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The Art of Saying No: The Economics and Ethics of Healthcare Rationing
Linköping University, Department of Medicine and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.ORCID iD: 0000-0002-8159-1249
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

It follows from resource scarcity that some form of healthcare rationing is unavoidable. This implies that potentially beneficial medical treatments must be denied to patients to avoid unacceptable sacrifices in other areas of society. By focusing on four, core, conceptual themes – individual responsibility, paternalism, incentives, and inequality – this thesis explores the matter of finding justifiable grounds for saying no in the context of health care.

By combining the perspectives of welfare economics and population-level ethics, the author explicate and discusses conflicting moral values involved in healthcare rationing. Four papers form the foundation for this thesis. Paper I articulates the potential role of individual responsibility as a welfarepromoting, rationing tool by exploring when healthcare services exhibit characteristics that facilitate individual responsibility for private financing. Paper II explores the normative relevance of individuals’ time preferences in healthcare rationing and when paternalism can be justified in the context of individuals’ intertemporal health choices. Paper III examines the compatibility between incentive-based organ donation and the ethical platform for setting priorities in Sweden. Paper IV empirically  investigates the existence of horizontal inequalities in using waiting lists to ration care.

From the discussion it is suggested, inter alia, that: I) Prospective responsibility as opposed to retrospective responsibility is a more productive notion of responsibility when discussing actual policies. However, potential positive effects need to be weighed against the increased economic inequality that it is likely to invoke. II) Although cost-effectiveness analysis provides valuable input when making rationing decisions it should not be viewed as a decision rule, since it is based on utilitarian values that constantly need to be balanced against other nonutilitarian values. III) Potentially, increased health could negatively affect individuals’ well-being if it creates opportunities that they are unable to take advantage of. This needs to be taken into account before embarking on paternalistic policies to improve health – policies that often target the lower socioeconomic segment.

The author concludes that decisions on rationing cannot be computed through a simple formula. Moreover, given that rationing is bound to be associated with reasonable disagreements we are unlikely to ever fully  resolve these disagreements. However, by explicitly stating conflicting moral values we are more likely to narrow the disagreements and achieve a healthcare system that is both fairer and more efficient.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2011. , 91 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1215
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-65397ISBN: 978-91-7393-282-0 (print)OAI: oai:DiVA.org:liu-65397DiVA: diva2:395442
Public defence
2011-02-04, Berzeliussalen, ingång 64, plan 9, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2011-02-07 Created: 2011-02-07 Last updated: 2015-09-22Bibliographically approved
List of papers
1. Individual responsibility for what?: A conceptual framework for exploring the suitability of private financing in a publicly funded health-care system
Open this publication in new window or tab >>Individual responsibility for what?: A conceptual framework for exploring the suitability of private financing in a publicly funded health-care system
2010 (English)In: Health Economics, Policy and Law, ISSN 1744-1331, E-ISSN 1744-134X, Vol. 5, no 2, 201-223 p.Article in journal (Refereed) Published
Abstract [en]

Policymakers in publicly funded health-care systems are frequently required to make intricate decisions on which health-care services to include or exclude from the basic health-care package. Although it seems likely that the concept of individual responsibility is an essential feature of such decisions, it is rarely explicitly articulated or evaluated in health policy. This paper presents a tentative conceptual framwork for exploring when health-care services contain characteristics that facilitate individual responsibility through private financing. Six attributes for exploring the suitability of private financing for specific health-care commodities are identified: (i) it should enable individuals to value the need and quality both before and after utilization; (ii) it should be targeted toward individuals with a reasonable level of individual autonomy; (iii) it should be associated with low levels of positive externalities; (iv) it should be associated with a demand sufficient to generate a private market; (v) it should be associated with payments affordable for most individuals; and finally, (vi) it should be associated with 'lifestyle enhancements' rather than 'medical necessities'. The tentative framework enables exploration of individual responsibility connected to health care as a heterogeneous group of commodities, and allows policymakers to make decisions on rationing by design rather than default.

Place, publisher, year, edition, pages
Cambridge University Press, 2010
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Economics
Identifiers
urn:nbn:se:liu:diva-56316 (URN)10.1017/S174413310999017X (DOI)
Available from: 2012-11-23 Created: 2010-05-07 Last updated: 2017-12-12Bibliographically approved
2. Discounting, Preferences, and Paternalism in Cost-Effectiveness Analysis
Open this publication in new window or tab >>Discounting, Preferences, and Paternalism in Cost-Effectiveness Analysis
2012 (English)In: Health Care Analysis, ISSN 1065-3058, E-ISSN 1573-3394, Vol. 20, no 3, 297-318 p.Article in journal (Refereed) Published
Abstract [en]

