The Art of Saying No

191 Pages·2011·0.96 MB·English

Linköping University Medical Dissertation No. 1215

The Art of Saying No
The Economics and Ethics of Healthcare Rationing

Gustav Tinghög

Department of Medical and Health Sciences
Linköping University, Sweden

Linköping 2011
Edition 1:1
ISBN 978-91-7393-282-0
ISSN 0345-0082

(cid:2) Gustav Tinghög, 2011
Published articles have been reprinted with the permission of the copyright
holder.

Cover artwork and design: Marit Furn
Webpage: www.maritfurn.se

Printed in Sweden by LiU-Tryck, Linköping, Sweden, 2011
To the Tinghögs

I’m gonna run to you – Bryan Adams

Contents
CONTENTS

ABSTRACT .................................................................................................................. 4
LIST OF PAPERS ........................................................................................................ 5
ABBREVIATIONS ...................................................................................................... 7
INTRODUCTION ....................................................................................................... 9
Thesis Aim ........................................................................................................... 10
A Short Note on Disposition ........................................................................... 11
METHODOLOGICAL CONSIDERATIONS AND SPECIFICATION OF
THE AIM .................................................................................................................... 13
A Population-Level View on Efficiency and Fairness ................................ 13
Economics and Ethics ........................................................................................ 14
Normative Economics and Positive Economics ....................................... 14
Normative Ethics and Meta-Ethics ............................................................ 16
Reasonable Disagreement ................................................................................ 16
Moral Intuition and Moral Reasoning ....................................................... 18
BACKGROUND........................................................................................................ 21
What is Healthcare Rationing? ........................................................................ 21
What is Healthcare Need? ................................................................................ 24
Explicit Healthcare Rationing in Practice ..................................................... 27
The Case of Oregon ...................................................................................... 27
The Case of Sweden ...................................................................................... 31
THEORETICAL CONTEXT .................................................................................... 37
Economics ............................................................................................................ 37
Welfare Economics ....................................................................................... 37
Utilitarianism ................................................................................................. 39
Cost-Effectiveness Analysis and Quality Adjusted Life Years .............. 42
Contents
Ethics..................................................................................................................... 47
Distributive Fairness and Healthcare Rationing ...................................... 48
Fair Equality-of-Opportunity and Healthcare Rationing ....................... 51
Procedural Fairness and Healthcare Rationing ........................................ 52
MAIN FINDINGS AND DISCUSSION – A WELFARE ECONOMIC
PERSPECTIVE ON HEALTHCARE RATIONING ........................................... 55
Paper I: “Individual Responsibility for What? – A Conceptual
Framework for in a Publicly Funded Healthcare System” ..................... 55
Paper II: “Discounting, Preferences, and Paternalism in Cost-
Effectiveness Analysis” ................................................................................ 57
Paper III: “Incentivizing Deceased Organ Donation: A Swedish
Priority-Setting Perspective” ....................................................................... 60
Paper IV: “Horizontal Inequality in Rationing By Waiting Lists” ........ 62
EXTENDED DISCUSSION – A POPULATION-LEVEL ETHICAL
PERSPECTIVE ON HEALTHCARE RATIONING ........................................... 67
Individual Responsibility – A Prospective Approach ............................. 67
Paternalism – Why Health is not Always Good ...................................... 70
Incentives – Persuasion or Coercion? ........................................................ 73
Inequality – When are Inequalities Unfair? .............................................. 75
FINAL REMARKS .................................................................................................... 79
ACKNOWLEDGEMENTS ...................................................................................... 83
REFERENCES ............................................................................................................ 85

PAPER I - IV ............................................................................................................... 93
Abstract
ABSTRACT
It follows from resource scarcity that some form of healthcare rationing is
unavoidable. This implies that potentially beneficial medical treatments must
be denied to patients to avoid unacceptable sacrifices in other areas of society.
By focusing on four, core, conceptual themes – individual responsibility,
paternalism, incentives, and inequality – this thesis explores the matter of
finding justifiable grounds for saying no in the context of health care.

By combining the perspectives of welfare economics and population-level
ethics, the author explicate and discusses conflicting moral values involved in
healthcare rationing. Four papers form the foundation for this thesis. Paper I
articulates the potential role of individual responsibility as a welfare-
promoting, rationing tool by exploring when healthcare services exhibit
characteristics that facilitate individual responsibility for private financing.
Paper II explores the normative relevance of individuals’ time preferences in
healthcare rationing and when paternalism can be justified in the context of
individuals’ intertemporal health choices. Paper III examines the compatibility
between incentive-based organ donation and the ethical platform for setting
priorities in Sweden. Paper IV empirically investigates the existence of
horizontal inequalities in using waiting lists to ration care.

From the discussion it is suggested, inter alia, that: I) Prospective responsibility
as opposed to retrospective responsibility is a more productive notion of
responsibility when discussing actual policies. However, potential positive
effects need to be weighed against the increased economic inequality that it is
likely to invoke. II) Although cost-effectiveness analysis provides valuable
input when making rationing decisions it should not be viewed as a decision
rule, since it is based on utilitarian values that constantly need to be balanced
against other nonutilitarian values. III) Potentially, increased health could
negatively affect individuals’ well-being if it creates opportunities that they
are unable to take advantage of. This needs to be taken into account before
embarking on paternalistic policies to improve health – policies that often
target the lower socioeconomic segment.

The author concludes that decisions on rationing cannot be computed through
a simple formula. Moreover, given that rationing is bound to be associated
3
Abstract
with reasonable disagreements we are unlikely to ever fully resolve these
disagreements. However, by explicitly stating conflicting moral values we are
more likely to narrow the disagreements and achieve a healthcare system that
is both fairer and more efficient.

4
List of papers
LIST OF PAPERS

I. Gustav Tinghög, Carl Hampus Lyttkens and Per Carlsson.
Individual Responsibility for What? – A Conceptual Framework for
Exploring the Suitability of Private Financing in a Publicly Funded
Health-Care System. Health Economics Policy and Law (2010) vol. 5: 201-
223

II. Gustav Tinghög.
Discounting, Preferences, and Paternalism in Cost-Effectiveness
Analysis. Submitted

III. Faisal Omar, Gustav Tinghög and Stellan Wellin.
Incentivizing Deceased Organ Donation: a Swedish Priority Setting
Perspective. Scandinavian Journal of Public Health (in press)

IV. Gustav Tinghög, David Andersson, Petter Tinghög, Carl Hampus
Lyttkens.
Horizontal Inequality when Rationing by Waiting Lists. Submitted

5
List of papers

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