[CASE REPORT: LEGAL, PSYCHOLOGICAL AND ETHICAL ASPECTS OF THE DYING PATIENT ACT].

INTRODUCTION: We present a patient with amyotrophic lateral sclerosis (ALS), dependent on noninvasive ventilation, whose advance directives precluded life-prolonging measures. The patient was found in cardiac arrest and in accordance with the directives of her surrogate decision maker, underwent intubation and mechanical ventilation. Later, an additional surrogate decision maker disapproved of ventilation and when the ventilator was disconnected for bronchial suctioning, she asked the nurse not to reconnect the patient to the ventilator. We discuss the legal, psychological and ethical aspects of implementation of Israeli law in this complex patient.

Efficiency and equity considerations in the preferences of health policy-makers in Israel.

BACKGROUND: There is a traditional tension in public policy between the maximization of welfare from given resources (efficiency) and considerations related to the distribution of welfare among the population and to social justice (equity). The aim of this paper is to measure the relative weights of the efficiency- and equity-enhancing criteria in the preferences of health policy-makers in Israel, and to compare the Israeli results with those of other countries. METHODS: We used the criteria of efficiency and equity which were adopted in a previous international study, adapted to Israel. The equity criteria, as defined in the international study, are: severity of the disease, age (young vs. elderly), and the extent to which the poor are subsidized. Efficiency is represented by the criteria: the potential number of beneficiaries, the extent of the health benefits to the patient, and the results of economic assessments (cost per QALY gained). We contacted 147 policy-makers, 65 of whom completed the survey (a response rate of 44%). Using Discrete Choice Experiment (DCE) methodology by 1000Minds software, we estimated the relative weights of these seven criteria, and predicted the desirability of technologies characterized by profiles of the criteria. RESULTS: The overall weight attached to the four efficiency criteria was 46% and that of the three equity criteria was 54%. The most important criteria were "financing of the technology is required so that the poor will be able to receive it" and the level of individual benefit. "The technology is intended to be used by the elderly" criterion appeared as the least important, taking the seventh place. Policy-makers who had experience as members of the Basket Committee appear to prefer efficiency criteria more than those who had never participated in the Basket Committee deliberations. While the efficiency consideration gained preference in most countries studied, Israel is unique in its balance between the weights attached to equity and efficiency considerations by health policy-makers. DISCUSSION: The study explored the trade-off between efficiency and equity considerations in the preferences of health policy-makers in Israel. The way these declarative preferences have been expressed in actual policy decisions remains to be explored.

Which health technologies should be funded? A prioritization framework based explicitly on value for money.

BACKGROUND: Deciding which health technologies to fund involves confronting some of the most difficult choices in medicine. As for other countries, the Israeli health system is faced each year with having to make these difficult decisions. The Public National Advisory Committee, known as 'the Basket Committee', selects new technologies for the basic list of health care that all Israelis are entitled to access, known as the 'health basket'. We introduce a framework for health technology prioritization based explicitly on value for money that enables the main variables considered by decision-makers to be explicitly included. Although the framework's exposition is in terms of the Basket Committee selecting new technologies for Israel's health basket, we believe that the framework would also work well for other countries. METHODS: Our proposed prioritization framework involves comparing four main variables for each technology: 1. Incremental benefits, including 'equity benefits', to Israel's population; 2. Incremental total cost to Israel's health system; 3. Quality of evidence; and 4. Any additional 'X-factors' not elsewhere included, such as strategic or legal factors, etc. Applying methodology from multi-criteria decision analysis, the multiple dimensions comprising the first variable are aggregated via a points system. RESULTS: The four variables are combined for each technology and compared across the technologies in the 'Value for Money (VfM) Chart'. The VfM Chart can be used to identify technologies that are good value for money, and, given a budget constraint, to select technologies that should be funded. This is demonstrated using 18 illustrative technologies. CONCLUSIONS: The VfM Chart is an intuitively appealing decision-support tool for helping decision-makers to focus on the inherent tradeoffs involved in health technology prioritization. Such deliberations can be performed in a systematic and transparent fashion that can also be easily communicated to stakeholders, including the general public. Possible future research includes pilot-testing the VfM Chart using real-world data. Ideally, this would involve working with the Basket Committee. Likewise, the framework could be tested and applied by health technology prioritization agencies in other countries.

Shared decision-making in Israel: status, barriers, and recommendations.

Shared decision making (SDM) - involving patients in decisions relevant to their health - has been increasingly influential in medical thought and practice around the world. This paper reviews the current status of SDM in Israel, including efforts to promote SDM in the legislation and healthcare system, its influence in medical training and the national health plans, and funding for SDM-related research. Published studies of SDM in Israel are also reviewed. Although informed consent and patients' right to information are regulated by Israeli law, little provision is made for SDM. Further, there are few organized programs to promote SDM among medical professionals or the public, and governmental support of SDM-related research is minimal. Nonetheless, patients have begun to influence litigation in both formal and informal capacities, medical schools have begun to incorporate courses for improving physician-patient communication into their curricula, and the largest national health plan has initiated a plan to increase public awareness. A review of the limited research literature suggests that although patients and physicians express a desire for greater patient involvement, they often have reservations about its implementation. Research also suggests that despite the positive effects of SDM, such an approach may only infrequently be applied in actual clinical practice. In conclusion, though not actively promoting SDM at present, Israel's universal coverage and small number of health plans make rapid, widespread advances in SDM feasible. Israeli policymakers should thus be encouraged to nurture burgeoning initiatives and set plausible milestones. Comparing the status of SDM in Israel with that in other countries may stimulate further advancement.

