The film John Q provides a model for the analysis and demonstration of ethical principles of distributive justice as they pertain to healthcare and, more specifically, organ allocation in the face of scarcity. The film portrays the shortcomings of a managed care system as well as the pitfalls of a libertarian approach to allocation.
Here discussed are the ethical approaches of Eglitarianism, Prioritarianisn, Utilitarianism, and Libertarianism to organ allocation as they pertain to the film as well as the situational change in the plot if these approaches were considered.
The topics of hopelessness and helplessness experienced by the patient and family in a dire circumstances as observed in John Q is confronted in the context of the picture . Also provided is a brief ethical critique of the movie and a personal reaction to the topics addressed in the film
When dealing with the issue of scarcity and allocation of resources, the health care industry provides a controversial and ethically challenging model for working though dilemma scenarios such as making distributive decisions with respect to donor organs to the most appropriate recipient.
Scarcity is defined as a condition in which the demand for a resource greatly exceeds the supply of the resource, and the fact of the matter is there are many more people that need transplant organs than there are organs to be allocated.
This circumstance is well presented in the movie John Q, written by James Kearns. The main point made throughout the film seems to be that the process of organ procurement is not only difficult and trying on the patient and family, but can also be fraught with the dilemmas of resource allocation and providing healthcare using a Libertarian allocation approach that need be addressed by healthcare administrators.
Focusing on the theme of distributive justice, the film comes across to imply that care hould be made available to all regardless of their ability to pay and allocation be based on a Prioritarianistic “according to their need” distributive model rather than a Libertarian approach to allocation. In modern healthcare there is a constant struggle to provide the most and greatest healthcare to the greatest number of people in society. Fueling the debate over effective care allocation strategies, for decades the media has been filled with the echoes of socialized healthcare, and in recent decades multiple nations have adopted the model of a governmentalized healthcare system.
In the United States resides a mixed system supported by tax dollars as well as managed care model that is fueled by the desire to reduce cost and still provide necessary care to subscribers. To that end, the film depicts the short comings of a managed care system with seen in the lack preventative screening that might have led to the recognition a young boy’s heart condition at a time when preventative steps could have been taken to mitigate the situation observed in the film.
In the context of resource allocation and particularly organ allocation, at the heart of the ethical issue is the concept of scarcity. According to the University of Minnesota’s Center for Bioethics, there were approximately 83,000 people on the waiting list to receive an organ with an additional 106 (average) being added per day in 2003 (Ethics of Organ Transplantation, 2004).
When considered in relation to the 9,800 donors and the roughly 6,000 people that died in 2002 while waiting for a transplant, it becomes clear a point of equilibrium between supply and demand / necessity has yet to be reached (Ethics of Organ Transplantation, 2004). Summary In the 2002 film, John Q, John Q. Archibald, an American factory worker that has been the victim of a declining economy, and is faced with the difficulty of paying for medical services when his son is struck down at a baseball game with heart failure due to a congenital defect.
The boy suffers from an enlarged heart that went undetected so far. It was made clear that without a heart transplant, the boy would die. To further complicate the situation, the hospital administrator informed the Archibald family that their insurance had changed from a PPO to an HMO type plan and that the transplant surgery is considered an elective procedure and would not be covered by their insurance.
The insurance company issued by his employer informs John that the policy had changed and that only $20,000 of the required $250,000 will be paid under the claim. John Q then decided to take measures into his own hands and persuades the head of the cardiology department to find a replacement heart for the boy at gunpoint. He takes the cardiologist and several patients hostage and demands that his son be placed on the recipient list.
One of the predominant points made in the film is that the process of organ allocation is often unjust by the libertarian approach that is used when dealing with a managed care system that provides insufficient coverage for the terminally ill. The film implies that the decision making process of organ distribution id too greatly influenced by the recipient’s ability to pay for the treatment and does not sufficiently consider the patient’s deserving of the organ based on his life experience, usefulness and right to equitable treatment.
The effects of organ procurement can instill a sense of helplessness in those linked to the patient dying from a terminal condition. The picture illustrates the manifestation of this stress and emotional strain in irrational behavior of the father of a terminal child and seems to justify his actions by hinting at the unjust nature of the organ distributive process. Analysis
The depiction of a young boy falling deeper into the hopelessness of being rejected as an heart recipient and the helplessness of the parents as they watch their son’s condition continue to worsen because they are unable to provide the funds necessary to pay for the intervention successfully conveys the message that the results of allocative decisions are not always just and favor those with the ability to pay for the procedure.
