ethics equity and economics

8/11/2019 Ethics Equity and Economics

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INEQUALITY, EQUITY * EQUALITY *ECONOMICS


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Factors Affecting Social Inequalities in Health

1. Social Status

2. Geographical Factors

3. Income and economic resources

4. living and working conditions 5. Attitudes and behaviour


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SC I : Professional Occupations ( UniversityAcademic Staff, Physicians, Lawyers)

SC II : Managerial and Technical Occupation

SC III : Non Manual Skilled Occupation (Clerks andshop assistants)

SCIII : Manual Skilled Occupation ( Coal Miners)

SC IV : Partly Skilled Occupation ( Bus Conductorsand postmen)

SC V : Unskilled Occupation ( laborers)

Classification of Social Class


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Geographical Factors

Education

Diet

Income

Working Conditions Living Environments

Lifestyle


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Ethics, equity and economics

Ethics - theories of justice- medical versus economic polarisation

Equity - definitions- health, need and access vs. use

- micro versus macro

Economics - equity and efficiency


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Why ethics?

Philosophy determines objectives of health caresystem e.g.

-maximise social well-being based on(consequentialist) utilitarianism

Different philosophical concepts have differentimplications, esp. for efficiency

Main practical manifestation = equity


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Categorising ethical theories (1)

Distributive justice - political or socialphilosophy - concerned with outcome

Procedural justice - moral philosophy -concerned with process used in achieving theoutcome


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Political philosophy - societal focus e.g. Rawls

Moral philosophy - individual focus e.g KantianImperative

Interaction e.g. utilitarianism - social utilitymaximised by each individual maximising ownutility


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Individual Society

Process Entitlement

DeontologicalVirtue

Outcome Utilitarianism

RawlsianEgalitarianRights


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Ethical theories

Utilitarianism

Rawlsian

Entitlement/libertarian

Egalitarian Deontological

Virtue

Rights


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Utilitarianism

Jeremy Bentham (classic) and John Stuart Mill(adapted)

Maximising greatest utility for greatest number

Underlies efficiency Issues - domain (whose utility)

- malevolence (utility from suffering)


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Utilitarianism

Utilitarianism was described byBentham as "the greatesthappiness or greatest

felicity principle".[Utility, thegood to be maximized, has been

defined by various thinkersas happinessor pleasure(versus suffering or pain),although preferenceutilitarians define it as thesatisfaction of preferences. Itmay be described as a lifestance, with happiness orpleasure being of ultimateimportance.

Act utilitarianism states that,when faced with a choice, wemust first consider the likelyconsequences of potentialactions and, from that, chooseto do what we believe will

generate the most pleasure.The rule utilitarian, on theother hand, begins by lookingat potential rules of action.
http://en.wikipedia.org/wiki/Happinesshttp://en.wikipedia.org/wiki/Pleasurehttp://en.wikipedia.org/wiki/Sufferinghttp://en.wikipedia.org/wiki/Painhttp://en.wikipedia.org/wiki/Preference_utilitarianismhttp://en.wikipedia.org/wiki/Preference_utilitarianismhttp://en.wikipedia.org/wiki/Life_stancehttp://en.wikipedia.org/wiki/Life_stancehttp://en.wikipedia.org/wiki/Intrinsic_value_(ethics)http://en.wikipedia.org/wiki/Intrinsic_value_(ethics)http://en.wikipedia.org/wiki/Intrinsic_value_(ethics)http://en.wikipedia.org/wiki/Intrinsic_value_(ethics)http://en.wikipedia.org/wiki/Intrinsic_value_(ethics)http://en.wikipedia.org/wiki/Life_stancehttp://en.wikipedia.org/wiki/Life_stancehttp://en.wikipedia.org/wiki/Life_stancehttp://en.wikipedia.org/wiki/Preference_utilitarianismhttp://en.wikipedia.org/wiki/Preference_utilitarianismhttp://en.wikipedia.org/wiki/Preference_utilitarianismhttp://en.wikipedia.org/wiki/Painhttp://en.wikipedia.org/wiki/Sufferinghttp://en.wikipedia.org/wiki/Pleasurehttp://en.wikipedia.org/wiki/Happiness


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Rawlsian maximin

John Rawls 1971

Allocationconducted under

veil of ignorance- leads to positionof less well off insociety beingmaximised


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Theory of Justice

Each person is to havean equal right to themost extensive scheme ofequal basic liberties

compatible with asimilar scheme ofliberties for others

Social and economicinequalities are to bearranged so that (Rawls,1971, p.303):

a) they are to be of the

greatest benefit to theleast-advantaged membersof society (the difference

principle).

b) offices and positions

must be open to everyoneunder conditions offairequality of opportunity


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Entitlement/libertarian

Robert Nozick 1974

Individuals entitled to what they have acquiredjustly i.e. within a market situation

Stresses freedom of choice and property rights -minimal state involvement

Similar to utilitarianism


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Egalitarian

Equal shares in the distribution of a commodity

Issues - of what? health, services?

