Upload
teresita-balgos
View
216
Download
0
Embed Size (px)
Citation preview
8/11/2019 Ethics Equity and Economics
1/35
INEQUALITY, EQUITY * EQUALITY *ECONOMICS
8/11/2019 Ethics Equity and Economics
2/35
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
8/11/2019 Ethics Equity and Economics
3/35
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
8/11/2019 Ethics Equity and Economics
4/35
Geographical Factors
Education
Diet
Income
Working Conditions Living Environments
Lifestyle
8/11/2019 Ethics Equity and Economics
5/35
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
8/11/2019 Ethics Equity and Economics
6/35
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
8/11/2019 Ethics Equity and Economics
7/35
Categorising ethical theories (1)
Distributive justice - political or socialphilosophy - concerned with outcome
Procedural justice - moral philosophy -concerned with process used in achieving theoutcome
8/11/2019 Ethics Equity and Economics
8/35
Categorising ethical theories (2)
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
8/11/2019 Ethics Equity and Economics
9/35
Categorising ethical theories (3)
Individual Society
Process Entitlement
DeontologicalVirtue
Outcome Utilitarianism
RawlsianEgalitarianRights
8/11/2019 Ethics Equity and Economics
10/35
Ethical theories
Utilitarianism
Rawlsian
Entitlement/libertarian
Egalitarian Deontological
Virtue
Rights
8/11/2019 Ethics Equity and Economics
11/35
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)
8/11/2019 Ethics Equity and Economics
12/35
8/11/2019 Ethics Equity and Economics
13/35
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/Happiness8/11/2019 Ethics Equity and Economics
14/35
Rawlsian maximin
John Rawls 1971
Allocationconducted under
veil of ignorance- leads to positionof less well off insociety beingmaximised
8/11/2019 Ethics Equity and Economics
15/35
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
8/11/2019 Ethics Equity and Economics
16/35
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
8/11/2019 Ethics Equity and Economics
17/35
Egalitarian
Equal shares in the distribution of a commodity
Issues - of what? health, services?
- according to what criteria?need, age?
8/11/2019 Ethics Equity and Economics
18/35
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
8/11/2019 Ethics Equity and Economics
19/35
Virtue theory
Not what should I do but what kind of personshould I be
Similar to deontological - absolute moral rules
8/11/2019 Ethics Equity and Economics
20/35
Medical vs. economic ethic (1)
Medical - individual (deontological) ethic
- Hippocratic oath, NightingalePledge
- Agency and professional codesconduct
- best interests of patient
- opportunity cost ignored (?)
8/11/2019 Ethics Equity and Economics
21/35
Medical vs. economic ethic (2) Economic - population based ethic- principally utilitarian
- based on opportunity cost
Overlap of considerations in both professions
8/11/2019 Ethics Equity and Economics
22/35
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.
8/11/2019 Ethics Equity and Economics
23/35
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.
8/11/2019 Ethics Equity and Economics
24/35
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.
8/11/2019 Ethics Equity and Economics
25/35
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
8/11/2019 Ethics Equity and Economics
26/35
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
8/11/2019 Ethics Equity and Economics
27/35
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
8/11/2019 Ethics Equity and Economics
28/35
Why equity? (1)
Health = fundamental commodity necessary forenjoyment of all else
Health care important determinant, but often
expensive/unpredictable Insurance = imperfect/expensive
8/11/2019 Ethics Equity and Economics
29/35
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?
8/11/2019 Ethics Equity and Economics
30/35
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
8/11/2019 Ethics Equity and Economics
31/35
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
8/11/2019 Ethics Equity and Economics
32/35
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
8/11/2019 Ethics Equity and Economics
33/35
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
8/11/2019 Ethics Equity and Economics
34/35
Measuring equity
Finance - Kakwai Index
- Suits Index
Health - Gini coeff - see McGuire p.59
Data - see Folland, Goodman & Stanobook p.487
- see Donaldson & Gerard
8/11/2019 Ethics Equity and Economics
35/35
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.