Economics, Political Philosophy and Ethics: The Role

78 Economics, Political Philosophy and Ethics: The Role of Public Preferences in Health Care Decision-Making JEFF RICHARDSON, JOHN MCKIE

A defining characteristic of economics is that it attempts to answer the question of how best to use our limited resources to achieve social objectives. This suggests that there is an important role for public preferences to play in the evaluation of health services. Accounts of this role are provided by different theories within the disciplines of economics, political theory and ethics, and are discussed in the first three sections of this chapter. In the next two sections, a more empirical approach is outlined and defended. The last section draws together the various themes discussed and ends with some practical recommendations and theoretical conclusions.

WELFARE THEORY The tools of orthodox Welfare Theory (WT) have been developed to a high degree of precision, and they are useful in a number of contexts. The fundamental normative assumption of WT is that the distribution of goods and services should be based upon individual preferences. At the macro- or health-system level, the theory provides the rationale for a competitive market and, at the micro-level, which is concerned with the evaluation of particular services, it provides the theoretical basis for cost–benefit analysis. The assumption enshrines the principle of ‘consumer sovereignty’ (Penz, 1986) at both these levels. However, WT is based on a number of specific assumptions that make it largely irrelevant in the health context. For example, it is assumed that the preferences consumers reveal

through their choices represent what is in their best interests. As Mishan (1971, p. 172) states: ‘economists are generally agreed – either as a canon of faith, as a political tenet, or an act of expediency – to accept the dictum that each person knows his own interests best’. Defending consumer sovereignty (at least by implication) J.S. Mill stated: ‘Most persons take a juster and more intelligent view of their own interests, and of the means of promoting it, than can either be prescribed to them by a general enactment of the legislature, or pointed out in the particular case by a public functionary’ (Mill, 1994, Book V, Chapter 11, Section 9). However, in the health context it is typically not the case that the ‘consumer’ is the best judge of the means of promoting his or her own interests. Most conspicuously, lack of knowledge is ubiquitous: consumers lack crucial information about their own health status, what treatments are available, their effectiveness, the risks involved, and so on (Rice, 2001). People may know what they want (health) but lack the knowledge to secure it (unless they are medically trained). (Further support for the tenuousness of the connection between behaviour and subjective well-being comes from psychology. Recent empirical work in psychology suggests that wanting and liking arise from two different neural systems (Berridge, 1996). Activities that arise from wanting, therefore, may not reflect what an individual likes, and may not produce subjective well-being, even assuming that subjective well-being is what people seek.) Orthodox WT also equates rationality with the maximization of self-interest. This excludes the possibility of rational self-sacrifice or ‘commitment’ (Sen, 2005). It

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is sometimes assumed that any action aimed at achieving something – any purposeful action – must reflect a self-interested preference, and thus be aimed at utility maximization, or some other action would have occurred. Interpreted in this way, no conceivable action can fail to be utility maximizing, and the revealed preference criterion becomes a tautology. As Thurow comments: ‘Revealed preferences … is just a fancy way of saying that individuals do whatever individuals do, and whatever they do, economists will call it “utility maximization”’ (Thurow, 1983, p. 217). Of course, there is a wealth of everyday observation, and systematic empirical evidence, suggesting that people do not invariably seek to maximize their own self-interest, when this is not defined tautologically. For example, there is a growing body of evidence from experimental economics which suggests that people are prepared to make significant sacrifices in order to obtain other social objectives which carry no obvious personal pay-off (Krebs, 1982; Kahneman et al., 1986; Andreoni, 1995; Keser, 1996; Bolton and Ockenfels, 2000). There has also been a recent resurgence of interest in ‘group selection’ in evolutionary theory, which is compatible with individual self-sacrifice (Seeley, 1996; Wilson, 1997; Sober and wilson, 1998). Excluding these preferences from consideration on the ground that they are irrational is itself a normative assumption and lacks justification when applied to otherwise rational people. In the context of the provision of public health services people have strong preferences for allocating resources fairly, which should not be deemed ‘irrational’ and ignored. A particularly limiting assumption of WT concerns the nature of social welfare itself: namely, the assumption that social welfare is a function exclusively of individual utilities. Sen describes the resulting doctrine as ‘welfarism’ and has vigorously criticized it as a normative doctrine. For example, he notes that individuals with disabilities often adjust their expectations downwards – they accommodate themselves to their condition – and, because well-being is largely determined by a person’s situation relative to their expectations, they may have relatively high utility levels (Sen, 1987). But the fact that a person has learned to live with adversity should not mean that they do not have a legitimate claim for special consideration. Sen maintains there is more to social welfare than the sum of individual utilities. He recommends a focus on functionings and capabilities in economic analysis: The freedom people have to pursue valuable goals in general, including non-self interested goals. (As Cohen explains it, functionings lie mid-way between goods (or services) and utility. For example, food is not the focus of attention because this ‘takes too little account of distinguishing facts about individuals’ (Cohen, 1993, p. 18), nor the satisfaction that a person derives from eating food because ‘this takes too much account of just such facts’ (Cohen, 1993, p. 18). Rather, the focus is on how