When assessing the cost effectiveness of health care programmes, health economists typically presume that distant events should be given less weight than present events. This article examines the moral reasonableness of arguments advanced for positive discounting in costeffectiveness analysis both from an intergenerational and an intrapersonal perspective and assesses if arguments are equally applicable to health and monetary outcomes. The article concludes that behavioral effects related to time preferences give little or no reason for why society at large should favour the present over the future when making intergenerational choices regarding health. The strongest argument for discounting stems from the combined argument of diminishing marginal utility in the presence of growth. However, this hinges on the assumption of actual growth in the relevant good. Moreover, current modern democracy may be insufficiently sensitive to the concerns of future generations. The second part of the article categorises preference failures (which justify paternalistic responses) into two distinct groups, myopic and acratic. The existence of these types of preference failures makes elicited time preferences of little normative relevance when making decisions regarding the social discount rate, even in an intrapersonal context. As with intergenerational discounting, the combined arguments of growth and diminishing marginal utility offer the strongest arguments for discounting in the intrapersonal context. However, there is no prima facie reason to assume that this argument should apply equally to health and monetary values. To be sure, selecting an approach towards discounting health is a complex matter. However, the life-ordeath implications of any approach require that the discussion not be downplayed to merely a technical matter for economists to settle.

Place, publisher, year, edition, pages
Springer, 2012
Keyword
Cost-effectiveness analysis; Discounting; Paternalism; Preference failures; Time preferences
National Category
Medical and Health Sciences Philosophy Medical Ethics Health Care Service and Management, Health Policy and Services and Health Economy Economics
Identifiers
urn:nbn:se:liu:diva-65394 (URN)10.1007/s10728-011-0188-6 (DOI)000306591400006 ()
Available from: 2011-02-07 Created: 2011-02-07 Last updated: 2017-12-11
3. Incentivizing deceased organ donation: A Swedish priority-setting perspective.
Open this publication in new window or tab >>Incentivizing deceased organ donation: A Swedish priority-setting perspective.
2011 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 39, no 2, 156-163 p.Article in journal (Refereed) Published
Abstract [en]

AIMS: The established deceased organ donation models in many countries, relying chiefly on altruism, have failed to motivate a sufficient number of donors. As a consequence organs that could save lives are routinely missed leading to a growing gap between demand and supply. The aim of this paper is twofold; firstly to develop a proposal for compensated deceased organ donation that could potentially address the organ shortage; secondly to examine the compatibility of the proposal with the ethical values of the Swedish healthcare system.

METHODS: The proposal for compensating deceased donation is grounded in behavioural agency theory and combines extrinsic, intrinsic and signalling incentives in order to increase prosocial behaviour. Furthermore the compatibility of our proposal with the values of the Swedish healthcare system is evaluated in reference to the principles of human dignity, needs and solidarity, and cost effectiveness.

RESULTS: Extrinsic incentives in the form of a €5,000 compensation towards funeral expenses paid to the estate of the deceased or family is proposed. Intrinsic and signalling incentives are incorporated by allowing all or part of the compensation to be diverted as a donation to a reputable charity. The decision for organ donation must not be against the explicit will of the donor.

CONCLUSIONS: We find that our proposal for compensated deceased donation is compatible with the values of the Swedish healthcare system, and therefore merits serious consideration. It is however important to acknowledge issues relating to coercion, commodification and loss of public trust and the ethical challenges that they might pose.

Place, publisher, year, edition, pages
SAGE, 2011
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-65395 (URN)10.1177/1403494810391522 (DOI)000288065000006 ()21239479 (PubMedID)
Available from: 2011-02-07 Created: 2011-02-07 Last updated: 2017-12-11Bibliographically approved
4. Horizontal Inequality in Rationing by Waiting Lists
Open this publication in new window or tab >>Horizontal Inequality in Rationing by Waiting Lists
2014 (English)In: International Journal of Health Services, ISSN 0020-7314, E-ISSN 1541-4469, International Journal of Health Services, ISSN 0020-7314, Vol. 44, no 1, 169-184 p.Article in journal (Refereed) Published
Abstract [en]

The objective of this article was to investigate the existence of horizontal inequality in access to care for six categories of elective surgery in a publicly funded system, when care is rationed through waiting lists. Administrative waiting time data on all elective surgeries (n = 4,634) performed in Östergötland, Sweden, in 2007 were linked to national registers containing variables on socioeconomic indicators. Using multiple regression, we tested five hypotheses reflecting that more resourceful groups receive priority when rationing by waiting lists. Low disposable household income predicted longer waiting times for orthopedic surgery (27%, p < 0.01) and general surgery (34%,p < 0.05). However, no significant differences on the basis of ethnicity and gender were detected. A particularly noteworthy finding was that disposable household income appeared to be an increasingly influential factor when the waiting times were longer. Our findings reveal horizontal inequalities in access to elective surgeries, but only to a limited extent. Whether this is good or bad depends on one's moral inclination. From a policymaker's perspective, it is nevertheless important to recognize that horizontal inequalities arise even though care is not rationed through ability to pay.

Place, publisher, year, edition, pages
Baywood Publishing Company, Inc., 2014
Keyword
Rationing, waiting list, horizontal equity, elective surgery, Sweden
National Category
Medical and Health Sciences Philosophy Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-65396 (URN)10.2190/HS.44.1.j (DOI)000331060500010 ()
Available from: 2011-02-07 Created: 2011-02-07 Last updated: 2017-12-11Bibliographically approved

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