Ethics and resource allocation: an economist's view

This paper debates some of the issues involved in attempting to apply economic analysis to the health care sector when medical ethics plays such an important part in determining the allocation of resources in that sector. Two distinct ethical positions are highlighted as being fundamental to the understanding of resource allocation in this sector -- deontological and utilitarian theories of ethics. It is argued that medical ethics are often narrowly conceived in that there is a tendency for the individual, rather than society at large, to form the focal point of the production of the service "health care'. Thus medical ethics have been dominated by individualistic ethical coded which do not fully consider questions relating to resource allocation at a social level. It is further argued that the structure of the health care sector augments these "individualistic' ethics. It is also suggested that different actors in the health care sector address questions of resource allocation with respect to different time periods, and that this serves to further enhance the influence of "individualistic' ethical codes in this sector.     

Ethik versus Ökonomie in Public Health?

In the course of establishing the discourse of public health ethics in Germany, we discuss whether economic efficiency should be part of public health ethics and, if necessary, how efficiency should be conceptualized. Based on the welfare economics theory, we build a theoretical framework that demands an integration of economic rationality in public health ethics. Furthermore, we consider the possible implementation of welfare efficiency against the background of current practice in an economic evaluation of health care in Germany. The indifference of the welfare efficiency criterion with respect to distribution leads to the conclusion that efficiency must not be the only criteria of public health ethics. Therefore, an ethical approach of principles should be chosen for public health ethics. Possible conflicts between principles of such an approach are outlined.     

基于经济伦理学角度对我国卫生制度的考察与建议

该文从经济伦理学角度提出经济伦理学对卫生制度的指导原则,并通过剖析我国卫生制度公平与效率的困境与矛盾,具体提出加大政府对公共卫生的投入、卫生供给主体多元化、构建合理的卫生服务体系和保障体系、建立有效的医疗服务信息机制、提高政府对贫困人口和弱势群体的转移支付等五项建议,以改善卫生资源配置公平性并提高卫生服务效率和质量.     

Bioethics and health care technology assessment

The simultaneous existence of a biotechnoscientific paradigm (which emphasizes technological incorporation) and a culture of limits (which selects technologies) challenges current health systems, raising ethical and political discussions as to the choices to be made. Health care technology assessment is mainly concerned with the consequences of health care and health care policies. Thus, there is significant overlap between this activity and bioethics, even though they are different fields of knowledge. Although the importance of ethical and social issues arising in technology assessment has been recognized, most publications emphasize only methodological and scientific aspects. There are different interests involved in technological incorporation, and many value conflicts arise. Ethical implications include those related to clinical trials, medical care assessment, incorporation of technology, resource allocation, equity, and the effectiveness gap. Incorporating the ethical dimension into technology assessment will foster a better understanding of health care practice and progress in its improvement.     

Advanced training in biomedical ethics: a curriculum in clinical specialty programmes

Summary. Medical ethics play an essential role in the practice of medicine, in the care of individual patients, in the allocation of health care resources, and in the formulation of health care policy. A specific body of knowledge, ‘biomedical ethics’, has developed which applies ethical theory to biomedical practice. This has provided doctors with tools systematically to integrate rational ethical analysis into clinical decision-making. Training in the discipline of biomedical ethics is now required for all doctors in Canada. The goals, content areas, learning objectives, and learning methods considered appropriate for advanced training in this field for medical specialists are provided in this paper. Six topic areas are discussed: introduction to ethical theory, clinical ethics, professional ethics, ethics of human experimentation, ethics of health policy, and independent study. Ways this curriculum could be organized and evaluated are also offered.     

Women, men and public health-how the choice of normative theory affects resource allocation

Women live longer than men in almost all countries, but men are more privileged in terms of power, influence, resources and probably morbidity. This investigation aims at illustrating how the choice of normative framework affects judgements about the fairness in these sex differences, and about desired societal change. The selected theories are welfare economics, health sector extra-welfarism, justice as fairness and feminist justice. By means of five Swedish proposals aiming at improving the population's health or "sex equity", facts and values are applied to resource allocation. Although we do not claim a specific ethical foundation, it seems to us that the feminist criterion has great potential in public health policy. The overall conclusion is that the normative framework must be explicitly discussed and stated in issues of women's and men's health.     

Longevity bias in cost-effectiveness analysis

We use a simple lifetime utility maximization model to study the problem of medical resource allocation. This model leads to a welfare specification with a QALY (quality-adjusted life-year) component that captures an individual's preferences over both life expectancy and health status. The goal of medical cost-effectiveness analysis (CEA) is characterized as maximizing the QALY measure for a given total medical expenditure. We show that the CEA with such a goal has a longevity bias: the CEA-based division of a given total medical expenditure between extending life and improving health gives the former a larger share than is called for by welfare maximization.     