much nourishment a person gets from food. The focus is on what goods and services allow people to do or to be (being adequately nourished, having mobility, being free from avoidable disease), but not exclusively on the utility they confer.) Efficiency in WT is defined by the Pareto criterion. A change is ‘Pareto efficient’ if it makes no one worse off and at least one person better off. Much of the appeal of WT stems from the fact that in the model defined by its core assumptions every competitive equilibrium results in a Pareto optimal outcome: it is not possible to make someone better off without making someone else worse off (Debreu, 1959; Arrow & Hahn, 1972). Achieving allocative efficiency in this sense has been an attractive goal in economics because it avoids the need for substantive ethical assumptions; a change that benefits at least one person without making anyone else worse off should command universal assent. However, a major obstacle to the use of the Pareto principle in the evaluation of health services is that most decisions result in winners and losers. Introducing a health service into one area commonly means not introducing it into another, and this means that policies are seldom, if ever, Pareto efficient, and the criterion fails to apply in many contexts. Of course, this is also true in other areas of the economy. To overcome this problem, the Kaldor–Hicks potential compensation principle is usually implicitly or explicitly evoked (Hicks, 1939; Kaldor, 1939). According to this principle, one state of the world is better than another if those who are made better off could potentially compensate those who are made worse off. However, in the context of a national health scheme, the winners are the patients who receive health care and the losers are the tax payers who pay for the services. Compensation would require the taxation of patients and the return of tax revenues, which is the exact reversal of the purpose of a national health scheme. More fundamentally, the Kaldor–Kicks principle can only apply if it is possible to compensate those who are made worse off. For patients left with a very poor quality of life this may be impossible, and it is unequivocally impossible when a patient dies. This implies that the attempt to base policy decisions on the achievement of Pareto efficiency fails in the health sector, and with it the attempt to by-pass ethical issues in the formulation of health policy. Although the economics literature usually acknowledges the unreality of much of WT, this final conclusion is less commonly acknowledged.

LIBERTARIANISM AND EGALITARIANISM The inapplicability of Welfare Theory in the health context creates a vacuum at the macro- or health-system level,

