Step 5. What are the potential benefits and burdens for the parties involved?
The patient. It will be an advantage to the patient to receive surgical treatment with an expected benefit of more than 1 – 2 years of life. Correspondingly, not receiving such treatment will be a disadvantage.
Fellow patients. Treatment of this group of patients may help produce expertise that can be beneficial to other patients. On the other hand, unruly and difficult patients with a drug dependency can be distressing for their fellow patients.
Next of kin. Most next of kin will perceive provision of potentially life-saving cardiac surgery to this patient group as an advantage, despite the fact that the patient’s drug addiction may be a strain on many of them.
Health personnel. To these, saving a life will be seen as an advantage, and they will also accumulate more experience and competence. It could be a disadvantage, however, that the treatment may include having to deal with behavioural problems, threats or even episodes of violent behaviour.
Other groups of patients. All patients who need valve replacement surgery will occupy beds in the emergency ward, affect the surgical capacity and spend long periods in hospital. Since health budgets are limited, prioritising one patient group may cause delays or provision of less than optimal services to other groups.
The health enterprise. The health enterprise is committed to providing adequate care to the patients in their catchment area. It has been decided to give priority to services for drug users, but these concerns must be balanced against the consequences this will entail for other patients.
Municipal health services. The municipal health services should follow up the patients after surgery, but in most cases their resources are insufficient. Uncooperative drug users may represent a greater than normal care burden for the staff.
Society. Society may document its ability and willingness to prioritise a disadvantaged group of patients, but nevertheless risk using resources inappropriately. Norwegian authorities have not specified a threshold value for this, as has been attempted in the UK (24). However, in its processing of several cases, the National Council for Priority Setting in Health Care has suggested a limit to resource use of NOK 300 000 – 800 000 (USD 51 000 – 136 000) per quality-adjusted year of life (25).