The ethical challenges of healthcare and peak oil
An ethical conflict occurs whenever the rights of two or more people, or groups of people, come into conflict. Put another way, it occurs when everyone can't get what they want, and tough decisions need to be made about the allocation of scarce resources.
It is particularly likely that ethical dilemmas will arise during the redesign of the healthcare system as a response to peak oil. This is because there will be a conflict between what is best for society as a whole, versus what is best for the individual.
It is also likely that the quality of life, safety and material abundance that we currently enjoy will decline once oil becomes scarce and expensive. It is probable that the next few decades will be characterized by the scarcity of many things, necessitating the need for rationing of healthcare and other important services.
Ethics are important because:
- Reasoned and ethical action is a sign of a civilised society.
- Ethics includes the ideas of fairness, equality and compassion. I believe that we must strive to remain as ethical as possible, so that the best qualities of humans and their society may survive for the benefit of future generations.
- Ethical societies value and care for their young, old and infirm.
- A more ethical approach to the environment is needed for its survival, and our own.
- Medical practice has always been informed and guided by ethics.
- Doctors have an ethical duty to patients that should be absolute, regardless of the society in which they practice, or the conditions in which they find themselves.
A physician has three main ethical duties to patients:
- Beneficence: "do good"
- Non-maleficence: "do no harm"
- Respect for autonomy: "a patient's rights and preferences are important"
These ethical duties are inviolate, and should form the foundation upon which all further activity (including considerations of rationing) is built. Ethics must be considered in our response to peak oil if we are to remain a just and compassionate society.
Rationing presents peculiar ethical challenges, because the conflict between community and individual rights is brought into stark relief. And while health care systems already have some rationing (in the form of the Pharmaceutical Benefits Scheme and public hospital waiting lists in Australia, for example), it is likely that much tougher decisions will need to be made in the future. These decisions are likely to involve issues of life and death, such as who may have access to potentially life-saving treatment, and who may not.
The case of renal dialysis
Consider the example of renal dialysis (as it has been discussed extensively in the bioethical literature). It is a complex and expensive undertaking, and is already being rationed in New Zealand. They have introduced a strict and explicit system of rationing to determine who may have access to dialysis, and essentially who may die fairly quickly of end-stage renal failure. Their system relies on a set of clinical guidelines that were developed by a consensus process in the early 1990s, and considers age and the presence of significant co-morbidities. The intent was originally that no-one over the age of 75 years would be dialysed. The system has generated a large amount of controversy and public discussion, and has been tested in the courts at least twice.
Rationing inevitable regardless of peak oil
Even if oil peaking wasn't imminent, it is likely that the ethical dilemma of rationing would become increasingly important anyway. There are two reasons for this statement:
- Ageing populations in Western socities will need much more care as the get older, especially as the baby-boomers enter their seventies.
- As medical technology continues to produce technological breakthroughs, the cost to access these treatments goes up. This is because 'designer drugs' and 'magic bullets' are becoming more common but have very high development costs. As these sorts of treatments (termed pharmacogenomics) tend to be targeted at uncommon or rare conditions, the cost per patient is high so that research and development costs can be recovered. They also tend to be targeted at age-related diseases like cancer, so demand will increase significantly in the coming years.
It is clear then that sooner or later, countries like Australia will need to make tough decisions about health care rationing, which will result in serious illness or death for those that miss out. There is no way to dodge the magic bullets! The rights of the individual will always collide with the good of society, thereby producing ethical dilemmas.
Developing ethical decision-making frameworks
Coming resource scarcity, whatever the cause, is adequate motivation to develop an ethically-based framework that can guide fair and just decisions about resource allocation. Such a framework ensures that the decision-making process is transparent, and that it satisfies the ethical duties of honesty and disclosure. It also ensures that the concept of justice (in this case distributive justice) is incorporated by including a process of public consultation. An honestly conducted public enquiry satisfies the ethical duty of fairness, and should reduce conflict down the track by seeking consensus up-front.
Having explicit guidelines for clinical decision making is one of the two ways that healthcare rationing can be achieved. Explicit guidelines are prescriptive and relatively inflexible. The New Zealand experience shows that they may be open to legal challenge, or trigger widespread debate and dissent in a population. Even though the idea of such guidelines is attractive, there are several potential problems in addition to legality and public opinion:
- Fails to acknowledge that medicine is both art and science.
- Difficult to incorporate new information or clinical developments once treatment has started.