Should we provide life-sustaining treatments to patients with permanent loss of cognitive capacities?

A very troubling issue for health care systems today is that of life-sustaining treatment for patients who have permanently lost their cognitive capacities. These include patients in persistent vegetative state (PVS), or minimally conscious state (MCS), as well as a growing population of patients at the very end stage of dementia. These patients are totally dependent on life-sustaining treatments and are, actually, kept alive "artificially." This phenomenon raises doubts as to the ethics of sustaining the life of patients who have lost their consciousness and cognitive capacities, and whether there is a moral obligation to do so. The problem is that the main facts concerning the experiences and well-being of such patients and their wishes are unknown. Hence the framework of the four principles-beneficence, non-maleficence, autonomy, and justice-is not applicable in these cases; therefore we examined solidarity as another moral value to which we may resort in dealing with this dilemma. This article shows that the source of the dilemma is the social attitudes towards loss of cognitive capacities, and the perception of this state as loss of personhood. Consequently, it is suggested that the principle of solidarity-which both sets an obligation to care for the worst-off, and can be used to identify obligations that appeal to an ethos of behavior-can serve as a guiding principle for resolving the dilemma. The value of solidarity can lead society to care for these patients and not deny them basic care and life-sustaining treatment when appropriate.

The status of shared decision making and citizen participation in Israeli medicine.

WHAT ABOUT POLICY REGARDING SDM? Though informed consent and patients' right to information are regulated by Israeli law, there is a low level of formal activities focused on shared decision making (SDM) in Israel. Further, there are few organized programs to promote SDM among medical professionals or the public, and governmental support of SDM-related research is minimal. WHAT ABOUT TOOLS - DECISION SUPPORT FOR PATIENTS? The Israeli government does not have a program on development of patient decision aids. WHAT ABOUT PROFESSIONAL INTEREST AND IMPLEMENTATION? Nonetheless, patients have begun to influence litigation in both formal and informal capacities, medical schools have begun to incorporate courses for improving physician-patient communication into their curricula, and the largest national health plan has initiated a plan to increase pubic awareness. Funding for researching and promoting SDM is not centrally allocated, and studies show that despite the positive effects of SDM, such an approach is infrequently applied in actual clinical practice, and initiatives to promote SDM (e.g., decision aids) are in their infancy. WHAT DOES THE FUTURE LOOK LIKE? In conclusion, though not actively promoting SDM at present, Israel, with its governmentally regulated universal coverage with good access to high-level services possesses all the requisite elements for rapid, widespread advances in SDM in future years.

Touching ethics: assessing the applicability of ethical rules for safe touch in CAM--outcomes of a CAM (complementary and alternative medicine) practitioner survey in Israel.

INTRODUCTION: Recently, ethical guidelines regarding safe touch in CAM were developed in Israel. Publishing ethical codes does not imply that they will actually help practitioners to meet ethical care standards. The effectiveness of ethical rules depends on familiarity with the code and its content. In addition, critical self-examination of the code by individual members of the profession is required to reflect on the moral commitments encompassed in the code. METHODS: For the purpose of dynamic self-appraisal, we devised a survey to assess how CAM practitioners view the suggested ethical guidelines for safe touch. We surveyed 781 CAM practitioners regarding their perspectives on the safe-touch code. RESULTS: There was a high level of agreement with general statements regarding ethics pertaining to safe touch with a mean rate of agreement of 4.61 out of a maximum of 5. Practitioners concurred substantially with practice guidelines for appropriate touch with a mean rate of agreement of 4.16 out of a maximum of 5. Attitudes toward the necessity to touch intimate areas for treatment purposes varied with 78.6% of respondents strongly disagreeing with any notion of need to touch intimate areas during treatment. 7.9% neither disagreed nor agreed, 7.9% slightly agreed, and 7.6% strongly agreed with the need for touching intimate areas during treatment. There was a direct correlation between disagreement with touching intimate areas for therapeutic purposes and agreement with general statements regarding ethics of safe touch (Spearman r=0.177, p<0.0001), and practice guidelines for appropriate touch (r=0.092, p=0.012). CONCLUSION: A substantial number of practitioners agreed with the code, although some findings regarding the need to touch intimate area during treatments were disturbing. Our findings can serve as a basis for ethical code development and implementation, as well as for educating CAM practitioners on the ethics of touch.

Health technology prioritization: which criteria for prioritizing new technologies and what are their relative weights?

