When treatments are deemed not to be cost-effective and face non-reimbursement, policymakers in publicly funded healthcare systems may decide to ration treatments by withholding it from future patients. However, they must also address a critical question: should they also ration treatments by withdrawing it from patients already having access to the treatment, or is there an ethical difference between withdrawing and withholding treatments? To explore this question, we conducted a behavioural experiment (n=1404), examining public support for withdrawing and withholding treatments in reimbursement decisions across eleven different circumstances. Overall, public support for rationing by withdrawing and withholding was low, with no general perceived difference between withdrawing and withholding treatments. However, when we analysed the different circumstances separately, there were multiple circumstances where withholding was deemed ethically more problematic than withdrawing. Moreover, there was an overall preference for allowing individual assessments compared to ensuring that treatments are equally rationed between different healthcare providers. This result may indicate a preference for procedural fairness compared to outcome fairness. In addition, it was deemed more important to allow for individual assessments and to ensure equal rationing when withdrawing treatments compared to withholding. Overall, these findings reveal nuances in public preferences regarding withdrawing and withholding treatments, challenging the prevailing beliefs that withholding treatments is psychologically easier and ethically less problematic than withdrawing. They also challenge assertions of ethical equivalence between these two rationing approaches. If policymakers want to align their policies with public attitudes, our results suggest adopting a nuanced approach towards withdrawing and withholding treatments, recognizing that public support for ethical equivalence between withdrawing and withholding treatments varies depending on the circumstances.

The allocation of resources is a crucial part of political decision-making in healthcare, but explicit priorities are rarely set when resources are distributed. Two areas that have received some attention in research about legitimacy and priority-setting decisions in healthcare are the role of technical expert agencies as mediating institutions and the role of elected politicians. This paper investigates a political priority-setting advisory committee within a regional authority in Sweden. The aim is to explore how a political body can serve as a mediating institution for priority-setting in healthcare by disentangling the arrangements of its work in terms of what role it performs in the organisation and what it should do. The findings illustrate that promoting the notion of explicit priority-setting and the political aspects inherent in priority-setting in political healthcare management can contribute to consolidating political governance and leadership. There is, however, a complex tension between stability and conflicting values which has implications for the role of politicians as citizens' democratic representatives. This paper enhances our understanding of the role of mediating institutions and political properties of healthcare priority-setting, as well as our understanding of political and democratic healthcare governance in local self-government.

Detta är en heltäckande etikbok för dig som arbetar med vårdande, från grundläggande kunskaper till fördjupning och reflektion. 

Du kommer att få ta del av:

• Beskrivningar av centrala etiska teorier och begrepp.

• Konkreta fall från vårdens vardag.

• Analysinstrument för etiska problem.

• Etiska dilemman från olika professioners perspektiv.

I den reviderade utgåvan har innehållet uppdaterats med den senaste lagstiftningen och ny relevant forskning har lagts till. Boken har även kompletterats med ett avsnitt om moralpsykologi och strukturen i vissa kapitel har förbättrats.

Etikboken är en mycket uppskattad bok som riktar sig främst till studenter på grundläggande nivå inom omvårdnad och vårdvetenskap men är också högst relevant för studenter inom socialt arbete, fysioterapi, arbetsterapi och på läkarprogrammet.

In this article we discuss some ethically and legally controversial issues in the Swedish priority guidelines for intensive care during the recent covid pandemic. We show how the Swedish ethics platform for priority setting constitutes a robust starting point for such guidance, but that there is a lack of detail leaving some of the more challenging situations without explicit guidance. To provide guidance, which we have reason to do in order to avoid inequality and arbitrariness, we should try to interpret the ethics platform, based on how it is applied in practice together with ethical reasoning. In this article, we illustrate this by focusing on contested guidance concerning biological age when distributing scarce intensive care beds. We conclude that biological age should be interpreted in terms of long-term survival. We also conclude that the ethical platform does not provide guidance in these challenging situations, but needs interpretation. Therefore, there is a need of a legal overview of the principles in order to create an even stronger basis for support in the future

When considering the introduction of a new intervention in a budget constrained healthcare system, priority setting based on fair principles is fundamental. In many jurisdictions, a multi-criteria approach with several different considerations is employed, including severity and cost-effectiveness. Such multi-criteria approaches raise questions about how to balance different considerations against each other, and how to understand the logical or normative relations between them. For example, some jurisdictions make explicit reference to a large patient benefit as such a consideration. However, since patient benefit is part of a cost-effectiveness assessment it is not clear how to balance considerations of greater patient benefit against considerations of severity and cost-effectiveness. The aim of this paper is to explore the role of a large patient benefit as an independent criterion for priority setting in a healthcare system also considering severity and cost-effectiveness. By taking the opportunity cost of new interventions (i.e., the health forgone in patients already receiving treatment) into account, we argue that patient benefit has a complex relationship to priority setting. More specifically, it cannot be reasonably concluded that large patient benefits should be given priority if severity, cost-effectiveness, and opportunity costs are held constant. Since we cannot find general support for taking patient benefit into account as an independent criterion from any of the most discussed theories about distributive justice: utilitarianism, prioritarianism, telic egalitarianism and sufficientarianism, it is reasonable to avoid doing so. Hence, given the complexity of the role of patient benefit, we conclude that in priority practice, a large patient benefit should not be considered as an independent criterion, on top of considerations of severity and cost-effectiveness.

