This report is about ethical thinking in the field of health and health care. But it is no abstract philosophical tract. It is designed to be of practical help to those struggling with the complex questions of allocating resources in health care and to encourage a wider involvement at all levels in health debates. The questions it raises stimulate new thinking about today's institutional structures. As we proceeded with our work, we became aware that (...) it is easier to state problems than to solve them. However, we were also aware of the opposite danger of oversimplification implicit in the view that there was a moral calculus to which decisionmakers could turn when they were confronted by an ethical problem in the allocation of resources, and which would yield mechanical solutions to human problems. (shrink)

Leading scholars in the field of health economics evaluate the role of incentives in health and health-care decision making from the perspectives of both supply and demand.

There has been much discussion about how to obtain legitimacy at macro-level priority setting in health care by use of fair procedures, but how should we consider priority setting by individual clinicians or health workers at the micro-level? Despite the fact that just health care totally hinges upon their decisions, surprisingly little attention seems being paid to the legitimacy of these decisions. This paper addresses the following question: what are the conditions that have to be (...) met in order to ensure that individual claims on health care are well aligned with an overall concept of just health care? Drawing upon a distinction between individual and aggregated needs, I argue that even though we assume the legitimacy of macro-level guidelines, this legitimacy is not directly transferable to decisions at micro-level simply by adherence to the guidelines’ recommendation. Further, I argue that individual claims are subject to the formal principle of equality and the demands of vertical and horizontal equity in a way that gives context- and patient-related equity concerns precedence over equity concerns captured at the macro-level. I conclude that if we aim to achieve just health care, we need to develop a complementary framework for legitimising individual judgment of patients’ claims on health care resources. Moreover, I suggest the basic structure of such a framework. (shrink)

I argue that it can be morally permissible to coerce people into doing what is good for their own health. I discuss recent initiatives in New York City that are designed to take away certain unhealthy options from local citizens, and argue that this does not impose on them in unjustifiable ways. Good paternalistic measures are designed to promote people's long-term goals, and to prevent them from making short-term decisions that interfere with reaching those, and New York's attempts to (...) ban the sale of sugary drinks larger than 16 ounces and the use of trans fats fall within those parameters. Given our tendency to cognitive bias, we need help in making choices that truly instantiate our values. (shrink)

Lifestyle diseases constitute an increasing proportion of health problems and this trend is likely to continue. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge. Holding individuals accountable for their choices in the context of health care is, however, controversial. There are powerful arguments both for and against such policies. In this article the main arguments for and the traditional arguments against the use of individual responsibility (...) as a criterion for the distribution of scarce health resources will be briefly outlined. It is argued that one of the most prominent contemporary normative traditions, liberal egalitarianism, presents a way of holding individuals accountable for their choices that avoids most of the problems pointed out by the critics. The aim of the article is to propose a plausible interpretation of liberal egalitarianism with respect to responsibility and health care and assess it against reasonable counter-arguments. (shrink)

Coercive Care asks probing and challenging questions regarding the use of coercion in health care and the social services. The book combines philosophical analysis with comparative studies of social policy and law in a large number of industrialized countries.

Some healthcare systems are said to be grounded in solidarity because healthcare is funded as a form of mutual support. This article argues that health care systems that are grounded in solidarity have the right to penalise some users who are responsible for their poor health. This derives from the fact that solidary systems involve both rights and obligations and, in some cases, those who avoidably incur health burdens violate obligations of solidarity. Penalties warranted include direct (...) patient contribution to costs, and lower priority treatment, but not typically full exclusion from the healthcare system. We also note two important restrictions on this argument. First, failures of solidary obligations can only be assumed under conditions that are conducive to sufficiently autonomous choice, which occur when patients are given ‘Golden Opportunities’ to improve their health. Second, because poor health does not occur in a social vacuum, an insistence on solidarity as part of healthcare is legitimate only if all members of society are held to similar standards of solidarity. We cannot insist upon, and penalise failures of, solidarity only for those who are unwell, and who cannot afford to evade the terms of public health. (shrink)

Coercive Care: The Ethics of Choice in Health and Medicine asks probing and challenging questions regarding the use of coercion in health care and social services. This book combines philosophical analysis with comparative studies of social policy and law in a large number of industrialized countries and proposes an ideal of judicial security on a global scale.

