Marlies Ahlert

Necessary and Sufficient Conditions to Make the Numbers Count

The article transfers an argument of Pattanaik and Xu on ranking opportunity sets to tragic choices and the so called “numbers problem”. We characterize conditions that make the numbers count. This in itself will not resolve any problem relevant to the ongoing ethical debate but should shed some fresh light on it by forcing participants to state specifically which of the assumptions (axioms) should give way for what reasons.

Thresholds, productivity, and context: an experimental study on determinants of distributive behaviour

In our questionnaire experiment we confronted students of economics, law and medicine with distributive situations in different contexts characterised by two features inspired by medical decision problems: First, individual threshold values indicate minimal amounts needed by potential recipients of the given resource to obtain positive benefits. Second, recipients differ with respect to their ability to benefit from the given quantity, which indicates the productivity of the resource. Allocations offered in the questionnaire are theoretically grounded. However, respondents were also able to make their own proposals. Well-known allocation rules, but also new procedures, were witnessed. Two multistage principles were most prominent: After distributing all minimal amounts, in a second step one aims for resource-equality while the other principle in the second step demands the maximisation of the sum of payoffs. Besides threshold values and productivity, the acceptance of different principles also depended on the field of study, the degree of scarcity of the resources and the sequential order of situations.

Common sense in organ allocation

Abstract In a questionnaire study on organ allocation 348 students of medicine (102) and economics (246) at the universities of Halle (114 students) and Hannover (234 students) responded to questions concerning their basic attitudes toward alternative criteria of organ allocation. Medical criteria were widely accepted by the respondents. Considerations concerning the patients value to society were seen as being of minor importance. With respect to reciprocity, we could detect a high share of respondents who would favor former living donors and discriminate against murderers. Among considerations of fairness, the criterion of waiting time gained the highest support. Furthermore, majorities favored the view that health-compromising behavior and differences in age should play a role. Economic considerations were strongly rejected as criteria of organ allocation.

How you ask is what you get: Framing effects in willingness-to-pay for a QALY.

In decisions on financing new and innovative health care technologies a central question is how to determine the value citizens place on the gains in health and life expectancy that result from respective medical treatments. We report results of surveys of four representative samples of the German population. In 2010 and 2012, in total about 5000 respondents were asked for their willingness-to-pay (WTP) for either an extension of their life or an improvement in their health corresponding to a gain of one quality-adjusted life year (QALY). Specific changes of the study design allow for ceteris paribus comparisons of different survey versions. While the initial version exactly copied a questionnaire used in the EuroVaQ (European Value of a QALY) project, which was conducted in nine European countries and Palestine, but not in Germany, in other versions the wording and the survey technique were modified. The findings show that the technique of posing the questions plays an important role when respondents are asked to imagine being in hypothetical situations. This clearly refers to the wording of the questions and the survey setting (personal or online interview). But even simple design elements such as putting a yes/no filter in front greatly affect the answers in terms of both the frequency of zero WTP and the distribution of positive amounts. From the different results, we conclude that it is inevitable to conduct studies comprising a broad variety of versions when trying to elicit WTP for a specific type of QALY in order to achieve an array of values combined by insights into the principles of their sensitivity.

Kidney Allocation in Eurotransplant

Abstract In the Eurotransplant region transplantable kidneys from cadaveric donors are allocated according to the Wujciak-Opelz algorithm. This paper shows that the algorithm as it stands fulfils certain normative standards of a more formal nature while violating others. In view of these insights, it is explored how the algorithm could perhaps be improved. Even if issues of substantial rather than formal adequacy need to be addressed separately, analyses as presented in this paper can prepare the ground for a discussion of substantive normative issues. In any event, axiomatic accounts can tell us something about what we are in fact doing when using a procedure like the Wujciak-Opelz algorithm.

An Experimental Analysis of Equal Punishment Games

In equal punishment games first the proposer suggests how to split the pie, i.e. a positive monetary reward. Unlike in the ultimatum game, the responder can decide among many (for proposer and responder) equal penalty payments. To exclude negative payoffs, punishment was bounded from above depending on the proposal and the (for proposer and responder) same show up-fee, our only treatment variable. Although inequality aversion (Bolton and Oekenfels, 1999, and Fehr and Schmidt, 1999) predicts zero-punishments, we observe positive punishments which, however, became smaller in the repetition. Initial fairness is often substituted in the repetition by extreme greed. Whereas greed is sticky, fairness is more characteristic for initial inclinations and not a stable behavioral pattern.

