Page 236 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 12
in 2019, spent as much as €80.9 billion on healthcare in 2019, an increase of 4.8% compared to 2018. 104 This accounts for 10% of total gross domestic product 104, similar to many other high-income countries: 11.5% (9.6% – 12.4). 103 Although treating more s-TBI patients could be legitimized by more patients with improved and hopefully ‘acceptable’ outcome, the future of healthcare systems requires prudence and optimal use of restricted resources.
Justice, as one of four moral principles in medical ethics (Table 3), requires the fair distribution of benefits, risks and limited medical goods and services. 105-107 With respect to its many variations, this is in line with the principle of utilitarianism, which seeks to maximize the well-being of most of the people, instead of the individual. 108,109 Incorporating these principles in acute treatment decision-making could mean that resources, potentially beneficent for an individual patient, are ethically restricted for the wellbeing of the entire society. In line with this, resources should not be used on so-called ineffective and disproportional treatments in s-TBI patients with a very low chance of achieving ‘acceptable’ outcome, because it will deprive other patients of potentially effective treatments. 110 Cost-effectiveness analyses and concepts such as value-based healthcare can be used to substantiate acute treatment decision-making and prevent inefficient use of limited healthcare resources.
Table 3: Moral principles in medical ethics
Principle
1. Autonomy 2. Beneficence
3. Nonmaleficence 4. Justice
In-hospital costs
Description
A norm of respecting and supporting autonomous decisions.
A group of norms pertaining to relieving, lessening, or preventing harm and providing benefits and balancing benefits against risks and costs.
A norm of avoiding the causation of harm.
A group of norms for fairly distributing benefits, risks, and costs.
The true cost-effectiveness and feasibility of the proposed strategy has not been investigated in this thesis, and also remains unknown based on the in-hospital healthcare consumption and in-hospital costs that are reported in chapter 3, 4 and 5. 6,7,111 It is also difficult to make statements based on available literature, since cost- effectiveness literature in s-TBI is scarce and inconclusive. Some studies report TBI treatment to be cost-effective 112-115, while others report the opposite. 113,116 The feasibility of the proposed strategy remains unclear and requires further investigation with actual cost-effectiveness analyses.
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