The tyranny of a kilogram : should we untie rather than cut the Gordian knot?

Howarth, Graham Robert (1999-12)

Thesis (MPhil) -- University of Stellenbosch, 1999.

Thesis

ENGLISH ABSTRACT: The number of babies requiring neonatal intensive care exceeds the facilities available. The assignment questions the perceived shortage of resources and investigates methods of resource allocation. The first chapter addresses the development of technology and reflects briefly on the romance between medicine and technology. The second chapter addresses the issue of prognosis of the small preterm neonate and reflects on how these data are derived and the assumptions that are often made based on prognostic data. Chapter three concentrates on how outcomes discussed in the second chapter may be quantified. Individual utility quantification plays a role in decision making for the individual neonate, while comparative utility quantification addresses some of the issues concerned with the macroallocation of resources. This leads into chapter four that addresses macroallocation and challenges some of the assumptions that resource allocation is based upon. Are resources scarce? Are there financial constraints? What is the role of medicine in health? Will redistribution of wealth necessarily improve the health of the population? Who should. make decisions for individual sick neonates regarding neonatal intensive care is addressed in the next chapter. The tension between sanctity-of-life and quality-of-life ideologies, created by life sustaining technology has been legally and ethically settled in favour of the patient's right to self-determination, based on the principle of respect for patient autonomy. It will however be argued that the traditional four principles cannot be utilised as the neonate is at best pre-autonomous. Moral obligations towards the neonate are dependent on the beneficence and non-maleficence obligations of the parents and the caregivers. Both these principles are prima facie and may have to be tempered by distributive justice. Plato's absolutist thinking and Descartes mathematician's perspective, have influenced medicine's romance with certainty. If knowledge and certainty are necessary for decision· making and it is shown that absolute certainty is elusive, should we be nihilistic about decision making in neonatal intensive care? Chapter 6 critically assesses three approaches to decision making in the presence of prognostic uncertainty. In contemporary medicine there is a constant tension between the traditional commitment to the patient on the one hand and the awareness that resources are finite on the other, this tension is an unfortunate reality of medicine. To constrain the growth of medical expenditure, doctors are now asked to serve simultaneously as society's agent of cost containment and as the patient's agent for maximum health. There is increasing pressure on doctors to serve two masters, society and the patient. Acting on behalf of society as a gatekeeper, while for the patient the doctor is expected to act as advocate. Chapter seven investigates both gate-keeping and advocacy and attempts to answer the question whether doctors can and indeed should try to serve two masters Simultaneously? The final chapter brings together the threads of the various extended arguments and attempts to give solutions to some of the conundrums.

AFRIKAANSE OPSOMMING: Die hoeveelheid babas wat neonatale intensiewe sorg benodig oorskry die beskikbare fasiliteite. Die taak bevraagteken die waameming van 'n tekort aan hulpbronne en ondersoek dus metodes van hulpbronallokasie. Die eerste hoofstuk bespreek die ontwikkeling van tegnologie en reflekteer kortliks oor die romanse tussen medisyne en tegnologie. Die tweede hoofstuk handel oor die uitslag van die prognose van die klein voortydse neonaat en reflekteer hoe die data afgelei word en die veronderstellings wat dikwels gemaak word, gebaseer op prognostiese data. Hoofstuk drie konsentreer op die bespreekte uitkomste van hoofstuk twee en hoe dit bepaal kan word. Nuttige individuele bepaling speel 'n rol tydens besluitneming ten opsigte van die individuele neonaat, andersyds, vergelykende nuttige bepaling spreek sommige van die punte ten opsigte van die makro-allokasie van hulpbronne aan. Laasgenoemde gee inleiding tot hoofstuk vier, wat makro-allokasie aanspreek en sommige van die aannames waarop hulpbronallokasie gebaseer is uitdaag. Is hulpbronne skaars? Is daar finansiele beperking? Wat is die rol van medisyne in gesondheid? Sal herverspreiding van rykdom noodwendig die gesondheid van die populasie verbeter? Wie verantwoordelik is vir besluitneming ten opsigte van die siek neonaat in intensiewe sorg word in die volgende hoofstuk bespreek. Die spanning tussen onskendbaarheid-van-lewe en kwaliteitvan-lewe ideologie, moontlik gemaak met behulp van lewens-onderhoudende tegnologie is wettig sowel as eties vasgestel ten gunste van die pasient se reg tot selfbeskikking, gebaseer op die beginsel van respek vir die pasient se selfbeskikking. Dit sal egter betwis word dat die tradisionele vier beginsels nie aangevoer kan word nie omdat die neonaat pre-outonomies is. Morele verpligtinge teenoor die neonaat is afhanklik van die weldadigheid en onskadelike verpligtinge van die ouers en versorgers. Seide hierdie beginsels is prima facie en sal moontlik deur verdelende reg getemper moet word. Plato se absolutistiese denke en Descartes se wiskundige perspektief het die medisyne se romantiek met sekerheid beinvloed. Indien kennis en sekerheid nodig is vir besluitneming en dit is bewys dat absolute sekerheid misleidend is, moet ons nihilisties wees oor besluitneming in neonatale intensiewe sorg? In Hoofstuk 6 word die drie benaderings tot besluitneming in die teenwoordigheid van prognostiese onsekerheid krities beraam. In die hedendaagse medisyne is daar 'n konstante spanning tussen die tradisionele verpligting teenoor die pasient aan die een kant en die bewustheid dat hulpbronne beperk is aan die ander kant - hierdie spanning is 'n tragiese werklikheid in die medisyne. Om sodoende die mediese uitgawe te beperk, word medici versoek om gelyktydig te dien as die gemeenskap se agent om koste te beperk asook die pasient se agent vir maksimum gesondheid. Daaris toenemende druk op Medici om twee meesters te dien - die gemeenskap en die pasient. Om op te tree as hekwagter namens die gemeenskap, terwyl daar van die dolder verwag word om namens die pasient as sy advokaat op te tree. Hoofstuk sewe ondersoek, beide die hekwagter en advokaat en daar word gepoog om die vraag te beantwoord of dolders kan en inderdaad durf poog om twee meesters gelyktydig te dien? Die finale hoofstuk dien as samebindende faldor van die verskeie uitgebreide argumente en pogings om oplossings te bied tot sommige van die vraagstukke.

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