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where decisions are made with respect to the allocation of resources between services, the distribution of and access to those services, and the distribution of health care costs. Similarly, the limited applicability of Pareto efficiency and the Kaldor–Hicks potential compensation principle creates a vacuum at the micro-level, which is concerned with the evaluation of particular services or programmes, such as cancer screening programmes and transplant programmes. At both levels the exact role of public preferences (preferences for the type and content of a national health scheme) in economic analysis remains problematical although there is almost universal agreement that these preferences are of importance. Williams clearly and persuasively identifies two major viewpoints in the literature dealing with system-level issues – namely, libertarianism and egalitarianism, and contrasts them along four dimensions (Williams, 1988). With respect to personal responsibility, the libertarian viewpoint holds that unearned rewards weaken the motive force that assures economic well-being and places great emphasis upon achievement. The egalitarian viewpoint places less emphasis upon personal incentives to achieve and does not equate economic failure with social worthlessness. With respect to social concern, libertarianism advocates private charity for those who fail despite appropriate efforts. Egalitarianism sees charity as potentially degrading and inequitable and advocates public support mechanisms to maintain self-sufficiency as a matter of entitlement. The libertarian viewpoint places great emphasis upon personal freedom and sees government involvement in the financing of health care as a restriction of the freedom of consumers and providers. The egalitarian viewpoint sees government involvement as necessary for real freedom, by removing economic constraints that limit opportunities for meaningful choice. With respect to equality, libertarians see it as less important than freedom and focus primarily on equality before the law. Egalitarians place greater emphasis upon equality of opportunity because without this the moral worth of achievement is undermined. All public health systems incorporate elements of both viewpoints, with national health schemes differing in the subsidy they provide for different services, the relative cost of these services to government and to individual patients, the ownership of assets, the incentives and remuneration offered to service providers, and the type of regulatory controls employed. For pragmatic and ethical reasons neither unfettered freedom nor unfettered paternalism is advocated in the literature, and the extremes on the libertarianism/ egalitarianism spectrum are avoided. However, this still leaves a range of feasible alternatives occupying the ‘middle ground’, and views differ regarding which alternative represents the right balance between these two viewpoints for a given society. This limits the amount of practical guidance

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that can be derived from an abstract consideration of arguments for and against libertarianism and egalitarianism. There is no simple way of trading off these theories in their more abstract form to arrive at an acceptable balance from within the theories themselves.

TRADITIONAL ETHICS The literature applying ethical theories, and their derivative ethical principles, to the problem of fairly allocating health care resources is also characterized by disagreement. For example, utilitarianism holds that the right action, choice or policy is the one that will maximize happiness, or pleasure, or preference-satisfaction, taking everyone’s interests into account. By contrast, Rawls uses social contract theory to argue that social and economic inequalities are justifiable only if they are of the greatest benefit to the least advantaged members of society (Rawls, 1971). In the health context, this may lead to a head-on collision between the distribution of resources to maximize health (e.g. minimize the cost per QALY); distributing to favour those in greatest need (e.g. those with the lowest pre-treatment QALY score); and distributing to maximize utility (as revealed by a free market supplemented to overcome market failures). (In its simplest form the QALY (Quality-Adjusted Life Year) represents a year of life that has been weighted by an index representing quality of life. By tradition, full health has a weighting of 1 and death has a weighting of 0. For example, if years on dialysis are judged to be worth only 57% as much as years of normal health (Torrance, 1986) then 20 years of dialysis would be discounted to 20 ⫻ 0.57 ⫽ 11.4 QALYs.) There is no clear way to resolve the impasse while debate remains at the level of philosophical analysis. The hope has sometimes been expressed that convergence may be possible in ethics, especially with the decline of religion, but there is no evidence of this occurring (Parfit, 1984; Smith, 1994). On the contrary, new variants of the traditional ethical theories continue to appear. Of course, the desire to increase welfare and the desire to help the worst off are both important and widespread in most communities. But in practice they often pull in different directions, and it is difficult to know how to balance these various desiderata when they conflict. In the absence of consensus, we are again at an impasse.

THE EMPIRICAL APPROACH Given the lack of practical guidance and uncertainty surrounding the political and ethical solutions discussed above, a good case can be made for investigating the preferences of