This essay contends that individual liberty, understood as the permissibility of making choices about one’s own health care in support of one’s own good and the good of one’s family utilizing private resources, is central to the moral foundations of a health care system. Such individual freedoms are important not only because they often support more efficient and effective health care services, but because they permit individuals to fulfill important moral duties. A comparative (...) study of the health care systems in Hong Kong and mainland China is utilized to illustrate the conceptual and moral concerns at stake. Both regions have implemented two-tier health care systems with a public tier of basic health care services together with a second tier of privately purchased health care. As we document, Hong Kong permits patients and doctors significantly greater opportunities to choose private health care of typically higher medical quality than their mainland counterparts. As a result, individuals are able to obtain higher quality health care while also fulfilling important moral duties for themselves and their families. In this sense, Hong Kong’s health care system is morally superior to mainland China’s. In each case, Confucianism’s concerns regarding equality are partly satisfied through the provision of public health care services on the basic tier, while appropriate use of private resources in support of oneself and one’s family is permissibly exercised on the private tier. Although it is true that inequalities in health care access and outcome are inevitable within a system that permits such individual freedoms, we argue that such inequalities are morally justifiable in terms of Confucian ethical thought. (shrink)

The rise of genetic techniques presents a great promise as well as some difficult dilemma's about how genetics will affect the way we will be able to live our lives. For this reason, in many countries, public debates are organized to reflect upon the development of predictive medicine. In this essay we focus on economist A. Hirschman's work on “exit, voice and loyalty” to analyse and enrich these public debates. We first introduce Hirschman's triad of concepts and focus on the (...) concept of “voice,” which refers to an institution's ability to allow clients to give feedback about products or services, and its ability to listen to the feedback given. We argue that voice is particularly important for the health care system in which predictive medicine is developing. Voice is crucial because how predictive medicine will become institutionalised is now in the process of becoming determined. However, in public debates about predictive medicine, voice tends to be reduced to providing people with the option of making a choice whether to use genetic techniques or not. We argue that this reduction of voice to choice is not very informative about predictive medicine and suggest an amendment of Hirschman's concept of voice, which we call “hesitant voice.” Hesitant voice attempts to be informative about the uncertainty people experience in addressing predictive medicine and topicalises the gradual, the embodied, the tentative character of voice in developing situations like that of predictive medicine. (shrink)

Health care organization is entering a new age. Focus is increasingly shifting from individual health care institutions to interorganizational collaboration and health care networks. Much hope is set on such networks which have been argued to improve economic efficiency and quality of care. However, this does not automatically mean they are always ethically justified. A relevant question that remains is what ethical obligations or duties one can ascribe to these networks especially because networks (...) involve many risks. Due to their often amorphous and complex structure, collective responsibility and accountability may increase while individual responsibility goes down. We argue that a business ethics approach to ethical obligations for health care networks, is problematic and we propose to opt for a patient perspective. Using the classic four principles of biomedical ethics it is possible to identify specific ethical duties. Based on the principle of justice, health care networks have an ethical duty to provide just and fair access for all patients and to be transparent to patients about how access is regulated. The principle of nonmaleficence implies an obligation to guarantee patient safety, whereas the principle of beneficence implies an obligation for health care networks to guarantee continuity of care in all its dimensions. Finally, the principle of autonomy is translated into a specific obligation to promote and respect patient choice. Networks that fail to meet any of these conditions are suspect and cannot be justified ethically. Faced with daunting challenges, the health care system is changing rapidly. Currently many hopes ride on integrated care and broad health care networks. Such networks are the topic of empirical debate, but more attention should be given to the ethical aspects. Health care networks raise new and pressing ethical issues and we are in need of a framework for assessing how and when such networks are justified. (shrink)

Abstract:In this paper we highlight the emergence of organizational ethics issues in health care as an important outcome of the changing structure of health care delivery. We emphasize three core themes related to business ethics and health care ethics: integrity, responsibility, and choice. These themes are brought together in a discussion of the process of Mission Discernment as it has been developed and implemented within an integrated health care system. Through this discussion (...) we highlight how processes of institutional reflection, such as Mission Discernment, can help health care organizations, as well as corporations, make critical choices in turbulent environments that further the core mission and values and fulfill institutional responsibilities to a broad range of stakeholders. (shrink)

