Gibson Jennifer L, Martin Douglas K, Singer Peter A
University of Toronto Joint Centre for Bioethics, 88 College Street, Toronto, Ont., Canada M5G 1L4.
Soc Sci Med. 2005 Dec;61(11):2355-62. doi: 10.1016/j.socscimed.2005.04.037. Epub 2005 Jun 9.
Priority setting tends to take place in health care settings that are hierarchical and politically complex. Fair processes, as defined for example by Daniels' and Sabin's accountability for reasonableness framework, have been identified as essential for securing socially acceptable priority setting decisions. However, power differences in the decision-making context can pose a serious impediment to fair priority setting in health care organizations. Comparatively little attention has been paid to examining the institutional conditions within which priority setting decisions are made. We review a case study of priority setting in hospital operational planning in Toronto, which had been designed by executive leaders to be broadly inclusive of senior and middle-level clinical and administrative leaders. We report three power differences that arose as limiting factors on the inclusiveness of the priority setting process. We argue that these findings have significant theoretical implications for the accountability for reasonableness framework and propose a fifth condition, the "empowerment condition", which states that there should be efforts to minimise power differences in the decision-making context and to optimise effective opportunities for participation in priority setting.
确定优先事项往往发生在等级森严且政治情况复杂的医疗环境中。公平程序，例如由丹尼尔斯和萨宾的合理性问责框架所定义的，已被视为确保社会可接受的优先事项设定决策的关键。然而，决策背景中的权力差异可能对医疗组织中公平的优先事项设定构成严重障碍。相对而言，很少有人关注审查做出优先事项设定决策的制度条件。我们回顾了多伦多医院运营规划中优先事项设定的一个案例研究，该研究由行政领导设计，广泛纳入了高级和中级临床及行政领导。我们报告了出现的三个权力差异，它们成为优先事项设定过程包容性的限制因素。我们认为这些发现对合理性问责框架具有重大理论意义，并提出了第五个条件，即“赋权条件”，该条件指出应努力尽量减少决策背景中的权力差异，并优化参与优先事项设定的有效机会。