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the community as a way of arriving at the desired compromise between alternative principles. At the microlevel there are now a large number of studies that demonstrate the existence of societal preferences that are not narrowly self-interested. For example, when informed that patients regard the health improvements from two services as being identical, people generally indicate a strong ‘social’ preference for giving priority to the patient with the poorer initial health state. Consequently, priority does not only reflect the utility gained from a procedure but also the distribution of health benefits. For example, in an early study, Nord examined public preferences associated with two health states A and B. These were described to survey respondents as: ‘unable to work, unable to pursue family and leisure activities, strong pain, depressed’ (A); and ‘unable to work, moderate pain’ (B). Nord found that returning one person from A to full health was regarded by respondents as being as valuable as returning 50 people to full health from B. However, the utility values for these states (assigned by the participants using a rating scale) implied that curing one person in a more severe state should be equivalent to curing two people in a less severe state (Nord, 1991, 1993, p. 33). Similarly, returning one person to full health from the first state was considered as valuable as returning 100 people to full health from a state of ‘moderate pain’, even though the utility associated with ‘moderate pain’ implied that this number should have been five. The societal value of treating the more severely ill was much higher than would be expected from only taking account of patient utilities. The sentiment expressed in this, and other, surveys is summed up by Callahan: ‘Our bias, I contend, should be to give priority to persons whose suffering and inability to function in ordinary life is most pronounced, even if the available treatment for them is comparatively less efficacious than for other conditions’ (Callahan, 1994, p. 463). Support for severity can also be found in official government guidelines in several countries, and in reports of government-appointed commissions (Dutch Committee on Choice in Health Care, 1992; Campbell & Gillett, 1993; Swedish Health Care and Medical Priorities Commission, 1993). Importantly, studies of societal preferences regarding the importance of severity offer the possibility of quantifying the trade-off between minimizing the cost per QALY and giving priority to the worst off. Several empirical studies have also observed a societal preference for giving equal consideration to patients irrespective of their potential for health improvement. For example, Nord (1993) conducted a study in which subjects were asked to choose between two 60-year-old housewives, each of whom had contracted a life-threatening disease. An operation would make Mrs Anderson ‘completely healthy’, whereas it would give Mrs Peterson a life ‘with moderate pain and dependency on crutches for walking’. Subjects were asked whether they thought Mrs Anderson

should be operated first, or whether they should be taken in the order in which they were admitted to the hospital. The results showed that the majority of participants, 78.7%, chose the option that afforded both patients an equal chance of being treated (order of admission), whereas only 14.8% favoured the option that would maximize health (treating Mrs Anderson). Other studies show that many citizens in Australia, the USA, England and Spain share this reluctance to discriminate against the permanently disabled, the chronically ill and others with a limited potential for health improvement (Nord et al. 1995; Abellan-Perpiñán & Prades, 1999; Dolan & Cookson, 2000; Ubel Richardson & Baron, 2002). Of course, it cannot be concluded from this that the state of health after treatment is irrelevant. When the potential for improvement is very limited subjects place considerably more weight on health outcome (Abellan-Perpiñán & Prades, 1999; Dolan & Cookson, 2000). None the less, potential for improvement does not have the importance for the general public that an exclusive focus on health maximization would suggest; the public also considers ‘realizing one’s potential for health improvement’, whether large or small, important in social decision-making. Confirming this, in 1992 the United States Secretary for Health and Human Services rejected the Oregon plan for prioritizing the state’s health services on the ground that it discriminated against the disabled when the improvement in health from a medical cure is limited by the patient’s disability (Daniels, 1993). Work by Ubel et al. indicates that the public would support this rejection. Survey respondents would not prioritize (longterm) paraplegics below other patients when both groups faced a life-threatening illness even though their paraplegia meant that they would gain less health (the so-called ‘double jeopardy’ of those with a long-term illness) (Ubel, Richardson & Baron, 2002). Importantly, the trade-off between realizing potential and maximizing health can be precisely calculated, which is not to deny the technical problems confronting preference elicitation. Empirical studies also suggest that many people are willing to give certain age groups priority in the competition for limited health care. For example, in one study, subjects were asked to choose between two equally costly projects that would enable patients to continue living in normal health for 10 years (Nord et al. 1996). Project A would allow the treatment of more patients, but project B would benefit younger patients. Subjects were asked to adopt the role of health administrators and say how many patients treated under project B were considered equivalent to 10 patients being treated under project A. The study found that saving the lives of 10 twenty-year-olds was considered equivalent to saving the lives of 9.5 ten-year-olds, and that saving the lives of 10 eighty-year-olds was considered equivalent to saving the life of 1 twenty-year-old.

