The ethical platform for priority setting in Health Care

Swedish National Council on Medical Ethics
Date: 2009-02-19


The Council on Medical Ethics has in an opinion to the Government commented on a proposal from the National Centre for Priority Setting in Health Care, to change the ethics framework for priority setting in health care.

The Centre has proposed that the formulation of the current ethics principles is clarified and that the option to add a responsibility/liability principle is further investigated. Furthermore, it is proposed that the clear hierarchy between the ethics principles is changed.

The Council, however, rejects the proposal of the Centre and offers several arguments as to why the proposed changes should not be adopted.

The ‘ethics platform’ for priorities in health care was adopted by the parliament (Riksdagen) in 1997. It is based on the principles of human dignity, needs and solidarity, and cost-effectiveness.
The three principles have a joint ranking placing the principle of human dignity first, followed by the principle of needs and solidarity, followed by the principle of cost effectiveness. Since the principle of needs and solidarity precedes the cost-effectiveness principle, severe diseases and substantial deterioration or inequality of life should take priority over the less severe, even though treating severe conditions may cost substantially more. Hence, the principle of cost-effectiveness cannot be used to deny care or offer a lower quality of care, e.g. to the dying, severely and chronically ill, elderly, functionally disabled or others for whom delivering care would not be “profitable”.

The recommendations from 1997 also identified several ethically unacceptable principles for priority setting. High age per se cannot be grounds for prioritisation, nor can premature, low birth weight infants be subject to any form of general restrictions in care. Self-inflicted injuries should not lead to negative, special treatment since at the outset the individual might not have known about the harmful consequences of a behaviour. It is not possible to distinguish between effects of lifestyle versus inherited factors.

According to the Council the recommendations and the ranking/clear hierarchy of the principles should remain. The Centre proposed that the ranking between the principles should be equal, so called prima facie principles, which means that in each situation you have to establish the correct ranking. The Council pointed out that a platform without a ranking would not offer an appropriate guidance for decision-making in health care and the fundamental values of the ‘platform’ could be lost. The Council argues that an ‘ethics platform’ without ranking between the principles may lead to arbitrary decisions. The Council also rejects the proposal to include the principle of responsibility/liability.