Determining the parameters in social welfare function using stated preference data: an application to health

Title: Determining the parameters in social welfare function using stated preference data: an application to health
Authors: Dolan, Paul and Tsuchiya , Aki
Publisher: Applied economics, pp. 1466-4283
ISSN: 0003-6846
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Abstract: One way in which economists might determine how best to balance the competing objectives of efficiency and equity is to specify a social welfare function (SWF). This paper looks at how the stated preferences of a sample of the general public can be used to estimate the shape of the SWF in the domain of health benefits. The results suggest that it is possible to determine the parameters in a social welfare function from stated preference data, but show that people are sensitive to what inequalities exist and to the groups across which those inequalities exist.

The social welfare function and individual responsibility: some theoretical issues and empirical evidence

Title: The social welfare function and individual responsibility: some theoretical issues and empirical evidence
Authors: Dolan, Paul and Tsuchiya , Aki
Publisher: Journal of health economics, 28 (1). pp. 210-220
ISSN: 0167-6296
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Abstract: The literature on income distribution has attempted to evaluate different degrees of inequality using a social welfare function (SWF) approach. However, it has largely ignored the source of such inequalities, and has thus failed to consider different degrees of inequity. The literature on egalitarianism has addressed issues of equity, largely in relation to individual responsibility. This paper builds upon these two literatures, and introduces individual responsibility into the SWF. Results from a small-scale study of people’s preferences in relation to the distribution of health benefits are presented to illustrate how the parameter values of a SWF might be determined.

Equality of what in health? Distinguishing between outcome egalitarianism and gain egalitarianism

Title: Equality of what in health? Distinguishing between outcome egalitarianism and gain egalitarianism
Authors: Tsuchiya, Aki and Dolan, Paul
Publisher: Health economics, 18 (2). pp. 147-159
ISSN: 1057-9230
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Abstract: When deciding how to weigh benefits to different groups, standard economic models assume that people focus on the final distribution of utility, health or whatever. Thus, an egalitarian is assumed to be an egalitarian in the outcome space. But what about egalitarianism in the gains space, such that people focus instead on how equally benefits are distributed? This paper reports on a study in which members of the public were asked to rank a number of health programmes that differed in the distribution of benefits and final outcomes in ways that enabled us to distinguish between different types of egalitarianism. The results suggest that outcome egalitarianism dominates, particularly for differences in health by social class, but a sizeable minority of respondents appear to be gain egalitarians, especially when the health differences are by sex. These results have important implications for how we think about outcome-based social welfare functions in economics.

Examining the attitudes and preferences of health care decision-makers in relation to access, equity and cost-effectiveness: a discrete choice experiment

Title: Examining the attitudes and preferences of health care decision-makers in relation to access, equity and cost-effectiveness: a discrete choice experiment
Authors: Ratcliffe , Julie and Bekker , Hilary L. and Dolan , Paul and Edlin, Richard
Publisher: Health policy, 90 (1). pp. 45-57
ISSN: 0168-8510
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Abstract: To describe the views of health care decision-makers and providers operating in the UK National Health Service (NHS) concerning the concepts of cost-effectiveness, equity and access through a series of attitudinal questions; to evaluate the preferences of health care providers in relation to each of these concepts using a discrete choice experiment (DCE); to assess the impact of prior completion of an attitude questionnaire on preferences elicited through a DCE.

Do NHS clinicians and members of the public share the same views about reducing inequalities in health?

Title: Do NHS clinicians and members of the public share the same views about reducing inequalities in health?
Authors: Tsuchiya , Aki and Dolan, Paul
Publisher: Social science & medicine, 64 (12). pp. 2499-2503
ISSN: 0277-9536
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Abstract: Decisions about how to allocate resources in health care are as much about social value judgements as they are about getting the medical facts right. In this context, it is important to compare the social preferences of members of the general public with those of National Health Service (NHS) staff involved in service delivery. A questionnaire eliciting peoples’ preferences over maximising life expectancy and reducing inequalities in life expectancy between the highest and lowest social classes was completed by 271 members of the UK public and 220 NHS clinicians. The two samples have different preferences with the general public showing a greater willingness than clinicians to sacrifice total health for a more equal distribution of health. These differences may highlight tensions between what the public wants and what clinicians want, and should be subject to further investigation.

