1. 1 Ethics & Decision Making a case of providing RRT in Thailand Yot Teerawattananon International Health Policy Program Journal club, 17 March 2006

2. 2 Background Introduction of universal health insurance (NHS-like system) in 2001 Dialysis for chronic renal disease (CRD) was excluded from the health service package Disease incidence is 10,000 patients/year. Only 5% of patients with CRD can afford for dialysis (~ £6,000 per year)

3. 3 VS. Estimated programme output Saving 9,500 lives each year

4. 4 Cost effectiveness analysis –Renal Replacement Therapy (RRT) Cost per life year saved (Teerawattananon et al 2005) –Peritoneal dialysis 10,170 US$ –Hemodialysis 10,490 US$ –Anti Retroviral Therapy - ART Cost per life year saved (Lertiendumrong et al 2005) –Antiretroviral Therapy 590 US$ –GNI Thailand US$ 2,540 per capita (2006 WDR) –RRT is not cost-effective, as cost per life year saved is 4 times of GNI per capita, 18 times as expensive as the current national ART program.

5. 5 Budget impact analysis 2005 (year 1) 2009 (year 5) 2014 (year 10) 2019 (year 15) Universal access to RRT (million Baht) 3,99418,05832,25543,804 As % of UC budget5.518.423.723.6 As % of THE1.75.97.7 RRT for KT eligible (mil Baht) 1,9818,94415,96621,625 As % of UC budget2.79.111.7 As % of THE0.92.93.8

6. 6 Question? Given resource constraints and substantial budget is needed to spend on dialysis programme, is the programme justifiable on ethical and moral grounds?

7. 7 Options Fund the dialysis programme Not fund the dialysis programme but spend on other cost-effective programme

8. 8 Options Fund the dialysis programme Saving lives regardless its cost Not fund the dialysis programme but spend on other cost-effective programme

9. 9

10. 10 Options Fund the dialysis programme Saving lives regardless its cost Equity—not let the poor die Not fund the dialysis programme but spend on other cost-effective programme

11. 11 Options Fund the dialysis programme Saving lives regardless its cost Equity—not let the poor die Share risks and benefits Not fund the dialysis programme but spend on other cost-effective programme

12. 12 We should not let some people in our society suffered without help!

13. 13 Options Fund the dialysis programme Saving lives regardless its cost Equity—not let the poor die Share risks and benefits Not fund the dialysis programme but spend on other cost-effective programme More benefits could be obtained (Utilitarianism)

14. 14 Statins: underused by those who would benefit More people would benefit from prevention of coronary heart disease! Lipid lowering drugs e.g. statins reduces the odds of a coronary heart disease event by 30% e.g. reduce risk of cardiac death by 0.000X %

15. 15 Options Fund the dialysis programme Saving lives regardless its cost Equity—not let the poor die Share risks and benefits Not fund the dialysis programme but spend on other cost-effective programme More benefits could be obtained (Utilitarianism) Distribution problem (Fair-inning)

16. 16

17. 17 Options Fund the dialysis programme Saving lives regardless its cost Equity—not let the poor die Share risks and benefits Not fund the dialysis programme but spend on other cost-effective programme More benefits could be obtained (Utilitarianism) Distribution problem (Fair-inning) Equity—patients with other diseases

18. 18

19. 19 Options Fund the dialysis programme Saving lives regardless its cost Equity—not let the poor die Share risks and benefits Not fund the dialysis programme but spend on other cost-effective programme More benefits could be obtained (Utilitarianism) Distribution problem (Fair-inning) Equity—patients with other diseases Rule of rescue

20. 20 The rule of rescue There is an identified person whose life is at risk There exists an intervention which has a good change of saving the person’s life It is justified to save this person’s life rather than others who cannot be identified e.g. a case of lipid lowering drugs

21. 21 For Death is a very significant harm but a very small chance of death is by no mean a great harm In our lives, all of us trades small increase in the chance of death against really quite small benefits!

22. 22 Against A women trapped in a house-fired. Without rescue she will die. She can be saved if a large number of people doing a rescue. Do you think you will join/support? -If you face 1:1000 risk of death in doing so -if 3,000 people joining the rescue

23. 23

24. 24 Options Fund the dialysis programme Saving lives regardless its cost Equity—not let the poor die Share risks and benefits Not fund the dialysis programme but spend on other cost-effective programme More benefits could be obtained (Utilitarianism) Distribution problem (Fair-inning) Equity—patients with other diseases Rule of rescue Your turn! What do you support? And why?

25. 25 Utilitarianism vs. Kant’s moral theory

26. 26 Utilitarianism The conversion of all things is to happiness or pleasure or utility Everything has a common denominator— ready-made formula for assessing of what one should do morally It downplays respect, human dignity, individual rights etc.

27. 27 Checking utilitarianism A case of Somsri and her rich uncle

28. 28 Kant’s moral theory The will to do the right thing only for the sake of doing the right thing regardless of its consequences The moral principle should be ‘universalizable’ and ‘categorical imperative’

29. 29 Checking Kant’s moral theory A case of Somchai and a hiding would-be victim for a pursuing criminal

30. 30 Reference 1. Thomson A. Critical reasoning in ethics: a practical introduction. London: Routledge, 1999. 2. Hope T. Medical ethics: a very short introduction. Oxford: Oxford University Press, 2004. 3. Cookson R, Dolan P. Principles of justice in health care rationing. J Med Ethics 2000;26(5):323-9. 4. Pinkerton SD, Johnson-Masotti AP, Derse A, Layde PM. Ethical issues in cost-effectiveness analysis. Evaluation and Program Planning 2002;25(1):71-83. 5. Pignone M, Phillips C, Mulrow C. Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials 10.1136/bmj.321.7267.983. BMJ 2000;321(7267):983-986.