In the context of the film, it is important to note the role of hopelessness and helplessness felt by the Archibald family as a result of the organ allocation process and decision. It is no secret that illness and bodily deterioration can adversely affect the mood and emotions of a patient by promoting feelings of helplessness and a loss of hope. But, frequently one might observe the emotions of family members be similarly affected when a grim prognosis is delivered sensing that the situation is beyond anyone’s control and this leads to a deep sense of helplessness.
This holds true especially for parents as in the case of the Archibald family. As a parent raises a child, benevolence and pleasing sacrifice are at the core of the parental emotional complex. So, when a child become ill, it presents as one of the few situations in which the parent is unable to offer more than comforting words of compassion and love. A parent that has devoted years of aid and care can become overwhelmed by a mood of desperation.
However, the film’s portrayal of an illicit act of perceived violence and deception as being one of heroism and justice serves only to further incite one with the discontent at the current system and justifies the use of such force to serve one’s own end, however desperate it might be, the justification of any sort of deception and manipulation, as Mr. Archibald deceived and manipulated hostages and hospital administrators as a means to his desired end, is in conflict with the familiar categorical imperative of Kantian Deontology.
This in itself is, by that theory, unethical and a deplorable action in the context of deontology. On the topic of the ethics of organ allocation, distributive justice can be described as the deciding how to fairly divide and allocate resources in the face of scarcity (Ethics of Organ Transplantation, 2004). In distributive justice, there are thought to be six major theories on how best to do this: to each an equal share, to each according to his need, according to his effort, according to his contribution, according to the merit achieved, and to each according to his ability to pay (Ethics of Organ Transplantation, 2004).
It can be simplified further in that all six of these allocation theories can be summed up in four primary categories of thought: equality, favoring the neediest, utilitarianism, and rewarding social usefulness (Emanuel, Persad, Werthiemer 2009). First of these categories is that of equality. Treating everyone equally is known as the distributive justice theory of Egalitarianism. In this system, judgments are made based on objective factors ideally in the absence of any bias (Ethics of Organ Transplantation, 2004).
A classic example of this type of model at work is the first come first serve method (Emanuel et al. 2009). Ideally, these types of approaches are, with some exception, fairly good at eliminating selection bias, however, in doing so can ignore factors such as social standing, quality of life and issues of medical worthiness (Ethics of Organ Transplantation, 2004). In the scenario of John Q. , the utilization of such a system might have ensured the placement of the boy’s name on the transplant list. However, the odds that the boy would have received the heart would have actually not have ncreased.
Therefore, the situation of the enragement of John Q. Archibald would probably not have been avoided. In the model of Prioritarianism, the sickest and the youngest receive priority care over those less afflicted (Emanuel et al. 2009). This approach has the advantage of aiding those who are critical and serves to eliminate selection bias in response to factors of social and economic standing but rather bases allocation on the need and urgency of care considering the condition of each patient. Prioritarianism however also have its disadvantages.
One such is the need for a prognosis that must be estimated by human evaluation and is therefore vulnerable to persuasion and bias. Also, the allocation of organs parallels the preventative care of offered to the son of Michael Archibald in that the determination that treatment is necessary is contingent on the illness of the patient and thus requires the patient’s condition to deteriorate before the he or she is considered to among the sickest and eligible to receive the allocation of care and or organ that is required.
A system that favor the sickest inherently fails to account for those who will become sick if the treatment or organ is not received in their current state Rationalizing the youngest first approach is the thought that the worst off in this case are those who would perish with fewer years lived and would potentially have more years to benefit from the organ (Emanuel et al. 2009). Pertaining to the case of Michael Archibald, he would probably have gotten the heart with ample time for treatment and recovery and the hostage situation initiated by his father would have been avoided.
Third is the ever popular Utilitarian approach to the question of allocation striving to maximize the benefit obtained from each of the organs. This benefit is measures in life-years, that is, the number of years the patient would live beyond the number of years he or she would live if not granted the organ, adjusted with lifestyle and disability projected (Ethics of Organ Transplantation, 2004), (Donaldson & Mitton, 2004). This is one of the models in which the patient’s future is considered.
