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Priority setting in health care: on the relation between reasonable choices on the micro-level and the macro-level

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Abstract

There has been much discussion about how to obtain legitimacy at macro-level priority setting in health care by use of fair procedures, but how should we consider priority setting by individual clinicians or health workers at the micro-level? Despite the fact that just health care totally hinges upon their decisions, surprisingly little attention seems being paid to the legitimacy of these decisions. This paper addresses the following question: what are the conditions that have to be met in order to ensure that individual claims on health care are well aligned with an overall concept of just health care? Drawing upon a distinction between individual and aggregated needs, I argue that even though we assume the legitimacy of macro-level guidelines, this legitimacy is not directly transferable to decisions at micro-level simply by adherence to the guidelines’ recommendation. Further, I argue that individual claims are subject to the formal principle of equality and the demands of vertical and horizontal equity in a way that gives context- and patient-related equity concerns precedence over equity concerns captured at the macro-level. I conclude that if we aim to achieve just health care, we need to develop a complementary framework for legitimising individual judgment of patients’ claims on health care resources. Moreover, I suggest the basic structure of such a framework.

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Notes

  1. In providing answers to this question, I rely upon a crucial presumption that should be made explicit from the start. I presuppose that the clinician(s) involved in micro level decision-making should be considered responsible for the content of these decisions despite the participation of the patient. Although the patient has the opportunity to choose his or hers own treatment, the choice should not include alternatives the clinician does not find appropriate. This is why I ascribe micro-decisions and individual claims to the clinicians rather than the individual patient or a constellation of the two of them. Consequently, this should not be interpreted as excluding patient participation.

  2. The objectives of health care and just distribution referred to here should be considered revisable principles according to the ideas of coherent justification and reflective equilibrium. For support of this claim, see [13, pp. 21–46].

  3. The reason for this is not that different interpreters might weight considerations differently due to the substantive content of what they take to be the objectives of health care and distribution. In this part of the analysis, the multitude of different context- and patient-related reasons compared to the more limited number of reasons potentially constituting an aggregated need is to be considered as a structural difference in macro- and micro-level needs.

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Acknowledgments

I am grateful for comments on earlier drafts of this manuscript from Ole Frithjof Norheim, Trygve Ottesen, Sigurd Lauridsen, Silje A. Langvatn and two anonymous reviewers for this journal. The project is funded by The Research Council of Norway.

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Correspondence to Kristine Bærøe.

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Bærøe, K. Priority setting in health care: on the relation between reasonable choices on the micro-level and the macro-level. Theor Med Bioeth 29, 87–102 (2008). https://doi.org/10.1007/s11017-008-9063-3

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