Recommendations for Conduct, Methodological Practices, and Reporting of Cost-effectiveness Analyses: Second Panel on Cost-Effectiveness in Health and Medicine.

Importance: Since publication of the report by the Panel on Cost-Effectiveness in Health and Medicine in 1996, researchers have advanced the methods of cost-effectiveness analysis, and policy makers have experimented with its application. The need to deliver health care efficiently and the importance of using analytic techniques to understand the clinical and economic consequences of strategies to improve health have increased in recent years.

Objective: To review the state of the field and provide recommendations to improve the quality of cost-effectiveness analyses.

Good medical ethics.

This paper summarises the features of my paper, 'Voluntary Active Euthanasia', and a later jointly authored paper, 'Moral Fictions', which I believe are examples of good medical ethics.

Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis.

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria.

Reflections on the patient preference predictor proposal.

There are substantial data establishing that surrogates are often mistaken in predicting what treatments incompetent patients would have wanted and that supplements such as advance directives have not resulted in significant improvements. Rid and Wendler's Patient Preference Predictor (PPP) proposal will attempt to gather data about what similar patients would prefer in a variety of treatment choices. It accepts the usual goal of patient autonomy and the Substituted Judgment principle for surrogate decisions.

Deactivation of pacemakers and implantable cardioverter-defibrillators.

Cardiac implantable electrical devices (CIEDs), including pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs), are the most effective treatment for life-threatening arrhythmias. Patients or their surrogates may request device deactivation to avoid prolongation of the dying process or in other settings, such as after device-related complications or with changes in health care goals. Despite published guidelines outlining theoretical and practical aspects of this common clinical scenario, significant uncertainty remains for both patients and health care providers regarding the ethical and legal status of CIED deactivation.

Prioritizing registered donors in organ allocation: an ethical appraisal of the Israeli organ transplant law.

Purpose Of Review: A new organ transplant law in Israel, which gives priority in organ allocation to candidates who in various ways support organ donation, has resulted in a significant increase in organ donation in 2011. We provide an ethical analysis of the new law.

Recent Findings: We note that by continuing to require opt-in consent, the Israeli law has an ethical advantage over opt-out laws, which may result in some use of organs from donors who have not consented.

Should patients receive general anesthesia prior to extubation at the end of life?

Billings has proposed that any potentially conscious and imminently dying patient who is undergoing withdrawal of ventilator support should be offered general anesthesia to fully protect against suffering. Here we examine whether his proposal is compatible with the doctrine of double effect, a philosophical construct that is generally in accord with the legal requirements for palliative care in the United States. We review the essential elements of the doctrine of double effect, and emphasize the importance of pre-medicating patients before ventilator withdrawal (anticipatory dosing) and of titrating medications to the needs of the patient.

Informed consent in cardiac resynchronization therapy: what should be said?

Cardiac resynchronization therapy (CRT) improves symptoms and prolongs life in selected patients with heart failure and systolic dysfunction. Newer studies suggest important benefits in earlier stages of heart failure, which may stave off future development of severe symptoms and may even improve cardiomyopathy primarily. CRT can be offered with and without defibrillator therapy, which may extend its potential to prolong life at the cost of increased complications.

Ethical and legal views regarding deactivation of cardiac implantable electrical devices in patients with hypertrophic cardiomyopathy.

Little is known about patients' views surrounding the ethical and legal aspects of managing pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs) near the end of life. Patients with hypertrophic cardiomyopathy (HC) are at heightened risk of sudden cardiac death and are common recipients of such devices. Patients with HC recruited from the membership of the Hypertrophic Cardiomyopathy Association were surveyed about their clinical histories, advance care planning, legal knowledge, and ethical beliefs relating to the withdrawal of PM and ICD therapy.

Value and cancer care: toward an equitable future.

Health care expenses in the United States are increasing inexorably. At the current rate of growth, it is anticipated that 20% of the gross national product will consist of health-related expenditures within the next decade. Cancer is the second leading cause of death in the United States, and it is increasing in prevalence because of the aging of the population and the limited number of successful prevention strategies.