- according to what criteria?need, age?


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Deontological (deon (Gk) = duty)

Immanuel Kant

Moral rules of how to live which should not bebroken (ie absolute moral code)

Do to others as you would have done to you Humans as end, not means


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Virtue theory

Not what should I do but what kind of personshould I be

Similar to deontological - absolute moral rules


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Medical vs. economic ethic (1)

Medical - individual (deontological) ethic

- Hippocratic oath, NightingalePledge

- Agency and professional codesconduct

- best interests of patient

- opportunity cost ignored (?)


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Medical vs. economic ethic (2) Economic - population based ethic- principally utilitarian

- based on opportunity cost

Overlap of considerations in both professions


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Medical dilemma (1)

I recall a patient who bled massively from his inoperablecancer of the stomach, I was the houseman and I had a strongsense that I must do my utmost for my patient, I ordered large

quantities of blood to be cross matched and set up an infusionto replace the blood the patient had lost. It was not that Ibelieved that the blood would cure him, but it would veryprobably save his life for a while longer, whereas without the

blood transfusion he would have probably died there and then.

A few days later the patient had another massive bleed and Iagain ordered more blood and set up a transfusion, again thepatient survived what would almost certainly have been a fatal

blood loss. The patient himself, knowing the situation, waskeen to fight it as hard as possible.


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Medical dilemma (2)

After the second massive bleed and equally massive bloodtransfusion, my chief gently pointed out that there was nopoint in pouring in the blood as I had been, the patient had

widespread cancer secondaries, his stomach was riddled withcancer and likely to bleed whenever the cancer eroded a bloodvessel; blood transfusions could do no more than prolong thepatients life by a very short time. If I went on ordering bloodat the predigious rate I had been, I would literally break the

bank, the blood bank, causing enormous expense whilstseriously jeopardising the chances of other patients for whoma blood transfusion could really be lifesaving, rather thanmerely death prolonging.


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Medical dilemma (3)

I wanted to discuss all this with the patient, but he died thesame day from a further massive bleed and that time I simply

was not called. My superior had decided that there was

nothing beneficial that could be done. More precisely,however, his analysis was surely based on a differentassessment, notably that the benefit to the patient of repeated

blood transfusions each time his stomach cancer bled, even ifhe himself wanted to fight to the last second, was insufficientto justify the enormous cost (to others) of providing the

blood.


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Tavistock Group - BMJ, Jan 23, 1999- healthcare is a human rightprovideaccessregardless of their ability to pay

- care of individuals is at centre of health care but

must be viewed within context of [generating]greatest possible health gains for groups andpopulations

CONCEPTS OF EQUITY IN THE


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CONCEPTS OF EQUITY IN THEDISTRIBUTION OF HEALTH CARE

Utilitarianism Equality of Health

Equality of Expenditure

Equality of Use for equal

need

Equality of access forequal need

Rawlsian Maximin


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Definitions of equity (2)

Equal access (opportunityto use) for equal need e.gequal waiting time per condition

Equal utilisation (use) for equal need e.g. equallength of stay per condition

Equal treatment for equal need

Equal health


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Why equity? (1)

Health = fundamental commodity necessary forenjoyment of all else

Health care important determinant, but often

expensive/unpredictable Insurance = imperfect/expensive


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Why equity? (2)

Healthcare should not be allocated/distributedaccording to income/wealth

Equity main reason government involvement in

health care world-wide Issues - concern with existing distribution

income/wealth then why not change

this directly?- trade off with efficiency?


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Why equity in health care?

The social conscience is more offended by severe

inequality in nutrition and basic shelter, or inaccess to medical care, than by the inequality inautomobiles, books, furniture or boats

Tobin 1970


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Equal health?

Definition e.g. QALYS, LYs?

Influence of non-health care factors e.g.housing, diet

Choice versus coercion e.g.smoking, diet

Implies reducing overall health not

increasing - only truly equal state = dead

Maximising versus minimum standards


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Equity and need (1)

Need = ambiguous and confusing

Who determines need - producer

- individual

- elite Supply driven - what is available determines

what is needed

Need versus capacity to benefit - treat worse offeven if health improvement less than treatingbetter off


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Equity and need (2)

need versus preference

objective versus subjective need

maximising - quantity of resources required toensure individual becomes /maintained as healthyas possible = bottomless pit

Minimising - standard of care which ensures

individual not fall below adequate level of health


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Measuring equity

Finance - Kakwai Index

- Suits Index

Health - Gini coeff - see McGuire p.59

Data - see Folland, Goodman & Stanobook p.487

- see Donaldson & Gerard


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Equity not necessarily= equality Equity concerned with fairness' justice (i.e.ethicaltheories)

May not necessarily entail equality. e.g.minimum

standards of care, postitive discrimination etc. However, equity usually synonymous with equality

of something.

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