Abstract
It is often assumed that decision-makers pursue the goal of fair allocation of health-care resources besides or in addition to the goal of maximizing health (multiple goals assumption). The task of combining the goals is then assumed to involve a trade-off. Its quantitative shape, or so it is usually argued, should be based on data from social preference studies. The amendment of the conventional, health-maximizing approach is thus conceived to involve a change toward social value maximization. This chapter, however, suggests that an adequate conceptualization of fair resource allocation involves a break not only with health maximization but, more generally, with the idea of maximizing any value or values at all. It involves, in other words, a break with the link between (“social”) preference and value. If this is true, integrating fairness is beyond the paradigm. The point is exemplified by commenting on the idea of equity weights for QALYs.
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Notes
- 1.
This is known as the leveling down objection. It objects to conceiving equality per se – of welfare, of resources, chances, or whatever – as a valuable property of outcomes, be it within a monistic or within a pluralistic axiology. See, for a seminal text, Parfit (1995). The force of the objection is occasionally recognized in the context of publications that contribute to health economic issues. See, for instance, Broome (2002).
- 2.
One indication that they are indeed untackled is the purely intuitive nature of enumerations like “equity, fairness, and other political goals” in the quote given before: What is “equity”, and how does it relate to “fairness”? Are these two goals or two names for one goal? Analysts who conceptualize the goals of decision-makers in such a pêle-mêle fashion have no clear picture of what these objectives are and how they relate to the concept and the foundational principles of efficiency.
- 3.
National Institute for Health and Care Excellence (formerly National Institute for Health and Clinical Excellence), the British official institution for Health Technology Assessment.
- 4.
One such debate is the debate on whether the number of people saved is a morally relevant consideration when persons are grouped in different, non-overlapping groups which can only be saved alternatively. The question is directly relevant for judging the merits, or demerits, of the person trade-off. The seminal text is Taurek (1977). For some contributions, see Parfit (1978), Rakowski (1993), Kamm (1993, Ch. 5–7), Scanlon (1998: 230–241), Lübbe (2008), and Hirose (2015). For an effort to link this foundational debate with the debate on medical priority setting, see the proceedings of the 2009 conference of the Harvard University Program in Ethics and Health “Ethical Issues in the Prioritization of Health Resources,” http://peh.harvard.edu/events/2009/priority_resources/, Day Two, Session 1 (3.3.15).
- 5.
This is due to the utilitarian background of the field and is acknowledged as a problem within modern welfare economics. Two authors who have, over many years, tried to overcome the problems associated with this fact are Amartya Sen and John Broome. See Sen (1981) and Broome (1984) for starting points. Both authors stay, however, within the consequentialist paradigm – the idea that the rightness of choices is determined by the overall goodness (or value) of outcomes. For a foundational critique of the consequentialist assumption, developed out of the debate referred to in footnote 4, see Lübbe (2009) and Lübbe (2015), Ch. 3–5.
- 6.
The point is developed, with detailed references to the health economics literature, in the overview article of Klonschinski and Lübbe (2011). The relevance of the rights/value distinction for judging the role which has been claimed for the QALY approach in the German debate on the evaluation of medical benefits and costs of drugs – a task with which Germany’s official institution for Health Technology Assessment, the IQWiG (“Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen”), has been legally charged in 2007 – is set out in Lübbe (2011).
- 7.
In particular, the Sure Thing Principle, as applied to social choices, is not compatible with the demands of fair allocation. An argument to this effect, made originally by Peter Diamond (1967), was the starting point of John Broome’s endeavors to develop a theory of fairness that could supplement axiomatic utilitarianism without destroying its basis in expected utility theory. See Broome (1984: 624): “It is a popular belief that there is merit in equalising people’s utilities […]. The same belief is sometimes extended to expected utility too […]. If this is true it is profoundly important for welfare economics. It means […] that ‘social’ preferences do not obey the sure thing principle, which is generally taken to be an essential requirement of rationality.” Broome here acknowledges the force of the objection that Diamond (1967) brings forward against John Harsanyi’s (1955) addition theorem; see also Broome (1991:110–117). For discussion, see, among others, Verbeek (2001), Risse (2002), Stefánsson (2015), Lübbe (2015), Ch. 4–5.
