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The meaning of severity - do citizenś views correspond to a severity framework based on ethical principles for priority setting?
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0003-0987-7653
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0002-3300-5516
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
2018 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 122, no 6, p. 630-637, article id S0168-8510(18)30081-2Article in journal (Refereed) Published
Abstract [en]

The importance for governments of establishing ethical principles and criteria for priority setting in line with social values, has been emphasised. The risk of such criteria not being operationalised and instead replaced by de-contextualised priority-setting tools, has been noted. The aim of this article was to compare whether citizenś views are in line with how a criterion derived from parliamentary-decided ethical principles have been interpreted into a framework for evaluating severity levels, in resource allocation situations in Sweden. Interviews were conducted with 15 citizens and analysed by directed content analysis. The results showed that the multi-factorial aspects that participants considered as relevant for evaluating severity, were similar to those used by professionals in the Severity Framework, but added some refinements on what to consider when taking these aspects into account. Findings of similarities, such as in our study, could have the potential to strengthen the internal legitimacy among professionals, to use such a priority-setting tool, and enable politicians to communicate the justifiability of how severity is decided. The study also disclosed new aspects regarding severity, of which some are ethically disputed, implying that our results also reveal the need for ongoing ethical discussions in publicly-funded healthcare systems.

Place, publisher, year, edition, pages
Elsevier, 2018. Vol. 122, no 6, p. 630-637, article id S0168-8510(18)30081-2
Keywords [en]
Citizens views, Directed content analysis, Ethical principles, Priority setting, Severity of ill health, Sweden
National Category
Medical Ethics
Identifiers
URN: urn:nbn:se:liu:diva-147772DOI: 10.1016/j.healthpol.2018.04.005ISI: 000438479000010PubMedID: 29728287OAI: oai:DiVA.org:liu-147772DiVA, id: diva2:1205463
Available from: 2018-05-14 Created: 2018-05-14 Last updated: 2019-06-27
In thesis
1. Asking the public: Citizens´ views on priority setting and resource allocation in democratically governed healthcare
Open this publication in new window or tab >>Asking the public: Citizens´ views on priority setting and resource allocation in democratically governed healthcare
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Resource allocation in publicly funded healthcare systems is inevitably linked with priority setting between different patient groups and between different service areas, so-called meso level priorities. Behind every priority-setting decision (investments, reallocating or rationing), are values affecting both the content of the decisions and how the decisions are made. The importance for priority-setting to reflect social values, has been emphasised for the legitimacy of the healthcare systems and the decision makers. Also important, if supposed to provide enough guidance in practice, is that content values, expressed in ethical principles and criteria, are further operationalised. Few studies exist where Swedish citizens have been asked about priority setting and rationing at meso level, and findings from other countries cannot automatically be transferred to the Swedish context.

The overall aim of this thesis is to extend and deepen the knowledge of the Swedish citizens´ views on acceptance of rationing in healthcare, on appropriate decision makers for rationing, and on the severity criterion for priority setting. Two qualitative and one mixmethod study were conducted, where citizens were interviewed. Citizens´ views on severity were also compared, both with a Severity Framework, derived from parliamentary-decided ethical principles and used for resource allocation, and with health professionals´ and politicians´ ranking of different aspects of severity in a quantitative, survey study.

Study I shows that citizen participants perceived that acceptance of rationing at meso level is built on the awareness of priority-setting dilemmas between patient groups. No such spontaneous awareness was found. Depending on reactions of self-interest or solidarity, acceptance was also perceived to be built on acceptable principles for rationing and/or access to alternatives to public care. Study II shows that awareness of the meso level forms the basis for awareness of different risks of unfairness, linked with potential decision makers (even health professionals). Collaborative arrangements were promoted in order to control for such risks, especially the risk of self-interest. Politicians, in contrast to previous studies, were favoured as final decision makers for rationing healthcare. In study III, citizen participants identified the same severity aspects as health professionals and experts had done in the Severity Framework. They contributed with some possible refinements, but also promoted aspects not in line with established ethical criteria for priority setting in Sweden. Study IV shows that citizen respondents differ to a larger proportion compared to politicians´ ranking of severity aspects, than with that of health professionals´. The greatest number of significant differences was found between politicians and health professionals.

This thesis has several implications. Politicians ought to strive for greater public awareness of the priority-setting dilemma at the meso level in healthcare, both according to the process and the content values behind the decisions. Social values not in accordance to the parliamentary decision indicate a need to facilitate an ongoing dialogue, reason-giving activities and promotion of content values of solidarity. To capture social values on priority setting and rationing, ambitious public deliberation is not the only way. Methodologically stringent research, with a variety of study designs, could contribute in many important ways.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2018. p. 138
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1587
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Medical Ethics Public Administration Studies Social Sciences Interdisciplinary
Identifiers
urn:nbn:se:liu:diva-146217 (URN)10.3384/diss.diva-146217 (DOI)9789176854518 (ISBN)
Public defence
2018-04-20, Hasselquistsalen, Campus US, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2018-04-03 Created: 2018-04-03 Last updated: 2019-09-30Bibliographically approved

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Broqvist, MariSandman, LarsGarpenby, PeterKrevers, Barbro

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