Public values and plurality in health priority setting: What to do when people disagree and why we should care about reasons as well as choices

Abstract

Context ‘What does ‘The Public’ think?’ is a question often posed by researchers and policy makers, and public values are regularly invoked to justify policy decisions. Over time there has been a participatory turn in the social and health sciences, including health technology assessment and priority setting in health, towards citizen participation such that public policies reflect public values. It is one thing to agree that public values are important, however, and another to agree on how public values should be elicited, deliberated upon and integrated into decision-making. Surveys of public values rarely deliver unanimity, and preference heterogeneity, or plurality , is to be expected. Methods This paper examines the role of public values in health policy and how to elicit, analyse, and present values, in the face of plurality. We delineate the strengths and weaknesses of aggregative and deliberative methods before setting out a new empirical framework, drawing on Sunstein's Incompletely Theorised Agreements, based on three levels: principles, policies and patients. The framework is illustrated using a recognised policy dilemma – the provision of high cost, limited-effect medicines intended to extend life for people with terminal illnesses. Findings Application of the multi-level framework to public values permits transparent consideration of plurality, including analysis of coherence and consensus, in a way that offers routes to policy recommendations that are based on public values and justified in those terms. Conclusions Using the new framework and eliciting quantitative and qualitative data across levels of abstraction has the potential to inform policy recommendations grounded in public values, where values are plural. This is not to suggest that one solution will magically emerge, but rather that choices between policies can be explicitly justified in relation to the properties of public values, and a much clearer understanding of (in)consistencies and areas of consensus.

Public Preferences for Allocation Principles for Scarce Medical Resources in the COVID-19 Pandemic in Korea: Comparisons With Ethicists’ Recommendations

“…These differences between the general public and expert ethicists call for the need to further investigate the public’s moral preferences regarding the allocation principles for scarce medical resources in the COVID-19 pandemic. Doing so is necessary because moral value judgments should not be monopolized by ethicists, who tend to emphasize the coherence of arguments, which is not a sufficient condition for justice [ 13 , 14 ]. When rationing policies or guidelines are developed and implemented, the public is most affected by them.…”

Eliciting public values on health inequalities: missing evidence for policy windows?

“…First, there is no one public. Many different public(s) can be assembled with people asked to occupy different roles depending on the situation (Baker et al, 2021;Barnett, 2008;Escobar, 2017;Stewart, 2016). Different subsets, or communities, of people can be constructed who share a common characteristic around, for example, place and/or interest (Brunton, 2017;Popay, 2006).…”

“…Value(s) can also take different forms. Baker et al (2021) differentiate between two forms of value: ethical/philosophical values and economic values. For the former, values are high-level principles or moral standards, such as equity, efficiency, human dignity or security that can be used to justify a choice or decision.…”

“…There are two broad categories of reasons for eliciting public values for policies that impact on health inequalities -intrinsic and instrumental rationales. Intrinsic rationales relate to democratic arguments for accounting for public values in the allocation of public resources: taxes fund public policies and the general public are affected, positively and negatively, by resource allocation decisions (Baker et al, 2021;Tenbensel, 2010). This assumes that how resources are currently allocated should be indicative of the public value placed on different prospects, and the importance of different kinds of benefits to different beneficiaries.…”

“…Qualitatively exploring why downstream, individualised policies and/or less cost-effective policies are favoured (if this is the case) would help to understand the reasons for such findings as well as why one upstream policy is preferred over another. Frameworks also exist for combining aggregative elicitation approaches with deliberative approaches, such as citizen's juries, to explore reasons, beliefs and principles underlying public values and provide ways to analyse and present plurality when people disagree (Baker et al, 2021). Understanding reasons for public values can aid the revision and adaption, or 'softening' (Kingdon, 2011), of policies to a form more likely to gain traction within policy communities.…”