Ethics,equity and economics

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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

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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

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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

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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

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Categorising ethical theories (3)
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Ethical theories

• Utilitarianism
• Rawlsian
• Entitlement/libertarian
• Egalitarian
• Deontological?
• Virtue
• Rights

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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)

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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

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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

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Egalitarian

• Equal shares in the distribution of a commodity
• Issues - of what? health, services?
• - according to what criteria?
• need, age?

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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

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Virtue theory

• Not what should I do but what kind of person
  should I be
• Similar to deontological - absolute moral rules

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Rights based theories

• Unassailable rights which cannot be overridden
  e.g.right to life
• Underlies social contract theory
• Absolute - inflexible

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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 (?)

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Medical vs. economic ethic (2)

• Economic - population based ethic
• - principally utilitarian
• - based on opportunity cost
• Overlap of considerations in both professions

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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.

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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
  patients 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.

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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.

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Tavistock Group - BMJ, Jan 23, 1999

• Prepare shared code based on consistent moral
  framework
• - healthcare is a human rightprovide
  accessregardless 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

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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...

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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?

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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

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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.

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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.

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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?

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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)

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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

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Access or use?

• Access - maintain consumer sovereignty
• - unlikely to achieve equal health
• Use - closer to achieving equal health
• - compromises consumer sovereignty

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Equal health?

• Definition e.g. QALYS, LYs?
• 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

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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

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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

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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)

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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

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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

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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

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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

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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?

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Social welfare function
UB
2 W
1 W
U
0 W
Umin
45
U
UA
Umin
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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)

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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

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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

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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)