It ain’t what you do, it’s the way that you do it: characteristics of procedural justice and their importance in social decision-making

Title: It ain’t what you do, it’s the way that you do it: characteristics of procedural justice and their importance in social decision-making
Authors: Dolan, Paul and Edlin, Richard and Tsuchiya , Aki and Wailoo, Allan
Publisher: Journal of economic behavior & organization, 64 (1). pp. 157-170
ISSN: 0167-2681
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Abstract: Standard welfare economic analysis evaluates all actions by their consequences. However, evidence from other disciplines suggests that the procedures by which decisions are made also affects the welfare of individuals. This paper outlines six characteristics on which judgements about procedural justice may be based. Using the example of health care rationing, we examine the importance of each characteristic using qualitative and quantitative methods. We further consider the importance of each of these characteristics relative to one another and examine whether they are important for consequential or non-consequential reasons.

Health priorities and public preferences: the relative importance of past health experience and future health prospects

Title: Health priorities and public preferences: the relative importance of past health experience and future health prospects
Authors: Dolan, Paul and Tsuchiya , Aki
Publisher: Journal of health economics, 24 (4). pp. 703-714
ISSN: 0167-6296
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Abstract: We explore people’s choices where the preference for those with worse future health prospects and the preference for the young over the old conflict. The empirical study used scenarios with four attributes: past years, past health, future years without treatment, and future health without treatment. One hundred respondents ranked various patient groups described in these terms. The results suggest a strong effect of past years: younger groups (40-year-olds) were always chosen over older ones (60-year-olds). Past health was significant in one question but not the other and future health and years without treatment were both non-significant

Procedural justice in public health care resource allocation

Title: Procedural justice in public health care resource allocation
Authors: Dolan, Paul and Tsuchiya , Aki and Miguel, Luis and Edlin, Richard and Wailoo, Allan
Publisher: Applied health economics and health policy, 4 (2). pp. 119-127
ISSN: 1175-5652
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Abstract: Introduction: The legal studies literature on procedural justice identifies six key characteristics of procedural justice: accuracy, consistency, impartiality, reversibility, transparency and voice. However, the relative importance of these in the context of public healthcare resource allocation is unclear, as is whether they are valuable instrumentally (because it contributes to better outcomes) or inherently (for its own sake). Methods: A survey of 80-odd members of the UK public determined the following: the ranking of all the six characteristics; the pairwise comparisons of the characteristics; and whether each characteristic was important for instrumental reasons, for intrinsic reasons or for both. Results: Respondents ranked the procedures in the order of accuracy, consistency, impartiality, reversibility and transparency. Procedural justice was valued for both instrumental and inherent reasons. Discussion/conclusion: A robust ranking of five of the six procedural characteristics was found. The ranking for voice was sensitive to the question format, which has methodological implications. Around a quarter to a third of respondents regarded a procedural characteristic to have entirely intrinsic value.

A note on a discussion group study of public preferences regarding priorities in the allocation of donor kidneys

Title: A note on a discussion group study of public preferences regarding priorities in the allocation of donor kidneys
Authors: Dolan, Paul and Shaw, Rebecca
PublisherHealth policy, 68 (1). pp. 31-36
ISSN: 0168-8510
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Abstract: Objective: To explore whether and how people wish to give differential priority based on certain characteristics of the potential recipient of a donor kidney. Design: A random sample of people resident in York was invited to attend two focus group meetings each, a fortnight apart. Setting: The City of York. Participants: Twenty-three randomly chosen people meeting in four groups of five or six. Main outcome measures: Those factors that people think should be taken into account when allocating donor kidneys, in addition to the expected benefits from transplantation. Results: People are willing and able to distinguish between potential recipients of a kidney transplantation according to a range of characteristics beyond the expected benefits from treatment. There is a clear consensus across the four groups that one of the most important considerations is what will happen to the patient without treatment, and so priority is given to those with a poor prognosis. There is also a strong view that priority should be given to younger patients and to those with dependants. The time spent waiting for a transplant is also important, but less so. Conclusions: A sample of the general public, after discussion and debate, wish to take account of a number of patient characteristics when allocating donor kidneys. There is some degree of consensus about what these factors should be and this suggests that it might be possible to develop a set of guidelines for the allocation of donor kidneys.

