Alternatives in Jewish Bioethics

6. Allocating Medical Resources: Global Planning and Immediate Obligations

6 Allocating Medical Resources: Global Planning and Immediate Obligations I. Treatment versus Medical Progress In Chapter 4 we examined Feinstein's notion of entitlement , whereby a patient who should have been low on the priority list may, simply by virtue of early arrival, gain an exhaustive claim on limited resources. I offered an explanation for this in terms of a conception of the duty to help as a concrete obligation to a specific individual, as opposed to an abstract obligation of general scope. This notion of individualized duty seems also to be central in the traditions of the medical profession. The Hippocratic tradition, after all, commits the physician to focus on the welfare of his individual patient.1 But when we move beyond the micro-level, of "one bed, two patients" addressed by Feinstein, to the issues of allocating resources at macrolevels , we must ask about other, and possibly contrary, obligations. Do health-care providers also have a duty to the public in general? Do they, more precisely, have a duty to dedicate some effort and resources to preparations for treating future patients? The question is posed most directly in terms of money. Suppose that a finite sum is available for health care,2 and that it could be spent entirely on curing or sustaining lives of existing patients. Should some part of it be diverted instead to prevention, research, development, and building infrastructure-all aimed at future life saving? Obviously, this question has force mainly where such a diversion is cost-effective, that is, where it is expected to save more 144 Alternatives in Jewish Bioethics people (or also, arguably, more life-years) than would be saved by applying the funds exclusively to immediate treatment . There is a rough resemblance here to the question addressed by Feinstein at the micro-level. In his view, health-care providers ought in principle to opt for saving the patient with a significantly longer life expectancy. Nevertheless, once they have become committed to another patient with far worse long-term prospects, that patient is said to have acquired an "entitlement" to the available resources, and may not be sacrificed for the sake of greater utility. Might this suggest an analogous social commitment to patients with immediate needs? Can these persons, as a class, claim an entitlement to medical services, leaving no resources free for meeting future needs? Extending the idea of concrete commitment in this manner seems rather problematic, especially when we consider the most plausible grounds for preferring this notion of commitment and duty over the alternative notion of general , abstract duty. Surely, it is the force of the direct human encounter, the concrete situation, that urges a response and may arguably produce a binding commitment . But there is hardly such a direct encounter supporting a demand to maintain a putatively exhaustive commitment of health-care resources to meeting present needs. It is one thing to forbid removing an individual from intensive care for the sake of greater utility; it is quite another thing to oppose the transfer of funds from intensive care to research expected to save more people. Still, the claims of future patients are more nebulous than those of the late-arriving claimant for intensive care in Feinstein's discussion. Indeed, as we saw in Chapter 5, Feinstein radically denies that there is a duty upon anyone to acquire or expand capabilities for life saving. Admittedly , this denial comes in the very different context of forestalling an emergency override of prohibitions for the sake of medical research. But ought it not to carry over also to the context of resource allocation? Allocating Medical Resources 145 A clear affirmative answer has been advocated by Feinstein's grandson in law and disciple, S. Rapaport. Citing Feinstein's statement that "One has no duty to acquire knowledge of healing," he concludes: creating infrastructure not yet in existence, and likewise [conducting] medical research and development and training physicians in new fields ofexpertise, do rwt constitute a duty akin to actual life saving. Since in the [presently] obtaining conditions there is no cure for a particular illness-or no infrastructure for transplanting a particular organ-such a patient is in fact untreatable.3 Going a step beyond Feinstein, Rapaport does attach some value to enhancing future capabilities, but this value is rather modest. With respect to such a presently "untreatable " patient, Generating treatment for his illness is a valuable and worthT enterprise...