Rumbold Benedict, Weale Albert, Rid Annette, Wilson James, Littlejohns Peter
Kennedy Inst Ethics J. 2017;27(1):107-134. doi: 10.1353/ken.2017.0005.
Health systems that aim to secure universal patient access through a scheme of prepayments-whether through taxes, social insurance, or a combination of the two-need to make decisions on the scope of coverage that they guarantee: such tasks often falling to a priority-setting agency. This article analyzes the decision-making processes at one such agency in particular-the UK's National Institute for Health and Care Excellence (NICE)-and appraises their ethical justifiability. In particular, we consider the extent to which NICE's model can be justified on the basis of Rawls's conception of "reasonableness." This test shares certain features with the well-known Accountability for Reasonableness (AfR) model but also offers an alternative to it, being concerned with how far the values used by priority-setting agencies such as NICE meet substantive conditions of reasonableness irrespective of their procedural virtues. We find that while there are areas in which NICE's processes may be improved, NICE's overall approach to evaluating health technologies and setting priorities for health-care coverage is a reasonable one, making it an exemplar for other health-care systems facing similar coverage dilemmas. In so doing we offer both a framework for analysing the ethical justifiability of NICE's processes and one that might be used to evaluate others.
旨在通过预付费计划（无论是通过税收、社会保险还是两者结合）确保全民患者可及性的卫生系统，需要就其保障的覆盖范围做出决策：此类任务通常由一个确定优先事项的机构负责。本文特别分析了其中一个这样的机构——英国国家卫生与临床优化研究所（NICE）——的决策过程，并评估其伦理合理性。具体而言，我们考量NICE的模式在多大程度上能基于罗尔斯的“合理性”概念得到辩护。这个检验与著名的“合理性问责”（AfR）模式有某些共同特征，但也提供了一种替代方案，关注诸如NICE这样的确定优先事项机构所使用的价值观在多大程度上符合合理性的实质条件，而不论其程序优点如何。我们发现，虽然NICE的流程在某些方面可能有待改进，但NICE评估卫生技术和确定医疗保健覆盖优先事项的总体方法是合理的，使其成为面临类似覆盖困境的其他卫生保健系统的典范。在此过程中，我们既提供了一个分析NICE流程伦理合理性的框架，也提供了一个可用于评估其他流程的框架。
