Ethics, equity and economics
• Ethics
- theories of “justice”
- medical versus economic polarisation
• Equity
- definitions
- “health”, “need” and “access vs. use”
- micro versus macro
• Economics
- equity and efficiency
Why ethics?
• Philosophy determines objectives of
health care system e.g.
-maximise social well-being based on
(consequentialist) utilitarianism
• Different philosophical concepts have
different implications, esp. for “efficiency”
• Main practical manifestation = equity
Categorising ethical theories (1)
• Distributive justice - “political” or “social”
philosophy - concerned with outcome
• Procedural justice - “moral” philosophy concerned with process used in achieving
the outcome
Categorising ethical theories (2)
• Political philosophy - societal focus e.g.
Rawls
• Moral philosophy - individual focus e.g
Kantian Imperative
• Interaction e.g. utilitarianism - social
utility maximised by each individual
maximising own utility
Categorising ethical theories (3)
Individual
Process
Outcome
Society
Entitlement
Deontological
Virtue
Utilitarianism
Rawlsian
Egalitarian
Rights
Ethical theories
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•
•
•
•
•
•
Utilitarianism
Rawlsian
Entitlement/libertarian
Egalitarian
Deontological?
Virtue
“Rights”
Utilitarianism
• Jeremy Bentham (classic) and John
Stuart Mill (adapted)
• ‘Maximising greatest ‘utility’ for greatest
number’
• Underlies ‘efficiency’
• Issues - domain (whose utility)
- malevolence (utility from suffering)
Rawlsian ‘maximin’
• John Rawls 1971
• Allocation conducted under ‘veil of
ignorance’ - leads to position of less
well off in society being maximised
• Issues - assumes total risk averseness
- ‘bottomless pit’ argument
Entitlement/libertarian
• Robert Nozick 1974
• Individuals ‘entitled’ to what they have
acquired ‘justly’ i.e. within a market
situation
• Stresses freedom of choice and
property rights - minimal state
involvement
• Similar to utilitarianism
Egalitarian
• Equal shares in the distribution of a
commodity
• Issues - of what? health, services?
- according to what criteria?
‘need’, age?
Deontological (deon (Gk) = duty)
• Immanuel Kant
• Moral ‘rules’ of how to live which should
not be broken (ie absolute moral code)
• ‘Do to others as you would have done to
you’
• Humans as end, not means
Virtue theory
• Not ‘what should I do’ but ‘what kind of
person should I be’
• Similar to deontological - absolute moral
‘rules’
‘Rights’ based theories
• Unassailable ‘rights’ which cannot be
overridden e.g.’right’ to life
• Underlies ‘social contract’ theory
• Absolute - inflexible
‘Medical’ vs. ‘economic’ ethic (1)
• Medical
- individual (deontological) ethic
- Hippocratic oath, Nightingale
Pledge
- ‘Agency and professional codes
conduct
- ‘best interests’ of patient
- opportunity cost ignored (?)
‘Medical’ vs. ‘economic’ ethic (2)
• Economic - population based ethic
- principally ‘utilitarian’
- based on opportunity cost
• Overlap of considerations in both
professions
Medical dilemma (1)
“I recall a patient who bled massively from his inoperable
cancer of the stomach, I was the houseman and I had a strong
sense that I must do my utmost for my patient, I ordered large
quantities of blood to be cross matched and set up an infusion
to replace the blood the patient had lost. It was not that I
believed that the blood would cure him, but it would very
probably save his life for a while longer, whereas without the
blood transfusion he would have probably died there and then.
A few days later the patient had another massive bleed and I
again ordered more blood and set up a transfusion, again the
patient survived what would almost certainly have been a fatal
blood loss. The patient himself, knowing the situation, was
keen to fight it as hard as possible.”
Medical dilemma (2)
After the second massive bleed and equally massive blood
transfusion, my chief gently pointed out that there was no
point in pouring in the blood as I had been, the patient had
widespread cancer secondaries, his stomach was riddled
with cancer and likely to bleed whenever the cancer eroded a
blood vessel; blood transfusions could do no more than
prolong the patient’s life by a very short time. If I went on
ordering blood at the predigious rate I had been, I would
literally break the bank, the blood bank, causing enormous
expense whilst seriously jeopardising the chances of other
patients for whom a blood transfusion could really be
lifesaving, rather than merely death prolonging.
Medical dilemma (3)
I wanted to discuss all this with the patient, but he died the
same day from a further massive bleed and that time I simply
was not called. My superior had decided that there was
nothing beneficial that could be done. More precisely,
however, his analysis was surely based on a different
assessment, notably that the benefit to the patient of
repeated blood transfusions each time his stomach cancer
bled, even if he himself wanted to fight to the last second,
was insufficient to justify the enormous cost (to others) of
providing the blood.”
Tavistock Group - BMJ, Jan 23, 1999
• Prepare shared ‘code’ based on
consistent moral framework
- “healthcare is a human right…provide
access…regardless of their ability to pay”
- “care of individuals is at centre of health care
but must be viewed within context of
[generating] greatest possible health gains for
groups and populations”
Why equity? (1)
• ‘Health’ = fundamental commodity (Sen)
necessary for enjoyment of all else
• Health care important determinant, but
often expensive/unpredictable
• Insurance = imperfect/expensive
• Thus...
