Norman Daniels

Health Care Needs and Distributive Justice

A theory of health care needs should serve two central purposes. First, it should illuminate the sense in which we—at least many of us—think health care is “special” and that it should be treated differently from other social goods. Specifically, even in societies in which poeple tolerate (and glorify) significant and pervasive inequalities in the distribution of most social goods, many feel there are special reasons of justice for distributing health care more equally. Some societies even have institutions for doing so. To be sure, others argue it is perverse to single out health care in this way, or that if we have reasons for doing so, they are rooted in charity, not justice. In any case, a theory of health care needs should show their connection to other central notions in an acceptable theory of justice. It should help us see what kind of social good health care is by properly relating it to social goods whose importance is similar and for which we may have a clearer grasp of appropriate distributive principles.

Normal Functioning and the Treatment-Enhancement Distinction

The treatment-enhancement distinction draws a line between services or interventions meant to prevent or cure (or otherwise ameliorate) conditions that we view as diseases or disabilities and interventions that improve a condition that we view as a normal function or feature of members of our species. The line drawn here is widely appealed to in medical practice and medical insurance contexts, as well as in our everyday thinking about the medical services we do and should assist people in obtaining.

QALYs: Some Challenges

In the preceding article, Weinstein et al. [1] explain the QALYconcept, its methods, and their underlying assumptions. Anumber of interesting themes for discussion arise from thisfactual presentation. We restrict ourselves to addressing fourissues that we deem particularly challenging.As a general background for our selection of issues, we reit-erate a basic point about valuation perspectives: StandardQALYs are meant to express the personal utility of health out-comes as judged ex ante and “on average” by the general publicfrom behind a veil of ignorance about future health (so-called“decision utility”). Standard QALYs thus express value in termsof ex ante self-interest. There are, however, possible alternatives.First, health state utilities may in principle be elicited ex postrather than ex ante, i.e., from people who have or have had directexperience with the health states that are the object of the valu-ation (so-called “experienced utility”). Second, QALYs may beconstructed to express society’s valuation of health outcomeswhen not only self-interest but also concerns for fairness aretaken into account. The choice of approach depends on thequestion one wishes to answer, and the choice of health statevaluation techniques depends on the choice of perspective.The issues we address in the following reflect the aboveplurality in possible valuation perspectives and are in part inde-pendent of each other. One issue is intermethod variation in theestimation of ex ante health state utilities. A second is the exist-ence of unwillingness to trade lifetime in elicitations of experi-enced utility. A third is the discrepancy between aggregateindividual utility of health programs on the one hand and, on theother hand, societal valuations that include concerns for fairness.A fourth is a hitherto much overlooked distinction betweenhealthy individuals’ valuations of states of illness (which

Accountability for reasonableness: an update

Twelve years ago (BMJ 1996;312:1553-4) the BMJ argued that health systems needed to be explicit about rationing and published articles describing different ways of rationing fairly. Here a clinician (doi:10.1136/bmj.a1846), two ethicists, and four health economists (doi:10.1136/bmj.a1872) discuss how their ideas have developed—and been put into practice—since then

Determining “Medical Necessity” in Mental Health Practice

Should mental health insurance cover only disorders found in DSM-IV, or should it be extended to treatment for ordinary shyness, unhappiness, and other responses to lifes hard knocks?

Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria.The guidance was develop through a series of expert consultation meetings and involved three steps: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders.The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).

Duty to Treat or Right to Refuse

By entering the medical profession, physicians have consented to accept a standard level of risk of infection. In most instances, the risk of contracting HIV does not exceed this level.

Process is the point: justice and human rights: priority setting and fair deliberative process.

Most people responsible for setting priorities in health have considerable expertise relevant to deciding how to use resources effectively and the kinds of improvements that should be emphasized. Most are also concerned with distributing improvements equitably. Accordingly, they often invoke human rights or principles of distributive justice to legitimize choices that create winners and losers. We propose an approach that draws on the strengths of both perspectives as a way to add legitimacy to efforts to set priorities in health. Our proposal provides a process for setting priorities but is not a formula or an algorithm for generating particular priorities. We propose an approach that would do away with the process through which priorities are set and decisions made, and suggest the value of a focus on the process of legitimizing these decisions.

Fair process in patient selection for antiretroviral treatment in WHO's goal of 3 by 5

How can we assure fair treatment in selecting HIV/AIDS patients for antiretroviral treatment? Who should be selected and how? I set aside older ethical and policy controversies about prevention versus treatment and address instead the urgent issue created by the WHO goal of treating 3 million by 2005. By WHO criteria the goal means selection of only 3 of the 6 million people who would benefit. How should we pick the lucky 3 million assuming countries develop or scale up their capacity to deliver antiretroviral treatments and patient demand for them is great? Unfortunately we lack agreement on ethical principles that can resolve key policy decisions involved in scaling up treatments including those relating to cost recovery patient eligibility siting of treatment centres and giving priority to special groups. As a result equality in outcomes can only be established through a fair deliberative process that is transparent encourages relevant stakeholders to deliberate on relevant reasons provides room for revising decisions and enforces adherence to the process. Of course basic human rights considerations such as universal access and prohibition on discrimination act as necessary constraints on these processes and outcomes. (excerpt)

Exploring the Relationship Between Absolute and Relative Position and Late-Life Depression: Evidence From 10 European Countries

PURPOSE Socioeconomic inequality has been associated with higher levels of morbidity and mortality. This study explores the role of absolute and relative deprivation in predicting late-life depression on both individual and country levels. DESIGN AND METHODS Country- and individual-level inequality indicators were used in multivariate logistic regression and in relative indexes of inequality. Data obtained from the Survey of Health, Ageing and Retirement in Europe (SHARE, Wave 1, Release 2) included 22,777 men and women (aged 50-104 years) from 10 European countries. Late-life depression was measured using the EURO-D scale and corresponding clinical cut point. Absolute deprivation was measured using gross domestic product and median household income at the country level and socioeconomic status at the individual level. Relative deprivation was measured by Gini coefficients at the country level and educational attainment at the individual level. RESULTS Rates of depression ranged from 18.10% in Denmark to 36.84% in Spain reflecting a clear north-south gradient. Measures of absolute and relative deprivation were significant in predicting depression at both country and individual levels. Findings suggest that the adverse impact of societal inequality cannot be overcome by increased individual-level or country-level income. Increases in individual-level income did not mitigate the effect of country-level relative deprivation. IMPLICATIONS Mental health disparities persist throughout later life whereby persons exposed to higher levels of country-level inequality suffer greater morbidity compared with those in countries with less inequality. Cross-national variation in the relationship between inequality and depression illuminates the need for further research.