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To save – a dramatic decision

The public and future administrators accept the selection of patients

ED. 53 | MAY 2000


Two men, injured in a car crash, arrive at the emergency ward of a public hospital on the outskirts of São Paulo. One is 25 years of age and the other 65 years of age. There is only one vacancy. Which one of them should receive attention? The question was asked of two groups. One representative of the public in general, the second, students of hospital administration. The results were very different.
The public in general opted for the 65 year-old man. The older, determined these people, had a greater necessity for treatment than the younger man. The students gave their priority to the man of 25 years of age.

Their argument was that the expenses taken on by the hospital, in this case, would have a greater benefit. This type of reaction gained ground during the academic time of the students. Within the 1st year students the proportion in favor of the 25 year-old man was 51.5%. In the 4th and final year students it rose to 92%

“One of the most relevant factors in this type of work is the option of the hospital administration students for the alternative which gives less costs to the hospital”, says  Paulo Antônio de Carvalho Fortes, professor of Ethics of  School of Public Health of the University of São Paulo (USP) and coordinator of the research. “However, one of the most important conclusions is the very fact that the users of the public system of health, accept that it is necessary to have criteria to define who will have priority of attention”, he adds.

The research, called The Dilemma to Decide Who Should Live, which took place with the help of FAPESP, collected the testimonies, in one of its stages, from 400 people, both men and women, who accompanied women in labor attended to at the Public Hospital of Diadema, one of the poorest municipalities in the metropolitan area of São Paulo. The area was chosen because the research wanted to listen to needy people those without another option of healthcare other than an unit of public service health. In another stage, testimonies were taken from 64 students in their 1st year, and 25 students in 4th and final years of the graduation course in hospital administration of São Paulo.

The institution in which the course took place requested anonymity in the use of its name in exchange for the authorization for the carrying out of the research within its student body. In both cases, 15 options were presented of which those interviewed had to choose between one and another case as having the preference for attention. It was the first time that such an investigation was carried out in Brazil.

“There have been similar investigation in Australia, in England and in the United States, but they involved only situations of intensive therapy, transplants and new technologies”, he informs.  “In countries such as France or England, this type of research can’t even take place, since for a citizen of this these countries it is inconceivable that there will not be a hospital place and a choice has to be made”, he says. “In France, over the last few years, was only one case of non-admittance, considered as an omission of help to a patient and the person responsible is in prison.”

In Brazil, says the professor, the needs of the public health system are so huge that the population has resigned itself to the existence of unequal access to medical treatment. One sign of this is the relatively small proportion of 5% of the people asked who refused to answer in full the questionnaire. In the English and Australian investigations those refusing varied between 30 % and 40 %. “The low level of refusals is yet another indicator that our society admits to the necessity of having social criteria for making a choice of this type”, declares Fortes.

A characteristic of the replies of the general public was the constant preference for people socially more needy. The preference for the elderly of 65 years of age in relation to the adult of 25 years of age, is an example of this, according to Fortes. Another example was the fact that the general public had opted for help for a 1 year-old child over a child of 7 years of age. Once more the students of hospital administration had a contrary reaction. The students of 1st year preferred the child of  7 years in the proportion of 60% and by the 4th year the preference had risen to 71%

Another difference came up in the case of two people, one a smoker and the other a non-smoker, attended to with a crisis of bronchitis. Around half of the people interviewed  the general public opted for attention for the smoker, probably understanding that smoking should not be a considered a factor of negative discrimination. Among the students, 84% of the final year students made the option of the non-smoker. The alcoholics, for their part, had general  condemnation. For the public, people with this habit “look for the sickness. ” On the other hand, a case involving a woman with HIV positive, sick with pneumonia, provoked compassion among the general public interviewed. She was considered a victim of her situation.