The moral relevance of personal characteristics in setting health care priorities

Title: The moral relevance of personal characteristics in setting health care priorities
Authors: Olsen, Jan Abel and Richardson, Jeff and Dolan, Paul and Menzel, Paul
Publisher: Social science & medicine, 57 (7). pp. 1163-1172
ISSN: 0277-9536
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Abstract: This paper discusses the moral relevance of accounting for various personal characteristics when prioritizing between groups of patients. After a review of the results from empirical studies, we discuss the ethical reasons which might explain–and justify–the views expressed in these studies. The paper develops a general framework based upon the causes of ill health and the consequences of treatment. It then turns to the question of the extent to which a personal characteristic–and the eventual underlying ethical justification of its relevance–could have any relationships to these causes and consequences. We attempt to disentangle those characteristics that may reflect a potentially relevant justification from those which violate widely accepted principles of social justice.

A note on the relative importance that people attach to different factors when setting priorities in health care

Title: A note on the relative importance that people attach to different factors when setting priorities in health care
Authors: Dolan, Paul and Shaw, Rebecca
Publisher: Health expectations, 6 (1). pp. 53-59
ISSN: 1369-6513
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Abstract: Objective To explore whether and to what extent people wish to give differential priority when asked to choose between providing health care treatment for different individuals or groups, on the basis of a range of factors, ranging from health gain to the number of dependants a person has. Design A sample of people resident in York self-completed a questionnaire. Setting The City of York. Participants Twenty-three members of the general public and 29 undergraduate students. Main outcome measures The relative importance of factors that people think should be taken into account when choosing between providing health care treatment for individuals or groups. Results The results suggest that health gain and the consequences for health without treatment are two of the most important considerations. Conclusions A sample of the general public and undergraduate students wish to take account of a number of personal characteristics when setting priorities in health care.

Measuring people’s preferences regarding ageism in health: some methodological issues and some fresh evidence

Title: Measuring people’s preferences regarding ageism in health: some methodological issues and some fresh evidence
Authors: Tsuchiya , Aki and Dolan, Paul and Shaw, R.
Publisher: Social science & medicine, 57 (4). pp. 687-696
ISSN: 0277-9536
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Abstract: In this paper, we outline the three main concepts of ‘ageism’; health maximisation ageism, productivity ageism, and fair innings ageism. We provide a methodological overview of the existing empirical literature on people’s preferences regarding age and classify these studies according to the types of questions that have been asked. We consider some of the methodological issues involved in eliciting preferences regarding ageism and propose using a fixed duration of benefit rather than, as some studies have done, a benefit that lasts for a full lifetime. Informed by this discussion, we present the results from our own empirical study, carried out in the UK, which combines qualitative and quantitative methods to explore the reasons people have for choosing one age over another. In so doing, we are able to consider the extent to which respondents might bring extraneous factors to bear on their responses and/or disregard relevant information (such as that relating to the fixed nature of the benefit). The results suggest that people are broadly in favour of giving priority to younger over older people, based on arguments relating to both productivity ageism and fair innings ageism. However, respondents appear to assume that a benefit would last for a full lifetime (even if they are told to assume a fixed benefit), unless they are asked to consider a ‘full-life’ benefit first. This particular framing effect has important implications for preference elicitation studies, suggesting that if you want people to answer the question you have in mind, first ask them the question you think they may have in mind.