Ethical and legal views of physicians regarding deactivation of cardiac implantable electrical devices: a quantitative assessment.

Background: Despite the high prevalence of pacemakers and implantable cardioverter-defibrillators, little is known about physicians' views surrounding the ethical and legal aspects of managing these devices at the end of life.

Objective: The purpose of this study was to identify physicians' experiences and views surrounding the ethical and legal aspects of managing cardiac devices at the end of life.

Methods: Survey questions were administered to internal medicine physicians and subspecialists at a tertiary care center.

Creating embryos for use in stem cell research.

In this paper I will address whether the restriction on the creation of human embryos solely for the purpose of research in which they will be used and destroyed in the creation of human stem cell lines is ethically justified. Of course, a cynical but perhaps accurate reading of the new Obama policy is that leaving this restriction in place was done for political, not ethical, reasons, in light of the apparent public opposition to creating embryos for use in this research. But the issue of whether the restriction is ethically justified remains important, even if only for another day in the policy arena.

The dead donor rule: can it withstand critical scrutiny?

Transplantation of vital organs has been premised ethically and legally on "the dead donor rule" (DDR)-the requirement that donors are determined to be dead before these organs are procured. Nevertheless, scholars have argued cogently that donors of vital organs, including those diagnosed as "brain dead" and those declared dead according to cardiopulmonary criteria, are not in fact dead at the time that vital organs are being procured. In this article, we challenge the normative rationale for the DDR by rejecting the underlying premise that it is necessarily wrong for physicians to cause the death of patients and the claim that abandoning this rule would exploit vulnerable patients.

Ethical and value issues in insurance coverage for cancer treatment.

Many new cancer drugs provide only limited benefits, but at very great cost, for example, $200,000-$300,000 per quality-adjusted life year produced. By most standards of value or cost-effectiveness, this does not represent good value. I first review several of the causes of this value failure, including monopoly patents, prohibitions on Medicare's negotiating on drug prices, health insurance protecting patients from costs, and financial incentives of physicians to use these drugs.

Ethical challenges in long-term funding for HIV/AIDS.

The global response to the AIDS pandemic aims for universal access to treatment and for pursuing every possible avenue to prevention. Skeptics, doubting that the huge increases in current funding levels needed for universal treatment will ever happen, would scale back antiretroviral treatment in favor of more cost-effective preventive interventions. Economics, politics, and science figure in this debate.

Last-resort options for palliative sedation.

Despite receiving state-of-the-art palliative care, some patients still experience severe suffering toward the end of life. Palliative sedation is a potential way to respond to such suffering, but access is uneven and unpredictable, in part because of confusion about different kinds of sedation. Proportionate palliative sedation (PPS) uses the minimum amount of sedation necessary to relieve refractory physical symptoms at the very end of life.

Moral fictions and medical ethics.

Conventional medical ethics and the law draw a bright line distinguishing the permitted practice of withdrawing life-sustaining treatment from the forbidden practice of active euthanasia by means of a lethal injection. When clinicians justifiably withdraw life-sustaining treatment, they allow patients to die but do not cause, intend, or have moral responsibility for, the patient's death. In contrast, physicians unjustifiably kill patients whenever they intentionally administer a lethal dose of medication.

Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?

Some medical services have long generated deep moral controversy within the medical profession as well as in broader society and have led to conscientious refusals by some physicians to provide those services to their patients. More recently, pharmacists in a number of states have refused on grounds of conscience to fill legal prescriptions for their customers. This paper assesses these controversies.

Rationing in the intensive care unit.

Background: Critical care services represent a large and growing proportion of health care expenditures. Limiting the magnitude of these costs while maintaining a just allocation of these services will require rationing. We define rationing as "the allocation of healthcare resources in the face of limited availability, which necessarily means that beneficial interventions are withheld from some individuals.