SOCIETAL PREFERENCES IN THE ALLOCATION OF HEALTHCARE RESOURCES: AN EMPIRICAL ETHICS APPROACH

  

Purpose: To identify characteristics or attributes relevant to conceptions of the societal value of healthcare and health gains using an empirical ethics approach.   

Methods: Attributes were derived from a review of empirical studies, identified using a ‘citation pearl growing’ search strategy.  The review took an empirical ethics approach: attributes had to have evidence of significant public support in empirical studies and had to be compatible with a coherent and defensible theory of distributive justice.  Together, these requirements ensured that selected attributes reflected public preferences while ‘laundering’ perverse or prejudicial attitudes.  Theories of distributive justice were limited to those with an explicit maximand, including need principles, maximising principles, egalitarian principles, and Rawls’ Difference principle.    

Results: The review identified 13 attributes within three broad aspects of healthcare: the patient, the treatment and distributional issues.  Of these, 4 attributes had clear evidence of public support and defensible ethical justifications: patient age, initial and final health states and distributional concerns.  The review did not find a strong preference for prioritizing by absolute health gain.  There was support for prioritizing patients with a healthy lifestyle, but this preference was laundered on the grounds that it reflects moralistic attitudes rather than principles of distributive justice.  Preferences for duration of benefit were ambiguous.   

Conclusions: The conventional quality-adjusted life year (QALY) maximization approach to healthcare priority setting explicitly assumes that the only factors relevant to the societal value of health gains are the absolute health gain, the duration benefit and the number of patients treated.  An increase in any of these factors is associated with a proportional increase in value.  This review, however, is consistent with growing evidence of a reluctance to allocate healthcare solely on the basis of maximizing expected QALYs and a willingness to sacrifice efficiency for distributive justice.  Younger patients and patients in more severe health states were consistently favoured over older or healthier patients and the quality of the final health state was more important than the absolute health gain.  There was also a distributional preference for smaller health gains to many over larger gains to few.  A fuller conception of societal value may improve priority setting, but it will be necessary to consider the relative strength of preferences for equity relative to efficiency before rejecting QALY maximization.