Using this approach and applying it to the situation of the Archibald family, it is irrefutably clear that the boy would receive nearly maximum benefit from the heart in both life-years and the ability to maintain a high quality of life throughout those years and would therefore be a priority recipient for the heart. To that end, there would have been no reason for John Q. to carry out his act of desperation. As the Utilitarian approach does not consider the ability to pay for the service as criteria for allocation, the financial and hostage crises would have been averted.
Finally, the use of social usefulness as a factor for determining one’s eligibility as an organ recipient is the most relative to the film. At the heart of social usefulness allocation is the idea of instrumental value, that is, that which shows promise of future usefulness (Emanuel et al. 2009). Most specifically pertaining to the film, this implies Libertarian distribution theory and the use of one’s ability to pay as a gauge of usefulness and ability to contribute back to the healthcare system, in this instance, the managed care system, and society as a whole.
By my rationale, if one is able to pay for, or has coverage that can pay for a procedure the individual is probably more able to make contributions to the market and thus society as a consumer, and might also have a higher probability of possessing the intellectual capacity and education level that is thought to enable one in providing the most useful contributions to society. Following that logic, it is natural to say that favoring those who are able to pay for treatment is in a way rewarding their perceived social usefulness.
It is because of this method of thought that the son of John Q. Archibald was denied the transplant that was necessary to prolong his life. Mr. Archibald’s inability to pay the $250,000 required for the surgery served as an indicator of his social usefulness when the healthcare administrators were confronting the dilemma of placing the boy’s name n the transplant list. The Libertarian approach to allocation of healthcare resources bases decisions on too few dimensions of the patient’s experience.
In the case of Michael Archibald the potential usefulness of a child, and even the policy holder for that matter, cannot be determined to degree of completeness that can be used to base decisions of organ allocation by using the parent’s ability to pay for the procedure as proxy to future social usefulness of the child. Even if it was, the perceived usefulness of a child can be viewed as less than that of an adult because it is not an autonomous being and lacks the investment of education and life experiences that shape autonomous adults.
To the same effect, the usefulness of the mentally ill or elderly can be perceived to be lessened because they have less years or intellectual contributions to make to society. It is for this reason that I feel that this model as it is portrayed in the film is insufficient for the determination of organ recipients. Ethically, to the question of how scarce resources should be allocated, there is no easy or definite answer. However, the four main categories mentioned can be combined in use to provide some insight on how to best fairly distribute organs.
It seems logical that to make determinations of allocation that ultimately prolong life and the human experience, it is necessary to take into account the factors that affect that experience such as quality of life and providing the maximum number of life-years from each organ. However, as organs are a scarce societal resource, it is also important to factor in the benefit to society that might be obtained by each scenario of the allocation of this resource.
In my personal opinion, I feel that the cost of providing healthcare warrants the use of some aspect of a model based on one’s ability to pay. However, I also hold that as a libertarian approach ignores several crucial aspects of the patient’s experience and the utility the organ might provide to the patient as well as to society, the utilitarian view of utility in adjusted life-years and that those who are sickest with the greatest chance for recovery and to make a contribution to society should be considered first.
Conclusion To all who have seen the James Kearns’s film, John Q, it is no secret that the ethical implications of resource allocation in healthcare can have emotionally devastating effects on patients and their families. The point is successfully made that the emotional effects of a perceived improper Libertarian system that only considers only one’s ability to pay to make distributive decisions can result in the loss of future productive members of society as well as the innocence and opportunity of youth.
The principles and theories of distributive justice that are used in the decision making process when attempting to discern the “best” way to allocate organs, in the face of scarcity can often ignore essential elements of the suffering and life experience faced by the patient and his or her family as well as provide insufficient approximations of the worth of the patient in the scheme of society.
For this reason, and the limited supply of organs and other medical resources, the denial of life sustaining interventions might ead the patient and family into a deep sense of hopelessness and helplessness when they come to the realization that there is nothing more they can do to aid themselves or their loved ones. In the case of John Q. Archibald this sense of hopelessness and despair was so great that it forced an otherwise rational and law abiding man to commit an act illicit and ethically reprehensible as a result of the denial of a heart for his terminal son.