During the last decade a “technical” approach has become increasingly influential in health care priority setting. The various country reports illustrate, however, that non-technical considerations cannot be avoided. As they often remain implicit in health care package decisions, this paper aims to make these normative judgements an explicit part of the procedure. More specifically, it aims to integrate different models of distributive justice as well as the principle of solidarity in four different phases of a decision-making (...) procedure, and to identify important moral choices which present themselves. First four important justice models are discussed, then a justification is given for their inclusion in a four-step decision making procedure. This is followed by a discussion of different justice and solidarity problems—with their inherent conceptual difficulties in each of these stages. The paper concludes with a summary of the major moral choices that are to be made in health care package decisions. (shrink)

Abstract:In this paper we highlight the emergence of organizational ethics issues in health care as an important outcome of the changing structure of health care delivery. We emphasize three core themes related to business ethics and health care ethics: integrity, responsibility, and choice. These themes are brought together in a discussion of the process of Mission Discernment as it has been developed and implemented within an integrated health care system. Through this discussion (...) we highlight how processes of institutional reflection, such as Mission Discernment, can help health care organizations, as well as corporations, make critical choices in turbulent environments that further the core mission and values and fulfill institutional responsibilities to a broad range of stakeholders. (shrink)

Health-care goods are goods with peculiar properties, and where they are scarce, societies face potentially explosive distributional conflicts. Animated public and academic debates on the necessity and possible justice of limit-setting in health care have taken place in the last decades and have recently taken a turn toward procedural rather than substantial criteria for justice. This article argues that the most influential account of procedural justice in health-care rationing, presented by Daniels and Sabin, is (...) indeterminate where concrete properties of rationing institutions are concerned. Such properties inscribe substantial norms into institutions. These norms can derive validity only from democratic majority decisions, which must be seen as an instance of pure procedural justice. We therefore have to move the discussion to a meta-level and ask how concrete properties of institutions are being chosen. I suggest four criteria for sufficiently democratic institutional design choice and conclude that as institutional properties are likely to have effects on the resulting distribution of health care, design choices should be empirically informed and taken both democratically and deliberately. (shrink)

In decisions about inclusion (or exclusion) of health care services in the benefit package, different interpretations of notions like health, health risk, disease, quality of life or necessary care often remain implicit. Yet they can lead to different benefit package decisions. After a brief discussion of these concepts in definitions of the goals of medicine, the various value-judgements implicit in interpretations of key notions in health care are analysed and conclusions are drawn with (...) regard to the composition of decision making bodies at various levels. It is further argued that such a body needs to discuss the various interpretations of key-notions explicitly in the various phases of a priority-setting procedure so that more consistent choices can be made in health care priority setting. (shrink)

Tragic choices arise during the COVID-19 pandemic when the limited resources made available in acute medical settings cannot be accessed by all patients who need them. In these circumstances, healthcare rationing is unavoidable. It is important in any healthcare rationing process that the interests of the community are recognised, and that decision-making upholds these interests through a fair and consistent process of decision-making. Responding to recent calls to safeguard individuals’ legal rights in decision-making in intensive care, and for (...) new authoritative national guidance for decision-making, this paper seeks to clarify what consistency and fairness demand in healthcare rationing during the COVID-19 pandemic, from both a legal and ethical standpoint. The paper begins with a brief review of UK law concerning healthcare resource allocation, considering how community interests and individual rights have been marshalled in judicial deliberation about the use of limited health resources within the National Health Service. It is then argued that an important distinction needs to be drawn between procedural and outcome consistency, and that a procedurally consistent decision-making process ought to be favoured. Congruent with the position that UK courts have adopted for resource allocation decision-making in the NHS more generally, specific requirements for a procedural framework and substantive triage criteria to be applied within that framework during the COVID-19 pandemic are considered in detail. (shrink)

In this paper an economics approach to assessing community values in health care priority setting is examined. The approach is based on the concept of ‘willingness to pay’ (WTP). Eighty two parents were interviewed with regard to three aspects of provision of child health services. For each aspect a choice of two courses of action was presented. Parents were asked which course of action they preferred and what was the maximum amount of money they would be prepared (...) to pay for this rather than their less preferred option. WTP responses are acceptable to the majority of respondents and appear to ‘behave’ in accordance witha priori expectations. A method of assessing the influence of ability to pay on preferences and WTP is outlined. Preferences and WTP do not appear to have been unduly distorted by ability to pay. Use of WTP data does have the potential to provide health care purchasers and providers with information on intensity as well as direction of the preferences of members of the community. (shrink)