基于老年人心理健康指标选取的医学伦理体系构建

为从医学伦理角度对老年人的心理健康问题进行有效分析,研究提出一种基于老年人心理健康指标选取的医学伦理体系.通过对老年人智力水平、行为协调能力、人际关系适应性三个方向的判定,选取心理健康衡量指标.在此基础上,利用医学伦理内涵的分析结果,确定伦理指标的约束能力,并以此为标准完成基于老年人心理健康指标选取医学伦理体系的搭建....     

对经济学在医疗卫生领域应用的清算——从健康福利的视角谈起

经济学的逻辑目标是经济福利的最大化。而医疗卫生领域的的改革目标则是健康福利最大化，与经济福利并不是一回事。经济学的一系列概念和逻辑在医疗卫生改革领域的应用，都可能会产生对最终目标健康福利最大化的偏离．如果是这样，则经济学的分析就不利于改革向正确的方向前进．因此，必须对经济学的基本目标、主要概念及其分析逻辑在卫生改革中的应用进行清算。在分析经济学应用于卫生改革合理性的同时，提出医疗卫生领域一些特有的经济性质，并提出健康福利下对卫生改革分析的逻辑主线。     

A universal preference for equality in health? Reasons to reconsider properties of applied social welfare functions

The literature on how to combine efficiency and equity considerations in the social valuation of health allocations has borrowed extensively from applied welfare economics, including the literature on inequality measurement. By so doing, it has adopted normative assumptions that have been applied for evaluating the allocation of welfare (or income) rather than the allocation of health, including the assumption of a monotonically declining social marginal value of welfare/income/health. At the same time, empirical studies that have elicited social preferences for allocation of health have reported results that are seemingly incompatible with this assumption. There are two ways of addressing this inconsistency; we may censor the stated preferences by arguing that they cannot be supported by normative arguments, or we may reject or modify the analytical framework in order to accommodate the stated preferences. We argue that the stated preferences can be supported by normative reasoning and therefore conclude that one should be cautious in applying the standard welfare economic framework to the allocation of health.     

健康中国视角下江西省医疗资源配置与经济高质量耦合协调发展研究

目的:探究江西省医疗资源配置与经济高质量协调发展现状,分析二者之间的耦合协调变化趋势、协调程度。方法:通过文献分析、专家咨询、系统调研等方式确立江西省医疗资源配置和经济高质量发展综合指标,构建二者的耦合协调模型,对二者的耦合协调以及收敛程度进行实证测评。结果:江西省医疗资源配置与经济高质量发展耦合协调度呈上升态势,但大部分城市耦合协调程度属于濒临失调和勉强协调,城市间耦合协调水平存在较大差距。结论:优化医疗资源扩容和区域布局是促进全民健康、实现健康中国战略的前提。为缩小江西省各地医疗资源配置与经济水平耦合协调发展的差距,推动医疗服务全面发展,应结合各地的经济水平、社会发展、人口结构等因素,优化医疗资源配置,实现医疗资源配置与经济高质量耦合协调发展。     

Public health equity in refugee situations

Addressing increasing concerns about public health equity in the context of violent conflict and the consequent forced displacement of populations is complex. Important operational questions now faced by humanitarian agencies can to some extent be clarified by reference to relevant ethical theory. Priorities of service delivery, the allocation choices, and the processes by which they are arrived at are now coming under renewed scrutiny in the light of the estimated two million refugees who fled from Iraq since 2003. Operational questions that need to be addressed include health as a relative priority, allocations between and within different populations, and transition and exit strategies. Public health equity issues faced by the humanitarian community can be framed as issues of resource allocation and issues of decision-making. The ethical approach to resource allocation in health requires taking adequate steps to reduce suffering and promote wellbeing, with the upper bound being to avoid harming those at the lower end of the welfare continuum. Deliberations in the realm of international justice have not provided a legal or implementation platform for reducing health disparities across the world, although norms and expectations, including within the humanitarian community, may be moving in that direction. Despite the limitations of applying ethical theory in the fluid, complex and highly political environment of refugee settings, this article explores how this theory could be used in these contexts and provides practical examples. The intent is to encourage professionals in the field, such as aid workers, health care providers, policy makers, and academics, to consider these ethical principles when making decisions.     

试论医疗经济活动中的伦理道德标准和价值取向

该文从医疗资源分配，交换以及医院的市场经营等三个方面对医疗经济活动中涉及的伦理道德标准和价值取向进行分析，并对市场中如何获得相应伦理道德标准和价值取向进行探讨。     

Public-Health-Ethik in Abgrenzung zur Medizinethik

Until now there are only a few approaches in the German-speaking realm to establish an explicit ethical framework for moral issues of public health--although a need for public health ethics in times of SARS and avian flu is obvious. One deficit of the discussion so far is that there is no systematic separation of medical ethics and public health ethics. Thus, the core and interdisciplinary focus of public health is often not met. However, to frame discussions of moral issues within a specific public health ethics framework seems to be fruitful. This paper deals with the conceptual differences of medical ethics and public health ethics. The discussion helps both applied ethical discourses to sharpen their focus and strengthen their appeal. The author develops and presents a conceptual and normative frame for public health ethics and offers a concise set of ethical principles for the discussion of moral challenges in public health.     

Differences in primary health care delivery to Australia's Indigenous population: a template for use in economic evaluations

ABSTRACT: BACKGROUND: Health economics is increasingly used to inform resource allocation decision-making, however, there is comparatively little evidence relevant to minority groups. In part, this is due to lack of cost and effectiveness data specific to these groups upon which economic evaluations can be based. Consequently, resource allocation decisions often rely on mainstream evidence which may not be representative, resulting in inequitable funding decisions. This paper describes a method to overcome this deficiency for Australia's Indigenous population. A template has been developed which can adapt mainstream health intervention data to the Indigenous setting. METHODS: The 'Indigenous Health Service Delivery Template' has been constructed using mixed methods, which include literature review, stakeholder discussions and key informant interviews. The template quantifies the differences in intervention delivery between best practice primary health care for the Indigenous population via Aboriginal Community Controlled Health Services (ACCHSs), and mainstream general practitioner (GP) practices. Differences in costs and outcomes have been identified, measured and valued. This template can then be used to adapt mainstream health intervention data to allow its economic evaluation as if delivered from an ACCHS. RESULTS: The template indicates that more resources are required in the delivery of health interventions via ACCHSs, due to their comprehensive nature. As a result, the costs of such interventions are greater, however this is accompanied by greater benefits due to improved health service access. In the example case of the polypill intervention, 58% more costs were involved in delivery via ACCHSs, with 50% more benefits. Cost-effectiveness ratios were also altered accordingly. CONCLUSIONS: The Indigenous Health Service Delivery Template reveals significant differences in the way health interventions are delivered from ACCHSs compared to mainstream GP practices. It is important that these differences are included in the conduct of economic evaluations to ensure results are relevant to Indigenous Australians. Similar techniques would be generalisable to other disadvantaged minority populations. This will allow resource allocation decision-makers access to economic evidence that more accurately represents the needs and context of disadvantaged groups, which is particularly important if addressing health inequities is a stated goal.     

2015—2018年四川省卫生资源配置及公平性分析

目的为推动四川省区域内卫生健康事业协同发展,优化医疗卫生资源配置效率,提升医疗服务效能。方法从人口、地理两个维度,利用基尼系数和泰尔指数对四川省2015—2018年5大经济区的医疗卫生资源配置情况进行指标数据分析。结果2015—2018年四川省各项医疗卫生资源总量增加,其中注册护士数年均增长率9%,增幅最显著;按人口分布的医疗卫生资源基尼系数均<0.2且波动较小,各项资源配置公平性较好;按人口分布的医疗卫生资源优于按地理分布的资源配置;按地理分布的医疗卫生资源不公平性主要源于区域之间的差异。结论四川省医疗卫生资源总量增加,资源配置结构不断优化;区域内差异化缩小,区域间差异占主导地位,需要加强政府宏观干预,合理配置卫生医疗资源,扩大公众享受医疗卫生服务辐射面,促进区域医疗卫生协同发展。     

中国医学伦理学研究论纲

对医学伦理学的概念、学科性质、研究内容、研究方法进行了简要的描述;对我国医学伦理学研究涉及的脑死亡、安乐死、克隆人、器官移植、基因治疗、健康伦理、卫生资源分配等研究成果及存在争议的问题进行了探讨和梳理。     

Judging the ethics of qualitative research: considering the "ethics as process" model

Decision-making about the ethics of qualitative research is problematic where the research design is emergent, and the balance between risks and benefits for research subjects are difficult to ascertain prior to study implementation. The discourses of health/medical research ethics and those of social research are shown to be divergent and, furthermore, where ethics committees tie themselves to the health/medical model of ethical decision-making, qualitative research approaches can be disadvantaged. Having demonstrated the dual discourses and their relevance to qualitative research ethics, a critical review of current approaches to maximising the success of qualitative research proposals being considered for approval by ethics committees is undertaken. This leads to a call for a system of monitoring qualitative research so that the "benefit to risk" ratio is always on the side of benefit. This has implications for the ways in which ethics committees are organised and the ways in which they function.