National Center for Priority Setting in Health-Care, Department of Medicine and Health, Linköping University, Linköping, Sweden.
Academy for Care, Worklife and Welfare, University of Borås, Borås, Sweden.
Int J Health Policy Manag. 2018 Jun 1;7(6):532-541. doi: 10.15171/ijhpm.2017.125.
Priority setting in publicly financed healthcare systems should be guided by ethical norms and other considerations viewed as socially valuable, and we find several different approaches for how such norms and considerations guide priorities in healthcare decision-making. Common to many of these approaches is that interventions are ranked in relation to each other, following the application of these norms and considerations, and that this ranking list is then translated into a coverage scheme. In the literature we find at least two different views on how a ranking list should be translated into coverage schemes: (1) rationing from the bottom where everything below a certain ranking order is rationed; or (2) a relative degree of coverage, where higher ranked interventions are given a relatively larger share of resources than lower ranked interventions according to some "curve of coverage."
The aim of this article is to provide a normative analysis of how the background set of ethical norms and other considerations support these two views.
The result of the analysis shows that rationing from the bottom generally gets stronger support if taking background ethical norms seriously, and with regard to the extent the ranking succeeds in realising these norms. However, in non-ideal rankings and to handle variations at individual patient level, there is support for relative coverage at the borderline of what could be covered. A more general relative coverage curve could also be supported if there is a need to generate resources for the healthcare system, by getting patients back into production and getting acceptance for priority setting decisions.
Hence, different types of reasons support different deviations from rationing from the bottom. And it should be noted that the two latter reasons will imply a cost in terms of not living up to the background set of ethical norms.
公共资助的医疗体系中的优先事项设定应遵循被视为具有社会价值的伦理规范和其他考虑因素，我们发现有几种不同的方法可以用这些规范和考虑因素来指导医疗决策中的优先事项。这些方法中的许多方法都有一个共同点，即根据这些规范和考虑因素对干预措施进行相互排序，然后将此排序列表转换为覆盖方案。在文献中，我们至少发现了两种不同的观点，即如何将排名列表转换为覆盖方案：（1）从底部配给，即对低于特定排名的所有内容进行配给；或（2）根据某种“覆盖曲线”，对排名较高的干预措施给予相对较大的资源份额，对排名较低的干预措施给予相对较小的资源份额。
本文的目的是对背景设定的伦理规范和其他考虑因素如何支持这两种观点进行规范性分析。
分析结果表明，如果认真对待背景伦理规范，并且排名在多大程度上实现了这些规范，那么从底部配给通常会得到更强有力的支持。然而，在非理想的排名和处理个体患者层面的差异时，在可以覆盖的边界内，支持相对覆盖。如果需要为医疗体系创造资源，可以通过让患者重新投入生产并接受优先事项设定决策，也可以支持更一般的相对覆盖曲线。
因此，不同类型的原因支持对从底部配给的不同偏差。需要注意的是，后两个原因将意味着在违背背景设定的伦理规范方面付出代价。