This paper takes up the question of the role of philosophical moral theory in our attempts to resolve the ethical problems that arise in health care, with particular reference to the contention that we need theory to be determinative of our choice of actions. Moral theorizing is distinguished from moral theories and the prospects for determinacy from the latter are examined through a consideration of the most promising candidates: utilitarianism, deontology and the procedures involved in reflective equilibrium. It (...) is argued that the current lack of any generally accepted method of solving moral problems, together with the extreme improbability of philosophy achieving a plausibly determinate theory, should encourage us to approach the problems in a spirit of agnosticism regarding the way in which theoretical material might be of relevance. The practical test for both moral theorizing and moral theories is thus not determinacy but the degree to which they increase our understanding of moral problems by serving, as they do in philosophy, as a means of inquiry into their nature. (shrink)

As resources in health care are scarce, managers and clinicians must make difficult choices about what to fund and what not to fund. At the level of a regional health authority, limited approaches to aid decision makers in shifting resources across major service portfolios exist. A participatory action research project was conducted in the Calgary Health Region. Through five phases of action, including observation of senior management meetings, as well as two sets of one-on-one interviews (...) and two focus groups, an approach to priority setting at the macro level within the health region was developed and implemented. The resulting macro level approach builds on the program budgeting and marginal analysis (PBMA) framework. Using a multi-disciplinary expert panel, about $45M (CAN) was released for the 2002/03 fiscal year and made available for re-allocation to service growth areas and the deficit. Important qualitative themes from the managers and clinicians informed both process development and refinement. The approach developed here not only facilitated re-allocation of resources, but also drew in both clinicians and managers to work together on this challenging task. The approach is pragmatic, transparent and evidence based, and should have application elsewhere. (shrink)

Protecting the Vulnerable explores the reality of patient control and choice in health care and analyzes how decisions should be made on behalf of those deemed incapable of making decisions. The contributors, distinguished experts from the disciplines of medicine, ethics, theology, and law, look at the complex problem of autonomy and consent in health care and clinical research today from an illuminating perspective--its impact on the vulnerable members of society. The essays move from the exploration of (...) lingering paternalism in health care to the acute dilemma of treatment of and research on newborn babies. In covering both general and specific problems the collection reveals how exploitation can occur when the right of autonomy is eroded and where informed consent is illusory. Particularly vulnerable groups, such as children and people with mental handicaps, are discussed alongside cases where the vulnerability is itself an issue. Other areas covered include: `gesture' suicides, the practical problems of doctors in dealing with dependent patients, and the limits of proxy consent. All health care professionals, ethicists, policy makers, and lawyers currently engaged in the study or practice of health care ethics will find Protecting the Vulnerable to be a vital source of information for many years to come. (shrink)

In this companion volume to their 1981 work, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma examine the principle of beneficence and its role in the practice of medicine. Their analysis, which is grounded in a thorough-going philosophy of medicine, addresses a wide array of practical and ethical concerns that are a part of health care decision-making today. Among these issues are the withdrawing and withholding of nutrition and hydration, competency assessment, the requirements for valid surrogate decision-making, (...) quality-of-life determinations, the allocation of scarce health care resources, medical gatekeeping, and for-profit medicine. The authors argue for the restoration of beneficence to its place as the fundamental principle of medical ethics. They maintain that to be guided by beneficence a physician must perform a right and good healing action which is consonant with the individual patient 's values. In order to act in the patient 's best interests, or the patient 's good, the physician and patient must discern what that good is. This knowledge is gained only through a process of dialogue between patient and/or family and physician which respects and honors the patient 's autonomous self-understanding and choice in the matter of treatment options. This emphasis on a dialogical discernment of the patient 's good rejects the assumption long held in medicine that what is considered to be the medical good is necessarily the good for this patient. In viewing autonomy as a necessary condition of beneficence, the authors move beyond a trend in the medical ethics literature which identifies beneficence with paternalism. In their analysis of beneficence, the authors reject the current emphasis on rights- and duty-based ethical systems in favor of a virtue-based theory which is grounded in the physician- patient relationship. This book's provocative contributions to medical ethics will be of great interest not only to physicians and other health professionals, but also to ethicists, students, patients, families, and all others concerned with the relationship of professional to patient and patient to professional in health care today. (shrink)

