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The Art of Saying No the Economics and Ethics of Healthcare Rationing

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The Art of Saying No the Economics and Ethics of Healthcare Rationing Linköping University Medical Dissertation No. 1215 The Art of Saying No The Economics and Ethics of Healthcare Rationing Gustav Tinghög Department of Medical and Health Sciences Linköping University, Sweden Linköping 2011 Edition 1:1 ISBN 978-91-7393-282-0 ISSN 0345-0082 @ Gustav Tinghög, 2011 Published articles have been reprinted with the permission of the copyright holder. Cover artwork and design: Marit Furn Webpage: www.maritfurn.se Printed in Sweden by LiU-Tryck, Linköping, Sweden, 2011 To the Tinghögs I’m gonna run to you – Bryan Adams Contents CONTENTS ABSTRACT .................................................................................................................. 4 LIST OF PAPERS ........................................................................................................ 5 ABBREVIATIONS ...................................................................................................... 7 INTRODUCTION ....................................................................................................... 9 Thesis Aim ........................................................................................................... 10 A Short Note on Disposition ........................................................................... 11 METHODOLOGICAL CONSIDERATIONS AND SPECIFICATION OF THE AIM .................................................................................................................... 13 A Population-Level View on Efficiency and Fairness ................................ 13 Economics and Ethics ........................................................................................ 14 Normative Economics and Positive Economics ....................................... 14 Normative Ethics and Meta-Ethics ............................................................ 16 Reasonable Disagreement ................................................................................ 16 Moral Intuition and Moral Reasoning ....................................................... 18 BACKGROUND........................................................................................................ 21 What is Healthcare Rationing? ........................................................................ 21 What is Healthcare Need? ................................................................................ 24 Explicit Healthcare Rationing in Practice ..................................................... 27 The Case of Oregon ...................................................................................... 27 The Case of Sweden ...................................................................................... 31 THEORETICAL CONTEXT .................................................................................... 37 Economics ............................................................................................................ 37 Welfare Economics ....................................................................................... 37 Utilitarianism ................................................................................................. 39 Cost-Effectiveness Analysis and Quality Adjusted Life Years .............. 42 Contents Ethics..................................................................................................................... 47 Distributive Fairness and Healthcare Rationing ...................................... 48 Fair Equality-of-Opportunity and Healthcare Rationing ....................... 51 Procedural Fairness and Healthcare Rationing ........................................ 52 MAIN FINDINGS AND DISCUSSION – A WELFARE ECONOMIC PERSPECTIVE ON HEALTHCARE RATIONING ........................................... 55 Paper I: “Individual Responsibility for What? – A Conceptual Framework for in a Publicly Funded Healthcare System” ..................... 55 Paper II: “Discounting, Preferences, and Paternalism in Cost- Effectiveness Analysis” ................................................................................ 57 Paper III: “Incentivizing Deceased Organ Donation: A Swedish Priority-Setting Perspective” ....................................................................... 60 Paper IV: “Horizontal Inequality in Rationing By Waiting Lists” ........ 62 EXTENDED DISCUSSION – A POPULATION-LEVEL ETHICAL PERSPECTIVE ON HEALTHCARE RATIONING ........................................... 67 Individual Responsibility – A Prospective Approach ............................. 67 Paternalism – Why Health is not Always Good ...................................... 70 Incentives – Persuasion or Coercion? ........................................................ 73 Inequality – When are Inequalities Unfair? .............................................. 75 FINAL REMARKS .................................................................................................... 79 ACKNOWLEDGEMENTS ...................................................................................... 83 REFERENCES ............................................................................................................ 85 PAPER I - IV ............................................................................................................... 93 Abstract ABSTRACT 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 welfare- promoting, 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 3 Abstract 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. 4 List of papers LIST OF PAPERS I. Gustav Tinghög, Carl Hampus Lyttkens and Per Carlsson. Individual Responsibility for What? – A Conceptual Framework for Exploring the Suitability of Private Financing in a Publicly Funded Health-Care System. Health Economics Policy and Law (2010) vol. 5: 201- 223 II. Gustav Tinghög. Discounting, Preferences, and Paternalism in Cost-Effectiveness Analysis. Submitted III. Faisal Omar, Gustav Tinghög and Stellan Wellin. Incentivizing Deceased Organ Donation: a Swedish Priority Setting Perspective. Scandinavian Journal of Public Health (in press) IV. Gustav Tinghög, David Andersson, Petter Tinghög, Carl Hampus Lyttkens. Horizontal Inequality when Rationing by Waiting Lists. Submitted 5 List of papers 6 Abbreviations ABBREVIATIONS A4R Accountability for Reasonableness CEA Cost-Effectiveness Analysis DALY Disability Adjusted Life Years DU Discounted Utility EQ-5D EuroQol 5-Dimension OECD The Organisation for Economic Co-operation and Development PTO Person Trade Off QALY Quality Adjusted Life Years SG Standard Gamble SF-36 The Short Form (36) Health Survey TTO Time Trade Off VAS Visual Analogue Scale 7 Abbreviations 8 Introduction INTRODUCTION It is an unfortunate, but unavoidable, truth about the world that not all theoretically feasible enhancements to health and wellbeing can, or even should, be attempted. All healthcare systems must decide how to set limits, explicitly or implicitly, efficiently or inefficiently, fairly or unfairly. The idea of rationing health care might seem like cold-hearted policymaking to many. However, resources are not limitless.
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