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Workshop

Democracy, Technocracy and Priority Setting in Health

Through five different lectures this open workshop will discuss who should be involved in issues of health care priority setting, and how this can be legitimized.

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Workshop:

Democracy, Technocracy and Priority Setting in Health

Bergen, 26th of October, 2017, 10:00-16:15

Venue: Western Norway University of Applied Sciences, Møllendalsveien 6–8, M6-623

Participants should register to amm(at)hvl.no by Tuesday 24 of October.

 

10:00-10:15: Welcome, by Kristine Bærøe

 

10:15-11:15

Matthew McCoy, Assistant Professor, Department of Medical Ethics and Health Policy, University of Pennsylvania: Legitimacy, public engagement, and priority setting: why conceptual clarity matters 

In recent years, there has been a global push for greater levels of public engagement in health care priority setting. Among the most common justifications for public engagement is that it contributes to the legitimacy of priority setting decisions. Surprisingly often, however, the concept of legitimacy is not clearly defined by those who cite it as a justification for public engagement. This lack of clarity is not merely a matter of bad conceptual bookkeeping; it has implications for our understanding of why, when, how, and with whom public engagement in priority setting ought to be pursued. Against this backdrop, my presentation has three aims. First, in order to show that the meaning of legitimacy is far from settled, I will canvas different accounts of legitimacy that have been distinguished by political philosophers. Second, I will demonstrate that while several of these accounts provide a plausible justificatory basis for public engagement in priority setting, they are marked by consequential differences. Third, turning to the meeting’s overarching question of whether we should aim for democracies or technocracies in health care priority setting, I will show that how we understand the concept of legitimacy also has implications for how we think about the difference between democracy (rule by the people) and technocracy (rule by scientific or technical experts). Specifically, I will argue that democracy is compatible with the delegation of decision-making authority to experts. But how we define the threshold where democratic rule with expert input crosses into technocratic rule by experts depends upon the underlying account of legitimacy we assume.

 

11:15-12:15    

Kristine Bærøe Kristine Bærøe, Associate Professor, Departement of Global Public Health and Primary Care, University of Bergen, Norway: Democracy, technocracy and priority setting in health: on central values, perspectives and challenges

The aim of this presentation is three-folded. First, I will present a model that i) visualises how real world, organised, intentional priority setting in health care can occur on democratic (democracy - rule by people) and technocratic (technocracy - rule by experts) conditions respectively, and ii) demonstrates how these different versions of political governing can be seen related to each other. At the same time, the model illustrates a huge 'grey zone area' of political decision-making calling for further clarification. Second, I will make sense of this grey zone area in terms of a (preliminary) set of central values and epistemic perspectives that can shape priority-setting processes towards democracy on the one hand, or technocracy on the other. Finally, I will discuss how normatively well-justified claims on practical priority setting can - and should - be presented as narratives that explicitly address and clarify necessary trade-offs, values and epistemic perspectives the approach is based on.

 

12:15-13:15: Lunch

 

13:15-14:15

Gert Jan van der Wilt, PhD, Donders Institute for Brain, Cognition and Behaviour Radboud University Medical Centre Nijmegen, the Netherlands: Structuring public deliberations about choices in healthcare

Healthcare can be conceived as a practice through which communities express communal values (Giddens A. The Constitution of Society. Oakland (CA), 1984: University of California Press). This is a complex and dynamic process, since practices are constantly changing and multiple values are involved that can be seen as having conflicting requirements. However, logically speaking, general values cannot be conflicting per se, since they need specification in order to establish what follows from them in concrete situations (Richardson HS. Specifying norms as a way to resolve concrete ethical problems. Philos Publ Aff 1990; 19 (4):  279 – 310). Therefore, if a conflict of values is perceived, this derives from the way the relevant values have been specified. To resolve such problems, either further specification or a re-specification of one or more general norms is needed. Such a specification should adhere to a number of formal criteria and should be aimed at maximal coherence between practice and the general norms that are involved. The ability to organize and conduct this type of public deliberations can be considered as an important asset in itself (Arendt H. The Human Condition. Chicago (IL), 1958: University of Chicago Press). In this paper, we will argue that in the context of choices in healthcare, insufficient attention has been paid to how general norms can be brought to bear on concrete situations. The process of specifying norms will be illustrated, and implications for public deliberations on choices in health care will be discussed.

 

14:15-15:15

Maarten Jansen, PhD-student, Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands: Involving the public in priority setting: The organization of a citizen forum in the Netherlands

We are currently implementing a citizen forum in the Netherlands. Over the course of 3 weekends 24 citizens will discuss the value of 8 different health interventions and whether these interventions should be publically reimbursed. The Dutch National Healthcare Institute (the Dutch NICE) is involved on the sideline and interested in outcomes of the forum: what criteria, values and argumentation do citizens endorse when they have taken their time to deliberate with one-another. The idea behind the citizen forum is that it may help legitimatize decisions in the future. I will present some preliminary outcomes and observations and raise some questions with regard to how this forum is organized in relation to its goal of enhancing legitimacy of priority setting decisions in the Netherlands. In particular, it will be interesting to discuss this citizen forum in light of reflections by other presenters.

 

15:15-16:15

Ole F. Norheim, Professor, Departement of Global Public Health and Primary Care, University of Bergen, Norway: Involving the public in priority setting: Where to draw the line between medical, technical, and political questions in need of an answer?

Based on my experience with priority setting in Norway, I will reflect on the possible distinctions between medical, technical, and political questions. Who should answer them, and how can it be done? My reflections will further draw upon the distinction between the epistemic role and the legitimizing role of deliberative democracy.