You Have To Decide Who I Heal!

[pseudocyst]

As part of a Medical Ethics course I'm taking, we were given this dilemma. I'd love to hear your choice, and reasons why you made it.

Originally Posted by instructions

You have got $25,000 which you must use to fund only one of the scenarios described – who would you spend the money on and why?

Patient – Steve
Steve is 18 years old, an apprentice electrician and is the victim of a hit-and-run car accident. He has severe facial scarring and psychological problems as a result. Plastic surgery would correct the scarring.

Patient – Joanne
Joanne is 42 years old and has no dependants. She has just been diagnosed as HIV positive as a result of her drug taking. She no longer takes drugs. Drug treatment for HIV is available and 75% effective. This could extend her life expectancy and minimise symptoms.

Patient – Marinder
Marinder is 65 years old and has been waiting 16 months for a hip replacement. Soon, she will be no longer able to live alone. Her only son lives 200 miles away. Eventually her hip will fracture; when it does, 8 out of 10 people like Marinder will die within 6 months. The hip replacement would allow her to live independently.

Patient – Daniel
Daniel is 8 years old and has cancer. He has a 50/50 chance of survival. There is however a new drug treatment available that has been partially tested on a limited number of cases.


My thoughts: Naturally, I have my thoughts on this, and I'll post a reply later on, but with the group's permission, I'm going to keep them to myself for now so that giving my opinon at the beginning doesn't stymie debate.

[disulfiram_effect]

Ooh, hypothetical. I love it!

Actually, for me this was an incredibly easy choice. Medically and ethically, children always come first in my eyes. There is nothing more important than the wellbeing of a child to me and as such a child's care must be put above all others' care (unless it's something rediculous like the child only has a 5% chance of surviving anyway). Ergo, Daniel gets the $25,000 treatment.

The only other even remote contender in this was Steve the 18-year-old car accident victim. Key word there being victim, meaning it wasn't his fault. Yes, it is important to treat him as it wasn't even his fault he was injured, but all the treatment will do anyway is fix scarring. Psychological damage will always be there and when it comes down to it, the damage fixed will only be cosmetic. Is saving someone's looks worth the life of a child? No way, no how.

My rationale for discounting the others is this:

Joanne- plain and simple, this was her fault. She took the drugs and got sick. Now I'm not saying nobody should care because of this, nothing like that. Just that since she's not a victim here, like Steve of the car accident and Daniel of cancer. When there's a choice between a victim and a perpetrator (which for all intents and purposes she is, reformed or not), the victim will absolutely always win. Also, this has no chance of curing her, only relieving symptoms and lengthening her life. She will still die of her HIV (most probably).

Marinder (what a strange name.)- yes, poor Marinder has been waiting for a hip. With this hip, she won't need to put her son to trouble or hire a nurse. Poor, poor her. Meanwhile, we've got a patient testing positive for HIV, one badly injured in a car accident and a child suffering from cancer. Additionally, and as cruelly heartless as this sounds, she has lived most of her life. The others have not. She simply doesn't enter into it for me; this isn't life saving or even critically important, mostly just a matter of convenience. She can wait for another damn hip. EDIT: I misread the part where it'll eventually fracture and possibly kill her. My point still stands, though.

So there you go. My choice would unhesitatingly be Daniel, followed by Steve, Joanne and Marinder all far, far behind.

[cute_angina]

This is a good idea - we medstudents need to think about the hard decisions.

In last, I place Steve. disulfiram_effect, you say he is a victim. But he is still less important then Joanne. That is because Joanne's life is in danger, that of Steve is not.
Steve is only severely scarred, and he got some psyschilogical damage!!!

Joanne took drugs, so she got herself in trouble. This doesn't say I would never help her, but others come first. Also, there is a 75% chance that her life expectancy is EXTENDED, so if there won't be another cure found, she will die of her sickness anyway.

She will come third.

Marinder will come second, cause there is a reliable chance that she will get another hip before the situation is getting REALLY critical. I despise the arguement that she is older, that is just heartless and VERY pragmatic, and I think being pragmatic isn't to be allowed in medical considerations.
Oh and if there wasn't a chance that she would die, but solely the chance that she would be dependent, then I would put her last. Bringing her son back to her and re-establishing contact between those two seems quite important.

