Setting priorities for the elderdly in health care: Ethical, political and social aspects
Format
Completed research project
Key Words
Health care rationing, prioritization, ethics, old age
Time table
The project started in March 1999 and was completed in December 2003.
Financial support
The Swedish Foundation For Health Care Sciences and Allergy Research (Vårdalstiftelsen), the Uppsala County Council and Uppsala Municipality and the National Centre for Priority Setting (Prioriteringscentrum) in Linköping.
Objectives
To identify and describe different settings of priority decision-making in the Swedish health care system and analyze it's social, political and ethical consequences with special regard to the elderly.
Brief Description
The need for well-informed priorities in Swedish health care has increased since the 1990’s. This development is due to different factors, such as the advances made in biotechnology, which has raised expectations in health care. But also demographic changes, in particular, the increase in the ranks of the elderly, are expected to put pressure on available health- care resources. Finally, political and economic developments have been marked by increasing demands and diminishing allocations for health care.
According to the ethical platform approved by the Swedish Parliament in 1997, three ethical principles should guide priority-setters on all levels: the principle of human dignity, the principle of need and solidarity, and the cost-benefit principle. Following these guidelines, chronological age is not a valid ground for priority setting, as it would violate the principle of human dignity. According to several sources, however, there is a growing conflict between the ageing of the population and the allocations available to provide good medical care.
Against this background, a study of how prioritization in health care affects senior citizens was initiated in 1999. In the project, the priority-setting process is assessed with regard to its ethical, political and social aspects. Decision making on health care rationing is taking place at several levels: the clinical, the political-administrative and the national level. All these levels are addressed in the project. Concerning the ethical aspects of priority setting, the main purpose in the investigation was to unveil the professional moral competence of doctors and nurses in their daily treatment of difficult ethical dilemmas in general and priority setting in particular. This was reached through an empirical study consisting of open interviews made with narrative methodology. The empirical data was analysed in relation to the ethical guidelines given on a national level. One important aim of the study was to investigate whether the health care givers have a ”tacit moral knowledge” in their every day work and whether the national guidelines for prioritisation are of any help in priority setting on the clinical level. The results point to a gap between ethical principles and moral competence. For example, the informants do set priorities based on chronological age, which they justify through a justice argument, namely that “it is not fair if some people live for only 50 years”. The conclusion of the study is that we need to make the health care providers’ moral competence more conscious, which require supporting structures for example in the form of ethical discussion forum or case rounds in hospital clinics.
A general assumption in the sociological study is that different actors argue about priority setting and the aged in different ways, and further, that their argumentation reflects their specific cultural and organizational affiliation and their compliance with its norms and values. One of the empirical studies concerns a decision-making process regarding cost reductions in a hospital, and is thus a study of health-care rationing and priority setting on the political-administrative level. The actors in this study are politicians, the medical profession and the administration. The analysis is based on the written documents produced during the decision process by these actors. One of the results is that the politicians and the medical profession in general differ in their rhetoric and argumentation, implying different views of the patients. Their specific argumentation is seen as inclusive to members of their own category, possibly facilitating acceptance of their own suggestions. At the same time, the argumentation might be seen as exclusive to people outside of that category. Another study is focused on the municipal level. The analysis is based on in-depth interviews with administrative staff and nurses working with the aged. These two categories are central for decisions regarding which people will be allowed to move to nursing homes. The interviews cover several aspects, e.g., the informants’ understanding of concepts such as ageing, rehabilitation and priority setting.
The point of departure in the political science part of the project is a comparison between two regional bodies, Östergötland and Uppsala. Östergötland is the only county council that so far in Sweden has managed to move in a direction where the political body takes responsibility for priority setting. A list of non-prioritised diagnoses was presented by the county council in the autumn of 2003. Uppsala represents the opposite. How can this variation in the outcome of the regional bodies be explained? The hypothesis investigated in the study suggests that it is a difference in trust and confidence within the regional bodies’ leading groups – the politicians, the professionals and the administrators – that explains the larger capacity of Östergötland to conduct “risk politicies”. Intraorganisational trust is defined as a capacity to listen to the arguments of others, to respect and understand each others’ different roles and identities in the organisation and a mutually shared will to take responsibility. Intra-organisational trust is a desired and highly beneficial capacity to lead the county council forward. To cerate this kind of trust the organisation of decision-making concerning priority-setting is crucial.
Scientific publications
Bennich-Björkman L, Förutsättningar för politiska prioriteringar i offentlig sjukvård – en jämförelse mellan landstingen i Östergötland och Uppsala. Linköping: PrioriteringsCentrums rapportserie, 2004:2.