The unfortunately vast history of paternalism in both medicine and clinical research has resulted in perpetually increasing respect for patient autonomy and free choice in Western health care systems. Beginning with the negative right to informed consent, the principle of respect for autonomy has for many patients evolved into a positive right to request treatments and expect accommodation. This evolution of patient autonomy has mirrored a more general social attitude of market liberalism where increasing numbers of patients have (...) come to embody the role of the “consumer.” This paper explores this transformation and critiques the current way in which respect for patient autonomy is put into practice. Ultimately, this paper concludes that the consumer view of patient autonomy is dysfunctional. Moreover, this paper argues that, based on the inherent goals of medicine, some form of paternalism is required in any meaningfully therapeutic relationship. (shrink)

In a world of rapid technological advances, the moral issues raised by life and death choices in healthcare remain obscure. _Life and Death in Healthcare Ethics_ provides a concise, thoughtful and extremely accessible guide to these moral issues. Helen Watt examines, using real-life cases, the range of choices taken by healthcare professionals, patients and clients which lead to the shortening of life. The topics looked at include: * euthanasia and withdrawal of treatment * the persistent vegetative state * (...) abortion * IVF and cloning * life-saving treatment of pregnant women Clearly written and insightful, _Life and Death in Healthcare Ethics_ presupposes no prior knowledge of philosophy. It will be of interest to anyone confronting healthcare ethics for the first time, or seeking to develop his or her understanding of some core topics in the field. (shrink)

Luck egalitarianism, a theory of distributive justice, holds that inequalities which arise due to individuals’ imprudent choices must not, as a matter of justice, be neutralized. This article deals with the possible application of luck egalitarianism to the area of health care. It seeks to investigate whether the ethos of luck egalitarianism can be operationalized to the point of informing health care policy without straying from its own ideals. In the transition from theory to practise, (...) luck egalitarianism encounters several difficulties. We argue that the charge of moral arbitrariness can, at least in part, be countered by our provided definition of “imprudent actions” in the health area. We discuss the choice for luck egalitarianism in health care between ex ante and ex post policy approaches, and show how both approaches are flawed by luck egalitarianism’s own standards. We also examine the problem of threshold setting when luck egalitarianism is set to practise in health care. We argue that wherever policy thresholds are set, luck egalitarianism in health care risks pampering the imprudent, abandoning the prudent or, at worst, both. Furthermore, we claim that moves to mitigate these risks in turn diminish the normative importance of the ethos of luck egalitarianism to policy. All in all, our conclusion is that luck egalitarianism cannot be consistently applied as a convincing and relevant normative principle in health care policy. (shrink)

That the maximization of quality-adjusted life years violates concerns for fairness is well known. One approach to face this issue is to elicit fairness preferences of the public empirically and to incorporate the corresponding equity weights into cost-utility analysis (CUA). It is thereby sought to encounter the objections by means of an axiological modification while leaving the value-maximizing framework of CUA intact. Based on the work of Lübbe (2005, 2009a, 2009b, 2010, forthcoming), this paper questions this strategy and scrutinizes the (...) concomitant assumptions concerning the nature of prioritization decisions. Empirical studies indicate that these premises are in fact unwarranted. People chose a certain resource allocation because they perceive it as a fair way to treat the persons concerned, not because it maximizes something valuable, and it is questionable if prioritization decision can be represented as value-maximizing choices at all. This reflection on the fundamental distinction between deontological and consequentialist reasoning bears general implications for the scope of ‘economic imperialism.’. (shrink)

This article investigates the scope and effects of enhanced consumer choice in health insurance that is presented as a cornerstone of the new health insurance legislation in the Netherlands that will come into effect in 2006. The choice for choice marks the current libertarian trend in Dutch health care policymaking. One of our conclusions is that the scope of enhanced choice should not be overstated due to many legal and non-legal restrictions to it. The consumer choice (...) advocates have great expectations of the impact of enhanced choice. A critical analysis of its impact demonstrates that these expectations may not become true and that enhanced consumer choice should not be perceived as the ‘magic bullet’ for many problems in health care. (shrink)

