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Article Excerpt
Imagine you are the CEO of a hospital [...]. Decisions are constantly being made in your organization about how to spend the organization's money. The amount of money available to spend is never adequate to pay for everything you wish you could spend it on, therefore you must set spending priorities. There are two questions you need to be able to answer ... How should we set priorities in this organization? How do we know when we are doing it well?
When people seek to achieve good public policy, the result will tend to be good public policy. In a collective choice process, public-spirited individual participants produce good public policy by deliberating--talking with each other, listening to each other's arguments, and being willing to learn and change their minds based on such dialogue.--Steven Kelman (1992: 181)
Before beginning, there is one caveat for the professional philosopher. Rather than operating in the airy heights of ideal theory, wherein the subject-matter is appreciated under best-possible conditions (e.g., Habermas's ideal discourse situation or Rawls's original position), my argument is situated instead on what might be called the 'tree-tops' of non-ideal theory, wherein the subject-matter is examined under more realistic conditions, or what might be called 'moderate feasibility constraints'. Institutional design and non-ideal theory are areas that, I believe, are ripe for philosophical inquiry. (1)
Health Care Priority Setting--Consultative or Deliberative?
In the past decade, policy scholars have reached a general consensus that eliciting the views of the public is an ethical requirement for making health care rationing decisions. (2)
Reaching out to the affected public is important because (i) rationing involves difficult value choices that members of the affected public are better suited to make than policy analysts and (ii) the process of eliciting public input tends to increase popular support for eventual rationing policies. (3) Investigations of best practices, as mentioned, usually recommend either (i) consultation or (ii) deliberation. (4)
Consultation, or the 'technocratic approach', requires that policy analysts survey raw opinion, measure public values, and then factor this information into a decision-making formula--for instance, into a cost-utility analysis or Quality of Life Years (QALY) assessment. (5) In these one-way consultations, data is gathered through various tools and in multiple contexts, including opinion polls, mail/phone surveys, focus groups, citizen hearings and even town hall meetings. (6) For instance, a phone survey conducted in Brant County, Ontario (Canada), sought to determine how residents would rank the following health concerns in order of priority for action: (i) teen pregnancy rates, (ii) heart disease, (iii) lung disease, (iv) injuries, and (v) mental illness. (7) The limitation of this approach is three-fold. First, the opinions surveyed typically remain ill-informed. Second, the values measured are often the byproducts of an 'echo chamber' effect, that is, the public merely parrots or echoes elite and media-dominated views. Finally, if the factors used to model public values are complex and the process transparent, then the outcome will be underdetermined by the theory and the data, thus giving way to competing interpretations and an indeterminate profile of the public's views. (8) So, given the irrational and indeterminate nature of the consultative process, critics can reasonably challenge whether the resulting public input should be the final arbiter in allocating health care resources. As a consequence, these charges of irrationality and indeterminacy tend to undermine the legitimacy of the technocratic approach. (9)
Scholars favoring deliberation, or the 'participatory approach', demand that policy-makers do more than merely consult with those who are affected by priority-setting decisions. They should also assist the public in developing informed judgments about policy options in a two-way process of education, inquiry and discourse. The decision to elicit public input via deliberation rather than consultation is, according to some participatory policy scholars, equivalent to the decision to appeal to an "active, engaged citizen" rather than a "passive recipient of information" (Abelson, Forest et al., 2003: 240). Borrowing from the deliberative democracy literature, particularly their coveted notion of public justification, the inventors of the "accountability for reasonableness" framework propose that rationing decisions should abide by four standards: (i) relevance, or that the rationale for the decision should be generally acceptable, (ii) publicity, or that the public should have access to the decision process, (iii) appeals, or that there should be a procedure to criticize and revise the decision, and (iv) enforcement, or that there should be a way to ensure that the first three standards are met. (10)
Deliberative methods for eliciting public input tend to be more rational and legitimate than consultative ones because of the former's dual focus on the process as well as the product, the justification as well as the outcome, of the policy cycle. The design of deliberative policy forums vary considerably, from citizens' juries and panels to planning cells, from deliberative polls to consensus conferences. (11) In citizens' juries convened to set health care priorities, a random sample of twelve to twenty-four community members hear testimony from the affected public, policy analysts and health care experts; then, they question these witnesses; next, they partake in extended inquiry and discussion about a slate of policy options; and finally, they decide on an appropriate rationing policy. (12) Rather than dictate policy outcomes, policy analysts typically provide deliberative bodies with tools to evaluate and rank health care programs and procedures. For example, in the early 1990s, drafters of the Oregon Health Plan tasked citizen deliberators to prioritize medical treatments covered by Medicare, relying on a 'reasonableness' test with six criteria: (i) the consequences for public health, (ii) the cost of treatment, (iii) the incidence rate of the medical condition to be treated, (iv) the efficacy of the treatment, (v) the social costs, and (vi) the costs associated with non-treatment. (13)
Although many objections have been leveled at the deliberative model (e.g., it ignores feasibility constraints, masks power differentials and breeds groupthink), one stands out as particularly devastating in the policy context: Ordinary citizens lack the cognitive resources to engage in the level of deliberation (both in terms of intensity and duration) required for evaluating and ranking health care programs and procedures. (14) This kind of activity is usually sequestered to policy analysts, clinicians and heath care administrators. The U.S. Circuit Court judge, economist and legal academic, has argued that we should be skeptical of modeling the policymaking process after a "faculty workshop." For a "faculty workshop...
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