It seems important to study public values regarding priority setting principles, but why exactly?

By Erik Gustavsson and Lars Lindblom.

If you visit a conference or workshop on priority setting there will most certainly be several slots on empirical studies exploring public values about principles for priority setting. Over the last 20 years, there has been numerous such studies, and the interest among researchers to perform such studies accentuated during the pandemic. If you attend one of these slots and stay around for the discussion you will notice that questions and comments tend to focus on methodological design. Indeed, these issues are of general importance for the research community – but why are the results from these studies relevant? If you have some background in ethics you might, for example, wonder what weight should be ascribed to these studies when making moral judgments about how priority setting should be done. When one faces this question, one may start to reason along the following lines.

On the one hand, public values cannot reasonably tell the whole story about the ethical question: how scarce health care resources should be distributed. For example, suppose a majority in your country believe that people with red hair should be denied intensive care. Such a conclusion seems counterintuitive, to say the least. The mere fact that people express discriminatory views cannot reasonably have anything to do with the moral rightness of such views. On the other hand, public values cannot reasonably have nothing to say about how scarce resources should be distributed. This seems especially strange in a democratic society. Some people think that this discussion can stop here. The conclusion is quite straightforward they say: public values carry some weight for the moral question about how resources should be distributed. We found it difficult to accept this conclusion.

Therefore, we went back to Rawls’ notion of reflective equilibrium. Drawing on these Rawlsian ideas, we discuss the relevance and roles that empirical studies may plausibly have for the justification of principles for priority setting. Our paper develops a framework that can articulate these different roles in relation to empirical studies of public values and make explicit how different empirical results may have different implications for justification.

The framework distinguishes between four steps in the reflective equilibrium process: i) filtering moral judgements, ii) formulating principles, iii) working back and forth between (i) and (ii), and iv) from the individual to the social.

We also realized that it adds to the richness of the framework to distinguish between the content of moral judgements and the process according to which people arrive at those judgements. Four times two is eight which gave us a matrix of eight positions. Accordingly, there are at least eight different ways in which empirical studies of moral judgment may have relevance for moral justification.

With this matrix in hand, we show, for all eight of the positions in this matrix, how empirical results can inform moral deliberation. This, in turn, indicates several perhaps surprising ways that ethicists should be interested in empirical results. For instance, empirical research on the content of peoples’ judgements regarding priority setting forms input into the process of moral deliberation. Moreover, empirical work with relevance for the process of formulating principles will be important for that stage of the reflective equilibrium process. The matrix also suggests a number of interesting avenues for empirical researchers to pursue in order to enrich normative work on priority setting. For instance, empirical research on possible propensities to commit fallacies in the process of working back and forth between judgements and principles regarding priority setting would potentially seem very useful. Moving from the individual to the social level, further work on the content of social equilibria regarding priority setting would also seem highly important. The answer, then, to the question of why it would be important to study public values regarding priority setting principles is that empirical results play important roles at all levels of moral deliberation.


Title of paper: Justification of principles for health care priority setting – the relevance and roles of empirical studies exploring public values

Authors: Erik Gustavsson [1, 2], Lars Lindblom [1],

  1. Division of Philosophy and Applied Ethics, Department of Culture and Society; Linköping University, Sweden.
  2. The National Centre for Priorities in Health, Department of Health, Medicine and Caring Sciences, Linköping University, Sweden.

Competing interests

The authors declare that they have no competing interests.

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