Result card

  • ETH9: How does implementation or withdrawal of STS affect the distribution of health care resources?
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How does implementation or withdrawal of STS affect the distribution of health care resources?

Authors: Plamen Dimitrov, Gottfried Endel, Anelia Koteva

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One of the key principles in bioethics is the principle of justice linked to law and equality. From an ethical point of view, it can be considered in three different ways and subdivided into three distinct categories, respectively: fair allocation of scarce resources (distributive justice); respect for people’s rights (rights-based justice) and compliance with morally acceptable laws (legal justice). Although the right to equal treatment, respectively, equal access to treatment has been formally enshrined in many constitutions, actually, many factors, such as age, place of residence, social status, ethnicity, culture, sexual preference, disability, legal capacity, health budgets, treatment price, insurance coverage, etc. may limit access to treatment. Justice in these cases, without neglecting or underestimating the right of equal access for all, requires that the individual’s needs be balanced with the needs of the general public.


In general, distributive justice in healthcare, which is being discussed in the present section, involves the application of fair standards that make quality healthcare both available and accessible to people in an effective way. A health system is deemed fair or equal in the cases when: 1.) persons are not deprived of health services based on criteria, such as class, race, gender and geography, and 2.) persons may be entitled to a guaranteed adequate level of care without exceptional harms/burdens.


A problem may be caused by the narrow interpretation of the term “quality of care” that is often understood as the ability of a new medical technology to improve care and outcome for the patient. Broadly speaking, quality refers to not only delivering services so as to avoid any errors but also providing them in a competent, compassionate and respectful way – that is why, the question of whether telemedicine enhances or reduces the quality of health services hasn’t been answered yet.


Next, of crucial importance is to distinguish between the concepts of “availability” and “accessibility” since both terms are not necessarily interchangeable in meaning. Although some resources may be available, they may as well be inaccessible for a number of reasons (for example: the digital gap generated by the lack of established telecommunications infrastructure in rural and some urban communities, where too often restrictions are associated with not only limited access to network environment but also with a deficit of knowledge, skills, experience, familiarity and a sense of comfort when handling new technologies; availability of health services in a particular community or region, meanwhile making them inaccessible to some people due to inadequate transportation, etc.).


Given the nature of structured telephone support, substantial conflicts regarding the financing of the selected technology are quite unlikely to be expected insofar as the adopted practice of telephone interviews between the healthcare staff and the patient, whether conducted by landline or through the use of mobile phones, does not presume a requirement for supplementary personal financial contributions by patients on additional installation of telemetry devices payable by the patients themselves and is therefore not an extra financial burden to them.


An essential variable in the equation of distributive justice is efficiency/effectiveness – due to limited health resources and their high demand, signs of inefficiency/ineffectiveness, such as duplicate services, overspendings, errors, etc. should be minimized.


With a view to healthcare distributive justice turning into reality, none of the components already discussed should be pursued for their own sake, while being at the expense of others. What is more, both the democratization and stratification potential of distributive justice must be considered, whose overcoming requires constant trade-offs (for example: increased access to medical services and health information but instead – decreased quality of the bilateral relationship, indicative of which is the lack of face-to-face clinical encounters as well as patient access to vast medical information but unreliable and of questionable quality at the same time).


Therefore, in view of the above considerations and in order to ensure fair and reasonable healthcare spending, it is necessary that decisions are made on a case-by-case basis, particularly in situations characterized by limited resources, unequal opportunities and/or other moral discrepancies.

Dimitrov P et al. Result Card ETH9 In: Dimitrov P et al. Ethical analysis In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 3 October 2022]. Available from: