Academic journal article Health Sociology Review

Justification of Ethical Considerations in Health Economics - Merging the Theories of Niklas Luhmann and Charles Taylor

Academic journal article Health Sociology Review

Justification of Ethical Considerations in Health Economics - Merging the Theories of Niklas Luhmann and Charles Taylor

Article excerpt

In the following, we analyze and justify ethical considerations in health economics based on socio-philosophical theories. There are many health economics works that account for ethical concerns such as equity. Examples are works by Bleichrodt, Brouwer, Culyer and Williams (Bleichrodt, Crainich, & Eeckhoudt, 2008; Bleichrodt & van Doorslaer, 2006; Brouwer, Culyer, van Exel, & Rutten, 2008; Brouwer et al., 2008; Culyer, 1979, 1983, 2001; Williams, 1991, 1995, 1998, 1999). In 2001, the Journal of Medical Ethics published a special issue on economics and ethics in health care. Interestingly, none of these works justify the consideration of ethical values on theoretical grounds. Ethical values are assumed to be valid, for instance, by reference to 'public concerns' (e.g., distributional equity), and the main goal is to incorporate them into economic theory, e.g., by means of social welfare functions. In addition to that, we suggest internalizing the justification for ethical values into health economics as well. This would enable health economics to acknowledge the inevitability of dealing with ethics in its theories and to broaden its perspective for ethical values other than equity or solidarity. In the terms of Kuhn, we thereby offer a new understanding which is more complete (Kuhn, 1996).

According to the majority of health economists, there is only one rational choice-based economic theory, which must be adapted to the special issues in the context of health care (cf. e.g., Drummond, Sculpher, Torrance, O'Brien, & Stoddart, 2006; Zweifel, Breyer, & Kifmann, 2009). For these authors, non-economical facts are the domain of other scientific disciplines, and economics can only deal with those cherished values that can be captured as primary goods (rights, liberties, opportunities, and health), or utilities (the measured mental satisfaction caused by goods); see Arneson (1990), Blair (1988), Schwartz (1973), and Tang (2010). Amartya Sen and his followers argue that economic theory has to account for more than utilities and primary goods; otherwise, it can generate solutions that violate basic ethical values (Culyer, 1979, 2001; Sen, 1991, 1993). Sen suggests using basic capabilities as additional values to utilities and primary goods (Kaplow, 2007; Nelson, 2008; Riddle, 2011; Sen, 1997). Basic capabilities relate to the abilities to do certain basic things such as moving. In summary, utility theory deals with the valuations of mental reactions (e.g., satisfaction); the theory of primary goods considers the possession of certain goods, such as opportunities and well-being, as relevant. With the notion of basic capabilities, Sen suggests a new view that is not contained within utility or primary-goods based theories.

Let us exemplify the differences in these approaches by their implications regarding the determination of QALY values in the 'jolly cripple' case (Bleichrodt et al., 2008; Bleichrodt & van Doorslaer, 2006; Sen, 1997). Quality adjusted life years (QALYs) are subjective measures of well-being or disease burden and unify the qualitative as well as the quantitative aspects of life (see Section A new perspective in health economics). Usually, QALYs are normalized in such a way that zero represents the worst case (e.g., death) and one the state of absolute well-being in a given year. Utility-based approaches and primarygood theories would assign a QALY value near one to the 'jolly cripple' because he is happy and has all he wants. The capability-equity approach of Sen would assign a value much below one because the cripple is restricted in his ability to move. Only in this case would health care resources (e.g., robotic wheelchair) be allocated to the cripple. A procedure based on our approach would imply two steps: first, reconstruction of relevant ethical values (and their weights) of involved parties; second, determination and weight-based aggregation of QALYs based on these values. In the result section of this paper, we show how to reconstruct patients' values by using a questionnaire. …

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