This article reviews recent developments in health care law, focusing on controversy at the intersection of health care law and culture. The article addresses: emerging issues in federal regulatory oversight of the rapidly developing market in direct-to-consumer genetic testing, including questions about the role of government oversight and professional mediation of consumer choice; continuing controversies surrounding stem cell research and therapies and the implications of these controversies for healthcare institutions; a controversy in India arising at the (...) intersection of abortion law and the rights of the disabled but implicating a broader set of cross-cultural issues; and the education of U.S. health care providers and lawyers in the theory and practice of cultural competency. (shrink)

The widespread emergence of innumerable technologies within health care has complicated the choices facing caregivers and their patients. The escalation of knowledge and technical innovation has been accompanied by an erosion of moral and ethical consensus among health providers that is reflected in the abandonment of the Hippocratic Oath as the immutable bedrock of medical ethics. Ethical conflicts arise when the values of health professionals collide with the expressed wishes of patients or the dictates of (...) regulatory bodies and administrators. Increasing attempts by groups outside of the medical profession to limit freedom of conscience for health providers has raised concern and consternation among some health professionals. The personal and professional impact of health professionals surrendering freedom of conscience and participating in actions they deem malevolent or unethical has not been adequately studied and may not be inconsequential when considering the recognized impact of other circumstances of coerced complicity. We argue that the distinction between the two ways that freedom of conscience is exercised (avoiding a perceived evil and seeking a perceived good) provides a rational basis for a principled limitation of this fundamental freedom. (shrink)

As health care costs continue to escalate, cost control measures will likely become unavoidable and painful. One approach is to engage external forces to allocate resources - for example, through managed care or outright rationing. Another approach is to engage consumers to make their own allocation decisions, through "self-rationing," wherein they are given greater awareness, control, and hence responsibility for their health care spending. Steadily gaining popularity in this context is the concept of "consumer directed (...) health care" (CDHC), which is envisioned to both control cost and enhance choice, by combining financial incentives with information to help consumers make more informed health care decisions and to appreciate the economic trade-offs of those decisions. While CDHC is gaining attention in the popular press, business publications, and academic journals, it is not without controversy about its relative merits and demerits. CDHC raises questions regarding the ethical limits of consumer responsibility for their choices. While the emphasis on consumer choice implies that autonomy is the ruling ethical principle in CDHC, it must be tempered by justice and beneficence. Justice must temper autonomy to protect disadvantaged populations from further widening disparities in health care access and outcomes that could arise from health care reform efforts. Beneficence must temper autonomy to protect consumers from unintended consequences of uninformed decisions. Thoughtful paternalism suggests that CDHC plans offer choices that are comprehensible to lay consumers, limited in their range of options, and carefully structured with default rules that minimize potential error costs. (shrink)

This article contends that an ethics of care has a particular moral ontology that makes it suitable to argue for the normative significance of relational responsibilities within professional health care. This ontology is relational. It means that moral choices always have to account for the web of relationships, the relational networks and responsibilities that are an essential part of particular moral circumstances. Given this ontology, the article investigates the conditions for health care professionals to (...) be partial and to act on the basis of particular responsibilities to their patients. We will argue that priorities could be partial in three ways: first, because there may be exceptional circumstances that allow for giving priority to one patient over another; second, because the integrity of the patient and a health care worker may be connected in special ways; and, finally, even if impartiality is essential, the institutional basis of health care must always give ample space for an ethically qualified individual and personal care for patients. Even if difficult priorities may be necessary, the conditions of institutional health care should always seek to create the prerequisites for nurses and doctors to administer proper care. (shrink)

This article examines the ethical basis for government involvement in health care. It first provides the case for individual autonomy, focusing on the justifications–particularly ethical ones–for allowing individuals to make their own choices in health care, and to control more of their own resources in doing so. Next, it provides the opposite case–for abridging individual autonomy, and in particular, for redistributing resources from those who are well off to those who are not. The overriding reason (...) for favouring the latter case, which trumps the notion of individual autonomy, is to ensure that individuals who are at a disadvantage have an equal probability of attaining good health. (shrink)