References
Broome J (1984) Uncertainty and fairness. Econ J 94:624–632
Broome J (1991) Weighing goods. Equality, uncertainty and time. Basil Blackwell, Cambridge, MA/Oxford
Broome J (2002) Fairness, goodness, and levelling down. In: Murray CJL, Salomon JA, Mathers CD, Lopez AD (eds) Summary measures of population health. Concepts, ethics, measurement and applications. World Health Organization, Geneva, pp 135–137
Diamond P (1967) Cardinal welfare, individualistic ethics, and interpersonal comparison of utility: a comment. J Polit Econ 75:765–766
Greiner W, Damm O (2012) Die Berechnung von Kosten und Nutzen. In: Schöffski O, Graf v. d. Schulenburg, J.-Matthias (eds) Gesundheitsökonomische Evaluationen, 4th edn. Springer, Berlin, pp 23–42
Harsanyi JC (1955) Cardinal welfare, individualistic ethics, and interpersonal comparisons of utility. J Polit Econ 63:309–321
Hirose I (2015) Moral aggregation. Oxford University Press, Oxford
Kamm FM (1993) Morality, mortality, vol. I: death and whom to save from it. Oxford University Press, New York
Klonschinski A, Lübbe W (2011) QALYs und Gerechtigkeit: Ansätze und Probleme einer gesundheitsökonomischen Lösung der Fairnessproblematik [QALYs and fairness: Health economic approaches to the fairness issue and their problems]. Das Gesundheitswesen 71:688–695
Lübbe W (2008) Taurek’s no worse claim. Philos Public Aff 36:69–85
Lübbe W (2009) The aggregation argument in the numbers debate. In: Fehige C, Lumer C, Wessels U (eds) Handeln mit Bedeutung und Handeln mit Gewalt. Philosophische Aufsätze für Georg Meggle. Mentis, Paderborn, pp 406–421
Lübbe W (2011) Dissenting opinion. In: German Ethics Council, Medical benefits and costs in healthcare: the normative role of their evaluation. German Ethics Council, Berlin, pp 96–121
Lübbe W (2015) Nonaggregationismus: Grundlagen der Allokationsethik. Mentis, Münster
Nord E, Pinto JL, Richardson J, Menzel P, Ubel P (1999) Incorporating societal concerns for fairness in numerical valuations of health programmes. Health Econ 8:25–39
Parfit D (1978) Innumerate ethics. Philos Public Aff 7:285–301
Parfit D (1995) Equality or priority? University of Kansas, Kansas
Rakowski E (1993) Saving and taking lives. Colum Law Rev 93:1063–1156
Risse M (2002) Harsanyi’s ‘utilitarian theorem’ and utilitarianism. Nous 36:550–577
Scanlon T (1998) What we owe to each other. Belknap, Cambridge MA/London
Sen A (1981) Rights and agency. Philos Public Aff 11:3–39
Stefánsson HO (2015) Fair chance and modal consequentialism. Econ Philos forthcoming, available on CJO2015. doi:10.1017/S0266267115000152
Taurek JM (1977) Should the numbers count? Philos Public Aff 6:293–316
Verbeek B (2001) Consequentialism, rationality and the relevant description of outcomes. Econ Philos 17:181–205
Weinstein MC, Torrance G, McGuire A (2009) QALYs: the basics. Value Health 12(Suppl I):S5–S9
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Lübbe, W. (2016). Social Value Maximization and the Multiple Goals Assumption: Is Priority Setting a Maximizing Task at All?. In: Nagel, E., Lauerer, M. (eds) Prioritization in Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-21112-1_5
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