Resource allocation in the Covid-19 health crisis: are Covid-19 preventive measures consistent with the Rule of Rescue?

The Covid-19 pandemic has led to a health crisis of a scale unprecedented in post-war Europe. In response, a large amount of healthcare resources have been redirected to Covid-19 preventive measures, for instance population-wide vaccination campaigns, large-scale SARS-CoV-2 testing, and the large-scale distribution of protective equipment (e.g., N95 respirators) to high-risk groups and hospitals and nursing homes. Despite the importance of these measures in epidemiological and economic terms, health economists and medical ethicists have been relatively silent about the ethical rationales underlying the large-scale allocation of healthcare resources to these measures. The present paper seeks to encourage this debate by demonstrating how the resource allocation to Covid-19 preventive measures can be understood through the paradigm of the Rule of Rescue, without claiming that the Rule of Rescue is the sole rationale of resource allocation in the Covid-19 pandemic.

Does NICE apply the rule of rescue in its approach to highly specialised technologies?

The National Institute for Health and Care Excellence (NICE), the UK’s main healthcare priority-setting body, recently reaffirmed a longstanding claim that in recommending technologies to the National Health Service it cannot apply the ‘rule of rescue’. This paper explores this claim by identifying key characteristics of the rule and establishing to what extent these are also features of NICE’s approach to evaluating ultra-orphan drugs through its highly specialised technologies (HST) programme. It argues that although NICE in all likelihood does not act because of the rule in prioritising these drugs, its actions in relation to HSTs are nevertheless in accordance with the rule and are not explained by the full articulation of any alternative set of rationales. That is, though NICE implies that its approach to HSTs is not motivated by the rule of rescue, it is not explicit about what else might justify this approach given NICE’s general concern with overall population need and value for money. As such, given NICE’s reliance on notions of procedural justice and its commitment to making the reasons for its priority-setting decisions public, the paper concludes that NICE’s claim to reject the rule is unhelpful and that NICE does not currently meet its own definition of a fair and transparent decision-maker.

RULE OF RESCUE E ASSISTÊNCIA FARMACÊUTICA NO BRASIL: O CASO DAS DOENÇAS RARAS

O artigo explora o rule of rescue como um critério para decisões de incorporação de tecnologias em sistemas de saúde. O conceito de rule of rescue é importante na decisão de incorporação de medicamentos órfãos, destinados a doenças raras, casos em que o exame da custo-efetividade das drogas nos parâmetros mais restritos da medicina baseada em evidências, determina a sua rejeição. Propõem-se duas questões: em primeiro lugar, se o rule of rescue exerceu impacto na doutrina produzida no campo do direito sanitário no Brasil, a partir de uma revisão bibliográfica das fontes. Em segundo lugar, investiga-se se a rule of rescue exerceu influência nas recomendações de incorporação de medicamentos pela Conitec, sobretudo no campo das doenças raras, no período compreendido entre 2012 e 2018. Na primeira parte do trabalho, é apresentado o processo institucional de incorporação de medicamentos no Brasil e o tema da incorporação dos medicamentos órfãos. Na segunda parte, parte-se para as questões propostas. A metodologia empregada para avaliar o impacto doutrinário do princípio é a da revisão bibliográfica, focando nos periódicos especializados em direito sanitário no Brasil. Com relação ao segundo problema, buscou-se identificar as recomendações da Conitec que envolviam doenças raras, e, nesses relatórios, foram identificados, no tópico da discussão, a fundamentação da conclusão pela incorporação ou não, buscando identificar a presença do rule of rescue. As conclusões indicam que os fundamentos da incorporação e da não incorporação não levam em consideração nenhuma forma de rule of rescue, o que sinaliza para uma possibilidade de aperfeiçoamento desse processo.

The ethical case for global measles eradication—justice and the Rule of Rescue

Measles causes a substantial disease burden for all countries, while mortality is greatest in underserved, marginalized populations. Global measles eradication is feasible and the strategies critically rely upon well-functioning national immunisation programs and surveillance systems. All six regions of the World Health Organisation have adopted measles elimination targets. The Rule of Rescue and the principle of justice leave no ethical place for health programs, governments, global public health bodies or donors to hide if they impede efforts to eradicate measles globally by not taking all necessary actions to establish a global eradication target and committing the resources essential to achieve this goal.

