Abstract
One merit of a compendium such as the present one lies in its potential to encompass different perspectives on a subject. It has the capacity to mirror the complexity of the topic, thus enabling the reader to evaluate the diverse arguments presented and to draw her own conclusions. This is not to say that she or he may not appreciate a little assistance in this process. Providing this help with regard to the contributions of Weyma Lübbe and Norman Daniels to this volume is the aim of the present paper. More precisely, it seeks to strengthen and complement Lübbe’s (2016) critique of the “multiple goals assumption” in health-care resource allocation – i.e., the idea that health policy has at least two goals: fostering efficiency and distributing resources fairly – and to establish a connection between her considerations and Daniels’ (2016) account. That being said, the paper is also accessible and worth reading for those readers who are unfamiliar with the papers by Lübbe and Daniels, because, first, the latter’s relevant aspects will be summarized and, second, the paper makes some general points and provides a relevant contribution to the priority setting debate on its own.
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- 1.
Note that Daniels uses the term cost-effectiveness analysis (CEA) to refer to the method of health economic evaluation called CUA in this paper.
- 2.
- 3.
- 4.
Italics added.
- 5.
On the relevance of her considerations for the fundamental debate on consequentialism, see Lübbe (2015).
- 6.
See Klonschinski (2013, 2014, and forthcoming).
- 7.
The seminal reference here is Robbins (1935), who maintains that there “is no means of testing the magnitude of A’s satisfaction as compared with B’s”, so that interpersonal comparisons of utility are “essentially normative”, begging a “great metaphysical question”, and, hence, fall “outside the scope of any positive science” (Robbins 1935: 140, 137, 139).
- 8.
See Le Grand (1990: 555f., 559), Lukes (1996: 41), and Schefczyk/Priddat (2000: 431). In contrast to the trade-off in terms of value, the equity-efficiency trade-off in terms of production refers to the “productive capacities” of social or economic system to bring about different combinations of efficiency (for instance, in terms of the GDP or QALYs) and equity (for instance, in terms of the formers’ equal distribution). The idea that each economy indeed faces an empirical trade-off between equity and efficiency was famously put forward by Okun (1975). The equity-efficiency trade-off in terms of value was taken up from Barry by John Rawls (1971: 37f.) and rapidly entered public discourse so that in the midst of the 1980s, it was already widely used, as McPherson (1987: 44) reports: “‘Trade-off’ is a fairly recent addition to the English language but it is now in common use in business and labour circles and by economists, politicians, and political commentators.”
- 9.
See also Lukes (1996: 36).
- 10.
See Le Grand (1990: 555) and Lübbe (see chapter “Social Value Maximization”).
- 11.
- 12.
See Sassi et al. (2001: 20).
- 13.
Indeed, indifference curve analysis of consumer choices cannot be understood without reference to a hedonistic quantitative entity such as pleasure or satisfaction at all. See Giocoli (2003: 95).
- 14.
I disregard special cases such as perfect substitutes or complementary goods here.
- 15.
On dead metaphors, see Henderson (1998: 293).
- 16.
Papers entitled Toward a broader view of values (Menzel et al. 1999) or phrases like “Our goal should be to capture the most important values that will affect most people” (Ubel et al. 2000: 900) suggest the quotidian meaning of “values” in terms of highly valued items or ideals. In doing so, they invoke the impression that these terms and, hence, their approach were normatively harmless. That being said, the quoted papers continue using the term “value” in a more specific, decidedly normative sense and assume that concerns for equity can indeed be represented in terms of stable and consistent “values.”
- 17.
As Daniels’ (see chapter “Accountability for Reasonableness”) discussion of the fairness problems is quite short, the analysis is complemented by referring to two other publications of his.
- 18.
Likewise, he states that achieving a more equitable distribution of health “is sometimes worth sacrificing some maximization of population health” (see chapter “Accountability for Reasonableness”; italics added).
- 19.
Recall the considerations on efficiency as a decidedly normative-ethical goal above.
- 20.
To be precise, in the quoted passage, Daniels refers to the way the WHO consulting group has handled the issue. Yet, on the basis of other utterances, it seems safe to assume that he endorses this view himself as well (see chapter “Accountability for Reasonableness”).
- 21.
Italics added.
- 22.
See, for instance, Lübbe (2005, 2009, 2011, and forthcoming).
- 23.
- 24.
As to the priority problem, Daniels (2008: 105) surmises in Just Health that one might be induced to give priority to the worse-off on the basis of “the fair equality of opportunity principle.”
- 25.
The criticism that Daniels assumes reasonable ethical disagreement far too soon and that the turn to deliberative methods is thus premature has also been raised by other authors. See, for instance, Powers/Faden (2006: 181) and Holm (2009). The question of whether Daniels’ accountability for reasonableness approach indeed constitutes an account of procedural justice is discussed by Rid (2009).
- 26.
Although Daniels (see chapter “Accountability for Reasonableness”) is not particularly clear as to how exactly his accountability for reasonableness account is supposed to contribute to health technology assessment (HTA), it seems as if the Mexican example can serve as a blueprint here. As far as I understand it, he basically argues that HTA should be expanded in order to include “broader ethical concerns” (ibid.). Together with other relevant concerns, such as safety, efficacy, cost-effectiveness, and affordability, these ethical concerns should then be subject to a fair deliberative process. The critical remarks in the main body thus apply to this approach as well.
References
Barry B (1965) Political argument. Routledge & Kegan Paul, London
Daniels N (1993) Rationing fairly: programmatic considerations. Bioethics 7(2):225–233
Daniels N (2008) Just health. Meeting health needs fairly. Cambridge University Press, Cambridge et al.
