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Ethics,equity and economics


maximise social well-being based on (consequentialist) utilitarianism ... Distributive justice - 'political' or 'social' philosophy - concerned with outcome ... – PowerPoint PPT presentation

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Title: Ethics,equity and economics

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

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

Categorising ethical theories (1)
  • Distributive justice - political or social
    philosophy - concerned with outcome
  • Procedural justice - moral philosophy -
    concerned with process used in achieving the

Categorising ethical theories (2)
  • Political philosophy - societal focus e.g. Rawls
  • Moral philosophy - individual focus e.g Kantian
  • Interaction e.g. utilitarianism - social utility
    maximised by each individual maximising own

Categorising ethical theories (3)
Ethical theories
  • Utilitarianism
  • Rawlsian
  • Entitlement/libertarian
  • Egalitarian
  • Deontological?
  • Virtue
  • Rights

  • Jeremy Bentham (classic) and John Stuart Mill
  • Maximising greatest utility for greatest
  • Underlies efficiency
  • Issues - domain (whose utility)
  • - malevolence (utility from suffering)

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

  • 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

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

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

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

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

Medical vs. economic ethic (1)
  • Medical - individual (deontological) ethic
  • - Hippocratic oath, Nightingale Pledge
  • - Agency and professional codes
  • - best interests of patient
  • - opportunity cost ignored (?)

Medical vs. economic ethic (2)
  • Economic - population based ethic
  • - principally utilitarian
  • - based on opportunity cost
  • Overlap of considerations in both professions

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

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.

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.

Tavistock Group - BMJ, Jan 23, 1999
  • Prepare shared code based on consistent moral
  • - healthcare is a human right…provide
    access…regardless 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

Why equity? (1)
  • Health fundamental commodity (Sen) necessary
    for enjoyment of all else
  • Health care important determinant, but often
  • Insurance imperfect/expensive
  • Thus...

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?

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
  • Tobin 1970

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
  • However, equity usually synonymous with equality
    of something.

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.

Ethics and equity
  • Mostly horizontal equity in distribution of
  • Based on broad egalitarian ethic, but
    compatible with most others
  • Basis equal distribution of x (according to
  • Issues - what are x and y to be?

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)

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

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

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

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

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

Equity and the NHS (1)
  • To provide the people of Great Britain, no
    matter where they may be, with the same level of
  • (Bevan 1948)

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
  • (Merrson 1979)
  • Report of the Royal Commission of the NHS

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

Measuring equity
  • Finance - Kakwai Index
  • - Suits Index
  • Health - Gini coeff - see McGuire p.59
  • Data - see Folland, Goodman Stano book
  • - see Donaldson Gerard

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

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?

Social welfare function
2 W
1 W
0 W
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
  • - constraint on utility maximisation (c.f.
  • constraint)

Utilitarianism encompasses all (2)
  • Participation altruism - utility gained from
    participation in social/collective acts
    regardless of utility from consumption which
  • Outcome altruism - utility gained from utility
    derived by others in consuming what is
    charitably provided

Utilitarianism encompasses all! (3)
  • Generates possibility of 2, interdependent,
    utility functions for individual - as citizen and
  • Diminishing marginal utility, and possibility of
    free riding, creates rationale for coercion
    in achieving citizen objectives

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)