“Suggesting queue-jumping: ethical justification for an informal resources allocation practice

Ethical Dimensions of Health Care´s Essay
“Suggesting queue-jumping:
Ethical considerations of an informal practice of
resource reallocation in health care”

Jaime Fontbona

Introduction

The waiting lists are a factor of the resource allocation process, which is worldwide spread. In general, it belongs to the micro-level of health care systems, but specially to the public health careone. However, the long waiting times may produce per sé suffering not only to the patients, but also to the health care professionals. Therefore, it is not strange that the latter could feel the ethical necessity to use their knowledge to try to allocate the existing resources in a “fairer way”. Although actions in that directions are legally punished in most countries, it is difficult to detectwhich information is provided to patients through the patient-health professionals relationship. For example, specific information about how the system “works”, in particular related to which are the more difficult priority criteria to check, who are the professionals more likely to get compassionate or pushed by recurrent claims. Or even, the existence of “errors” or ambiguities in the diagnosis ofthe severity of the patient´s health status, may follow this pattern.

In this essay I will expose the current settings for this phenomena, including factors, such as health care institution management, patients´ suffer at the queue and professionals´ moral distress. These arguments suggest that this practice could be more prevalent than expected, despite the almost absence of specificresearch. I will expand on the ethical process that allow and justify morally the practice of suggesting patients queue-jumping. In other words, as a consequence of a unfair distributive justice practices, professionals could be forced morally to illegal practices of restorative justice.

Little evidence about “suggesting queue-jumping”

There is little evidence that support the practice of suggestingpatients queue-jumping, despite the experience of common people and professionals. Most of it was tangential, but only one study provide information that permits to attempt a prevalence rate. More indirect descriptions about the methods used in different article is reported. The most of them showed physician colluded as result of patients´ requests, which showed this practice as a corruptedbehavior. Just seldom vignettes allow to identify professional´s initiatives and motivations in this practice as a way of patient´s advocacy. In consequence, no article discussing the ethical perspective of this behavior was found.

A sociological article (Finlay, Mutran, Zeitler and Randall, 1990, p. 293-299) described the functioning of a primary care clinic in a Veteran Administration hospital,staffed only by medicine residents, receiving only seldom supervision by their professors. They also have been encouraged by the hospital´s policies to provide full exam of every patients. This is the opposite to a triage approach, which only focus on one medical problem per time. So, the full exam usually last for 30 minutes to 2 hours. And the standard resident´s schedule considered fivepatients, but depending on the load of the shift, some resident extraordinary deal with fourteen patients a day.

In this context the care provided usually exceeded the standard of primary care, with the only boundary of the lack of resource. However, the working climate was described by the residents as highly motivating and full of “camaderie” within residents, who were supervised the most of the timeby the older residents (2nd or 3rd year of medical residence). Moreover, ethical value as integrity was strongly reinforcing, due the respect that they gain from consults and patients.

In this fully patient´s-advocacy setting residents also have problems to negotiate access for secondary care. 48% of the resident staff reported that had “beg” to book referrals when the hospital service was...