Clear options
Other preferences which came out very clearly were: the consideration for a married woman in relation to a single woman; that of a mother with three children in relation to a mother with one child; to a woman in relation to a man; to a woman with hepatitis in relation to an alcoholic. In the case of the student interviews, one of the objectives was to evaluate to which point the students of the final year had absorbed the values passed to them by the course. In a few cases, there was even an inversion of the values between the two groups. For example, in 1st year, with 75%, the preference for giving attention was for a working man who suffered from a heart crisis. In the final year, with 64%,  the preference shifted for an unemployed man.

According to Fortes, the usually say that when confronted with a decision of this type, they are guided by exclusively technical criteria. However, it is undeniable that social and socio-medical criteria are taken into account. For this reason, he intends to carry out the same survey  with doctors and other health professionals. “Only then will it be possible to draw conclusions about the motives of the doctors when taking decisions which go beyond technical criteria“, he states.

Fortes says that he is against the idea that there should be criteria which are non-technical when defining priorities for patient care. However, he admits that in the face of the difficulties for universal care in the Brazilian health system, this idea transformed itself into a utopia. Thus, he says, if it was necessary for the existence as well of social criteria or socio-medical “they need to be the fruit of a debate and of the consent of society.”

Two lines
For the professor, there are two very sharp lines of criteria for the options of Brazilian culture. One is that which is called utilitarian ethics, which looks to take decisions based on cost to benefits. The other tends to privilege the less favored. “The demarcation line in this situation of ethical diversity must be given through the guarantee of the respect for human dignity”, he says. “For this to happen, the rule must be obeyed that each individual must be treated as an end in himself, not only as a means for the satisfaction of a third party, for science, for scientists or of industrial or commercial interests.”

The technical criteria claimed by doctors, in general, are founded on what is presented as a scientific goal. Amongst them are clinical efficiency; the possibility of preventative actions; the vulnerability of the sickness to existing technology; the time necessary for the treatment; the seriousness of the illness; and the emergency situation.

The non-technical criteria, for their part, are not always presented with such clarity. “ Criteria socio-medical are used, such as cooperation, age, sex, progress of science, quality of benefit, cost efficiency, cost – benefit, work force to be potentially affected and recuperation, life potential, adjusted quality of life years and support environment for the continuation of treatment”, says Fortes. To them you can add social criteria, such as family conditions, social usefulness, barriers to the access of a continuation of treatment, social merit, social responsibility, level of income and productivity.

Different positions
One cannot say that doctors adopt one position or another regarding  the ethical dilemmas which go beyond technical questions. This depends on the general posture of the hospital in which he is working and of the individual’s own position. Fortes cited, as an example, the Childrens’s  Institute, where he worked there in the middle of the 80s. Even when receiving a patient sent by mistake by another hospital or from another municipality, the child was always considered the responsibility of the hospital. “He would only leave, if that was the case, with an order, negotiated and sealed with another hospital”, he explains.

Another underlined point for Fortes is the fact that Brazil, in international terms, is not so badly off when considering the availability of hospital beds. The proportion recommended by the World Health Organization (WHO) is of 4 beds per 1,000 inhabitants. Brazil has 3.2 per 1000. Logically, we are a long way form countries such as France with 9.2 per 1,000 inhabitants, and Germany with 8.3 per 1000. However, the main Brazilian problem, according to the professor, is the existence of the enormous regional and micro regional disparities.

Fortes calls the attention to the attempts to bring to Brazil a procedure introduced in the United States, the managed care in which the doctor is obliged to submit himself to norms of administrative control which end up limiting his autonomy  concerning decisions about the necessity of the treatment of a person. Fortes singles-out that the Regional Medical Board f São Paulo has been reacting against these attempts. “the system is advancing well in the United States but comes up against resistance in many sectors and the American Congress intends o introduce rules with respect to it”, he declares.

Paulo Antônio de Carvalho Fortes, is 49 years of age and lectures at the Department of Public Health Practice in the Public Health School f the University of São Paulo (USP). He is a master in Pediatrics and a doctor in Public Health. He is part of  the  [National Council of Research Ethics(Conep).

The Dilemma of Deciding Who Should Live; Investment: R$ 5.700,00

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