Withdrawing or withholding treatments in health care rationing: an interview study on ethical views and implications.

BACKGROUND: When rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a 'grandfather clause' when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians' and patient organization representatives' experiences- and perceptions of withdrawing and withholding treatments in rationing situations of relative scarcity. METHODS: Fourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used. RESULTS: Participants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients' need for treatment (e.g., the treatment's effectiveness and the patient's medical condition) withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers. CONCLUSIONS: We conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment's effect, and to provide guidelines on a national level.

Withdrawing versus Withholding Treatments in Medical Reimbursement Decisions: A Study on Public Attitudes.

BACKGROUND: The use of policies in medical treatment reimbursement decisions, in which only future patients are affected, prompts a moral dilemma: is there an ethical difference between withdrawing and withholding treatment? DESIGN: Through a preregistered behavioral experiment involving 1,067 participants, we tested variations in public attitudes concerning withdrawing and withholding treatments at both the bedside and policy levels. RESULTS: In line with our first hypothesis, participants were more supportive of rationing decisions presented as withholding treatments compared with withdrawing treatments. Contrary to our second prestated hypothesis, participants were more supportive of decisions to withdraw treatment made at the bedside level compared with similar decisions made at the policy level. IMPLICATIONS: Our findings provide behavioral insights that help explain the common use of policies affecting only future patients in medical reimbursement decisions, despite normative concerns of such policies. In addition, our results may have implications for communication strategies when making decisions regarding treatment reimbursement. HIGHLIGHTS: We explore public' attitudes toward withdrawing and withholding treatments and how the decision level (bedside or policy level) matters.People were more supportive of withholding medical treatment than of withdrawing equivalent treatment.People were more supportive of treatment withdrawal made at the bedside than at the policy level.Our findings help clarify why common-use policies, which impact only future patients in medical reimbursement decision, are implemented despite the normative concerns associted with thesepolicies.

Public Attitudes Toward Priority Setting Principles in Health Care During COVID-19.

What role should cost-effectiveness play in health care priority setting? We assess the level of acceptance toward different priority setting principles in health care during COVID-19 and in general, thereby exploring public support for principles presented at different levels of abstraction. An online survey was distributed to a diverse sample of the Swedish population (n = 1 553). The results show that respondents were generally more supportive of priority setting principles when expressed in general abstract terms than when expressed in more case specific concrete terms. However, prioritization based on cost-effectiveness was deemed as more acceptable when expressed in concrete terms related to health maximization rather than as an abstract principle. Respondents had a general inclination in support of physicians and other health care professionals the primary responsibility for the allocation of scarce resources in the healthcare during COVID-19, while being less supportive of health economists and politicians being involved in these decisions.

Medical Decision Style and COVID-19 Behavior.

Given the flood of health-related information stirred up by the coronavirus disease 2019 (COVID-19) pandemic, it is important to understand the factors that influence people to engage in protective public health measures so that medical communication can be tailored to be effective. Following the idea that people have a general inclination toward health care utilization, which is either more passive (i.e., medical minimizer) or more aggressive (i.e., medical maximizer), we assess if this inclination extends to being more or less willing to engage in protective public health behavior. We investigate the effect of individual differences in medical minimizing and medical maximizing orientation on COVID-19-related protective behaviors and attitudes. We used the validated Medical Maximizer-Minimizer Scale (MMS) and surveyed a diverse opt-in sample of the Swedish population (n = 806). Our results show that the MMS significantly predicts a wide range of self-reported behaviors and attitudes in relation to COVID-19. Participants with a stronger minimization orientation were significantly less likely to practice social distancing, follow hygiene recommendations, and be supportive of strict COVID-19 policies. Participants with a stronger maximization orientation had a larger discrepancy between perceived own risk and others getting infected. Thus, they perceived themselves as being less at risk for getting infected compared to the average person. Our findings imply that the MMS can be effectively used to predict who is more or less reluctant to follow public health recommendations.JEL codes: D70 E71 I12 I18.