Dr Shahram Yazdani Ethical Basis of Health Policies

Dr. Shahram Yazdani Ethical Basis of Health Policies Dr. Shahram Yazdani

Dr. Shahram Yazdani Relations between functions and objectives of a health system Functions the system performs Stewardship (oversight) Creating resources (investment And training) Financing (collecting, pooling And purchasing) Objectives of the system Responsiveness (to non-medical expectations) Delivering services (provision) Health Protection from Financial Risks

Dr. Shahram Yazdani Policy 1 Health Status Responsiveness Protection from Financial Risks

Dr. Shahram Yazdani Policy 2 Health Status Responsiveness Protection from Financial Risks

Dr. Shahram Yazdani Policy 3 Health Status Responsiveness Protection from Financial Risks

Dr. Shahram Yazdani § Judging health sector performance requires ethical analysis. § Three major ethical perspectives as a basis for making such judgments: • Utilitarianism • Liberalism • Communitarianism

Dr. Shahram Yazdani § Utilitarianism evaluates consequences by examining the effects of a decision on the sum total of individual wellbeing in a society. This perspective motivates many health reform efforts around the world.

Dr. Shahram Yazdani § Liberalism focuses on rights and opportunities, on where people start, not on where they end up. This view also has an important role in health sector reform debates. The frequent claim that citizens have rights to health care—or even to health itself—reflects liberal concerns.

Dr. Shahram Yazdani § Communitarianism states that what matters is the kind of society that public policy helps create and the kind of individuals who live in it. In this view, communities have an obligation to raise their members to share the community’s notions of virtue and good behavior. Communitarianism can conflict with both consequence-based and rightsbased thinking, since inculcating virtue can involve actions that do not maximize wellbeing or that constrain individual liberty

Dr. Shahram Yazdani Utilitarianism Ethical Theory

Dr. Shahram Yazdani Utilitarianism Ethical Theory § The most widespread approach to the problem of making ethical judgments about the performance of the health sector is based on consequences. § This approach generally assumes that “the end justifies the means. ” § It says we should judge a policy by asking how it affects the individuals in a society and pick the option that most improves the sum total of their well-being.

Dr. Shahram Yazdani Utilitarianism Ethical Theory § To be helpful in making decisions about health reform, several more specific questions need to be answered: • Whose well-being counts, and for how much? • How can well-being be measured in a practical way for the purpose of health reform? § There are two major intellectual traditions about how to answer these questions: • Subjective utilitarianism • Objective utilitarianism

Dr. Shahram Yazdani Subjective Utilitarianism § The first position derives from the work of the nineteenth-century English philosopher, Jeremy Bentham, who believed that individuals could best judge for themselves what makes them happy. § He argued that people experience different levels of utility in various situations, depending on their particular tastes and preferences.

Dr. Shahram Yazdani Subjective Utilitarianism § By “utility” he meant the internal feelings of happiness people had, and his doctrine came to be known as utilitarianism. § He proposed that the rightness of an action is determined by the “hedonic calculus” of adding up the pleasure and pain it produces. § The right action is the one that produces “the greatest happiness of the greatest number” (Bentham 1789).

Dr. Shahram Yazdani Subjective Utilitarianism § Bentham argued that all tastes are equally valid. § This viewpoint decentralizes evaluation, since all individuals judge their own happiness for themselves. § Judging a policy requires us to add up everyone’s utility level for each policy option and then choose the policy that leads to the most happiness or utility.

Dr. Shahram Yazdani Subjective Utilitarianism § Subjective utilitarianism has been very influential in debates about health reform. § Policymakers are often urged (especially by economists) to use markets to allocate health care. § The basic idea behind subjective utilitarians’ enthusiasm for markets is that when markets work well, consumers only buy those goods and services for which their willingness to pay exceeds the costs of production. § Such recommendations are based on economic models in which consumers have complete knowledge and markets are perfectly competitive.

Dr. Shahram Yazdani Subjective Utilitarianism § Unfortunately, most real health-care markets are far from satisfying the preconditions for perfect competition and hence far from Pareto Optimal. • Patients typically rely on doctors to tell them what care they should receive. For example, doctors paid fee-for-service have every reason to encourage unnecessary or inappropriate care • Buyers also have great difficulty in judging the clinical quality of the services they receive. • Health market can suffer from monopoly power § Health-care markets are often characterized by what economists call “market failure. ” § For these reasons, health-care markets are often heavily regulated to counteract these deficiencies.