Why equity? (2)
• Healthcare should not be allocated/distributed
according to income/wealth
• Equity main reason government involvement
in health care world-wide
• Issues - concern with existing distribution
income/wealth then why not change
this directly?
- trade off with efficiency?
Why equity in health care?
“ The social conscience is more offended
by severe inequality in nutrition and
basic shelter, or in access to medical
care, than by the inequality in
automobiles, books, furniture or boats”
Tobin 1970
Equity not necessarily = equality
• Equity concerned with ‘fairness' ‘justice’
(i.e.ethical theories)
• May not necessarily entail equality.
e.g.minimum standards of care,
‘postitive’ discrimination etc.
• However, equity usually synonymous
with equality of something.
Equity: Vertical and/or horizontal?
• Vertical - unequals treated unequally
- applies especially to finance i.e. inequality
in contribution by use (direct payments) or
income (taxation)
• Horizontal - equals treated equally
- applies especially to delivery of health
care e.g equal resources, utilisation,
access per head.
- most discussion refers to this.
Ethics and equity
• Mostly ‘horizontal’ equity in distribution
of health(care)
• Based on broad ‘egalitarian’ ethic, but
compatible with most others
• Basis = equal distribution of x
(according to y)
• Issues - what are x and y to be?
‘Definitions’ of equity (1)
•
•
•
•
Equal ‘chance’ of treatment - lottery
Equal expenditure per capita - geography.
Equal resources per capita - geography.
Equal expenditure/resources for equal
‘need’ (i.e. weighted for ‘premature’
mortality/morbidity e.g. RAWP)
‘Definitions’ of equity (2)
(opportunity to use)
• Equal access (opportunity to use) for
equal need e.g equal waiting time per
‘condition’
• Equal utilisation (use) for equal need
e.g. equal length of stay per ‘condition’
• Equal treatment for equal need
• Equal ‘health’
‘Access’ or ‘use’?
• Access - maintain consumer sovereignty
- unlikely to achieve equal ‘health’
• Use
- closer to achieving equal ‘health’
- compromises consumer
sovereignty
Equal ‘health’?
• Definition e.g. QALYS, LY’s?
• Influence of non-health care factors e.g.
housing, diet
• Choice versus coercion e.g.smoking, diet
• Implies reducing overall ‘health’ not
‘increasing’ - only truly equal state = dead
• Maximising versus minimum standards
Equity and ‘need’ (1)
• ‘Need’ = ambiguous and confusing
• Who determines need
- producer
- individual
- ‘elite’
• Supply driven - what is available determines
what is needed
• Need versus ‘capacity to benefit’ - treat worse
off even if health improvement less than
treating better off
Equity and ‘need’ (2)
• ‘need’ versus ‘preference’
• ‘objective’ versus ‘subjective’ need
• maximising - quantity of resources
required to ensure individual becomes
/maintained as healthy as possible =
‘bottomless pit’
• Minimising - standard of care which
ensures individual not fall below
‘adequate’ level of health
Equity and the NHS (1)
“To provide the people of Great Britain,
no matter where they may be, with the
same level of service”
(Bevan 1948)
Equity and the NHS (2)
“A fundamental purpose of a national
service must be equality of provision so
far as this can be achieved without an
unacceptable sacrifice of standards”.
(Merrson 1979)
Report of the Royal Commission of the NHS
Equity in practice
• Historically concerned with geographical
distribution of resources e.g. RAWP
• In financing usually concerned with
finance by taxation - represents ‘positive
discrimination’ by income
Measuring equity
• Finance - Kakwai Index
- Suits Index
• Health - Gini coeff - see McGuire p.59
• Data
- see Folland, Goodman & Stano
book p.487
- see Donaldson & Gerard
‘Micro’ versus ‘macro’ equity
• Micro - distribution between individuals e.g.
GP. Individual ethic
• Macro - distribution between groups e.g.
regions. Group ethic
• Useful to separate - not necessary for one
ethic to apply across all levels
Economics, equity and ethics
• Common root = limited resources
• Efficiency based on utilitarian ethic
• Equity maybe based on a range of ethics
• Does this lead to an inevitable conflict?
Social welfare function
UB
2
W
1
U
W
0
W
Umin
45
Umin
U
UA
Utilitarianism encompasses all! (1)
• Altruism = ‘caring externality’
- Sen (1977) concept of ‘sympathy’
- own utility enhanced by anothers well-being
- fits within utilitarian philosophy
• Altruism = ‘duty’ (Kantian imperative)
- Titmuss (1970) - ‘duty’ give for benefit of others
- constraint on utility maximisation (c.f. resource
constraint)
Utilitarianism encompasses all (2)
• Participation altruism - utility gained
from participation in social/collective
acts regardless of utility from
consumption which results
• Outcome altruism - utility gained from
utility derived by others in consuming
what is ‘charitably’ provided
Utilitarianism encompasses all! (3)
• Generates possibility of 2,
interdependent, utility functions for
individual - as citizen and consumer
• Diminishing marginal utility, and
possibility of ‘free riding’, creates
‘rationale’ for coercion in achieving
‘citizen’ objectives
Coming to a consensus?
• Efficiency & equity common root scarcity
• No universal agreed ethic for objectives
of health care sector
• But - ‘equality of access’ consistent with
most ethical theories and consistent
with efficiency (preserves consumer
sovereignty)