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Because all patients were stipulated to derive the same benefit (10 years in good health), this outcome is again inconsistent with health maximization. In general, Nord et al. found that ‘the preference for the young is more pronounced the greater the disparity in the two age groups’ (Nord et al. 1996, p. 106). Similar results were obtained for health-improving rather than life-saving treatments (see Choudhry et al. 1997; Ratcliffe, 2000; Tsuchiya, Dolan & Shaw, 2003). Even from within this empirical literature there is evidence that indicates the need for caution in the use of survey results to guide policy. In one study, respondents were asked whether they believed that the views of the public should be adopted even when they differed from the views of the government and government departments. Results varied with the context of the question, but at least in some cases the public rejected the use of public preferences (Richardson, 2002). In contrast, evidence from other studies suggests that the public does want a role in priority-setting. However, willingness to participate varies with the level of decisionmaking involved (individual patient, programme or health system) and the time commitment required for participation. (Richardson, Charny & Hanmer-Lloyd, 1992; Bowling, Jacobson & Southgate, 1993; Abelson et al. 1995, Bowling, 1996; Myllykangas et al., 1996; Litva et al., 2002; Wiseman et al., 2003). In this context, it has been argued that ‘where citizens would rather have professionals make decisions for them, these professionals should base their decisions on the community’s values, not their own (elitist) values’ (Black & Mooney, 2002). We explore the status of community preferences in the next section.

ETHICS AND SOCIAL SCIENCE Consulting the public on priority-setting in the health sector is important in a liberal democracy and offers a way of reconciling alternative political and ethical viewpoints. In a practical sense, researchers adopting this approach typically formulate hypotheses about societal preferences, undertake both quantitative and qualitative studies to test them experimentally, and subject the results to further testing and refinement. For example, there is evidence that the public believes it is fair for the benefits of health care to be distributed widely, rather than narrowly concentrated among a few (Nord et al., 1996, Johannesson & Gerdtham, 1996). It may be, however, that the public believes it is unfair to deny the few a significant health benefit if benefits are distributed too widely, and the benefit per person becomes trivial. This hypothesis has been confirmed (Olsen, 2000; RodríguezMíguez & Prades, 2002). In these cases, ethics can play an important role in clarifying population responses, drawing out the

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implications of policies and suggesting questions for further research. Ideally, the process should continue until relatively stable principles are derived, which can withstand (tolerably well) both ethical criticism and the test of population support. This process has been called ‘Empirical Ethics’ (Richardson, 2001). As part of this process of eliciting societal preferences, techniques should be used that will encourage reflection and deliberation, and a precise statement and specification of values. These techniques might include re-interviewing and different forms of information feedback (including Delphi techniques), the triangulation of issues (eliciting responses using different techniques and comparing results), focus groups, citizens’ juries and other qualitative methodologies. The hope is that the appropriate use of these methodologies will minimize ‘correspondence’ and ‘reflection’ irrationality. ‘Correspondence irrationality’ occurs when a person’s actual choices do not correspond with his or her reasoned reflection. ‘Reflection irrationality’ characterizes a failure of careful reflection itself (Sen, 1985). This is particularly important for the evaluation of health services and programmes, as the opportunities people have to reflect on the worth of these, in comparison with other conventional goods and services, are limited. For example, Dolan, Cookson & Ferguson (1999) found that participants in small groups commonly changed their mind after discussion and reflection. It is important that the results of this process are not misinterpreted. Frohlich and Oppenheimer, for example, suggest that definitive answers to ethical questions may exist, but that this requires ‘moving ethical theory out of the armchair and into the laboratory’ (Frohlich & Oppenheimer, 1992, Jacket). They conducted a series of experiments in Canada, Poland and the United States to identify attitudes towards fairness in the distribution of wealth and income. They conclude: ‘Our results lead us to believe that cumulative progress (like that achieved in the physical sciences) may even be possible in certain branches of ethics if philosophers adopt the techniques of experimental science and move beyond speculation and debate’ (Frohlich & Oppenheimer, 1992). Nord adopts the same approach when he writes: ‘I define a fair resource allocation in health care as one that accords with societal feelings about the strength of claims of different patient groups. A resource allocation that violates such feelings is defined as unfair’ (Nord, 1999, p. 23). However, this interpretation of the process misrepresents the nature of ethics. If this approach was adopted it would be impossible to critique the implications of empirical research as these would define or reveal what was ethical. It would only be possible to criticize the studies on technical grounds. But one of the main functions served by the moral component of language is criticism, and the belief that there are ‘scientific’ solutions to moral problems threatens this role. That is, ‘the autonomy of ethics’ must be preserved (Pigden,