Dr. Shahram Yazdani Subjective Utilitarianism § The enthusiasm for markets in health care also ignores important equity issues. § In a market, each person’s consumption is based on the individual’s income. § This means that the poor get less, often very much less than the rich.

ty Eq ui Responsiveness Dr. Shahram Yazdani Subjective Utilitarianism Health

Dr. Shahram Yazdani Objective Utilitarianism § Reformers who want to promote individual wellbeing, but are skeptical of the reliability and validity of individual choices, argue for basing decisions on individual well-being defined in objective terms by a group of experts. § These experts develop an index that embodies the “rationally knowable” components of wellbeing, and that index is then used to evaluate everyone’s circumstances. This position is known as objective utilitarianism

Dr. Shahram Yazdani Objective Utilitarianism History § In the 19 th century, Florence Nightingale showed that it was less costly for the British Army to care for the wounded than to let them die and then train new recruits. § There were various attempts to construct health status indices both before and after World War II. § Objective utilitarian approaches have also been widely employed in clinical research, where measures of “quality of life” have been developed to evaluate the results of alternative treatments § It is also the philosophical position behind the analysis of disease burdens through such measures as DALYs or QALYs, as conducted by the World Bank (1993) and the WHO (2000).

Dr. Shahram Yazdani Objective Utilitarianism History § In the broader world of policy analysis, objective utilitarianism provides the basis for cost-effectiveness analysis. This approach has been widely used beyond the health sector, under various labels. § During World War II, British mathematicians used such methods to calculate the best way to conduct military operations giving rise to the term operations research. § In the 1950 s, similar techniques were applied at the Rand Corporation in the U. S. to evaluate the comparative efficiency of different weapons systems, in what came to be called systems analysis

Dr. Shahram Yazdani Objective Utilitarianism § One example of this approach was the Oregon Health Plan in the United States. § In 1994, that state conducted a study to rank all medical treatments covered by the Medicaid program in terms of QALYs produced per dollar spent, and then proposed to restrict coverage to only the most cost-effective interventions § The plan was later drastically modified, because of public dissatisfaction with the results of the analysis, because it seemed to them to undervalue life-saving interventions

ty Eq ui Responsiveness Dr. Shahram Yazdani Health Objective Utilitarianism

Dr. Shahram Yazdani Liberalism Ethical Theory

Dr. Shahram Yazdani Liberalism § In the language of philosophy, utilitarians are willing to treat some individuals as means and others as ends—to sacrifice some for the sake of others. § But to many reformers, this attitude does not take the interests of those being sacrificed seriously enough. § Don’t those individuals have rights and aren’t they entitled to as much respect as those we wind up healing?

Dr. Shahram Yazdani Liberalism § The most influential philosopher associated with conceptions of individual respect and autonomy is the eighteenth century German philosopher Immanuel Kant. § According to Kant, all human beings have the capacity for moral action (Kant 1788), the power to know what is morally correct, and to decide whether to follow the dictates of morality. § Modern Kantians argue that since human beings have the capacity to develop and implement their own decisions about how to live—what philosophers call “life plans”—they have the right to do so. § This view, based on mutual respect, directly opposes utilitarianism’s willingness to treat some people as a means.

Dr. Shahram Yazdani Liberalism § The critical concept for liberals is rights— claims that all individuals can make on each other by virtue of their humanity. § The rights implied by the principle of mutual respect are interpreted by liberals in two different ways. 1. Libertarian Approach 2. Egalitarian Liberals Approach

Dr. Shahram Yazdani Libertarian Approach § Libertarians believe that only negative rights deserve protection. § These rights guarantee individual freedom, so that people can do what they want without state infringement on personal choice. § Extended to the political realm, this formulation leads to fundamental political and civil rights, like freedom of speech, assembly, and political participation. § Libertarians want the state to have only the limited role of protecting individual property rights and personal liberty. § They typically oppose restrictions on drug use, limits on abortion, or even the licensing of physicians, since these actions restrict individual freedom of choice.

Dr. Shahram Yazdani Egalitarian Liberals Approach § In contrast, egalitarian liberals argue that the right to choose is meaningless without adequate resources. § They argue that genuinely respecting others as moral actors requires us to provide them with the preconditions that make meaningful choice possible. § Therefore, everyone has a positive right to the minimum level of services and resources needed to assure fair equality of opportunity § Someone who is starving, homeless, uneducated and ill does not have much opportunity for meaningful choice. § The question is, what does the principle of mutual respect require that the state provide in order to ensure positive rights? In particular, is there a right to health care or to health itself?

Dr. Shahram Yazdani Egalitarian Liberals Approach § Positive-rights arguments generally lead to a redistributive perspective that favors people who are worst off from a lifetime perspective. § That is, the health care system should place priority on averting premature death and disability versus extending the life of the aged, who have already had the chance to develop and implement their life plans. § John Rawls (1971) called this perspective “justice as fairness. ”

Dr. Shahram Yazdani Egalitarian Liberals Approach § Egalitarian liberals disagree among themselves over exactly how positive rights should be addressed in the health care system. § Some assert that the best way to respect everyone’s moral capacity is to distribute income fairly, and let individuals buy the health care (or health insurance) they want (Dworkin 1993). § For these liberals, health is no different from other goods and services that people are free to purchase, like food and clothes. They believe there are no special rights to health or health care.

Dr. Shahram Yazdani § § Egalitarian Liberals Approach Other egalitarian liberals believe that society has a special obligation with regard to health (Daniels 1985). But here again there is division: 1. Some think that the key is providing a minimum level of health care for all, 2. Others think that the critical issue is individuals’ actual health status.

