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Priorities and Resource Allocation in Health Care

A Comparative Study of Some European Countries


  • Abstract:

    In all industrialized countries medical progress and demographic development lead to a shortage of funds for health care, and this in turn necessitates new considerations with respect to resource allocation and priority setting in the health care systems. The manner in which the various problems arising in this context are perceived and reacted upon differs from country to country and depends on a number of factors. Presumably, these factors are not only related to structural differences between the various health care systems, but also to different cultural traditions, norms, and value assumptions.

    Problems of resource allocation and priority setting in the health care system are likely to be discussed first and foremost with regard to the situation in one's own country. Therefore, the discussion is usually based on the value assumptions and the ethical and legal norms prevailing in one particular country. However, in an increasingly integrated Europe, it is necessary to direct one's attention across the national borders, and to analyse and compare the situation also in other European countries.

    In order to enable such comparisons, the EU Commission, from 1996 to 1999, funded a research project with participation of scientists from Sweden, Denmark, Germany, Spain and Portugal. The objective of the research project was to find out how problems related to the allocation of scarce resources in the health care systems of the five participating countries are perceived, how they are dealt with, which differences exist with respect to the handling of shortages, and whether such differences are related to different cultural traditions, norms and value assumptions.

    In a first step of the analysis the main structures of the five health systems were set out in working papers, and comparisons were made. These comparisons not only revealed manifold and far-reaching differences between the health care systems; they also showed that the manner in which the omnipresent problems of scarcity are dealt with, and the way in which the general public is taking part in the discussion of these problems, differ from country to country. In Denmark, for example, a national Ethics-Council plays a great role in giving advice as well as in preparing specific suggestions, whereas in Sweden a Parliamentary Priorities Commission was established expressly for this purpose and presented a report which gave rise to an extensive public debate. In Germany, where the health care system has an entirely different structure and is not nationalized, the issues are mainly addressed in the context of parliamentary discussions on legislation. In addition, the problems are touched in the published reports of an experts' commission on «Concerted Action in the Health Care System», i.e. a commission mainly giving advice with respect to the further development of statutory health care insurance.

    Taking into consideration that in each of the five countries the various historical, economic, legal and political factors interact in different ways, the second step of the analysis consisted in a documentation of the debates on resource allocation, scarcity, and priority setting in the various health care systems (Forsman et al. 1999). It became apparent that in Sweden the debate mainly focuses on problems brought to attention by the activities of the Parliamentary Commission and its published report. In Denmark, questions concerning the structure and objectives of the health care system are emphasized, and special attention is given to the efficiency of certain measures as well as to the question of whether preventive or curative medicine should be given priority. In Germany, the debate is mainly concerned with the problem of securing, in spite of high unemployment and declining receipts, the financing of the comprehensive services provided by statutory health insurance, whereas in Portugal reports about deficiencies in the present system and the existence of long waiting lists are receiving special attention.

    Based on an analysis of the discussion on priorities in health care systems, especially of the northern countries, where it has been going on for several years, S. Holm comes to the conclusion that two overlapping phases of priority setting can be discerned (Holm 1998, Holm 2000). In a first phase, an attempt is made to establish priority lists based on specific norms. However, experience then shows that soon there is a clash between different objectives, such as between the individual patient's wish for comprehensive and optimal health care, the desire of society to measurably improve the general quality of the population's health, and the constraints of economic reality. Given the fact that no widely accepted way exists to resolve such conflicts between different goals, and to establish priorities which can be sufficiently legitimatized solely by applying specific norms, in a second phase of priority setting another approach is pursued. The solution which presents itself then is to legitimatize the setting of priorities procedurally by basing the decision-making process on a specific procedure which requires each individual step of decision-making to be made public in order to secure a thorough discussion in which the citizens may participate from beginning to end. It is hoped that by establishing a procedure for adequate participation of the public, and by giving due regard to certain basic values such as human dignity, solidarity, security and freedom of self-determination, a higher degree of acceptability may be achieved for the different groups in a modern society.

    A comparative analysis of the value systems and cultural assumptions underlying the different ways in which problems of scarcity are dealt with in the various countries turns out to be extremely difficult because the characteristics of different health care systems depend on a complex interaction of numerous factors and circumstances. In order to elucidate the value assumptions and cultural traditions which implicitly are influencing this interaction, and in order to make useful comparisons, it was necessary to single out one well defined sub-system of the health care system in which at least the main factors determining scarcity are more or less identical in the five countries. One such sub-system is transplantation medicine, because due to the scarcity of organs and the difficulty of their procurement and allocation to the best suited recipient, each country participating in the project is confronted with similar problems of scarcity necessitating difficult and painful decisions of resource allocation.