Hammarström G, Ekonomi och etik: Argumentering vid besparingar inom sjukvården i ljuset av Prioriteringsutredningen. PrioriteringsCentrums Rapportserie 2003:4, Linköping ISSN 1650-8475
Hammarström G, Trygghet och omvårdnadsbehov: Förhållningssätt och frågeställningar om prioriteringar och kriterier för särskilt boende. Linköping: PrioriteringsCentrums Rapportserie 2004:7.
Hansson MG, Justice and solidarity with the old – two complementary moral concerns in health care, in: Matthews E (ed.), A Crisis of Aging, Nuffield Report (In press).
Höglund AT, Reflektioner över etik och prioriteringar i vården – intervjuer med vårdpersonal, (Reflections on Ethics and Priority Setting in Health Care – Interviews with Health Care Providers), Rapport 2003:7, Linköping: Prioriteringscentrum, 2003, 86 pp.
Höglund AT, Inga lätta val. Om riktlinjer och etisk kompetens vid prioriteringar i vården. En studie i empirisk etik. ( No Easy Choices. On Guidelines and Ethical Competence in Priority Setting in Health Care. A Study in Empirical Ethics), Uppsala Studies in Faiths and Ideologies 15. Uppsala: Acta Universitatis Upsaliensis 2005. 176 pp.
Miscellaneous
Meeting with reference-group comprised of representatives from County- and municipal councils, April 1999.
Meeting on priorities with the Uppsala County Council Board, Autumn 2001.
Project group participated in seminar arranged by the Priority delegation (Proriteringsdelegationen) "Prioriteringar i hälso- och sjunkvården - Internationella erfarenheter", Stockholm, January 2000.
Anna T. Höglund keynote speaker at Läkemedelskongressen, Stockholm, 10 oktober 2001 on "Inga lätta val. Etiska aspekter på prioriteringar inom hälso- och sjukvården."
Project group participation in the seminar "Kommunerna och prioriteringar i vård och omsorg", arranged by Pioriteringscentrum, Stockholm, January 24, 2002.
Anna T. Höglund keynote speaker at the seminar "Etiken i sjukvårdsekonomin - var finns den?". Akademiska barnsjukhuset, Uppsala, April 12, 2002. Arranged by Barnsjukhusets etikråd.
Anna T. Höglund moderated the press-seminar "Vem ska vården inte vårda när resurserna krymper?" Arranged by the department for information at Akademiska sjukhuset, Uppsala. UAS, May 20, 2003.
Co-operation and seminar exchanges with a research group at the University of Aberdeen, led by Professor Eric Matthews and Professor Elisabeth Russel.
Anna T. Höglund member of the planning committee for the VI Annual Swedish Symposium on Biomedince, Ethics and Society, "Just Health Care", Sandhamn Hotell & Konferens, 24-25 May 2004. The programme symposium was planned to adress questions pertinent to the project and served as final project seminar.
Anna T. Höglund keynote speaker at the VI Annual Swedish Symposium on Biomedince, Ethics and Society, "Just Health Care", Sandhamn Hotell & Konferens, 24-25 May 2004.
Contact and more information
- Anna T. Höglund, Associate Professor, Senior Lecturer
Project Group
Mats G Hansson, Professor of Biomedical Ethics
Anna T. Höglund, Associate Professor, Senior Lecturer
Gunhild Hammarström, Professor
Department of Sociology, Uppsala University
Li Bennich Björkman, Professor
Department of Political Science, Uppsala University
Reference group
Harriet Bohman, MAS Ansvarig
Municipality of Uppsala
Lena Kilander, MD
Geriatrics, Uppsala University Hospital
Eva Lantz, MD
Geriatrics, Uppsala University Hospital
Birgitta Lindahl, MD
Geriatrics, Uppsala University Hospital
Ingvar Sjögren
County Council of Uppsala
Karin Lund, Consultant
Prioriteringscentrum, Linköping
International Collaborators
Vilhjalmur Arnason, Professor
Department of Philosophy, University of Iceland
Kenneth Boyd, Professor
Institute of Medical Ethics, Edinburgh University
Sandra Marshall, Professor
Department of Philosophy, University of Stirling
Eric Matthews, Professor
Department of Philosophy, University of Aberdeen
Elisabeth Russel, Professor
Department of Public Health, University of Aberdeen
Iain Torrance, Professor
Department of Divinity and Religious Studies
University of Aberdeen
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