Abstract

Priority setting in healthcare is a highly contentious area of public decision making, in which different values often support incompatible policy options and compromise can be elusive. One promising approach to resolving priority-setting conflicts divides the decision-making process into two steps. In the first, a set of eligible options is identified; in the second, one of those options is chosen by a deliberative process. This paper considers the first step, examining proposals for identifying a set of options eligible for deliberation. It focuses on the approach proposed by Anders Herlitz, which limits deliberation to options that are on a par; neither better or worse than, nor strictly equal to the alternatives. Once these “maximal” options are identified, the choice among them is made though a deliberative process that acknowledges the difficult tradeoffs which must be made. While parity and kindred notions are clearly useful in resolving some priority-setting conflicts, this paper argues that the conflicts that arise in setting priorities make it as difficult to decide which options are on a par as it is to decide among those options. The paper draws on priority-setting debates that occurred during the recent pandemic to illustrate the challenges in identifying eligible options: There may be sharp disagreement about how to understand and individuate relevant values; about whether certain values are relevant in a priority-setting context; about how to establish parity between “consequential” and “deontic” options, and about whether one option remains on a par with others after it is modified in various ways.

中文翻译：

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医疗分配的两步法：平等对于选择合格选项有多大帮助？

摘要

医疗保健领域的优先事项设定是公共决策中一个备受争议的领域，其中不同的价值观往往支持不相容的政策选择，并且妥协可能难以捉摸。解决优先级设定冲突的一种有希望的方法是将决策过程分为两个步骤。首先，确定一组合格的选项；在第二种情况下，通过审议过程选择其中一个选项。本文考虑第一步，审查确定一组适合审议的选项的提案。它重点关注安德斯·赫利茨 (Anders Herlitz) 提出的方法，该方法将审议限制在同等的选项上；既不比替代方案更好也不差，也不严格等于替代方案。一旦确定了这些“最大”选项，就会通过一个深思熟虑的过程来做出选择，该过程承认必须做出困难的权衡。虽然平等和同类概念对于解决一些优先级设定冲突显然很有用，但本文认为，在设定优先级时出现的冲突使得决定哪些选项是同等的就像在这些选项中做出决定一样困难。本文利用最近大流行期间发生的优先事项辩论来说明确定合格选项的挑战：对于如何理解和个性化相关价值观可能存在尖锐分歧；关于某些值在优先级设置环境中是否相关；关于如何在“后果性”选项和“道义性”选项之间建立对等关系，以及一个选项在以各种方式修改后是否与其他选项保持同等。