Advertisement

Poiesis & Praxis

, Volume 2, Issue 2–3, pp 103–117 | Cite as

Integrating ethical enquiry and health technology assessment: limits and opportunities for efficiency and equity

  • Pedro Gallo
Focus

Abstract

This paper aims at discussing some contributions, limitations and opportunities that efficiency and equity studies could make to form a better understanding of ethical issues involved in health technology assessment (HTA). Prenatal detection of Down syndrome is used as a case study for further discussions regarding efficiency and equity, as well as other ethical principles including beneficence, non-maleficence and autonomy. The development and use of adequate methods and the need for context appraisal are two imperative issues in this field of knowledge. The analysis of ethical implications in HTA should account for both. Economic evaluation methodologies have great potential in the assessment of some key ethical principles such as efficiency and equity but are of limited use concerning other fundamental principles. Social and individual values play a prominent role in this respect.

Keywords

Down Syndrome Screening Program Ethical Principle Health Technology Assessment Foetal Loss 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Zusammenfassung

Dieser Artikel zielt darauf ab, Beiträge zu diskutieren, die Effizienz- und Verteilungsstudien zu einem besseren Verständnis der ethischen Fragen in der Technologiefolgenabschätzung im Gesundheitssektor (HTA) leisten könnten, und ihre Möglichkeiten und Begrenzungen zu erhellen. Pränatale Diagnose des Down-Syndroms dient hier als Fallstudie für weitere Diskussionen hinsichtlich Effizienz und Verteilung sowie andere ethische Prinzipien, darunter Wohltätigkeit (beneficence), die Pflicht, keinen Schaden zuzufügen (non-maleficence) und Autonomie. Die Entwicklung sowie Anwendung geeigneter Methoden und die Bereitstellung der notwendigen Kontextbeurteilung sind zwei dringende Fragen auf diesem Wissensgebiet. Die Analyse ethischer Aspekte in der HTA sollte beiden Rechnung tragen. Wirtschaftswissenschaftliche Auswertemethoden haben ein erhebliches Potential für die Beurteilung einzelner ethischer Schlüsselfragen, z. B. Effizienz oder Verteilung, sind jedoch nur von begrenztem Nutzen in Bezug auf andere fundamentale Prinzipien. Gesellschaftliche und individuelle Wertvorstellungen spielen hier eine herausragende Rolle.

Résumé

Cet article s’interroge sur les contributions, restrictions et possibilités que les études d’efficacité et d’équité pourraient apporter pour une meilleure compréhension des questions éthiques qui découlent de l’ETS (évaluation des technologies de la santé). La détection prénatale du syndrome de Down sert d’étude de cas pour d’autres discussions concernant l’efficacité, l’équité, de même que d’autres principes éthiques, notamment le caractère bénéfique ou non pernicieux et l’autonomie. Le développement et l’utilisation de méthodes adéquates et le besoin d’évaluation dans le contexte sont deux aspects urgents dans ce domaine du savoir. L’analyse des implications éthiques dans l’ETS devrait prendre l’un et l’autre en compte. Les méthodes d’évaluation économique renferment un fort potentiel pour l’évaluation de certains principes éthiques clés, tels que l’efficacité et l’équité, mais sont d’une utilité réduite en liaison avec d’autres principes fondamentaux. Les valeurs sociales et individuelles jouent un rôle éminent à cet égard.

