Ethical Considerations to Guide Accountable Policy ... · Trade-offs: Given resource constraints, ... Resnik 2009) NUS Presentation Title 2006 Trustworthiness and Trust Lim Mey Lee

Calvin WL Ho JSD, MSc (Econs), LLM

Centre for Biomedical Ethics, Yong Loo Lin School of Medicine,

National University of Singapore;

World Health Organization Collaborating Centre for Bioethics

Ethical Considerations

to Guide Accountable

Policy Decision-Making

NUS Presentation Title 2006

1. (Macro) Situating Accountability and Transparency in

UHC as an ethical enterprise

2. Two Ethics Goals:

• Social Justice

• Trustworthiness and Trust

3. Ethics is a matter of reflection and reasoned value-

based judgement

• There is no magic formula or panacea

4. (Micro) Conflicts of Interest – An illustration of Ethics

in Action

Overview

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Universal Health Coverage


Population Coverage: Expand coverage to allow equal access for all persons

Service Coverage: Define a set of essential health care services based on the priority health needs for each country

Financial Protection: Protect populations against impoverishment due to illnesses since most of health care is paid for out-of-pocket

Trade-offs: Given resource constraints, each country has to prioritise between increasing share of population covered, enhancing the level of financial protection, or to expand the range of health services


Guiding Considerations for Fair Progressive Realisation of UHC

Equity regarded as effectively synonymous with Fairness.

Horizontal Equity – Equal treatment of relatively similar cases

Vertical Equity – Appropriately unequal treatment of

dissimilar cases

Guiding Considerations:

Fairness:

Distribution (based on need; priority to worse off groups)

Contribution (based on ability to pay, not need)

Cost-effectiveness:

Benefit maximisation relative to cost


One Possible Approach• Categorise services (including medicines) into

priority classes. Considerations include:

• Cost-effectiveness

• Priority to the worse-off

• Financial risk protection

• First expand coverage for high-priority services to everyone.

• Eliminate OOP payments

• Increase mandatory progressive prepayment with pooling

of funds.

• Ensure that disadvantaged groups are not left behind.

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Five Unacceptable Tradeoffs

1. Expand coverage for low- or medium-priority services before there is near universal coverage (UC) for high-priority services. This includes reducing OOP payments.

2. First include in the UC scheme only those with the ability to pay and not include informal workers and the poor, even if such an approach is easier.

3. Giving high priority to very costly services when the health benefits are very small compared to alternative, less costly services.

4. Expanding coverage for well-off groups before doing so for worse-off groups when costs and benefits are not vastly different.

5. To shift OOP payment towards mandatory prepayment that makes the financing system less progressive.

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HEALTH SYSTEMS GLOBAL WORKING GROUP & FLAGSHIP REPORT

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Reasonableness and Accountability in choosing among values

• Public accountability and participation can take numerous forms (in relation to transparency, voice, inclusion, empowerment, responsiveness, etc)

• “Accountability for reasonableness” (A4R)

• Ethical framework to guide decision-makers in facilitating fair

realisation of UHC

• Emphasises democratic deliberation as a priority-setting

process

• Four basic conditions encompassed


Four Conditions in the A4R model

PublicityRationales for direct or indirect limits to care must be publicly

accessible

RelevanceRationales for limit-setting decisions must be based on reasons

that “fair-minded” people can agree are relevant in the context

Revision and AppealsShould be a mechanism for challenge, review and change

(includes feedback from stakeholders)

Enforcement / RegulationEnsure that the above conditions are met through voluntary or

public regulation


Ethical Code and Ethical GuidelinesParagraph 3: Patients and the public must be able to trust

doctors implicitly with their lives and well being. To justify this trust, doctors have to maintain a good standard of care, conduct and behaviour. The SMC prescribes an ethical code which doctors are expected to uphold. These principles are applicable to a wide variety of circumstances and situations. Adherence to this Code will enable society to have trust and confidence in the profession. … In general, a doctor is expected to: …Maintain a professional relationship with patients and their relatives and not abuse this relationship through inappropriate personal relationships or for personal gain.

Paragraph 4.6.1: A doctor shall not let financial considerations imposed by his own practice, investments or financial arrangements influence the objectivity of his clinical judgement in the treatment of his patients.


What is Conflicts of Interest (COI)?

Conflicts between the researcher’s personal or financial interests and the interests of a subject or participant, or otherwise conflicts that involve competing loyalties. (Rodwin 1993)

When the interests or commitments of a researcher compromise his or her judgment, research reports or communications to research subjects or participants. (NHRPAC 2001)

An individual has a conflict of interest when he or she has personal, financial, professional, or political interests that are likely to undermine his or her ability to meet or fulfill his or her primary professional, ethical, or legal obligations. (Shamoo & Resnik 2009)


Trustworthiness and Trust

Lim Mey Lee Susan v SMC [2013] SGHC 122There are ethical obligations which professionals must

observe regardless of their respective professions.Emphasis is on trust and confidence in a professional

relationship. Special professional knowledge and abilityRequires conduct in the spirit of truth and honestyE.g. Overcharging can constitute professional misconduct, as such

conduct is “dishonourable and is the very antithesis of the ideal of public service, which is the hallmark of what it means to be a professional”.

Even in the absence of express statutory provisions or regulations, there are ethical obligations over and above contractual and market forces (e.g. charging patients a fair and reasonable fee for services rendered).


Ethical Obligations are SubstantiveSupreme Court: “In the context of the medical profession, we found that given a doctor’s specialised knowledge and training (and his or her corresponding duty to utilise these skills with conscience and dignity in the patient’s best interests), there arises an ethical obligation on the part of a doctor not to take advantage of his or her patient (whether monetary or otherwise), which obligation operates over and above contractual and market forces.”

Ethical obligations are…not only procedural, but also substantive in nature.

In the ethical context, it is permissible for the court to examine the substantive fairness of the terms of an agreement between a doctor and his or her patient.


Practical Lessons

• UHC is an ethical enterprise focused on advancing social equity.

• Accountability and transparency are enabling conditions that promote trustworthiness and trust.

• Clarity of ethical goals helps make tough prioritisationand allocation decisions by teasing out the values dimensions of decisions.

• Include stakeholders (such as by creating advisory bodies like MeTA) with various voices.

• Ethical analysis provides practical decision support and education.

• Galvanise issues that make explicit the collective concerns.


Selected References

Backman G (ed). The Right to Health: Theory and Practice. Pozkal: Studentlitteratur, 2012.

King J. Judging Social Rights. Cambridge: Cambridge University Press, 2012.

Nuffield Council on Bioethics. Solidarity: An Emerging Concept in

Bioethics. London: Nuffield Council on Bioethics, 2011.

Rawls J. A Theory of Justice. Cambridge MA: Harvard University Press, 2000 (3rd Ed.).

Sen A. The Idea of Justice. Cambridge MA: Harvard University Press, 2009.

Singer PA, Viens AM (eds). The Cambridge Textbook of Bioethics. Cambridge: Cambridge University Press, 2008.

United Nations’ Committee on Economic, Social and Cultural Rights. The AAAQ Framework: General Comment 14, U.N. Doc. E/C.12/2000/4 (2000), paragraph 12.

Wagner AK, Graves AJ, Reiss S, LeCates R, Zhang F, Ross-Degnan D. Access to Care and16

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Ethical Considerations to Guide Accountable Policy ... · Trade-offs: Given resource constraints, ... Resnik 2009) NUS Presentation Title 2006 Trustworthiness and Trust Lim Mey Lee