- Doesn't acknowledge clinically-relevant differences between patients.
- Relatively inflexible.
- Susceptible to outside influence (such as political or media pressure).
The other way of rationing scarce healthcare resources is through an implicit process. Such a system relies on the making of discretionary decisions within a fixed healthcare budget. Strategies include:
- Queuing (eg public hospital elective surgery waiting lists).
- Decreased service intensity (eg monthly therapy sessions instead of weekly ones).
- Substitution of less expensive services for more costly ones (eg generic medications).
- Excluding some treatments from the public system completely (eg weight loss medications and the PBS).
So while at first explicit guidelines seem more attractive, implicit rationing (within a given budget) seems better able to respond to the complex, diverse and rapidly-changing environment likely to occur after peak oil. It will also be more likely to have the speed and flexibility required to cope with shortages, natural disasters, accidents and civil unrest, and allows physicians to make exceptions to rules that seem unfair or unwise in specific instances.
It is a moral imperative that rationing be fair and just. It is also a practical one both politically and socially (to maximise the chances of re-election, and reduce the risk of revolt, respectively). Inequality in the distribution of goods is evident when favouritism or discrimination occurs: the process is then said to be unfair or unjust.
According to Kjellstrand (1996), there are three theories of justice that are frequently applied to medical decision-making:
- Egalitarianism – All people have intrinsic worth. Equal access to health care is a right. Need for services is the primary criterion to make decisions.
- Utilitarianism – Values the good of the community over the good of the individual. Equality subordinated to overall outcome.
- Libertarianism – Primacy of personal autonomy. No automatic right to healthcare. Healthcare is just another service for those who want and can afford it.
These three different views of the one ethical principle explain how conflict in resource allocation occurs. We need to recognise the difficulty, complexity and challenge of making decisions after oil peaking. We should favour processes that are as fair and honest as possible, but which retain their flexibility and are able to react to changing conditions quickly.
Values after peak oil
In the interests of stability and safety after peak oil (themselves utilitarian values), it is likely that the order of priority for the three theories listed above will be (1) utilitarianism; (2) egalitarianism; (3) libertarianism. This is because the good of the community will be of primary importance as our society adapts to changed and unstable conditions, and resource scarcity means that limited medical services must be allocated to maximise the greater good, and promote security and safety. For instance it is likely that workers and those with useful skills will receive treatment first, as the survival of the group will depend on the survival of the able-bodied and skilled. Although the order of the other two approaches will depend on local factors, one would hope that compassion and charity might remain important.
A new land ethic
Different ethical viewpoints make distinctions between those entities that count in a moral consideration, and those that don't. At one extreme is the belief that only living humans with the capacity to think are worthy of moral consideration. This viewpoint excludes the foetus, unborn future generations, and the natural world from consideration.
At the other extreme is the viewpoint of deep ecology, whereby all things are seen as being equal, morally important, as having intrinsic net worth, and as deserving of being treated in an ethical manner. This includes nature. The current state of our environment serves as evidence that our globalised industrial society doesn't extend basic moral protection to the natural world, thereby allowing phenomena such as the clear-felling of old-growth forests, strip-mining and global warming.
In contrast, many indigenous peoples held their environment in high regard, often to the point of sacredness. This reverence for the natural world is one of the factors that allowed some indigenous cultures to develop sustainable societies.
In a scarce oil future, it is envisaged that many of us will live in much closer approximation to nature, spend a significant part of our time working the land using low-tech methods, and depend on the health of local ecosystems for our own health and survival.
Although this article is about medical ethics and rationing, it is worthwhile considering the type of ethical approach to nature that will be required to achieve long-term sustainability in a relocalised future. The 'land ethic' of Aldo Leopold and the ethics of the permaculture system demand a respect for and partnership with nature that will be crucial to our survival. Both approaches acknowledge that natural things have intrinsic worth and moral standing. It logically follows then that they deserve to have the same ethics applied to them as we use for ourselves.
Once the place of nature in an ethical framework has been clarified, the preceding discussion on rationing can be used to determine the way that other goods (such as water, food, clothing, shelter and energy) are shared and distributed. Indigenous people used an oral tradition of stories, rules and taboos to disseminate and enforce their systems of land stewardship (for example a prohibition on hunting female animals during breeding season, or the way that water holes were to be managed during a drought). Hopefully we can formulate a similar system of ethics that includes all of nature as a moral being worthy of ethical consideration. Only in that way can we effectively deal with peak oil and energy descent.