References

  1. Adams ME, McCall NT, Gray DT, Orza MJ, Chalmers TC (1992) Economic analysis in randomised control trials. Med Care 30:231–243CrossRefGoogle Scholar
  2. Australia Commonwealth Department of Health, Housing and Community Services (1992) Guidelines for the pharmaceutical industry on preparation of submissions to the Pharmaceutical Benefits Advisory Committee. Commonwealth Department, CanberraGoogle Scholar
  3. Backhouse ME, Backhouse RJ, Eddy SA (1992) Economic evaluation bibliography. Health Econ 1(supplement):s1–s236Google Scholar
  4. Birch S, Donaldson C (1987) Applications of cost-benefit analysis to health care. J Health Econ 6:211–225CrossRefGoogle Scholar
  5. Boyd NF, Sutherland HJ, Heasman KZ et al. (1990) Whose utilities for decision analysis? Med Decis Making 10:58–67CrossRefGoogle Scholar
  6. Bradshaw J (1972) The concept of social need. New Soc 30Google Scholar
  7. Briggs A, Sculpher M (1995) Sensitivity analysis in economic studies: a review of published studies. Health Econ 4:355–371CrossRefGoogle Scholar
  8. Briggs A, Sculpher M, Buxton M (1994) Uncertainty in the economic evaluation of health care technologies: the role of sensitivity analysis. Health Econ 3:95–104CrossRefGoogle Scholar
  9. British Medical Journal (1996) Working party on economic evaluation. Guidelines for authors and peer reviewers of economic submissions to the British Medical Journal. Brit Med J 313:275–283CrossRefGoogle Scholar
  10. Buxton M, Ashby J (1988) The time trade-off approach to health state valuation. Teeling A, Smith G (eds) Measuring health: a practical approach. Wiley, Chichester, p 69–87Google Scholar
  11. CCOHTA—Canadian Co-ordinating Office for Health Technology Assessment (1994) Guidelines for economic evaluation of pharmaceuticals: Canada. CCOHTA, OttawaGoogle Scholar
  12. Culyer A, Wagstaff A (1991) Need, equality and social justice. Discussion Paper 90, Centre for Health Economics, York University, YorkGoogle Scholar
  13. Detsky AS, Naglie IG (1990) A clinician’s guide to cost-effectiveness analysis. Ann Intern Med 113:147–154CrossRefGoogle Scholar
  14. Drummond MF, O’Brien B, Stoddart GL, Torrance GW (1997) Methods for the Economic Evaluation of Health Care Programmes, 2nd edn. Oxford University Press, New YorkGoogle Scholar
  15. Drummond M, Brandt A, Luce B, Rovira J (1993) Standardising methodologies for economic evaluation in health care. Practice, problems, and potential. Int J Technol Assess 9:26–36CrossRefGoogle Scholar
  16. Drummond MF, Davies L (1991) Economic analysis alongside clinical trials: revisited the methodological issues. Int J Technol Assess 7:561–573CrossRefGoogle Scholar
  17. Dworkin DR (1981) What is equality? Part 1: equality of welfare; Part 2: equality of resources. Philos Public Aff 10:185–247, 283–345Google Scholar
  18. Eddy DM (1992) A manual for assessing health practices & designing practice policies. The explicit approach. American College of Physicians, Philadelphia, PAGoogle Scholar
  19. Eisenberg JM (1989) Clinical economics: a guide to the economic analysis of clinical practices. J Amer Med Assoc 262:2879–2886CrossRefGoogle Scholar
  20. Elixhauser (ed) (1993) Health care cost-benefit and cost effectiveness analysis (CBA\CEA) from 1979 to 1990: a bibliography. Med Care 31:1–236CrossRefGoogle Scholar
  21. England and Wales Department of Health (1994) Guidelines on good practice in the conduct of economic evaluation of medicines. Department of Health, LondonGoogle Scholar
  22. Evans RG (1995) Manufacturing consensus, marketing truth: guidelines for economic evaluation. Ann Intern Med 123:59–60CrossRefGoogle Scholar
  23. Finkler SA (1982) The distinction between cost and charges. Ann Intern Med 96:102–109CrossRefGoogle Scholar
  24. Flemming TR, DeMets DL (1996) Surrogate end points in clinical trials: are we being misled? Ann Intern Med 125:605–613CrossRefGoogle Scholar
  25. Fox J (ed) (1989) Health inequalities in European Countries. GowerGoogle Scholar
  26. Gafni A, Birch S (1995) Preferences for outcomes in economic evaluation: an economic approach to addressing economic problems. Soc Sci Med 40:767–776CrossRefGoogle Scholar
  27. Gafni A, Birch S (1995) Preferences for outcomes in economic evaluation: an economic approach to addressing economic problems. Soc Sci Med 40:767–776CrossRefGoogle Scholar
