Raine Rosalind
Health Services Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
J Health Serv Res Policy. 2002 Jan;7(1):65-7. doi: 10.1258/1355819021927584.
The British National Health Service and other publicly funded health systems operate on the principle that health care should be provided solely on the basis of need. Yet the literature abounds with reports of bias in health care use. In order to defend such a charge, two conditions must be met. The first condition is that treatment decisions must be shown to be unfair in that they are not made solely on the basis of need. This paper demonstrates the importance of considering the fair distribution of health care from two, related, perspectives. The first is that people with equal needs should be treated the same (equal use for equal need). This is referred to as the achievement of horizontal equity. The alternative perspective is that people with greater needs should have more treatment than those with lesser needs (unequal use for unequal need). This is referred to as the achievement of vertical equity. Although these perspectives are logically linked, demonstration of equal use for equal need does not necessarily indicate unequal use for unequal need. This is because it cannot be assumed that equal use occurs at every level of need. The second condition that must be met is that clinical judgement must be shown to be influenced by prejudicial notions about patients. Such research is fraught with methodological difficulties, and the charge of biased clinical decision-making is usually made as a result of a process of exclusion. Methods that could be used to examine the extent to which inequalities in health care use are due to bias are described.
英国国民医疗服务体系及其他公共资助的医疗系统遵循的原则是，医疗保健应仅基于需求提供。然而，文献中充斥着关于医疗保健使用存在偏见的报道。为了应对这种指控，必须满足两个条件。第一个条件是，治疗决策必须被证明是不公平的，因为它们不是仅基于需求做出的。本文从两个相关的角度阐述了考虑医疗保健公平分配的重要性。第一个角度是，有同等需求的人应得到相同的治疗（同等需求同等使用）。这被称为实现横向公平。另一个角度是，需求较大的人应比需求较小的人接受更多治疗（不同等需求不同等使用）。这被称为实现纵向公平。尽管这些角度在逻辑上相互关联，但同等需求同等使用的证明并不一定意味着不同等需求不同等使用。这是因为不能假定在每个需求层面都存在同等使用的情况。必须满足的第二个条件是，临床判断必须被证明受到对患者的偏见观念的影响。此类研究充满方法上的困难，而有偏见的临床决策指控通常是由于排除过程而提出的。文中描述了可用于检验医疗保健使用不平等在多大程度上归因于偏见的方法。