So in the end I will choose for Daniel. Not because he is a child, or that he is younger, but he it wasn't his fault at all, and he got the smallest amount of time left, so his case is the most critical.

[DrIreland]

The only choice...not to make one.

I decided to give the money to Joanne...you gasp...the drug using HIV infected middle aged "I don't care about life" women? Yes...how could I do such a thing? I chose Joanne because in rationing of medical care I believe it to be unethical to decide why one person "deserves" care more than someone else...the only decision is to make a random unbiased decision, I did it by not reading any of the backgrounds and just choosing at random. If we start to argue that little Daneil deserves it because he's just a child and hasn't seen the world...he hasn't been on the tea cups at disneyland or had his first kiss...yada yada...we fall down a slippery slope. The decisions we make with regard to each of the people reflect our own biases...if I was a recovered IDU who was infected with HIV who turned his life around, was receiving treatment and had a near normal CD4 count, had started an AIDS awareness effort and saved millions of lives in South Africa I would say Joanna was the only choice! Way to go Jo! However, if I was an economist perhaps I would choose the elderly Marinder because her operation has the highest number of QALYS (Quality Associated Life Years)! If I was a new mom I would choose Daniel because I'm sympathetic and if I was a plastic surgeon perhaps I'd pick Steve as if would be a financial incentive and I would have seen through my career the astounding benefit that facial reconstruction can have on deformed people.

The only choice in medical care rationing is not to make one...choose at random!

[amitwadhwa]

Originally Posted by disulfiram_effect

Ooh, hypothetical. I love it!

Actually, for me this was an incredibly easy choice. Medically and ethically, children always come first in my eyes. There is nothing more important than the wellbeing of a child to me and as such a child's care must be put above all others' care (unless it's something rediculous like the child only has a 5% chance of surviving anyway). Ergo, Daniel gets the $25,000 treatment.

The only other even remote contender in this was Steve the 18-year-old car accident victim. Key word there being victim, meaning it wasn't his fault. Yes, it is important to treat him as it wasn't even his fault he was injured, but all the treatment will do anyway is fix scarring. Psychological damage will always be there and when it comes down to it, the damage fixed will only be cosmetic. Is saving someone's looks worth the life of a child? No way, no how.

My rationale for discounting the others is this:

Joanne- plain and simple, this was her fault. She took the drugs and got sick. Now I'm not saying nobody should care because of this, nothing like that. Just that since she's not a victim here, like Steve of the car accident and Daniel of cancer. When there's a choice between a victim and a perpetrator (which for all intents and purposes she is, reformed or not), the victim will absolutely always win. Also, this has no chance of curing her, only relieving symptoms and lengthening her life. She will still die of her HIV (most probably).

Marinder (what a strange name.)- yes, poor Marinder has been waiting for a hip. With this hip, she won't need to put her son to trouble or hire a nurse. Poor, poor her. Meanwhile, we've got a patient testing positive for HIV, one badly injured in a car accident and a child suffering from cancer. Additionally, and as cruelly heartless as this sounds, she has lived most of her life. The others have not. She simply doesn't enter into it for me; this isn't life saving or even critically important, mostly just a matter of convenience. She can wait for another damn hip. EDIT: I misread the part where it'll eventually fracture and possibly kill her. My point still stands, though.

So there you go. My choice would unhesitatingly be Daniel, followed by Steve, Joanne and Marinder all far, far behind.

No offence but I completely disagree with you. When one starts using words like in my opinion, you immediately are showing your bias whereas drireland correctly pointed out - medicine is not about bias. It is about treating people to the best of your ability and hoping that they pull through. You are criticising peoples lifestyles and life choices-is that fair? Would you like to be denied a chance to correct something just because you had stolen a classmates lunch way back in third grade? We all make mistakes my friend!

Yet at the same time I see that you are answering a hypothetical question so maybe hypothetically you can apply your bias here. But what if it was not a hypothetical question and you were in fact in a real life situation not too dissimilar to the one above? If you are going to be biased like in your hypothetical reply - I would choose drireland to goto instead.

I am no medic and not even going to be one but as a human being I think that Marinder will benefit most from the treatment. Her quality of life improves and she can be independent again.

[bobcommodore]

I break it down by the following in terms of importance:

AGE

Sometimes the young just need to come first.