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1989). Social surveys like those described above, which reveal support for the more severely ill, the disabled, the young and so on, should not be interpreted as attempts to arrive at the ‘truth’ concerning ethical matters, or as attempts to define away ethical problems. Rather, they are a way of reaching practical political solutions to complex social problems when there is a diversity of ethical views in the community.

CONCLUSION ‘Empirical Ethics’ provides one explanation of how the insights of ethics and economics can be used simultaneously to help answer policy questions. Ethics can play an important role in clarifying population responses, drawing out implications and suggesting questions for further research. Properly conducted, Empirical Ethics tells us what people believe is fair. However, it leaves unanswered the question of what is really fair, independently of the prevalence and distribution of social views. For example, community surveys may tell us that people are willing to give priority to the more severely ill, and may even allow a precise measure of the preferred trade-off between health maximization for the entire population and maximization for the worst off members of the community. But it is, and should always be, possible to ask whether or not a policy based on these results is really fair. As noted above, there are numerous ethical theories and derivative ethical principles that are applicable for health policy. Thus, there will always be multiple, incompatible answers to the question of what is really fair. Utilitarians may give one answer, Kantians another, Rawlsians another and so on. Moreover, the precise nature of this question and how one understands the various answers to it will vary according to which meta-ethical theory is adopted: that is, whether moral judgements are seen as objectively true or false (Moore, 1903; Prichard, 1912; Ross, 1930), as disguised factual statements (Harman, 1977), as reports of personal opinion (Westermarck, 1932; Perry, 1954), as expressions of emotion (Ayer, 1936; Stevenson, 1945) or without foundation at all (Ruse, 1988). For practical purposes, policy makers and their economic advisers cannot wait for such normative and meta-ethical disagreements to be resolved. As stated in the opening sentence of this chapter, a defining characteristic of economics is that it attempts to answer the question of how best to use our limited resources to achieve social objectives. In this chapter, we have argued that both ethics and empirical research into public preferences should have a role in this process. In this chapter, we have tried to give some insight into how this task might be conducted better. In summing up, we offer three practical recommendations and three theoretical conclusions.

Practical Recommendations: 1. Economists involved in economic evaluations of health services and programmes should consult the public regarding their preferred services and programmes, their preferred principles and methods for distributing health care, and their preferred method of paying for these services. 2. There is a lack of data on societal preferences and the acceptable trade-offs between social goals. There is an urgent need for research into the ethical values of health care ‘consumers’, and a need to further develop empirical methods that elicit deliberative rather than spontaneous societal preferences. 3. Although conventional ethics does not provide unambiguous answers to ethical questions, health economists should acquaint themselves with the major ethical theories, particularly regarding distributive justice and procedural fairness, in order to interpret and critique the results of community consultations. Theoretical Conclusions: 1. Health and health care are different from other goods and services. Orthodox welfare theory and cost-benefit analysis are based on a number of assumptions that severely limit their applicability in the health context. The ‘welfarism’ of welfare theory is not the only theoretical basis for health care policy. 2. Unambiguous policy recommendations cannot be derived from traditional political or ethical theories. Political and ethical disagreement will persist no matter how much discourse takes place and no matter how openly, rationally and conscientiously it is pursued. 3. Consulting the public on their ethical views does not jeopardize the autonomy of ethics. ‘Empirical ethics’ is a way of reaching practical solutions to complex social problems, given the diversity of ethical views in the community. It does not imply that there are ‘scientific’ solutions to moral problems.

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