Philosophical Approaches to Health Care Priority Setting: Moral Obligations, Practical Realities

Dissertation, University of Toronto (Canada) (2002)

Health care priority setting is a reality in any health system. Because demand for health care exceeds available resources, decision makers must make tough and often tragic choices about how scarce resources will be allocated to meet varied health care needs. The "core question" of my thesis is: What guidance can various philosophical approaches offer to decision makers in institutional contexts to assist them in making priority setting decisions that are just? ;Using a bioethics methodology, which seeks to develop empirically relevant bioethical theory to guide practice, I draw on the resources of philosophical bioethics and some lessons from experience of priority setting in three health institutions to develop a more robust ethical framework for health care priority setting. ;I look at the "core question" through a number of philosophical lenses: traditional bioethics appeals to substantive moral principles, Norman Daniels and James Sabin's deliberative model of legitimate and fair priority setting , theories of democratic inclusion, and feminist ethics. I argue that each of these approaches makes a necessary but not sufficient contribution to answering the "core question" and that a composite of these approaches will provide more adequate guidance to decision makers. ;To summarize the main argument of my thesis: Justice in health care priority setting requires substantive moral and empirical criteria, but a lack of consensus on such criteria leads us to search for a fair deliberative process that provides conditions for reaching reasonable consensus on priority setting outcomes. This must be an inclusive democratic process that supports stakeholder participation in determining how to set health care priorities. Moreover, justice in health care priority setting must ultimately address the problem of institutional forms of power, which can distort the priority setting process in unreasonable and exclusionary ways, leading to unjust outcomes. ;I conclude that if substantive middle-level moral principles and empirically-based criteria were incorporated into a fair deliberative process of legitimate priority setting under conditions of democratic inclusiveness and domination-free institutional arrangements, then decision makers would be in a better position to set priorities in justice-promoting ways than by appeal to any one philosophical approach alone.
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