Alternative medications: evidence, safety, and efficacy debate

Micro-Allocation

In the scheme of things the debate that Warren, Doran, and Patrick (Larry, Moe, and Curly would have been better) undergo regarding how limited resources should allocated in the medical field is in effect a "catch 22" situation. If any nurse or physician in a situation in line with the one Alice and Gurpreet were in such as being in a small rural area, everybody knows everybody, massive emergency situation, people with the same level of need and urgency, temporarily depleted resource base, etc., there would be no course of action that will satisfy every point-of-view under every outcome with the exception of one where everybody receiving the resources ends up with the best possible result. In effect the people who make these decisions make snap decisions based on a combination of their subjective views, training, and assessment of the relevant variables. Decisions like this are often based on mental heuristics, which are inevitably flawed in making decisions whose outcomes are ruled by probabilities. The person making the decision will later rationalize their decision from a totally different point-of-view than the one under which the decision was made. Snap decisions are made by one set of mental faculties (automatic mental processes); whereas rationalizations are made by the other set of mental processes (control mental processes). In the end, the outcome dictates the validity of the choices made. In current debate, if no one died and everyone came out of the emergency with the best possible result there would be little debate on the decisions made regarding who got treated first. However, that scenario is one many possible outcomes and the probability that it would occur is most likely very small (if it even really exists, because who can speculate what the "best" outcome for everyone would be). Having stated that there major flaws in the thinking of all parties involved.

First, the "worst first" scenario is indeed a standard in ED care; however, the key to actually applying it is Patrick's notion of impartiality, which is freedom from bias. Unfortunately, Patrick slips up when he states that these allocations should "usually" be impartial (what?) but at times should be consistent with human sympathy (huh?). So in effect Patrick is saying that decisions regarding the allocation of limited resources should be impartial when they are not biased. Well thank you Patrick. This really gets messed up when we have the worst first, first come first serve, hopeless second scenario. Technically a hopeless patient is worse than a non-hopeless patient and the designation of hopelessness is more often than not a value judgment. In a snap decision, without established protocols, deciding what patients are hopeless and what patients are not is a subjective decision made by the decision maker. In fact, the ideas of mitigating factors, excuses, and justifications all stem from subjective points-of-view. While I agree with the chapter's statement impartiality is often wrongly equated with fairness, it is also the case that when there is a micro-allocation of resources in an ER the only fair protocol is one of impartiality based on a strict decision tree. Fairness is really a subjective term and in order for such a distribution to truly offer valid considerations to everyone involved it must be impartial. In other in others the only allocation that is objectively fair by definition is one that is impartial.

From a true impartial medical standpoint (and not necessarily a societal one) it does matter if two equally critical patients (by the way there is no such thing) differ in social status or some other quality. What matters is which fits the protocol to receive treatment If one patient has a massive brain trauma and the other a MI, both of which are critical, the only impartial way to choose between the two would be a choice based on actuarial data of survival rates and treatability (more on this shortly). The doctor vs. drunk scenario, parent vs. childless, infective disease vs. non-infective disease scenarios are really not relevant to the allocation question when discussing medical issues. The only impartial method to allocate limited medical resources is based on the worst first and the first come first serve principles. However, the worst-first factor is mediated by the terminal case scenario (Patrick's notion of the hopeless patient). As stated above deciding what cases are indeed truly "hopeless" can be subjective and therefore open to bias when made on the basis of a human decision. The key to making such allocations impartial is to remove the human error factor from them.

How can human error be removed from such decisions one? It is actually much simpler than one might believe. There is a huge literature on clinical vs. actuarial decision-making in the behavioral science literature and in the medical literature. As it turns out, actuarial decisions are superior to human clinical judgment in the vast number of empirical investigations published regarding clinical decision making. The reason for this is quite simple: actuarial decisions take into account probabilities; clinical judgments (human decision making) often do not take them into account or misconstrue the relevant probabilities. As it turns out the human mind is not really very good at making decisions that probability based. However, given the vast amount of medical data available it would be very easy to develop computer programs that make such emergent decisions based on worst-first, first come first serve, terminal cases come second principles. The data could be updated to reflect changing medical treatments and of course could easily be made available to every hospital and clinic everywhere. This would be the only impartial allocation method. Allocation decisions would be made on the basis of actuarial data.