The person trade-off method and the transitivity principle: an example from preferences over age weighting

Title: The person trade-off method and the transitivity principle: an example from preferences over age weighting
Authors: Dolan, Paul and Tsuchiya , Aki
Publisher: Health economics, 12 (6). pp. 505-510
ISSN: 1057-9230
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Abstract: The person trade-off (PTO) is increasingly being used to elicit preferences in health. This paper explores the measurement properties of the PTO method in the context of a study about how members of the public prioritise between patients of different ages. In particular, it considers whether PTO responses satisfy the transitivity principle; that is, whether one PTO response can be inferred from two other PTO responses. The results suggest that very few responses to PTO questions satisfy cardinal transitivity condition. However, this study has produced results that suggest that cardinal transitivity will hold, on average, when respondents who fail to satisfy the ordinal transitivity condition have been excluded from the analysis. This suggests that future PTO studies should build in checks for ordinal transitivity.

An inquiry into the different perspectives that can be used when eliciting preferences in health

Title: An inquiry into the different perspectives that can be used when eliciting preferences in health
Authors: Dolan, Paul and Olsen, Jan Abel and Menzel, Paul and Richardson, Jeff
Publisher: Health economics, 12 (7). pp. 545-551
ISSN:  1057-9230
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Abstract: There are a number of perspectives that an individual could be asked to adopt in studies designed to elicit preferences for use in informing resource allocation decisions in health care. This paper develops a conceptual framework that clearly distinguishes between six different perspectives. It is argued that the appropriate perspective to use depends on normative considerations and the particular policy context to which it will be applied. We suggest a future research agenda that explicitly addresses these considerations and which involves direct empirical investigation into the effect of perspective on preferences.

The measurement of preferences over the distribution of benefits: the importance of the reference point

Title: The measurement of preferences over the distribution of benefits: the importance of the reference point
Authors: Dolan, Paul and Robinson, Angela
Publisher: European economic review, 45 (9). pp. 1697-1709
ISSN: 0014-2921
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Abstract: This paper uses the Atkinson method, which was initially developed to measure the shape of the social welfare function (SWF) in the domain of income, to measure the shape of the SWF with respect to the distribution of health benefits. Two separate studies were conducted involving a total of 71 respondents. A comparison of the results across the two studies suggests that reference point effects play an important role in determining responses. Thus, more research is needed on the role that reference point effects ought to and do play in determining the nature and extent of the efficiency – equity trade-off before the results of studies of this kind can be interpreted as ‘equity parameters’ which may simply be ‘plugged into’ an appropriately specified SWF.

Equity in health: the importance of different health streams

Title:  Equity in health: the importance of different health streams
Authors: Dolan, Paul and Olsen, Jan Abel
Publisher: Journal of health economics, 20 (5). pp. 823-834
ISSN: 0167-6296
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Abstract: This paper develops a conceptual framework in which preferences about the distribution of future health gains depend on differences in four ‘health streams’. These are as follows: (1) the amount of health to be gained; (2) the no-treatment profiles; (3) the amount of health experienced thus far; and (4) the amount of health gained previously as a result of public health interventions. This classification puts the well-established concerns for severity (stream 2) and age weights (stream 3) into a more complete analytical framework. Stream 4 has not been discussed to date and the paper suggests some moral arguments about the distributive relevance of this stream of health.

A qualitative study of the extent to which health gain matters when choosing between groups of patients

Title: A qualitative study of the extent to which health gain matters when choosing between groups of patients
Authors: Dolan, Paul and Cookson, Richard
Publisher: Health Policy, 51 (1). pp. 19-30
ISSN: 0168-8510
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Abstract: There is considerable debate about the appropriateness of allocating health care resources on the basis of the size of the health improvement that they generate. The aim of this study was to elicit the general public’s views about the extent to which health gain matters vis-à-vis other considerations. A total of 60 respondents took part in group discussions designed to enable them to raise, discuss, and reflect upon, different arguments. The qualitative data showed that many responses were being generated by factors that were not directly included in the questions, and so it is difficult to meaningfully interpret the results of other studies which have asked similar questions but which have not looked at the reasons underlying the responses. However, a clear message did come through from the data; namely, that equality of access should prevail over the maximisation of benefits. However, this was subject to the outcome constraint that treatments are sufficiently effective. An important question for future research, then, is ‘how effective do treatments have to be for the principle of equal access to apply?’