  28. Garattini L, Grilli R, Scopelliti D, Mantovani L (1995) A proposal for Italian guidelines in pharmacoeconomics. Pharmacoeconomics 7:1–6CrossRefGoogle Scholar
  29. Gerard K, Mooney G (1993) QALY league tables: handle with care. Health Econ 2:59–64CrossRefGoogle Scholar
  30. Gold MR, Siegel JE, Russell LB, Weinstein MC (1996) Cost-effectiveness in health and medicine. Oxford University Press, New YorkGoogle Scholar
  31. Goodman A, Craig T (1982) A need assessment strategy for an era of limited resources. IEA Health Unit, LondonGoogle Scholar
  32. Gotzsche PC, Liberati A, Torri V, Rossetti L (1996) Beware of surrogate outcome measures. Int J Technol Assess 12:238–246CrossRefGoogle Scholar
  33. Greenland S (1996) Basic methods for sensitivity analysis of biases. Int J Epidemiol 25(6):1107–1116CrossRefGoogle Scholar
  34. Jacobs P, Bachynsky J, Baladi JF (1995) A comparative review of pharmaco-economic guidelines. Pharmacoeconomics 8:2–9CrossRefGoogle Scholar
  35. Jacobs P, Baladi JF (1996) Biases in cost measurement for economic evaluation studies in health care. Health Econ 5:525–529CrossRefGoogle Scholar
  36. Johaannesson M (1995) Economic evaluation of health care and policymaking. Health Policy 33:179–190CrossRefGoogle Scholar
  37. Johansson M, Jonsson B (1991) Economic evaluation in health care: is there a role for cost benefit analysis? Health Policy 17:1–23CrossRefGoogle Scholar
  38. Koopmanschap MA, Rutten FFH, van Ineveld BM, van Roijen L (1995) The friction cost method for measuring indirect cost of disease. J Health Econ 14:171–89CrossRefGoogle Scholar
  39. Le Grand J, Propper C (1992) The economics of health care problems. Mac Millan Press, LondonGoogle Scholar
  40. Le Grand J (1978) The distribution of public expenditure: the case of health care. Economica 45:125–42CrossRefGoogle Scholar
  41. Le Grand J (1982) The strategy of equality. Redistribution and the social services. George Allen and Unwin, LondonGoogle Scholar
  42. Liljas B (1998) How to calculate indirect costs in economic evaluation. Pharmacoeconomics 13(1):1–7CrossRefGoogle Scholar
  43. Liss PE (1993) Health care need: meaning and measurement. Avebury, AldershotGoogle Scholar
  44. Luce BR, Elixhauser A (1990a) Estimating costs in the economic evaluation of medical technologies. Int J Technol Assess 6:57–75CrossRefGoogle Scholar
  45. Luce BR, Elixhauser A (1990b) Standards for socio-economic evaluation of health care products and services. Springer, Berlin Heidelberg New YorkCrossRefGoogle Scholar
  46. Manor O, Matthews S, Power C (1997). Comparing measures of health inequality. Soc Sci Med 45(5):761–71CrossRefGoogle Scholar
  47. Mauskopf JA, Paul JE, Grant DM, Stergachis A (1998) The role of cost-consequence analysis in healthcare decision-making. Pharmacoeconomics 13(3):277–288CrossRefGoogle Scholar
  48. Mehrez A, Gafni A (1989) Quality adjusted life years (QALYs), utility theory, and healthy years equivalent (HYE). Med Decis Making 9:142–149CrossRefGoogle Scholar
  49. Mooney G, Hall J, Donaldson C, Gerard K (1991) Utilisation as a measure of equity: weighting heat? J Health Econ 10(4):475–480CrossRefGoogle Scholar
  50. Mooney G (1987) What does equity in health mean? World Health Statistics Quarterly 4Google Scholar
  51. Newmann PJ, Johannesson M (1995) From principle to public policy: using cost-effectiveness analysis. Health Affair 14:206–214Google Scholar
  52. Ontario Ministry of Health (1994) Ontario guidelines for economic analysis of pharmaceutical products. Ontario Ministry of Health, TorontoGoogle Scholar
  53. Percy-Smith J (ed) (1996) Needs assessment in public policy. Open University Press, BristolGoogle Scholar
  54. Pereira J (1990) The economics of inequality in heath: a bibliography. Soc Sci Med 31(3):413–420CrossRefGoogle Scholar
  55. Petitti DB (1994) Meta-analysis, decision analysis, and cost-effectiveness analysis. Methods for quantitative synthesis in medicine. Oxford University Press, New YorkGoogle Scholar
  56. Polsky D, Glick HA, Willke R, Schulman K (1997) Confidence intervals for cost-effectiveness ratios: a comparison of four methods. Health Econ 6:243–252CrossRefGoogle Scholar