BackgroundThe use of policies in medical treatment reimbursement decisions, in which only future patients are affected, prompts a moral dilemma: is there an ethical difference between withdrawing and withholding treatment?DesignThrough a preregistered behavioral experiment involving 1,067 participants, we tested variations in public attitudes concerning withdrawing and withholding treatments at both the bedside and policy levels.ResultsIn line with our first hypothesis, participants were more supportive of rationing decisions presented as withholding treatments compared with withdrawing treatments. Contrary to our second prestated hypothesis, participants were more supportive of decisions to withdraw treatment made at the bedside level compared with similar decisions made at the policy level.ImplicationsOur findings provide behavioral insights that help explain the common use of policies affecting only future patients in medical reimbursement decisions, despite normative concerns of such policies. In addition, our results may have implications for communication strategies when making decisions regarding treatment reimbursement.

Purpose Identify ethical issues that arise in the coordination of return-to-work (RTW) among employees on sick leave due to common mental disorders (CMDs). Material and methods 41 semi-structured individual interviews and one focus group interview with stakeholders (n = 46) involved in RTW: employees on sick leave due to CMDs, coordinators and physicians at primary health care centres, managers, representatives of the Swedish social insurance agency and occupational health services. A six-step thematic analysis focused on the ethical values and norms related to autonomy, privacy, resources and organization, and professional values. Results Five themes were identified: (1) autonomous decision-making versus the risk of taking over, (2) employee rights versus restrictions to self-determination, (3) respect for employee privacy versus stakeholders interests, (4) risk of unequal inclusion due to insufficient organizational structure and resources, (5) risk of unequal support due to unclear professional roles and responsibilities. Conclusion The main ethical issues are the risks of unequal access to and unequal support for the coordination of RTW. For the fair and equal provision of coordination, it is necessary to be transparent on how to prioritize the coordination of RTW for different patient groups, provide clarity about the coordinators professional role, and facilitate ongoing boundary work between stakeholders.

Behovet av omdiagnostisering av patienter med olika tillstånd väcker etiska frågeställningar. I denna korta etiska analys som genomförts på uppdrag av Nationellt programområde för psykisk hälsa lyfts ett antal etiska frågeställningar kopplade till omdiagnostisering. Analysen går inte i på detaljer kring vem som ska genomföra en sådan, inte heller var i hälso- och sjukvårdssystemet det bäst sker – eftersom detta beror på vilket specifikt diagnosområde det handlar om.

Analysen landar i följande övergripande slutsatser:

• Generellt är diagnossättande förknippat med etiska principer om att göra gott(genom att ge underlag för att patienten får rätt insatser) och icke-skada(genom att förhindra uppkomst av risker och vårdskada).
• Vårdgivaren har ett etiskt ansvar för att patienten får rätt diagnos (ellerdiagnoser). I detta ansvar ingår att också överväga vilka konsekvenserdiagnostisering och omdiagnostisering får ur ett vidare perspektiv –exempelvis om det kan innebära risker för andra individer.
• Patientens önskemål om omdiagnostisering kan vara en utgångspunkt, meninte avgöra frågan om huruvida en omdiagnostisering bör ske – eller resultatetav en sådan omdiagnostisering.
• Det finns skäl att skilja mellan situationer där skälet för omdiagnostisering äratt patienten i nuläget har en diagnos som negativt påverkar tillgången tillbehovsbaserade insatser eller riskerar att leda till vårdskada – och de fall därskälet för omdiagnostisering snarare drivs av att diagnosen inte längre äraktuell och snarare har påverkan på patientens upplevelse eller innebär hinderi patientens övriga liv.
• I det första fallet finns det generellt skäl att prioritera omdiagnostisering högreän i det andra fallet – beroende på hur stora det potentiella konsekvensernaför patienten är. I det andra fallet beror det på hur livet i stort påverkas men vidmindre allvarlig påverkan finns det generellt skäl att prioritera diagnostiseringhögre än omdiagnostisering.

Background: Severity plays an essential role in healthcare priority setting. Still, severity is an under-theorised concept. One controversy concerns whether severity should be risk- and/or time-sensitive. The aim of this article is to provide a normative analysis of this question. Methods: A reflective equilibrium approach is used, where judgements and arguments concerning severity in preventive situations are related to overall normative judgements and background theories in priority-setting, aiming for consistency. Analysis, discussion, and conclusions: There is an argument for taking the risk of developing a condition into account, and we do this when we consider the risk of dying in the severity assessment. If severity is discounted according to risk, this will dilute severity, depending on how well we are able to delineate the population, which is dependent on the current level of knowledge. This will potentially have a more far-reaching effect when considering primary prevention, potentially the de-prioritisation of effective preventive treatments in relation to acute, less-effective treatments. The risk arguments are dependent on which population is being assessed. If we focus on the whole population at risk, with T-0 as the relevant population, this supports the risk argument. If we instead focus on the population of as-yet (at T-0) unidentified individuals who will develop the condition at T-1, risk will become irrelevant, and severity will not be risk sensitive. The strongest argument for time-sensitive severity (or for discounting future severity) is the future development of technology. On a short timescale, this will differ between different diagnoses, supporting individualised discounting. On a large timescale, a more general discounting might be acceptable. However, we need to also consider the systemic effects of allowing severity to be risk- and time-sensitive.