Justification of principles for healthcare priority setting: the relevance and roles of empirical studies exploring public values

Abstract

How should scarce healthcare resources be distributed? This is a contentious issue that became especially pressing during the pandemic. It is often emphasised that studies exploring public views about this question provide valuable input to the issue of healthcare priority setting. While there has been a vast number of such studies it is rarely articulated, more specifically, what the results from these studies would mean for the justification of principles for priority setting. On the one hand, it seems unreasonable that public values would straightforwardly decide the ethical question of how resources should be distributed. On the other hand, in a democratic society, it seems equally unreasonable that they would be considered irrelevant for this question. In this paper we draw on the notion of reflective equilibrium and discuss the relevance and roles that empirical studies may plausibly have for justification in priority setting ethics. We develop a framework for analysing how different kinds of empirical results may have different kinds of implications for justification.

The ethical canary: narrow reflective equilibrium as a source of moral justification in healthcare priority-setting

“…[45][46][47][48][49][50] Very recently, coherencebased arguments have been employed in emphasising and characterising the role that empirical studies might play in justifying priority-setting principles. 21 However, we believe that we are the first to suggest that coherence might be used as grounds for drawing evidence-based conclusions about the extent to which a priority-setter's overall approach-incorporating both policy (as constituted by its formal processes and methods of appraisal) and practice (as constituted by the judgements made over the course of many individual cases)-is morally justified and to specifically propose that NRE be used as a tool in systematically examining coherence in this context.…”

“…An alternative approach is to explicitly ground substantive principles for priority-setting on public views, for example, by conducting studies exploring societal values. [17][18][19][20][21][22] Doing so might i The opportunity cost associated with an intervention's adoption refers to the benefits foregone when a choice is made to employ resources on adopting that intervention rather than for some other purpose within the health system. enhance a priority-setter's perceived legitimacy and make its decisions less vulnerable to challenge.…”

“…Despite Rawls' misgivings about whether NRE is sufficient to justify a set of moral beliefs, others have argued that 'moral justification is a matter of degree' 21 and that 'in the vast majority of cases […] it will probably turn out that NRE, for all its limitations, will be a tolerably helpful methodological tool' 39 in conducting practical ethics. 40 Given the many background theories that could be considered relevant to matters of healthcare priority-setting-theories of distributive and procedural justice, conceptions of health, ideas about moral personhood, principles of medical ethics and so on-an institutional priority-setter could not reasonably be expected to justify its approach on the grounds of having achieved WRE.…”

“…Similarly, all else being equal, an equilibrium that reflects the fair consideration of societal views-as evidenced, for example, through public dialogue or the deliberations of a Citizens Jurymight be considered to carry more justificatory force than one that has not involved external participation and conflicts with public opinion. 21 If it is accepted that part of the justificatory power of coherence stems from the special status of considered moral judgements-that is, judgements that are reliable due to their 'inherent plausibility, stability and low likelihood of being motivated by biases' 37 -then a potential criticism is that this introduces a substantive component to an approach badged as avoiding such complications. However, we would argue that the need for judgements to be morally reliable imposes a relatively loose constraint and does not, to any meaningful extent, turn our approach into a substantive one.…”

An empirical ethics study of the coherence of NICE technology appraisal policy and its implications for moral justification

“…While our personal views and assumptions may have influenced the findings, we adopted several strategies to mitigate their impact, such as extensive double-coding and peer debriefing with experts not on the authorship team. More importantly, reflective equilibrium is a process and the conclusions we draw here should be viewed as a "resting point", not an end point [30,108]; for example, future engagement with decisionmakers at NICE may uncover implicit principles, informal standards not codified in policy [49] or alternative explanatory relationships between commitments that can help resolve some of the instances of dissonance discussed here.…”