  57. Popay J, Williams G (1994) Researching the people’s health. Rotledge, LondonGoogle Scholar
  58. Powe NR, Griffiths RI (1995) Clinical-economic trials. In: U.S. Congress, Office of Technology Assessment. Tools for evaluating health technologies. Government Printing Office, Washington D.C.Google Scholar
  59. Rawles J (1989) Castigating QALYs. J Med Ethics 15:143–147CrossRefGoogle Scholar
  60. Ried W (1998) QALYs versus HYEs—what’s right and what’s wrong: a review of the controversy. J Health Econ 17:607–625CrossRefGoogle Scholar
  61. Riegelman RK (1995) The measures of medicine. Benefits, harms, and costs. Blackwell, Cambridge, MAGoogle Scholar
  62. Riviere R, Berkowitz S, Carter C, Ferguson CG (1996) Needs assessment: a creative and practical guide for social scientists. Taylor & Francis, LondonGoogle Scholar
  63. Rovira J (1994) Standardising economic appraisal of health technology in the European community. Soc Sci Med 38:1675–1678CrossRefGoogle Scholar
  64. Rovira J (1994) The harmonisation by consensus of the methodology for economic evaluation of health technologies in the European Union. Newsletter 1, November, BarcelonaGoogle Scholar
  65. Rovira J, Antonanzas F (1994) Propuesta de estandarizacion de algunos aspectos metodologicos de los analisis coste-efectividad y coste-utilidad en la evaluacion de tecnologias y programas sanitarios. Ministerio de Sanidad y Consumo, MadridGoogle Scholar
  66. Russell LB, Gold MR, Siegel JE, Daniels N, Weinstein MC (1996) The role of cost-effectiveness analysis in health and medicine. J Amer Med Assoc 276(14):1172–1177CrossRefGoogle Scholar
  67. Sculpher M, Drummond M, Buxton M (1997) The iterative use of economic evaluation as part of the process of health technology assessment. J Health Serv Res Policy 2(1):26–30Google Scholar
  68. Serra-Prat M, Gallo P, Jovell AJ, Aymerich M, Estrada MD (1998) Trade-offs in prenatal detection of Down syndrome. Am J Public Health 88(4):551–557CrossRefGoogle Scholar
  69. Sox HC Jr, Blatt MA, Higgins MC, Marton KI (1988) Medical decision making. Butterworths, Boston, MAGoogle Scholar
  70. Stevens A, Raftery J (1997) Health care needs assessment. Radcliffe Medical, OxfordGoogle Scholar
  71. Stinnett AA (1996) Adjusting for bias in c/e ratio estimates. Health Econ 5:470–472CrossRefGoogle Scholar
  72. Task Force on Principles for Economic Analysis of Health Care Technology (1995) Economic analysis of health care technology. A report on principles. Ann Intern Med 122:61–70Google Scholar
  73. Torrance GW, Feeny D (1989) Utilities and quality-adjusted life years. Int J Technol Assess 5:559–575CrossRefGoogle Scholar
  74. Torrance GW (1986) Measurement of health state utilities for economic appraisal. A review. J Health Econ 5:1–30CrossRefGoogle Scholar
  75. Udvarhelyi SI, Colditz GA (1992) Cost-effectiveness and cost-benefit analyses in the medical literature. Ann Intern Med 116:238–244CrossRefGoogle Scholar
  76. Van Doorslaer E, Wagstaff A, Rutten F (1993) Equity in the finance and delivery of health care: an international perspective. Oxford University Press, New YorkGoogle Scholar
  77. Wagstaff et al. (1999) Equity in the finance of health care: some further international comparisons. J Health Econ 18:263–290CrossRefGoogle Scholar
  78. Wagstaff A, van Doorslaer E (1992) Equity in the finance of health care: some international comparisons. J Health Econ 11:361–387CrossRefGoogle Scholar
  79. Wagstaff A, Paci P, van Doorslaer E (1991) On the measurement of inequalities in health. Soc Sci Med 33(5):545–557CrossRefGoogle Scholar
  80. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB (1996) Recommendations of the panel on cost-effectiveness in health and medicine. J Amer Med Assoc 276(15):1253–1258CrossRefGoogle Scholar
  81. Weinstein MC (1990) Principles of cost-effective resource allocation in health care organisations. Int J Technol Assess 6:93–103CrossRefGoogle Scholar
  82. Weinstein MD, Stason WB (1977) Foundations of cost–effectiveness analysis for health and medical practices. New Engl J Med 296:716–721CrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  1. 1.University of Barcelona, Departament de Sociologia i Analisi de les OrganitzacionsBarcelonaSpain

Personalised recommendations