Elsevier

Social Science & Medicine

Volume 181, May 2017, Pages 158-167
Social Science & Medicine

Acceptable health and priority weighting: Discussing a reference-level approach using sufficientarian reasoning

https://doi.org/10.1016/j.socscimed.2017.03.051Get rights and content

Highlights

  • In standard QALY calculations, perfect health is implicitly taken as a reference point.

  • We investigate taking non-perfect, but still acceptable health as a reference point.

  • We use insights from sufficientarian reasoning and debates.

  • We present weighting functions for sufficientarian acceptable health thresholds.

Abstract

Health care systems are challenged in allocating scarce health care resources, which are typically insufficient to fulfil all health care wants and needs. One criterion for priority setting may be the ‘acceptable health’ approach, which suggests that society may want to assign higher priority to health benefits in people with “unacceptable” than in people with “acceptable” health. A level of acceptable health then serves as a reference point for priority setting. Empirical research has indicated that people may be able and willing to define health states as “unacceptable” or “acceptable”, but little attention has been given to the normative implications of evaluating health benefits in relation to a reference level of acceptable health. The current paper aims to address this gap by relating insights from the distributive justice literature, i.e. the sufficientarian literature, to the acceptable health approach, as we argue that these approaches are related. We specifically focus on the implications of an ‘acceptability’ approach for priority weighting of health benefits, derived from sufficientarian reasoning and debates, and assess the moral implications of such weighting.

Introduction

Scarcity in health care resources requires sensible decisions to be made about which treatments to fund publically and which not to fund. In a number of countries, cost-effectiveness analysis is used to inform such decision-making (Franken et al., 2012, Harris et al., 2001, Stevens and Milne, 2004). In such economic evaluations, health benefits of interventions are expressed in relation to their costs, thus providing information for priority setting on the basis of efficiency and maximization of health benefits within the available budget. Health benefits of interventions are usually expressed in quality-adjusted life years (QALYs), a measure that combines length and health-related quality of life in a health utility score. A quality of life score of 1 reflects perfect health and a score of 0 reflects dead. Scores below 0 reflect health states considered as being worse than dead (Drummond et al., 2005, Weinstein et al., 2009).

Recent literature (Brouwer et al., 2005, Wouters et al., 2015) has argued that economic evaluation studies commonly, albeit implicitly, take ‘perfect health’ as a reference point in the valuation of health gains. Such studies consider all health states below 1 as losses in health with a potential for improvement up to perfect health, and, ceteris paribus, give equal priority to equal-sized health improvements irrespective of the initial health state. However, we may wonder whether perfect health is always the most relevant reference point for the valuation of health benefits, because not all deviations from perfect health may be considered equally important for treatment.

Empirical findings, for instance, suggest that people may regard some non-perfect health states at older age as rather common and acceptable (Brouwer et al., 2005, Péntek et al., 2014, Wouters et al., 2015). In the context of limited resources, it may then be more appropriate to adopt a more modest reference level in priority setting, for example an age-dependent non-perfect but still acceptable level of health. Consequently, evaluation studies may not give all health gains of equal size equal value, and for instance may differentiate between health gains in people with unacceptable health states and in people with acceptable (although non-perfect) health states. In this line of reasoning, people with unacceptable health states may thus receive a higher priority for treatment than those with acceptable health states. For example, if for a specific group of people (say 80-year olds) a quality of life level of 0.7 is regarded acceptable, a higher value may be assigned to health gains in 80-year olds whose health currently is below 0.7 than to health gains in 80-year olds above that acceptable level of health.

Previous research on the ‘acceptability’ approach was mainly empirical in nature and suggests that people are willing and able to identify levels of acceptable health, and find health problems increasingly acceptable with rising age of patients (Brouwer et al., 2005, Péntek et al., 2014, Wouters et al., 2015). However, so far little attention has been given to the normative implications of the approach. The current paper aims to address this. We consider the premise that acceptable health could be used as a principle for health care resource allocation and investigate its consequences. We do this by relating insights from the distributive justice literature to the acceptable health approach. The sufficientarian literature is of particular interest here, because it is directly relevant for an allocation framework based on a notion of acceptable health. We specifically focus on the implications of an acceptability approach for priority weighting of health benefits, derived from sufficientarian reasoning and debates.

In the remainder of this paper, section 2 first provides brief overviews of the acceptable health and sufficientarian literature, and then discusses what the two have in common and how they differ. Then, the core of this paper, section 3, discusses the normative implications of using an acceptable health approach for health care priority setting, using insights from the sufficientarian literature. Section 4 concludes.

Section snippets

Acceptable health

The notion of acceptable health is derived from the idea that some health problems may be considered to be acceptable to live with (at some stage), while others are considered to be unacceptable to live with. Hence, to some extent, non-perfect health may be a ‘normal’ part of life and ageing (Brouwer et al., 2005, Wouters et al., 2015). In health state valuations, this level of acceptable health serves as a reference point for priority setting with higher priority to benefits in people with

A sufficientarian value function

The sufficientarian approach assumes that well-being should be treated discontinuously (Benbaji, 2005, Benbaji, 2006, Shields, 2012). Fig. 1a presents a sufficientarian value-function, with wb representing well-being, V(wb) representing the societal value of well-being, and the vertical dotted line representing the threshold for sufficient well-being. There is a sudden shock in the social value of well-being at the threshold when well-being increases from an insufficient to a sufficient level.

Discussion

We investigated the notion of acceptable health from a sufficientarian perspective, focussing on the normative implications of a (sufficientarian) acceptable health approach for the priority attached to health benefits. Our analysis indicated that a sufficientarian value function has serious implications for priority weights and correspondingly, for priority setting. In addition to the differential weighting of health benefits above and below the reference level of acceptable health, with

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