Cardiopulmonary Resuscitation and the Presumption of Informed Consent

Cardiopulmonary Resuscitation (CPR) is the default response for persons who suffer cardiac or pulmonary arrest, except in cases in which there exists a do-not-resuscitate order. This default mindset is based on the rule of rescue and the ethical principle of beneficence. However, due to the lack of efficacy and the high risk of potential harm inherent in CPR, this procedure should not be the default intervention for cardiac or pulmonary arrest. Although CPR is a lifesaving medical intervention, it has limited positive results and the potential for multiple harmful consequences. Given the limited potential of CPR as a medical procedure, clinicians and patients must be educated regarding its limited potential, and procedures must be developed to help determine when it is appropriate as a medical intervention.

Attitudes of health professionals concerning bedside rationing criteria: a survey from Portugal

This paper tests the factorial structure of a questionnaire comprising seven health care rationing criteria (waiting time, ‘rule of rescue’, parenthood of minors, health maximization, youngest first, positive and negative version of social merit) and explores the adherence to them of 254 Portuguese health care professionals, when considered individually and when confronted with two-in-two combinations. Data were collected through a self-administered questionnaire where respondents faced hypothetical rationing dilemmas comprising one rationing criterion and dichotomous options pairs with two rationing criteria. Confirmatory factor analysis and multinomial logistic regressions were used to validate the structure of the questionnaire and the data. The findings suggest that: (i) the hepta-factorial structure of the questionnaire presented a good fit of the data; and (ii) support for rationing criterion depends on whether they are individually considered or confronted in dichotomous options pairs. When only one criterion distinguishes the patients, healthcare professionals support six criteria (by descending order): waiting time, rule of rescue, health maximization, penalization of patients’ risky behaviors, youngest first and being parent of a young child. When two criteria were confronted, immediate threat of life/health and large expected benefits were the most preferred. Conversely, the positive version of social merit was an unappreciated rationing criterion.

Nahfolgen, Fernfolgen, zurechenbare Folgen – warum es nicht ohne das Konzept der Zurechnung geht

ZusammenfassungBreyer und Kliemt opponieren anscheinend nur gegen eine meiner 3 Thesen: dass die Allokationspräferenzen, die in der Priorisierungsdebatte unter dem Stichwort „Rule of Rescue“ diskutiert werden, nicht irrational seien. Den neuerdings gegen die einschlägige Praxis erhobenen Diskriminierungsvorwurf, den ich ebenfalls kritisiere, wollen die Kommentatoren ausdrücklich nicht verteidigen. Zusätzlich habe ich, drittens, die These vertreten, dass beide Vorwürfe – der Irrationalitätsvorwurf ebenso wie der Diskriminierungsvorwurf – auf einem Mangel an handlungstheoretischer Reflexion beruhen. Darauf nehmen Breyer und Kliemt in ihrem Beitrag nicht Bezug. In der Replik soll deutlich werden, dass es sich gelohnt hätte, diesen Hinweis auf die grundbegrifflichen Quellen der Debatte ernster zu nehmen. Auch meine Ausführungen zum Melanom-Beispiel wären dann anders gelesen worden. Sie belegen nämlich nicht, dass ich mich der Kosten-Nutzen-Abwägung auch selbst bediene.

Ist die „Rule of Rescue“ noch zu retten? Eine Antwort auf Weyma Lübbes „Rule of Rescue vs. Rettung statistischer Leben“

ZusammenfassungWeyma Lübbe adelt in ihrem Aufsatz „Rule of Rescue vs. Rettung statistischer Leben“ [1] die der „Rule of Rescue“ entsprechenden spontanen Wünsche zu „bürgerschaftlichen Urteilen“. Die Urteile und Wünsche der Bürger müssen zweifelsohne im demokratischen Rechtsstaat letztlich ausschlaggebend sein. Insbesondere in der Gesundheitspolitik bedarf die Voreingenommenheit für nahe- gegenüber fernliegenden, für konkrete gegenüber abstrakten Folgen aber eher der Korrektur als der Affirmation. Der „Rule of Rescue“ ist der durch ihre Verwirklichung im Gesundheitswesen entgehende Nutzen gegenüberzustellen. Eine gesundheitsökonomische Information über ihre „Opportunitätskosten“ ist Teil der „gesundheitsethischen Aufklärung“ der Bürger und nicht Teil eines Kampfes gegen die „Rule of Rescue“.