1. Ethics and Health Sector Reform Marc J Roberts Professor of Political Economy and Health Policy Harvard School of Public Health 1

2. 2 Why Is Ethical Analysis Needed? To decide which problems deserve attention To help us recognize when we have achieved good results To help in defining performance measurements— indexes, weights etc.

3. 3 The Role Of Ethical and Philosophical Theory Philosophers’ attempts to describe “The good society” lie behind positions taken in public health discussions Understanding these theories clarifies many common arguments and positions Exploring alternative theories can help us define our own positions

4. 4 Three Categories Of Ethical Argument: What Do We Care About? Rights (starting points):  Liberalism Consequences (end points)  Utilitarianism Virtue (the good society)  Communitarianism

5. 5 Theory I: Liberalism Basic idea: Individuals have certain rights that guarantee them a range of opportunity for making their own choices about how to live. Once we guarantee this starting point, what they do with their lives are their own business.

6. 6 Kinds Of Rights Negative rights - the right to make one’s own choices about how to live (dress, work, marriage and property) Positive rights - the right to a minimum level of opportunity: income, shelter, education etc. Political rights - speech, assembly, voting, access to information

7. Views about Rights Libertarians focus on negative and political rights (politically center right) Egalitarian Liberals focus on negative, political and positive rights (politically left) 7

8. 8 Rights Can Conflict My positive rights can require someone else to pay for them. This can conflict with payers’ negative (property) rights My political rights, as I view them, may be inconsistent with existing institutions (e.g. secessionist movements)

9. 9 Issues About Health Care Rights Do I have a right to care or a right to health? Do I have a right to some minimum, or should everyone have exactly the same? Since more rights require more money, how should the burden be divided? How does a country decide what health care rights it can afford?

10. 10 Where Do Rights Come From? The status of all human beings as creations of God? From human beings’ capacity for reason? From custom and tradition? From UN declarations and international treaties?

11. 11 The History Of Rights The earliest claims involved very narrow groups (e.g., the barons of England vs. the King) Rights ideas were advanced by the American and French revolutions The German philosopher Kant formulated much of the modern argument Over time, the set of people who are recognized as having rights has steadily widened

12. 12 Theory II: Utilitarianism Basic Idea: The goal of public policy should be to improve the well being (the so-called “utility level”) of citizens. We should arrange society to guarantee “the greatest good of the greatest number.” What matters are the consequences (end points).

13. 13 Implementing Utilitarianism First, we have to predict the results of any proposed policy We need to measure each person’s well being and add up the gains and losses Both the number of gainers or losers, and the size of their gains or losses matter

14. 14 How to Measure Well Being I: Subjective Utilitarianism What matters is how people feel Respond to wants (e.g. market demand) not expert opinion about needs This decentralizes valuation To estimate demand, ask what people do pay, or would be willing to pay (biased against poor) We could try to protect people from their own mistakes through information or regulation while still accepting their happiness as the goal

15. 15 How to Measure Well Being II: Objective Utilitarianism Experts construct an index to measure gains and losses—trading quantity against quality of life Assumes there is a right answer to what constitutes “well being” –centralizes valuation Constructing the index involves important value choices (e.g., the value of saving lives of people at different ages) Use cost-effectiveness to pick among options

16. 16 The History Of Utilitarianism Bentham and Mill formulated the modern analysis Early use was by engineers and public health advocates (Florence Nightingale) Used during WW II for military purposes: Operations Research (objective version ) Taken up by economists after World War II as cost benefit analysis (subjective version) Now used in studies of clinical cost-effectiveness as well as by WHO (objective version)

17. 17 Challenges to Utilitarianism Does not consider equity Individuals can be sacrificed for the sake of “the greater good” Role of experts in the process can mask value choices and limit political accountability Most countries spend more on high tech care than cost-effectiveness suggests

18. 18 Theory III - Communitarianism Basic idea: The goal of social policy should be to create citizens who are virtuous (have good character) and help them live together in a good society

19. 19 Who Decides What Is Virtuous? Each society decides for itself what is virtue (relative communitarianism) There is one definition of virtue for all societies (universal communitarianism)

20. 20 Challenges to Communitarianism What happens when those with conflicting universal visions meet? Can/should they tolerate each other? If communities can set their own rules--how do we know the boundaries of each community? How far can communitarians go to suppress dissent?

21. 21 The Politics Of Communitarianism Conservative parties are communitarian Some on the extreme left (e.g., Maoists) have their own communitarian vision There are some secular communitarians—e.g. Green Parties Europe moved from “universalism” too “toleration” to resolve Protestant/Catholic conflicts

22. 22 Mixed Positions Using more than one theory appeals to many Principled construction of a mixed ethical position can be a responsible stance – Utilitarians who respect some rights – Egalitarian liberals who are sensitive to local customs

23. 23 Implications You cannot make health policy without values Conflicts in values often occur in making health policy decisions Understanding ethical theory can help you clarify your own position and understand others more clearly

24. Some Questions What ethical position is implicit in the notion of “solidarity”? What ethical view lies behind the claim that citizens should be free to buy their own health insurance? How do the main political parties in your country divide in terms of philosophical theory? How are those divides reflected in their views about health care reform? 24