1. Daniel 8
2. Steve 18
3. Joanne 42
4. Marinder 65

IMPORTANCE TO SOCIETY

As much as I hate to place a value upon these people, it is sometimes necessary to see where the greatest chance of return is in the long run.

1. Daniel still a child, has a chance to become great in society one day
2. Joanne still can contribute some to society
3. Steve still fairly young and can contribute to society as an electrician.
4. Marinder has lived her life and has little left to contribute.

CHANCES OF SURVIVAL

Even with the money, what are the chances that the person will survive long enough to gain the benefits of what you give them?

1. Steve Chances of survival: over 90%. Cosmetic surgery is fairly routine, and he has a very good chance of survival since he's already survived being hit by a car.
2. Marinder Chances of survival: 80% and up. Hip surgery would allow her to live independantly, meaning she can live much longer without help if there are no comlications.
3. Joanne Chances of survival: 75%. With the drugs she's being given to treat HIV, she could live for a long time if she stays on the drugs as she's told to.
4. Daniel Chances of survival: 50%. The surgery to remove the cancer is very complicated and he could very well die, but after that his chances of survival go way up.

VOTE TALLY

Remember, votes are counted based on the requirements above. The winner is the one with the lowest vote count

Steve 2-3-1:6
Joanne 3-2-3:8
Marinder 4-4-2:10
Daniel 1-1-4:6

Since there is a tie between Steve and Daniel, since Daniel's case is more critical than Steve's, Daniel wins! yay

[Mfurfur]

Perhaps it would be interesting to apply QALYs to the scenario. A QALY is a quality adjusted life year and its essence is that it takes a year of healthy life expectancy to be worth one but regards a year of unhealthy life expectancy to be worth less than one. The plausibility is that given the choice a person would prefer a healthier shorter life than a longer period of survival in a state of severe discomfort and disability. So to find out who gets the money we have to look at who has the most potential QALYs at the lowest cost per QALY.

Marinder - At 65 her QALYs will be zero without the operation as she will be dead within 6 months, and after the operation she has the potential for an additional 10 QALYs if she lives to he life expectancy of a Western European female at 75. This is if she lives those years without the ill health that plagues the age bracket. In addition each of her respective QALYs will have a relatively high cost if she succumbs to illness.

So Marinder = 10 QALYs +/-

Steve - At 18 with facial scarring and psychological problems he has a long life ahead, and if age expectancy is 72 for males we would say he has the opportunity for 54 QALYs. However what is the ratio of a life year with scarring to a life year without scarring, will his QOL be 100% better, 200% better or only 50% better. Let's go with twice as good! If this is the case we must multiply his QALYs by the ratio of 0.5 as he will still have 27 QALYs without the procedure.

Steve - 27 QALYs

Joanne - Addict Joanne is 42 with 33 possible QALYs. If we assume she has given up the drugs (from the stem) and can afford treatment for the rest of her life with the money allocation (from the stem it appears that the money will cure or aid the said disease for an infinite amount of time) then she will be a healthy HIV positive person with no HIV associated morbidity assuming she adheres to the difficult drug adherance regimen. Let's say that her QOL is only 75% of an undiagnosed person due to the psychological effects of stigma, so 75% of 33 is 24.75.

Joanne - 24.75 QALYs

Little Danny - Danny with CA has a possible 67 QALYs if the treatment works, if the treatment doesn't work then he has 0 QALYs as he'll be dead. So we would have to use a ratio of the probability of the treatment working. If we take the fact that only 33% of drugs that make it to phase II trials succeed then we can say that the odds of this drug working can be estimated at 33%. That means there is a 66% chance the drug won't work and we will waste resources that would have helped three other possible contenders. Should a failed drug be negative QALYs or zero? Let's say 0. So if there is a 33% chance the treatment works let's multiple this by our possible QALYs and find out who wins. 67 at 33% is 22.

Danny - 22 QALYs

It must be added that according to this finding it would actually be a worse choice to give Danny the drug and the funding as the odds post treatment are worse (33%) then the odds of survival before treatment (50%).

Who gets the treatment in this analysis:

1. Steve
2. Joanne
3,4. Danny, Marinder

[~screenager~]

I think I'd have to go with either Joanne or Marinder.

