A central strand in philosophical debate over the just distribution of resources attempts to juggle three competing imperatives: helping those who are worst off, helping those who will benefit the most, and then – beyond this – determining when to aggregate such ‘worst off’ and ‘benefit’ claims, and when instead to treat no such claim as greater than that which any individual by herself can exert. Yet as various philosophers have observed, ‘we have no satisfactory theoretical characterization’ as to how (...) to weigh each of the three imperatives against one another, we find it ‘difficult to state... precise or comprehensive conclusions’, and we do not yet have a ‘metric for integrating the three measures’. In what follows, I offer an approach to weighing the three criteria against one another that yields resolutions – in Hard Cases of the ‘saving one infant's life versus replacing ten elderly people's hips’ sort – that are cardinally definitive, intuitively satisfactory and theoretically justified. (shrink)

Daniel Hausman’s book ‘Valuing Health’ is a valuable contribution to our understanding of QALYs and DALYs and to moving health economics to adopting a broader perspective than that taken in conventional cost-effectiveness analysis. Hausman’s attempt at constructing a public value table for health states without having recourse to data from population preferences studies is also a fascinating read. But I have serious concerns about his resulting table. Hausman’s views on which dimensions of health a benevolent liberal state should care about (...) are essentially not different from what has long been emphasized in health economists’ work on valuations of health outcomes. His table would have been helpful as a sketch if it was the first attempt in health economics to quantify numerically the societal value of different types and degrees of health improvement. But research in the field has gone far beyond that. Multi-attribute utility instruments with much more accurate health classification systems than Hausman’s sketch are now at hand. Available also are models of societal valuations of QALYs that are broadly consistent with general population values, incorporate wider concerns than Hausman’s table does and do not have the questionable numerical properties that characterize Hausman’s sketch. (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)

Quality Adjusted Life Years (QALYs) have become a household word among health economists. Their use as a means of comparing the value of health programmes and medical interventions has stirred up controversy in the medical profession and the academic community. In this paper, I argue that QALY analysis does not adequately take into account the differentiated nature of the health state values it measures. Specifically, it does not distinguish between needs and preferences with respect to its valuation of health states. (...) I defend the view that needs and preferences are clearly distinguishable, and that the concept of needs cannot be dispensed with, as many health economists suggest. It is argued that the scale along which health states are measured in QALY analysis is not a continuous interval scale, but one which concerns two distinctly different value dimensions. Measuring the values of health state intervals may reveal the weighting attached to the different value dimensions. (shrink)

Objectives: This study attempts to analyse the ethical dilemmas arising from the microallocation of scarce health care resources, in terms of deontology and utilitarianism.Methods: A group of 395 people were interviewed in the region of Diadema, greater San Paulo, Brazil, while visiting patients in the only state hospital in town. Each interviewee was given a list of eight simulated emergencies . In each of the eight cases the interviewee had to choose which of the two patients described, both of whom (...) suffered from exactly the same problem, should receive the only hospital bed currently available. The differences between the hypothetical patients were as follows: age, gender, family dependency, and lifestyle. Each interviewee was asked to justify one of their responses. These responses were then analysed.Results: The results pointed to the co-existence of deontological and utilitarian orientations among the people interviewed. A tendency to give priority to the destitute was revealed throughout the research, contradicting the idea that society, valuing only productive people, wishes only such people to receive the most resources, thus maximising the benefits to be gained from resources. The results showed that people’s disapproval of the alcoholic was stronger than that of the nicotine abuser. (shrink)

To give priority to the young over the elderly has been labelled ‘ageism’. People who express ‘ageist’ preferences may feel that, all else equal, an individual has greater right to enjoy additional life years the fewer life years he or she has already had. We shall refer to this asegalitarian ageism. They may also emphasise the greater expected duration of health benefits in young people that derives from their greater life expectancy. We may call thisutilitarian ageism. Both these forms of (...) ageism were observed in an empirical study of social preferences in Australia. The study lends some support to the assumptions in the QALY approach that duration of benefits, and hence old age, should count in prioritising at the budget level in health care. (shrink)

Is it possible to use the courts - or rights instruments - to advance fair access to health care? This article examines this question within the context of the Norwegian public health care system - one special example of the Scandinavian welfare system. In particular, it asks four basic questions: What are the normative justifications for rights to health care? What were the political processes and concerns leading up to the current Patients Rights Act in Norway? What kind of legal (...) status do these rights have? How can rights to access be implemented?Patient rights do not only concern the right to access to health care; they also include the right to information, the right to participate in decision-making, and informed consent. This article examines only the former aspect, the use of the legal system to secure access to prioritized specialized health care services. (shrink)

OBJECTIVE: This article describes a method for investigating attitudes towards prioritisation in medicine. SETTING: University of Kuopio, Finland. DESIGN: The method consisted of a set of 24 paired scenarios, which were imaginary patient cases, each containing three different ethical indicators randomly selected from a list of indicators (for example, child, rich patient, severe disease etc.). The scenarios were grouped into 12 random pairs and the procedure was repeated four times, resulting in 12 scenario pairs arranged randomly in five different sets. (...) SURVEY: This method was tested with four groups of subjects (n = 8, n = 47, n = 104 and n = 36). RESULTS: Children and patients with a severe disease were prioritised in all groups. The aged, patients with a mild disease and patients with a self-acquired disease were negatively prioritised in all groups. Poor or rich patients were prioritised in some groups but negatively prioritised in others. CONCLUSIONS: The validity and reliability of this method are good and it is suitable for investigating attitudes towards medical prioritisation. (shrink)

Priority-setting policy-makers often face moral and political pressure to balance the conflicting motivations of efficiency and rescue/non-abandonment. Using the conflict between these motivations as a case study can enrich the understanding of institutional design in developed democracies. This essay presents a cognitive-psychological account of the conflict between efficiency and rescue/non-abandonment in health care priority-setting. It then describes three sets of institutional arrangements—in Australia, England/Wales, and Germany, respectively—that contend with this conflict in interestingly different ways. The analysis yields at least three (...) implications for institutional design in developed democracies: (1) indeterminacy at the level of moral psychology can increase the probability of indeterminacy at the level of institutional design; (2) situational constraints in effect require priority-setting policy-makers to adopt normative-moral pluralism; and (3) the U.S. health care system may be in an anti-priority-setting equilibrium. (shrink)