    Therefore, in a third step of the analysis the procedures governing the procurement and allocation of organs as well as the underlying norms and directives for each participating country were investigated and compared. In face of the widely diverging views and the intense debate on brain-death and organ-explantation which for many years accompanied legislation of a transplantation law in Germany, the respective report has been published (Fleischhauer 1998).

    Comparison of the norms and guidelines regulating procurement and allocation of organs within the five European countries reveals that, although there are many points in common, significant differences do exist (Fleischhauer et al. 2000). Common to all countries is the fact that organs from a deceased organ donor are belonging to the common good and are allocated according to rules set by the state. (However, this practice, which presently is in force in all countries, is being challenged by some authors who propose that property-rights concerning one's own organs should extend beyond the death of the individual.) A further point in common is that every patient waiting for transplantation of a certain organ, e.g. a kidney, is put on a waiting list. However, as far as the details of the regulations, set by the state, for the handling of the waiting lists and, in particular, for the selection of the best suited candidate from the list are concerned, important differences exist between the five countries which we have studied. Thus for all those countries which, like Germany, participate in Eurotransplant, the allocation of organs is managed by a central office and, for each type of organ to be transplanted, refers to one central waiting list. In accordance with the binding regulations, the best suited candidate for receiving an organ is selected from this list by a central decision which is taken at the headquarters of Eurotransplant and which is arrived at by calculating a complex algorithm. In this calculation medical criteria which can be objectively assessed, such as e.g. blood group and certain immunological constellations, are given highest priority. However, other criteria, for instance criteria to secure a balanced relation between import and export of organs among the participating countries, also enter into the calculation of the algorithm, although with a different weighing. In countries which do not participate in Eurotransplant, other rules apply. In Denmark, for example, which is a member of Scandiatransplant, the rules prescribe that in cases in which two kidneys can be explanted from a donor, one of the two organs is to be placed at the disposal of the central organisation whereas the second may be kept at the local transplantation centre provided that a suitable recipient is on the waiting list of that centre. Thus in Scandinavia, the individual transplantation centres are accorded a greater freedom of decision than, for instance, transplantation centres in countries which are members of Eurotransplant.

    Great differences between the participating countries exist not only with respect to procurement and allocation of cadaveric organs, but also concerning the so-called live donation, which above all is practised for kidney transplantation. These differences are especially interesting because live donation poses ethical problems for the physician as well as for the donor and the recipient. In order to procure the organ, the doctor has to perform a mutilating operation on a healthy person for the benefit of another. For the donor, although the risk involved with the operative removal of one kidney is comparatively small, there is always the possibility of the remaining kidney being affected by some disease, e.g. a tumor, at a later date, so that, as a consequence of donating an organ, the donor may become dependent on dialysis or needing a transplant himself. And for the recipient, too, special problems arise. Thus the recipient may develop a feeling of guilt or excessive gratitude. In addition, it may not always be easy to judge between truly voluntary donation and donation under psychological pressure, for instance by members of the family. Much to our surprise enormous differences between the five countries exist with respect to the frequency of live donations. There is a steep gradient between countries in the north and in the south of Europe, with live donation being practised much more frequently in the northern than in the southern countries. Whereas in Sweden between 35 and 40% of kidney transplantation are from living donors (and in Norway almost 50%), the figure for Denmark is 25%, for Germany 6.5% and for Spain only 1.5%. It is quite obvious that such differences are related to different value assumptions and cultural traditions. Differences with respect to family influence on organ donation or different degrees of utilitarian thinking in northern and southern countries in Europe may play an important role. But which of such factors are predominant and how they influence each other is unknown and requires further insight which can only be provided by specific historical and sociological studies.

    The comparative analysis of how scarcity with respect to organ allocation is dealt with poses further questions of general interest. Thus the analysis reveals that the definition of what is to count as a «medical criterion» also differs from country to country. There is general agreement that data such as weight, blood group or certain immunological constellations, which can be determined by scientific methods, are «medical criteria». But are such unequivocal data the only ones that are used in medical decisions? And if only clear-cut medical criteria were sufficient for selecting a patient from the waiting list, why do considerable differences exist between the selection processes used in various countries and even between various centres in one country (e.g. in Sweden)? There is, for instance, the problem of compliance. Is this a «medical criterion» that ought to be taken into account for selection from the waiting list? There is no simple answer to this question. From the point of view of the physician, compliance is of utmost importance for the long-term success of a transplantation, because the patient has to suppress immunological reactions by regularly attending check-ups and continuously taking drugs for a long period of time, perhaps even for life. Therefore, from the doctor's perspective, compliance undoubtedly constitutes a «medical criterion». On the other hand, critics argue, compliance is very hard to predict and surely depends on various sociological circumstances, such as the family situation of the patient, the degree of his social integration and the intensity of help that can be provided by others. Compliance, it is argued, therefore extends beyond what might be regarded as a «medical criterion». The difficult question how «medical criteria» are to be defined is being addressed by G. Hermerén in an ongoing study.