The paper argues against the polarisation of the health economics literature into pro- and anti-QALY camps. In particular, we suggest that a crucial distinction should be made between the QALY measure as a metric of health, and QALY maximisation as an applied social choice rule. We argue against the rule but for the measure and that the appropriate conceptualisation of health-care rationing decisions should see the main task as the integration of competing and possibly incommensurable normative (...) claim types. We identify the main types as consequences, rights, social contracts, individual votes and community values and note situations in which the contribution of each claim type is limited. We go on to show that the integration of (at least some of) these claim types can be formalised within the mathematical framework provided by non-linear programming. (shrink)

This paper discusses the problematic and sometimes implicit nature of some central notions and criteria used in debates about inclusion (or exclusion) of health care services in the health care benefit package. An analysis of discussions about four health care services—lungtransplantation, statins, (sildenafil (viagra) and rivastigmine—illustrates a case-by-case approach and inconsistent use of criteria, which present a challenge to develop a decision-making procedure in which important criteria or central notions can be discussed explicitly.

Priority setting (also known as resource allocation or rationing) occurs at every level of every health system and is one of the most significant health care policy questions of the 21st century. Because it is so prevalent and context specific, improving priority setting in a health system entails improving it in the institutions that constitute the system. But, how should this be done? Normative approaches are necessary because they help identify key values that clarify policy (...) class='Hi'>choices, but insufficient because different approaches lead to different conclusions and there is no consensus about which ones are correct, and they are too abstract to be directly used in actual decision making. Empirical approaches are necessary because they help to identify what is being done and what can be done, but are insufficient because they cannot identify what should be done. Moreover, to be really helpful, an improvement strategy must utilize rigorous research methods that are able to analyze and capture experience so that past problems are corrected and lessons can be shared with others. Therefore, a constructive, practical and accessible improvement strategy must be research-based and combine both normative and empirical methods. In this paper we propose a research-based improvement strategy that involves combining three linked methods: case study research to describe priority setting; interdisciplinary research to evaluate the description using an ethical framework; and action research to improve priority setting. This describe-evaluate-improve strategy is a generalizable method that can be used in different health care institutions to improve priority setting in that context. (shrink)

This essay examines the right of health care freedom of choice contained in some state constitutions. It explores how courts have, and could, use this constitutional health care right as a basis for recognizing or reinforcing a fundamental right to choose an abortion.

OBJECTIVES: The subject of patient self-determination in health care has gained broad interest because of the increasing number of incompetent patients. In an attempt to solve the problems related to doctors' decision making in such circumstances, advance directives have been developed. The purpose of this study was to examine relationships between public attitudes towards patient autonomy and advance directives. SUBJECTS AND MAIN OUTCOME MEASURES: A stratified random sample of 600 adults in northern Sweden was surveyed by a questionnaire (...) with a response rate of 78.2%. The subjects were asked about their wish for control of their health care, their concerns about health care, their treatment preferences in a life-threatening situation (both reversible and irreversible), and their attitudes towards the application of advance directives. RESULTS: Numerous relationships between various aspects of self-determination in health care (desire for control, fears of over-treatment, and choice of treatment level) in general and advance directives, in particular, were found. Those who wanted to have a say in their health care (about 94%) also mainly supported the use of an advance directive. CONCLUSIONS: The fact that almost 30% of the respondents were undecided concerning their personal use of advance directives points to a lack of knowledge and to the necessity of education of the public on these issues. (shrink)

Modern health care rhetoric promotes choice and individual patient rights as dominant values. Yet we also accept that in any regime constrained by finite resources, difficult choices between patients are inevitable. How can we balance rights to liberty, on the one hand, with equity in the allocation of scarce resources on the other? For example, the duty of health authorities to allocate resources is a duty owed to the community as a whole, rather than to specific (...) individuals. Macro-duties of this nature are founded on the notion of equity and fairness amongst individuals rather than personal liberty. They presume that if hard choices have to be made, they will be resolved according to fair and consistent principles which treat equal cases equally, and unequal cases unequally.In this paper, we argue for greater clarity and candour in the health care rights debate. With this in mind, we discuss (1) private and public rights, (2) negative and positive rights, (3) procedural and substantive rights, (4) sustainable health care rights and (5) the New Zealand booking system for prioritising access to elective services. This system aims to consider: individual need and ability to benefit alongside the resources made available to elective health services in an attempt to give the principles of equity practical effect. We describe a continuum on which the merits of those, sometimes competing, values—liberty and equity—can be evaluated and assessed. (shrink)