Why do we care about opportunity costs?

Ethics…

Philosophically..• concerned with the evaluation of human conduct.

– Normative ethics, the development of theories that systematically denominate right and wrong actions;

– Applied ethics, the use of these theories to form judgments regarding practical cases (Kemerling 1997)

As Practice..• thoughtful, careful, systematic process of examining the beliefs

(facts) and values that underpin our attitudes, decisions and actions (Jiwani 2011)

• using the examination to get somewhere…

• We trade off on things that are important to allof us

• Resource allocation is fundamentally a moral task..

Why do we care about opportunity cost?

How policy decisions are made..

• Beyond considerations of health outcomes (QALYs), social values matter too (Shah et al. 2012)

– System responsiveness

–Patient experience and satisfaction

–Public trust and confidence

– Equity and fairness

Accounting for what else matters..

Ethics as Process – Based on understanding:

Key Question: The decision at hand

Facts: what we know to be true about the world

Values: what matters

Options: possible ways forward

Decision: the option that delivers what matters the most, all things considered

• Step 1.Establish the Team• Step 2. Select the Key

Question(s)• Step 3. Look at the

Evidence• Step 4. Consider What’s

Important• Step 4.b Synthesize

Values (optional)• Step 5.Brainstorm

Options• Step 6. Analyze Options• Step 7. The Preliminary

Decision

• Step 8. Engagement• Step 9. The Decision• Step 10.Communication

Strategy• Step 11. Education Plan• Step 12. Downstream

Support Plan• Step 13. Evaluation &

Sustainability Plan• Step 14.Ongoing

Feedback Plan• Step 15. Implement the

Decision

The Full Process…

Values, Two Ways

Process

How we arrive at a decision

Transparency

Inclusiveness

Recursiveness

Participation

Accountability

ContentCriteria for Decision-making

Clinical effectiveness

Cost effectiveness

Justice/Equality

Autonomy

Options/Alternatives

• Requires a reasonable brainstorming of possible alternates/options

• Options determined by good facts

• Good ethics work requires good facts –we understand the facts of the trade-offs as much as possible.

In Sum..

• Resource allocation is a moral project

• Values underlie content and process

• Values are understood and incorporated through respectful engagement

• Systematic decision making requires knowledge of alternatives

References

• Clark, S., Weale, A. 2012. Social values in health priority setting: a conceptual framework, Journal of Health Organization and Management 26(3): 293-316

• Kemerling, G. 1997. Philosophy Pages. www.philosophypages.com• Jiwani, B. 2011. Good Decision – A map to the best system-level

decision, all things considered. www.incorporatingethics.ca• Shah, K., Praet, C., Devlin, N., Sussex, J., Appleby, J., Parking, D.

2012. Is the aim of the English health care system to maximize QALYs? Journal of Health Services Research and Policy; 17(3): 157-163

• Soares, M.O. 2012. Is the QALY blind, deaf, and dumb to equity? NICE’s considerations over equity, British Medical Bulletin; 101: 17-31

A side point about quantifiability..

- Not all values are unquantifiable (e.g. if one of our values it to stay on budget)

Where are values are quantifiable we use scientific measures.

Where values are less quantifiable (value to maximize independence; promote respect) we use PROCESS

Thinking about ethics in this way…

We move away from thinking of ethics as a substantive and separate category…

..towards thinking about whether our decisions, whatever they may be, are ethically justified.

A decision is ethically justified if:o It is based on values we have good reason to cherisho It is based on beliefs we have good reason to think

are trueo We have made the justification for acting on these

values and beliefs clear and explicit

The health economists decide to bring a philosopher along….

Within QALY-based approaches

• Threshold method is abstract – does not spell out alternatives

• Threshold is intended as a guide – further analysis required

• Variations in monetizing QALYs(Shah et al 2012)

• Wanted: Methods to unpack and consider values dimensions within OC and more broadly

Key Question

• Ought we to implement technology A?

• Of these three technologies, which should be implement?

Facts

• Knowledge of alternatives/opportunity costs is relevant