of alcoholics and drug users who all require increased levels of health care.

Certain factors are worthy of increased consideration: additional demands made by citizens on health care, but with an absence of any sense of responsibility in relation to the expenditure because of health care being free, or practically free, of charge.

Factors which require radical action and which are often the responsibility of the governments:

1. the politicisation of health care, which results in the best medical services being used even more for electoral or propaganda purposes rather than serving the needs of the patient;

2. management systems which act in their own interest and which consequently divert financial resources intended for health care;

3. inflationary trends in running administrative charges;

4. payment for complementary therapies without any scientific basis.

Finally, factors in which the medical practitioners or health care institutions have their own responsibilities:

1. advertising which encourages the general public to use medical services even if they have no real need to do so;

2. medical practices which have been diverted from their original objective and which seek essentially to earn profits on the basis of inappropriate acts.


I. The responsibilities incumbent on medical practitioners

1. The first task of the medical practitioner is to act in the best interests of the patient.

2. It is incumbent upon the medical practitioners to oppose vigorously any measure which, by seeking to control costs, would infringe medical ethics.

3. Medical practitioners cannot remain indifferent to the problem of increasing expenditure and, although they must recognise the fact of health care rationalisation affecting them, they must nevertheless refuse the imposition of rationing which would lead to the non-treatment of disabilities or illnesses and to premature deaths for economic reasons on the one hand and to social discrimination, on the other hand, since the victims would be those who do not have the means of enjoying private and expensive health care, or which would lead to choices between those who are entitled to care and those who are not.

4. Where resources are inadequate for the purpose of covering the legitimate health care, it is also the duty of the medical practitioner to attract the attention of the public to the reasons for increasing levels of expenditure.

5. High standards of rigour must be applied when using the available resources. Medical practitioners must refrain from conducting superfluous examinations or engaging in superfluous ineffective or needlessly difficult treatment.

Any abuse of the medical practitioner's therapeutical freedom must be severely penalised by the profession itself.

6. Medical practitioners must above all seek to achieve quality in the care dispensed by them.

They must also feel concerned by economic issues.

They must therefore be conscious of the economic implications of the examination procedures and courses of treatment which they prescribe.

Therefore they are under the obligation to submit themselves to continuous medical training during the entire course of their careers in order to keep up to date and even to improve their knowledge.

They are also obliged to assess, or to take part in assessments, of the quality of the health care

which they provide.

II. The responsibilities of governments

1. It is for governments and those who finance health insurance to engage in a permanent dialogue with medical practitioners in relation to the best possible use of the means at the disposal of health care.

Only by granting doctors this right can governments obtain from them their full ethical and social responsibility as regards health care expenditure.

2. Cost control does not give the government any right to take measures which infringe the principles of medical ethics, in particular the right of the patient to choose his doctor, the professional freedom enjoyed by the medical practitioner and professional confidentiality.

3. Elderly persons, physically or mentally handicapped persons, patients afflicted with psychiatric illness have a right of access to health care equal to that of all other patients. The treatment given must only be adjusted in the light of the clinical judgement made and the likely response by the patient to the treatment and rehabilitation.

4. Like the medical practitioners, the governments must promote a sense of responsibility among members of the public in the field of health and prevention, particularly by means of educational programmes.

5. The governments must ensure that the resources which are intended for health care are not diverted from their original objective. Governments must meet their responsibilities in providing the necessary resources for the profession in order to improve the quality and efficacy of care.

6. Hitherto rationing measures have already been applied by the majority of governments.

1* Waiting lists

2* Limited access to health care

3* Monitoring of admissions to hospitals

4* Indicative budgets

5* Excessive bureaucracy and complex procedures which act as disincentives.

Governments must recognise that these mechanisms have proved to be of limited effectiveness and are contrary to medical ethics and the interest of patients.

7. Where resources which are available for health care purposes and which can no longer meet all the various needs, they must be used in such a way as to provide each person with access health care, in particular low-income groups.

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