Davis JB (1990) Cooter and Rappoport on the normative. Econ Philos 6:139–146
Dolan P (2001) Output measures and valuation in health. In: Drummond MF, McGuire A (eds) Economic evaluation in health care: merging theory with practice. Oxford University Press, Oxford et al., pp 46–67
Giocoli N (2003) Modeling rational agents: from Interwar Economics to Early Modern Game Theory. Edward Elgar, Cheltenham/Northampton
Harris J (1987) QALYfying the value of life. J Med Ethics 13:117–123
Henderson W (1998) Metaphors. In: Davis JB, Hands DW, Mäki U (eds) The handbook of economic methodology. Edward Elgar, Cheltenham/Northampton, pp 289–294
Holm S (2009) Review of Norman Daniels: Just health. Meeting health needs fairly. Notre Dame philosophical reviews. https://ndpr.nd.edu/news/24009-just-health-meeting-health-needs-fairly/. 25 Feb 2015
Klonschinski A (2013) Das Kosten-Nutzen Verhältnis als Priorisierungskriterium? Eine philosophisch-dogmenhistorische Betrachtung des ökonomischen Paradigmas der Wertmaximierung. In: Schmitz-Luhn B, Bohmeier A (eds) Priorisierung in der Medizin: Kriterien im Dialog. Springer, Berlin/Heidelberg, pp 79–107
Klonschinski A (2014) ‘Economic imperialism’ in health care resource allocation – How can equity considerations be incorporated in cost-utility analysis? J Econ Methodol 21(2):158–174
Klonschinski A (forthcoming) The Philosophy and Economics of Resource-Allocation in Healthcare: Cost-Utility, Social Value and Fairness. Routledge, London/New York.
Le Grand J (1990) Equity versus efficiency: the elusive trade-off. Ethics 100:554–568
Little IMD (1957) A critique of welfare economics, 2nd edn. Clarendon Press, Oxford et al.
Lukes S (1996) On trade-offs between values. In: Farina F, Hahn F, Vannucci S (eds) Ethics, rationality, and economic behaviour. Clarendon Press, Oxford et al., pp 36–49
Lübbe W (2005) Wirtschaftlichkeit und Gerechtigkeit: Zwei ethische Gebote? Eine Grundlagenreflexion. Das Gesundheitswesen 67:325–331
Lübbe W (2009) Aggregation in health resource allocation. Unpublished manuscript presented at the conference “Ethical issues in the prioritization of health resources”, Harvard University, Boston, 24 Apr 2009. http://peh.harvard.edu/events/2009/priority_resources/day_2/weyma_lubbe_paper.pdf. 10 Oct 2014
Lübbe W (2011) Dissenting opinion. In: German Ethics Council. Medical benefits and costs in healthcare: the normative role of their evaluation. Opinion. Berlin, pp 96–121
Lübbe W (2015) Nonaggregationismus: Grundlagen der Allokationsethik. Münster, Mentis
McPherson CB (1987) The rise and fall of economic justice. Oxford University Press, Oxford et al.
Menzel P, Gold MR, Nord E, Pinto-Prades JL, Richardson J, Ubel P (1999) Toward a broader view of values in cost-effectiveness analysis of health. Hastings Center Rep 29(3):7–15
Okun A (1975) Equality and efficiency: the big trade-off. Brookings Inst, Washington D.C
Powers M, Faden R (2006) Social justice: the moral foundations of public health and health policy. Oxford University Press, Oxford et al.
Rawls J (1971) A theory of justice. Harvard University Press, Cambridge, MA/London
Rid A (2009) Justice and procedure: how does ‘accountability for reasonableness’ result in fair limit-setting decisions? J Med Ethics 35:12–16
Robbins L (1935) Essay on the nature and significance of economic science, 2nd edn. Macmillan, London
Ryan M, Gerard K, Currie G (2006) Using discrete choice experiments in health economics. In: Jones AM (ed) The Elgar companion to health economics. Edward Elgar, Cheltenham/Northampton, pp 405–414
Sassi F, Archard L, Le Grand J (2001) Equity and the economic evaluation of health care. Health Technol Assess 5(3)
Schefczyk M, Priddat BP (2000) Effizienz und Gerechtigkeit. Eine Verhältnisbestimmung in sozialpolitischer Absicht. In: Kersting W (ed) Politische Philosophie des Sozialstaats. Velbrück, Weilerwist, pp 428–466
Schlander M (2007) The use of cost-effectiveness by the National Institute for Health and Clinical Excellence (NICE): No(t yet an) exemplar of a deliberative process. J Med Ethics 34:534–539
Schmidt V (1994) Some equity-efficiency trade-offs in the provision of scarce goods: the case of lifesaving medical resources. J Pol Philos 2(1):44–66
Tsuchiya A (2012) Distributional judgements in the context of economic evaluation. In: Jones AM (ed) The Elgar companion to health economics, 2nd edn. Edward Elgar, Cheltenham/Northampton, pp 406–414
Ubel PA, Nord E, Gold MR, Menzel P, Pinto-Prades JL, Richardson J (2000) Improving value measurement in cost-effectiveness analysis. Med Care 28(9):892–901
Williams A (1988) Ethics and efficiency in the provision of health care. In: Bell JM, Mendus S (eds) Philosophy and medical welfare. Cambridge University Press, Cambridge et al., pp 111–126
Williams A, Cookson R (2006) Equity-efficiency trade-offs in health technology assessment. Int J Technol Assess Health Care 22(1):1–9
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I want to thank Daniel Quanz for helpful comments on an earlier version of this paper.
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Klonschinski, A. (2016). The Trade-Off Metaphor in Priority Setting: A Comment on Lübbe and Daniels. In: Nagel, E., Lauerer, M. (eds) Prioritization in Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-21112-1_6
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