When deciding what medications to publicly fund PHARMAC uses multiple decision criteria, one of which is ‘health need’. So how can we establish who needs what in healthcare?
One approach is to take the perspective of justice. What factors do we need to consider to ensure a just distribution of resources? John Rawls provides an answer to this question by inviting us to consider what kind of society we would want, but we must consider it from an original position, behind a ‘veil of ignorance’ where we do not know who we will be in this society, or what our circumstances will be like.
Rawls thinks we would come to two conclusions.
Firstly, we would want there to be rights. In the case of healthcare everyone would have a right to healthcare because no one knows from the original position whether they will be sick or healthy.
Secondly, the only inequality in healthcare that ought to be pursued is inequality that also raises the health of those who are worst off. An example of this might be colorectal cancer screening programs, which are shown to widen health inequalities, while making the worst off better off. Overall, the aim of resource distribution should be to maximize the health of those worst off. This is deduced logically, because from the original position we ask ourselves, ‘what if we were the worst off?’
Impact of Justice on Population Health
This means that logically a minimum level of health will emerge, this occurs because all health resources will be distributed in the first instance to those least well off, to raise their quality of life to the degree currently possible with existing treatments.
Resources will also be justly given to those better off, if the process raises the level of health of those least well off. For example, the colorectal screening program identified above, or perhaps other health resources that improve the health of those already well off so that they can better care for those less well off.
Once those least well off have been allocated benefits to raise them to the level of the next least well off, or once they have been allocated all existing reasonable treatments, then we move allocation to the next least well off, and so on.
What might PHARMAC do?
So, how ought PHARMAC to interpret ‘health need’ from this viewpoint on distributive justice? I raise five issues:
- PHARMAC currently considers ‘government health priorities’ – this is fair enough, provided these priorities are: (a) looming big expense items (e.g. due to demographics or epidemics), (b) aimed at addressing unjust health inequality, or (c) targeting those individuals who are living below some minimum standard of health (this is the maximizing the minimum approach favored by a Rawlsian concept of justice).
- PHARMAC currently considers the ‘availability and suitability of existing treatments’ – this is also fair enough. The concept of a minimum standard of health ought to be important here. From the original position, we would all want to ensure that those who are very unhealthy are supported towards health if possible, whereas we would be less concerned about increasing health of those already in reasonable, though not perfect health (their health need is lower). There are usually diminishing returns by continuing to spend on those already nearer to full health but more importantly this does not help those worst off.
- PHARMAC considers the ‘health need of the person’. This should be important but only in the context of the population. This is a critical qualifier. The person only has a health need if they are below the mean or minimum standard of health for the population. If they are not then they don’t have as much need, but others who are below the standard do have need.
- A further point when considering need, is that quality adjusted life years (QALYs), which are the unit of accounting used by PHARMAC to designate utility, are not sufficient measures of worthwhile life. An example illustrates the point. It might be very meaningful for a grandparent to stay alive until her great grandchild is born. This could be true even if this means living a year at low quality of life rather than 6 months at higher quality of life. The person may prefer the first situation even if it amounts to fewer QALYs. So again context is critical.
- In pursuing the logically derived minimum standard of health (deduced from an impartial original position and the health budget) then there are two important needs: (1) cure for people suffering ill health, up to the level of the next worst off, iteratively. And (2) prevention, to stop people from dropping below the minimum standard. The concept of prevention is important, and it allows for allocating resources to those who are more well off currently, because it maximizes health resources available downstream to help those least well off. Preventive need is determined by the probability and time course of dropping below the level of the least well off. Curative need is determined by the probability of success of the treatment (reasonable chances) and the magnitude of the gain (up to the point of the next least well off).
There’s a lot more to be said on distributive justice in health care as informed by a Rawlsian viewpoint. But these points are a good place to start discussion.