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On value-judgements and ethics in health technology assessment

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Poiesis & Praxis

Abstract

The widespread application of technology in health care has imposed a broad range of challenges. The field of health technology assessment (HTA) is developed in order to face some of these challenges. However, this strategy has not been as successful as one could hope. One of the reasons for this is that social and ethical considerations have not been integrated in the HTA process. Nowadays however, such considerations have been included in many HTAs. Still, the conclusions and recommendations of the HTAs are not followed. The reason for this may be that the methods for integrating ethics for HTA are not sufficiently developed, or that they are not adequate. This article presents a supplementary approach to the ethical inquiry in HTA. It is argued that a value analysis is crucial in order to address the ethical issues of health care technology in a fruitful way and to make viable decisions about such technology.

Zusammenfassung

Die weit verbreitete Anwendung technischer Verfahren im Gesundheitswesen hat eine Vielfalt von Herausforderungen in den Vordergrund gerückt. Um einigen dieser Herausforderungen gegenübertreten zu können, ist das Gebiet des Health Technology Assessment (HTA, Beurteilung medizintechnischer Verfahren) entwickelt worden. Diese Strategie ist bisher jedoch nicht so erfolgreich wie man sich erhoffen könnte. Als einer der Gründe für diesen Umstand wurde früher angenommen, soziale und ethische Überlegungen seien aus dem HTA-Prozess ausgeklammert geblieben. Heute gehören jedoch gerade solche sozialen und ethischen Erwägungen zu vielen HTAs. Dennoch werden die Schlussfolgerungen und Empfehlungen der HTAs nicht befolgt. Der Grund hierfür könnte sein, dass die Ethik für HTA nicht ausreichend entwickelt ist, oder dass sie den Anforderungen von HTA nicht gerecht wird. In diesem Artikel wird ein ergänzender Ansatz zur ethischen Untersuchung im Rahmen von HTA präsentiert. Demnach ist eine Wertanalyse zwingend notwendig, um die ethischen Fragen bearbeiten zu können und zu angemessenen Entscheidungen über solche Technologien zu gelangen.

Rèsumé

L’application largement répandue de procédés technologiques dans le domaine de la santé a mis en lumiére un grand nombre de défis. Le domaine de l’évaluation des technologies de la santé (ETS) a été développé pour maîtriser quelques uns de ces défis. Cette stratégie n’a cependant pas rencontré le succés escompté. On en vit tout d’abord la raison dans le fait que les aspects sociaux et éthiques n’avaient pas été pris en compte dans le processus d’ETS. Aujourd’hui pourtant, des considérations sociales et éthiques ont été intégrées dans de nombreuses ETS. Mais les conclusions et les recommandations des ETS ne sont toujours pas suivies. Cela s’explique peut-être par un développement insuffisant des aspects éthiques appliqués à l’ETS, ou par leur caractére inadéquat. Cet article présente une approche complémentaire des réflexions éthiques dans l’ETS. Il montre qu’une analyse des valeurs est essentielle pour aborder de maniére fructueuse les questions éthiques liées aux technologies médicales et pour déboucher sur des décisions viables sur ces technologies.

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Notes

  1. The issue of how to assert that ethical issues in trials are addressed in systematic reviews has recently been addressed (Weingarten et al.2004); however, this concerns mainly research ethical issues

  2. The CI case is brilliant in that it illustrates some important moral and social issues that have been neglected by the assessment of the technology. However, the case is rather untypical, as the technology in question (CI) is assessed to be effective, but the social context of the patient disvalues it. Most frequently it is the other way around: there is a technology that is assessed and found to be ineffective, not efficient, and/or disvalued by a group of people, but it is still implemented and used in the health care system. Furthermore, some of the moral issues in the CI case are due to the guardianship of the parents, deciding what is best for the child. However, the case of CI clearly illustrates how important it is to address external values related to the assessed technology. Such values may be values of certain interest groups, or political, religious, as well as moral values and many more. However, even if one takes these values into account the assessment may be ignored in clinical practice. One of the reasons for this is that the HTA process itself involves a series of covert values

  3. A different way of phrasing the question would be: are we trapped in a hermeneutic circle?

  4. It is interesting to notice that there appear to be some semantic values at play: apparatus based technology is judged in a different manner than pharmaceuticals. They are classified differently, and in most countries they are differentiated legally as well. This contradicts most HTA definitions of technology

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Acknowledgements

I would like to thank the anonymous reviewer’s wise and inspiring comments and relevant suggestions.

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Hofmann, B. On value-judgements and ethics in health technology assessment. Poiesis Prax 3, 277–295 (2005). https://doi.org/10.1007/s10202-005-0073-1

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