Principles of justice in health care rationing

Title: Principles of justice in health care rationing
Authors: Cookson, Richard and Dolan, Paul
Publisher: Journal of medical ethics, 26 (5). pp. 323-329
ISSN: 0306-6800
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Abstract: This paper compares and contrasts three different substantive (as opposed to procedural) principles of justice for making health care priority-setting or “rationing” decisions: need principles, maximising principles and egalitarian principles. The principles are compared by tracing out their implications for a hypothetical rationing decision involving four identified patients. This decision has been the subject of an empirical study of public opinion based on small-group discussions, which found that the public seem to support a pluralistic combination of all three kinds of rationing principle. In conclusion, it is suggested that there is room for further work by philosophers and others on the development of a coherent and pluralistic theory of health care rationing which accords with public opinions.

Public views on health care rationing: a group discussion study

Title: Public views on health care rationing: a group discussion study
Authors: Cookson, Richard and Dolan, Paul
Publisher: Health policy, 49 (1-2). pp. 63-74
ISSN: 0168-8510
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Abstract: This small-scale study develops a new methodology for investigating which ethical principles of health care rationing the public support after discussion and deliberation. In ten groups of about six people, members of the public are asked to discuss a hypothetical rationing choice, concerning four identified patients who are described in general terms but without detailed information. It is explained to respondents that the purpose of the exercise is to find out what general ethical principles they support. Discussions are chaired by an academic specialising in health policy, whose role is to encourage debate but not actively to participate. On the basis of an innovative qualitative data analysis, which translates what people say into ethical principles identified in the theoretical literature, the public appear to support three main rationing principles: (1) a broad ‘rule of rescue’ that gives priority to those in immediate need, (2) health maximisation and (3) equalisation of lifetime health. To our knowledge, this pluralistic viewpoint on rationing has never been developed into a coherent theoretical position, nor into a quantifiable model that health care managers can use for guidance.

Effect of discussion and deliberation on the public’s views of priority setting in health care: focus group study

Title: Effect of discussion and deliberation on the public’s views of priority setting in health care: focus group study
Authors: Dolan, Paul and Cookson, Richard and Ferguson, Brian
Publisher: British medical journal, 318 (7188). pp. 916-919
ISSN: 0959-8138
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Abstract: Objective: To investigate the extent to which people change their views about priority setting in health care as a result of discussion and deliberation. Design: A random sample of patients from two urban general practices was invited to attend two focus group meetings, a fortnight apart. Setting: North Yorkshire Health Authority. Subjects: 60 randomly chosen patients meeting in 10 ugroups of five to seven people. Main outcome measures: Differences between people’s views at the start of the first meeting and at the end of the second meeting, after they have had an opportunity for discussion and deliberation, measured by questionnaires at the start of the first meeting and the end of the second meeting. Results: Respondents became more reticent about the role that their views should play in determining priorities and more sympathetic to the role that healthcare managers play. About a half of respondents initially wanted to give lower priority to smokers, heavy drinkers, and illegal drug users, but after discussion many no longer wished to discriminate against these people. Conclusion: The public’s views about setting priorities in health care are systematically different when they have been given an opportunity to discuss the issues. If the considered opinions of the general public are required, surveys that do not allow respondents time or opportunity for reflection may be of doubtful value.

The measurement of individual utility and social welfare

Title: The measurement of individual utility and social welfare
Author: Dolan, Paul
Publisher: Journal of health economics, 17 (1). pp. 39-52
ISSN: 0167-6296
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Abstract: It has been suggested by a number of economists that decisions about how to allocate scarce health care resources should be informed by the cost per quality-adjusted life-years (QALYs) of the different alternatives. One of the criticisms of the QALY approach is that it is based on the measurement of individual utility; yet the values elicited are used to inform social choice. In this respect, it is argued that the QALY approach fails to take account of distributional issues that are known to be important in the context of health care. This paper addresses this issue and presents an approach grounded in microeconomic theory that is flexible enough to deal with a wide range of efficiency-equity trade-offs, while making the nature of the trade-off transparent. In addition, it is an approach that is relatively simple to investigate empirically, and the results of a preliminary study are presented as illustration of this.