OBJECTIVES: To review the criteria and 'other' considerations used internationally for prioritizing new health technologies, and to demonstrate a conjoint-analysis methodology (also known as discrete choice experiments) for deriving relative weights for the criteria. METHODS: We searched the literature for criteria and other considerations for prioritizing new technologies. A convenience sample of 74 respondents completed a conjoint-analysis survey involving criteria related to technologies' 'benefits'. RESULTS: Encompassing 11 countries and the US state of Oregon, we were able to distinguish three main groups of criteria: (a) Need, appropriateness and clinical benefits; (b) Efficiency (including cost-effectiveness); and (c) Equality, solidarity and other ethical or social values. For several countries, the quality of the clinical and economic evidence and factors related to strategic issues and procedural justice respectively are also considered. The criteria and their weights from the conjoint-analysis survey are: 'Lives saved'=0.343, 'Life-prolongation benefits'=0.243, 'Quality-of-life gains'=0.217, a criterion representing the availability of alternative treatments=0.107, and 'Other important social/ethical benefits'=0.087. CONCLUSIONS: The criteria represent a pluralistic combination of needs-based, maximizing and egalitarian principles, and we demonstrated a methodology for deriving the weights for criteria related to technologies' 'benefits'.

Development of ethical rules for boundaries of touch in complementary medicine--outcomes of a Delphi process.

The practice of complementary medicine (CAM) often involves touch. The unique philosophy of many CAM therapies, and the setting in which treatments are provided create a therapeutic space which may be less clearly defined than in conventional settings - a space in which the boundaries between professional touch and personal/intimate touch may become easily obscured. Thus, complementary therapists need clear definitions and firm boundaries in order to maintain therapeutic efficacy and commitment. The aim of the process described in this article, was to develop ethical guidelines for boundaries of touch that will promote the safety and protection of the public which use CAM. Through a modified Delphi process, a diverse group of CAM practitioners, physicians, ethicists, legal consultants, health policy specialists, and representatives from the public, developed Ethical Rules for Boundaries of Touch in CAM. These guidelines may be implemented in ethical codes of professional CAM organizations, and also serve as a foundation for curriculums in ethics in CAM schools.

The right to treatment for self-inflicted conditions.

The increasing awareness of personal health responsibility had led to the claim that patients with 'self-inflicted' conditions have less of a right to treatment at the public's expense than patients whose conditions arose from 'uncontrollable' causes. This paper suggests that regardless of any social decision as to the limits and scope of individual responsibility for health, the moral framework for discussing this issue is equality. In order to reach a consensus, discourse should be according to the common basis of all theories of justice, Aristotle's formal principle of justice: 'equals must be treated equally and unequals must be treated unequally, in proportion to the relevant inequality'. This paper deals with the question of whether and under what circumstances risk-taking behaviour could be regarded as a 'relevant inequality' with respect to the right to health care. Following a discussion of the relevant inequalities in health care, the conclusion is reached that the fact that the condition was avoidably caused by the patient and is therefore his or her fault can not be regarded necessarily as a relevant inequality. Therefore, the issue is one of societal support for health care; after defining relevant inequalities in this respect, the paper attempts to apply them to self-inflicted conditions. This analysis reveals that, in theory, it may be just to restrict societal support in such cases. However, the application of this conclusion requires proof of many factual claims-for which there is often very limited evidence.

[Advance directives for end-of-life care].

The provision of care for the dying patient confronts the caring team with very complex ethical dilemmas that doctors have no "medical" means to manage. Such decisions should be made according to the patient's will and preferences reflecting the value of life and the quality of life. However, many patients are not competent at this stage to decide or to express their wishes. Therefore, the Dying Patient Law of 2005, recognized advance expression of will through advance directives and power of attorney. Yet, there are many difficulties in the actual application of this idea. Dr. Shalev's article in this issue, to which this editorial relates, discusses the problems of communication between doctor and patient at the stage of preparing advance directives, and suggests a way to handle these deliberations. The Israeli law of 2005 provides some original solutions to other obstacles presented in the Literature as causing "the failure of the Living will". One resolution is the requirement that an explanation of the relevant medical information be given by a doctor or a nurse to the person who wishes to prepare written advance directives. This article suggests that the required explanation should be given within the framework of a discussion that simulates a process of informed consent for an unknown scenario at the end-of-life. Such discussions should be conducted as a dialogue, in which the doctor, first and foremost, Listens to the patient in order to clarify his/her worries and wishes, according to which specific medical orders can then be formulated.

Ethical issues in integrative oncology.

Integrative oncology relates to an emerging dialog between complementary and alternative medicine (CAM) scholars, oncologists, family practitioners, and other health care providers who envision an extended and holistic patient-centered approach to oncology care. The multiple commitments of integrative oncology to a medical humanistic approach and to a strong evidence-based foundation may impose considerable ethical concerns and dilemmas. The authors use narrative ethics to present a case study that exemplifies the ethical challenges confronting physicians and health care providers who wish to provide an integrative approach for their patients. An ethical analysis of the narrative is provided to help clarify the ethical issues and conflicts within it. Finally, a framework that may transform ethical constraints to a communication tool is proposed.