Identifying Value(s): A Reflection on the Ethical Aspects of MCDA in Healthcare Decisionmaking

Abstract

Background: A number of ethical theories have been developed over many centuries, such as deontology, consequentialism (including utilitarianism), virtue ethics, and, more recently, for example, Rawls’ Theory of Justice and Habermas’ Ethics of Discussion, which have been investigated further in healthcare. These major ethical positions and procedural theories integrate many ethical aspects with which decisionmakers, in particular at policy level, are struggling to deliver the best treatments to patients, protect population health, and build sustainable healthcare systems (triple aim). While ethical dilemmas, rooted in this triple aim, are becoming more critical and the demand for accountable processes is rising, multi-criteria decision analysis (MCDA) offers an opportunity to integrate ethical aspects in an innovative manner to enhance accountability for reasonableness (A4R).

Objectives: This chapter is a first attempt to explore how MCDA may integrate ethical aspects inherent to healthcare decisionmaking. The reflection proposed here is primarily rooted in the real-life constraints of decisionmaking at the HTA/Ministry of Health (MoH) level, rather than in specific ethical positions.

Method: This chapter explores the ethical aspects of each MCDA development step, following the eight-step outline of the ISPOR Task Force on MCDA, as well as the legitimacy of decisions from the HTA/MoH perspective, using the triple aim as the goal to illustrate this exploration. For each step, we discuss the substantive and procedural elements of major ethical positions and procedural theories that such method can integrate.

Results: Legitimacy of decisions on healthcare interventions requires inclusion of representative stakeholders for both the design and operationalization of the MCDA to ensure that criteria included and their consideration are in agreement with the mission and values of the institution. Consideration of the triple aim as the goal of the MCDA (step 1) results in the definition of a broad range of criteria (step 2) derived from ethical aspects, such as the “imperative to help” at the patient level, the “prioritization of those who are worst off,” and the aim to achieve the “greatest good for the greatest number” to best serve the population, as well as maintain the sustainability of the healthcare system. The first two MCDA steps foster reflection, collaboration, and communication across stakeholders to define common ground upon which to establish what constitutes the holistic value of interventions, i.e., integrating all ethical aspects of the triple aim. Synthesis of evidence to consider these criteria (step 4) requires elements of practical wisdom to provide clear, transparent, and systematic evidence. Other aspects of MCDA, such as weighting (step 3), scoring (step 5), aggregating of weights and scores (step 6), and managing uncertainty (step 7), include ethical elements of practical wisdom as well as additional procedural values, such as transparency of values, consistency, participation, accountability, and deliberation. The criteria and their consideration through the MCDA process can result in an accountable and reasonable measure of “holistic value” of interventions contributing the most to the triple aim.

Conclusion: This reflection suggests that MCDA can be designed to integrate numerous ethical aspects inherent to healthcare decisionmaking. By enhancing their operationalization, MCDA can support accountable and reasonable decision processes rooted in a holistic consideration of value of healthcare interventions. Reflection on the ethical aspects of MCDA in healthcare is in its infancy, and further research on each aspect presented here is warranted.