Dr. Shahram Yazdani Egalitarian Liberals Approach § Much ill health today depends on each individual’s own behavior. Smoking, diet, substance abuse, exercise and risktaking of various kinds all have significant health consequences. § To say that government is responsible for everyone’s health means that society is responsible for influencing individual choices about such matters. § On the other hand, if society is only responsible for providing services, and not for whether people use them, then individuals have much greater responsibility for their own health. § This perspective is consistent with Amartya Sen’s argument that society should be responsible for creating opportunities among which citizens can choose, not for the choices that individuals make (Sen 1999).

Dr. Shahram Yazdani Egalitarian Liberals Approach § Asserting a right to health still leaves many questions unanswered. § If individuals have a right to a minimum health status, what should the minimum level be? § Are there limits to society’s obligation to very ill people, who require high-cost services to improve their health status even a little? § After all, society’s resources are limited, and the money to provide for such care comes from other citizens, in ways that effectively diminish their opportunities. § Moreover, what care should people receive if their ill health results from their own behavior?

Dr. Shahram Yazdani Liberalism and Health Care Financing § In deciding how much to spend on health (or health care), a critical issue for liberals is the legitimacy of taxation. § For libertarians, the negative right to be left alone includes a right to enjoy one’s own property. § For them, therefore, taxation is theft. § They might consent to limited taxes to provide minimal state services like defense and police, but taxation that seeks to redistribute resources is fundamentally not legitimate, because it treats one person (the taxpayer) as the means to another’s end (the benefit recipient).

Dr. Shahram Yazdani Liberalism and Health Care Financing § Egalitarian liberals, on the other hand, approve of redistributive taxation in part because they believe that much of the existing distribution of wealth in society has arisen in ways that do not deserve to be respected. § Aristocrats acquired wealth through force and conquest. Fortunes were made through monopoly or fraud. Some individuals earn high incomes due to superior education or family contacts because they were lucky enough to be born into privileged social groups (social lottery) § The gains they produced can be legitimately taxed to help the poor. Property rights are not violated by taxing away these various illegitimate gains, because the gains themselves were not properly obtained.

ty Eq ui Responsiveness Dr. Shahram Yazdani Health Egalitarian

Dr. Shahram Yazdani Communitarianism Ethical Theory

Dr. Shahram Yazdani Communitarianism § § § This theory argues that the character of a community depends on the character of the individuals who comprise it. The state, therefore, should ensure that individuals develop good character and help produce a good society. There are two type of communitarianism: 1. Universal Communitarianism 2. Relativist Communitarianism

Dr. Shahram Yazdani Universal Communitarianism § Believes there is a single universal model for the good individual and the good society. § There are many examples, both secular and religious. § The world’s proselytizing, monotheistic religions (Islam and Christianity) are forms of universal communitarianism.

Dr. Shahram Yazdani Relativist Communitarianism § This perspective recognizes the wide variety of cultural practices in the world and the extent to which individuals are embedded in those cultures. § This form of relativist communitarianism emphasizes that each community should decide its own norms and mode of social organization. § These communitarians see morality as inherently contextual, lacking a universal place outside of society to judge particular cultural traditions.

Dr. Shahram Yazdani Relativist Communitarianism § Certain practices, like female genital cutting, pose the question of the acceptability of local community norms in an acute manner. § Some relativist communitarians support this practice, arguing that it should be respected by outsiders, because it has deep meaning for people who belong to the culture, and constitutes an integral part of their life. § Objective utilitarians oppose this practice on the grounds that it injures the health of women. § Liberals consider the practice objectionable, because it is imposed on girls early in their lives and limits their longterm life opportunities.

Dr. Shahram Yazdani Relativist Communitarianism § Those who believe that each community defines its own norms, must decide on the boundaries of each community, and on who speaks for the community. § Many ethnic and religious minorities have asserted the right to depart from the norms of the larger community and the right to create their own communities. § How should such disagreements be decided?

Dr. Shahram Yazdani Can we combines these viewpoints?

Dr. Shahram Yazdani Combining ethical theories § We can adapt Egalitarian viewpoint through fair financing of health system and assuring delivery of basic services through essential package of services. § We can adapt Objective Utilitarian viewpoint when choosing services for strategic purchasing. § We can adapt Subjective Utilitarian viewpoint by informing people about constraint of health system and involving them in the process of explicit rationing. § We can adapt Libertarian viewpoint when thinking about availability of healthcare services (through private funding, and out of pocket purchasing).

Responsiveness Dr. Shahram Yazdani Eq ui ty Health Combining Egalitarian and Objective Utilitarian Viewpoints Including most cost-effective interventions in essential package of service

Responsiveness Dr. Shahram Yazdani Eq ui ty Health Combining Egalitarian, Objective and Subjective Utilitarian Viewpoints Including most cost effective interventions in essential package of service that is negotiated and explicitly rationed by an constraint informed and health aware community

Dr. Shahram Yazdani Thank You ! Any Question ?