How You Ask is What You Get: Willingness-to-Pay for a QALY in Germany

We report results of a survey of a representative sample of the German population in which respondents were asked in various scenarios for their willingness-to-pay (WTP) for a gain of one quality-adjusted life year. While one version of the survey exactly copied the setting (online survey) and the questionnaire used in the EuroVaQ project, in the second version the hypothetical nature of the questions was emphasized more strongly, and the survey was conducted as a computer-assisted personal interview. The results show that the average and median WTP responses differed between scenarios but, overall, became considerably larger in the second version.

Unverrechenbare Werte, verrechnende Prioritäten

Die im vorliegenden Sammelband angesprochenen allgemeinen Aspekte der Priorisierung medizinischer Leistungen wie „Nutzen bzw. Wirksamkeit“, „Kosten-Nutzen-Relation“, „Dringlichkeit“, „Erfolgsaussicht“, „Eigenverantwortung bzw. Selbstverschulden“, „Alter der Patienten“ etc. sind sehr heterogen.1 Diese Vielfalt steht einer einheitlichen theoretischen Begrundung von Prioritatssetzungen im Wege. Zwar kann man sich womoglich uber Disziplingrenzen hinweg auf die Relevanz von Bewertungsdimensionen einigen. Damit aber vollstandige Rangordnungen unter Alternativen – etwa wie beim Zehnkampf nach einem Punkteverfahren – erzeugt werden konnen, musste man sich auf Mase der Einzeldimensionen und auf deren relatives Gewicht einigen. Fur diese Wertentscheidung fehlt es an wissenschaftlichen Masstaben. Die Schwierigkeit der (theoriegeleiteten) Bewertung hindert uns zwar nicht daran, in der Praxis erfolgreich und durchaus mit einer gewissen BereichsSystematik Prioritaten zu setzen. Der einzelne Arzt entscheidet, welchem von zwei Patienten er sich zunachst zuwendet, die Notfallmedizin kennt Verfahren der „Triage“, um die Behandlung von Patienten nach Diagnose und Erfolgsaussicht in Dringlichkeitsklassen einzuteilen, die Gerichte fallen Urteile, in denen bestimmte Gesundheitsleistungen posteriorisiert werden, die Politik entscheidet sich, eine Herzklinik und keine Brandklinik zu bauen usw. Die Fahigkeit, in der Praxis Priorisierungen medizinischer Leistungen auch ohne systematische, theoriegeleitete Begrundungen vorzunehmen, entbindet uns nicht davon, in einer so wichtigen Frage nach Moglichkeiten einer Systematisierung unserer Bewertungen und Abwagungen zu suchen. Das Ideal intersubjektiv zuganglicher, rationaler und wissenschaftsbasierter Problembehandlung verlangt, so weit wie moglich allgemeine („standardisierte“) Verfahren der Problembehandlung zu entwickeln und anzuwenden. Dem Zweck, solche Moglichkeiten exemplarisch unter Ruckgriff auf die Wunsche, Interessen und Uberzeugungen verschiedener Stakeholder-Gruppen zu untersuchen, dient die Forschergruppe FOR 655 insgesamt. Der vorliegende Beitrag setzt sich zum Ziel, solche Bemuhungen in ein im weiteren Sinne wohlfahrtstheoretisches entscheidungslogisches Rahmenwerk so einzuordnen, dass eine Orientierung uber Disziplingrenzen hinweg erleichtert

Problems of priority change in kidney allocation and beyond

Standardized and transparent priority setting in medicine, desirable as it is, will generally exacerbate inter-temporal equity problems arising from changes in treatment priorities: when can it be fair that the treatment of already waiting patients who would have had priority under an established system should be postponed (withheld) for an extended period of time to advance the treatment of others under a reformed system? The reform of the Eurotransplant system of priority setting in kidney allocation (ETKAS), which is in many respects ideal, is a case in point. To give due weight to new medical knowledge, waiting time after the onset of end state renal failure should change from a priority-enhancing to a priority-reducing factor. Since those who have gained in priority by waiting under the present system would be set back under the new, severe problems of transitional justice must be overcome when responding to advances in medical knowledge. The paper explores conceptually some possible ways of rule change and indicates their general relevance from an ethical and a practical point of view for future problems of medical resource allocation under transparent, standardized priority-setting rules.

Aspiration Balancing Agreements: A New Axiomatic Approach to Bounded Rationality in Negotiations

Abstract A wealth of experimental findings on how real actors do in fact bargain exists. However, as long as there is no systematic general account of the several experiments bargaining theory remains dominated by axiomatic approaches based on normative requirements or on assumptions of full rather than bounded rationality. Contrary to that, the new axiomatic account of aspiration level balancing in negotiations of boundedly rational actors presented in this paper incorporates experimental findings systematically into economic bargaining theory. It thereby forms a descriptive theory of bargaining that has normative power as well.