Steve's life is not on the line here. Getting rid of the scarring would not fix the psychological damage, which is his most pressing problem.

Although I have complete sympathy for Daniel, I would not feel confident that the treatment available for him is effective: it's only been tried on a small number of cases, and in any case he still has a chance of pulling through without it.

If personal choice came into it, I'd spend the money on Marinder. When her hip breaks, her life will be on the line through no fault of her own. She has already been on the waiting list for over a year so this has already been affecting her quality of life.

However, Joanne's life is most immediately threatened. The issue at hand here is making her as healthy as possible, not passing judgement on past choices. Given the treatment she can have a longer and more comfortable life unless she eventually contracts AIDS.

[kev1n]

I'd opt to treat Marinder. Without treatment, she has an 80% chance of death within 6 months. With treatment, she can be expected to live out the balance of her life expectancy (barring other complications or issues). Hip replacement is a tried & true treatment, and it offers a 'cure', Vs just an ongoing or temporary fix/patch. Daniel, altho a hard call, due to his tender years, condition, and the potential he might offer the world if he lived, has at best a 50/50 chance, and on an untried methodology. with limited funds, can I afford to take that gamble? Medical funding is not mad money to toss away on long shots, no matter how hard that decision is due to circumstances. As for Joanne, HIV therapy is just that.. therapy. No chance of a cure, just the possibility of holding off the advance into AID's for some period of time. Even if joanne did not return to drug use, her outcome simply cannot be considered to achieving the most good with the funds. It's akin to gambling again, with an iffy patient whose long term prognosis isn't going to alter via these funds.
As for Steve, his condition is life altering, but not immediately life threatening. He has both time, youth and other options open to him. A skilled tradesman, his condition does not jeapordize his ability to earn a living, allowing him to pursue this treatment without my assistance. Does he really NEED my funds?
Overall, regardless of her advanced years, Marinder seems to qualify on more than a number of levels. Her risk of loss of life is 80% in 6 months or less, she has no other alternative prospects. No other conditions were mentioned to make her a less than viable prospect. If age is the deciding factor, then it's akin to age discrimination solely, and not other complicating factors. Anyone arguing that due to her age, she has already lived her life is overlooking the obvious that she has demonstrated the ability to be a survivor, and if she was to benefit from this, has the potential of living longer on this than say Joanne, or Daniel. Even Steve, due to the nature of his work, might not live as long as Marinder... I know there are other complex formulae that might aid in this decision, but I think sometimes the simplest are the best. Do the most good with what little you have, don't throw away your resources on lost causes or long shots, and don't focus on the mediocre when the urgent is facing you. I know there is no 'right' answer to this theoretical question, but this is mine!

[tyciol]

While my first instinct was Steve the electrician because he looks to be the one with the best chances for survival (a one-time incident with no chance of remittance) as well as being the more valuable member to society, there isn't really any immediate threat to his life. Plastic surgery would not guarantee a cure to his psychological trauma, and that is really more of a threat than facial scarring. He may adapt without plastic surgery, and when he becomes a well-paid electrician, would likely be able to afford it at a later date out of his own pocket. Until then he can wear a mask to do his job which he probably would be doing anyway to guard from sparks (or I may be thinking of welding...)

Joanne should be last in line because drug patients are too risky for investment as they could likely overdose putting it all to nought. That, and really, keeping a needle-sharing HIV user around in the world in a threat to public safety.

Marinder can just get a wheelchair, this will prevent the hip fracture and resulting life-threatening infections and related conditions. Not being able to live independantly can be a bother but it is not life-threatening and a lot of people deal with it.

Daniel confuses me, is he 50/50 with or without the drug? Would the drug increase chances of survival 50%>75% or something like that? Honestly, it seems like a risk to invest in him as cancer treatments (especially new ones) are often so risky, but he seems like the best choice. Probably the most obvious one too. Not simply because of youth, but because his is the only life-threatening condition. Due to his youth I could see him have a better chance of coping with the drugs' side effects. His condition is not one of comfort like the electrician and the elderly lady, and he is not a threat to others or a high-risk case like the drug addict. So definately go with Daniel.

[medical marvel]

i will go for the kid of course. because he's a kid and he needs proper treatment as early as possible. cancer spreads rapidly, that's why the kid needs to be treated as soon as possible.