1. An Empirical Ethics Approach to Identifying Societal Preferences for the Allocation of Healthcare Resources Chris Skedgel, Allan Wailoo & Ron Akehurst The University of Sheffield, School of Health & Related Research, Sheffield UK
The Decision Problem
The conventional extra-welfarist approach to health economic evaluation adopts a decision-maker perspective, where societal welfare is defined by the values that those responsible for policy attach to the characteristics of individuals.2 Influenced by Sen’s ‘capabilities theory’, these characteristics have most often been limited to individual health in terms of quality-adjusted life years (QALYs).3 This approach has become known as QALY maximisation and limits relevant factors to absolute health gain, duration of benefit and the number of beneficiaries. Many argue this is an overly restrictive perspective. As an alternative, a Communitarian approach allows the community to decide for itself what characteristics are important.4,5
Identifying Community Preferences
The most straightforward approach to identifying preferences is to simply ask members of a community which characteristics they consider important. Daniels, though, argues that majority support in preference surveys is not sufficient grounds for distributing something as fundamentally important as healthcare; a deliberative process is required to assure the minority that allocation preferences are based on reasons they can accept as relevant.6 Richardson and McKie argue that “defensible principles for allocating healthcare should be derived in an iterative way, involving both an empirical study of population values and ethical analysis of the results.” 7
Discussion The results of this empirical ethics review are consistent with growing evidence of a reluctance to allocate healthcare solely on the basis of maximising expected QALYs and a willingness to sacrifice efficiency for distributive justice. Younger patients and patients in more severe health states were consistently favoured over older or healthier patients and the quality of the final health state was more important than the absolute health gain. There was also a distributional preference for smaller health gains to many over larger gains to the few. A fuller conception of societal value may improve priority setting, but it will be necessary to consider the relative strength of preferences for equity relative to efficiency before rejecting QALY maximization.
References 1 New, B. 1996, "The rationing agenda in the NHS", BMJ, vol. 312, no. 7046, pp Sugden, R. & Williams, A.H. 1978, The principles of practical cost-benefit analysis, Oxford University Press, Oxford Culyer, A.J. 1989, "The normative economics of health care finance and provision", Oxford Review of Economic Policy, vol. 5, no. 1, pp Mooney, G. 1998, "“Communitarian claims” as an ethical basis for allocating health care resources", Social science & medicine, vol. 47, no. 9, pp Callahan, D. 2003, "Individual Good and Common Good: A Communitarian Approach to Bioethics", Perspectives in Biology and medicine, vol. 46, no. 4, pp Daniels, N. 1998, "Distributive justice and the use of summary measures of population health status" in Summarizing Population Health: Directions for the development and application of population metrics, eds. M.J. Field & M.R. Gold, National Academy Press, Washington, D.C., pp Richardson, J. & McKie, J. 2005, "Empiricism, ethics and orthodox economic theory: what is the appropriate basis for decision-making in the health sector?", Social science & medicine, vol. 60, no. 2, pp Ubel, P.A., Richardson, J. & Pinto-Prades, J.L. 1999, "Life-saving treatments and disabilities. Are all QALYs created equal?", International Journal of Technology Assessment in Health Care, vol. 15, no. 4, pp
Empirical ethics review: relevant attributes should demonstrate evidence of broad community support and “be consistent with some coherent and defensible ethical theory of justice.” 8
 Patient Age
Empirical Evidence?
Consistent prefs for younger patients
Hump-shaped age prefs?
No support for absolute age cutoffs
Ethical Justification?
Maximisation of life expectancy
Maximisation in productivity
‘Fair innings’ egalitarianism
 Initial Severity
Empirical Evidence?
Prefs for health gains to most severe, even when gains were smaller
Strong prefs for life-saving treatments
Ethical Justification?
Need principles
Rawls’ Difference principle
Equality of opportunity
 Lifestyle / Responsibility
Empirical Evidence?
Broad prefs for prioritising patients with healthy lifestyle
Minority often strongly opposed to prioritising by lifestyle
Epidemiological determinants?
Ethical Justification?
Luck-egalitarianism - inequalities driven by pat choices are fair
 ‘Healthism’ – idea that individuals have moral obligation to live healthily
 Final Health State
Empirical Evidence?
Prefs for final health state rather than absolute gain
Prefs against patients who remain in severe health state
Ethical Justification?
Maximisation interpretation of ‘equality of opportunity’?
 Absolute Benefit *
Empirical Evidence?
Prefs for equal opportunity regardless of absolute gain
Ethical Justification?
 Maximisation principles
“QALY Trap” – emphasis on absolute gain may discriminate against disabled
Prefs for max benefit may exacerbate health inequalities
 Prior Healthcare Consumption
Empirical Evidence?
Limited evidence of prefs against patients against patients who had received previous life-saving care
Ethical Justification?
Egalitarianism – no “second piece of the pie”
Exclusionary interpretation of egalitarianism
Narrow definition of healthcare
 Social Role & Productivity
Empirical Evidence?
Consistent with hump-shaped age preferences
Limited empirical support for discrimination by productivity
Ethical Justification?
Maximising principle of greatest happiness for greatest number
? Duration of Benefit *
Empirical Evidence?
Declining marginal value in duration
Duration a complex function of life expectancy, age, severity and time preferences
Ethical Justification?
Maximisation principles
 Prefs for longer duration may exacerbate inequalities in life expectancy
 Social Inequality
Empirical Evidence?
Limited support for prioritising low SES
Prefs for equality rather than low SES per se
Ethical Justification?
Specific egalitarianism, to extent low SES are disadvantaged in health
General egalitarianism, if health improves overall well-being of low SES
 Direction of Benefit
Empirical Evidence?
Inconclusive evidence of prefs for preventative vs. acute care
Difficulty in interpreting direction of benefit – just issue of timing?
Ethical Justification?
Implies pref for healthy over ill, violating vertical equity and Rawls’ Difference principle
 Could be consistent with Maximising principles if preventative maximises outcomes
 Desert & Merit
Empirical Evidence?
Little support for prioritisation based on past meritorious actions
Some evidence of prefs for ‘punishing’ illegal behaviour (e.g. drug use)
Ethical Justification?
Where health needs are result of voluntary efforts to improve societal well-being?
 Healthcare system as “omnipotent Supreme Court” dispensing reward/punishment?
 Distribution of Gains
Empirical Evidence?
Consistent prefs for smaller gains to many over larger gains to few
Aversion to ‘extreme distributions’
Ethical Justification?
Gain egalitarianism
Maintenance of hope
 Contrary to outcome egalitarianism?
* Attributes considered by QALY Maximisation