    The observation that in some countries allocation of organs from a waiting list is being taken far away from the patient, by central decision, whereas in other countries only specific cases are allocated centrally, but others locally and under greater consideration of individual aspects, leads to a further question of general interest: Which role does «closeness» or «distance» between the decision maker and the individual patient play in medical decisions under the constraints of scarcity? This question needs further clarification and will be addressed by B. Forsman in a forthcoming study.

    In summary, the research project has revealed that between the five countries significant differences exist with respect to the ethically difficult problem of how to cope with the allocation of scarce resources in the health care system. Part of the differences result from deeply rooted value assumptions, norms, and different cultural traditions But up to now little is known in detail about the nature of the different attitudes and their importance for the self-understanding of the population in a given country. Therefore, as long as such questions have not been systematically and thoroughly analysed, it would be premature and not advisable to try and develop European guidelines for the handling of situations of scarcity in the health care systems.

    In summary, the research project has revealed that between the five countries significant differences exist with respect to the ethically difficult problem of how to cope with the allocation of scarce resources in the health care system. Part of the differences result from deeply rooted value assumptions, norms, and different cultural traditions But up to now little is known in detail about the nature of the different attitudes and their importance for the self-understanding of the population in a given country. Therefore, as long as such questions have not been systematically and thoroughly analysed, it would be premature and not advisable to try and develop European guidelines for the handling of situations of scarcity in the health care systems.

  • Participants:
    Prof. Göran Hermerén, Ph.D. (Koordinator)
    Department of Medical Ethics, Lund University, Schweden

    Prof. Dr. med. Dr. h.c. Kurt Fleischhauer
    Institut für Wissenschaft und Ethik, Bonn

    Associate Prof. Birgitta Forsman, Ph.D.
    Centre for Research Ethics, Göteborg University, Schweden

    Dr. med. Søren Holm, B.A., Ph.D.
    Centre for Social Ethics and Policy, University of Manchester, Großbritannien

    Prof. Dr. phil. Dr. h.c. Ludger Honnefelder
    Institut für Wissenschaft und Ethik, Bonn

    Dr. med. Octavi Quintana
    INSALUD, Madrid, Spanien

    Prof. Dr. med. Daniel Serrão
    Laboratoire d'Anatomie Pathologique, Universität Porto, Portugal


  • Part-time Participants:

    Prof. Dr. jur. Dr. h.c. Erwin Deutsch
    Juristisches Seminar der Universität Göttingen

    Associate Prof. Dr. med. sci. Gunnel Elander
    Department of Medical Ethics, Lund University, Schweden 

    Dr. jur. Rainer Fuellmich, L.L.M.
    Juristisches Seminar der Universität Göttingen

    Dr. med. sci. Inger Hallström
    Department of Medical Ethics Lund University, Schweden

    Prof. Rihito Kimura, J.D., L.L.M.
    School of Human Sciences Waseda University, Tokio, Japan


  • Funding period:
    September 1996 - August 1999


  • Funding:
    BIOMED 2 der Europäischen Kommission


  • References:
    Fleischhauer, K.: Transplantation in Germany: Kidney, Liver, Heart (Studies in Medical Ethics 5), Lund 1998.

    Fleischhauer, K., Hermerén, G., Holm, S., Honnefelder, L., Kimura, R., Quintana, O., Serrão, D.: Comparative Report on Transplantation and Relevant Ethical Problems in Five European Countries, and Some Reflections on Japan. In: Transplant International 13 (2000), 266-275.

    Forsman, B., Holm, S., Fleischhauer, K., Serrão, D.:
    The Debate on Priorities in Health Care in: Sweden, Denmark, Germany & Portugal (Studies in Medical Ethics 6), Lund 1999.

    Holm, S.: Goodbye to the simple solutions: the second phase of priority setting in health care. In: British Medical Journal 317 (1998), 1000-1002.

    Holm, S.: Development in the Nordic Countries - Goodbye to the Simple Solutions. In: Coulter, A., Ham, C. (eds.): The Global Challenge of Health Care Rationing, Buckingham 2000, 29-37.
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