Dear Editor,
Regarding aging of modern societies, policy techniques often obscure the ethical and value issues at stake in elderly health care plans. In response to the published letter in the previous issue of Indian Journal of Pathology and Microbiology (IJPM) related to the Dr. Suguna Anbazhagan viewpoint about economic evaluation of health care in older people,[1] in addition to economic terms, there are some ethical values that should be considered in policy making for the elderly health care program.
Policy making and planning for elderly health care is an ethical issue of public health which requires balancing and justifying moral norms based on an ethical framework. Regarding shortcomings of principlism framework to address ethical issue of public health, we suggest applying practical public health ethical frameworks for legitimate and fair decision making. Effectiveness is a main moral norm in public health policy that explores the produced utility by balancing and maximizing the benefits over financial and non-financial burdens.[2] The quality-adjusted life years (QALYs) usually counts as the index of cost-effectiveness analysis in public health policy,[3] but it includes some weaknesses. First, QALY is a total index. For example, when it is predicted that implementation of a program can totally produce 40 QALYs, we do not think about the number of person's lives which saved; in other words, 40 QALYs is only 40, we do not make difference between 10 QALYs per life (10 × 4 lives) or 1 QALY per life (1 × 40 lives). Second, the health programs with target groups of elder people, newborns, and disable people produce less QALYs rather than programs which target youth people.[4,5] Despite the limitations of formal methods of cost-utility analysis, essential moral data are produced if they are used uncritically. Therefore, in order to reduce disparities between different groups and for an ethical evaluation in addition to cost-effectiveness, we need to consider cost-utility analysis.[6] In addition to the number of life years improved, cost-utility analysis includes more values such as the number of persons that will be covered by the program, degree of reducing symptoms, and improving functions.
The limitation of resources and the need for a priority setting, especially in developing countries, resulted in the formation of ethical frameworks based on fundamental values of fairness and accountability. The framework for “accountability for reasonableness” was proposed to ensure the involvement of all stakeholders and partners in policy decisions and a legitimate and fair decision-making process.[7] Regarding high costs of the elderly health care services and the need for participation of different sectors other than health sector such as social security, using suggested practical framework[8] not only helps to reduce conflict of interests of different partners but also balances and maximizes the benefits over financial and non-financial burdens through evaluating the elderly health interventions in a systematic manner.
In conclusion, the ethical decision making for health and well-being of elder people, moreover considering cost-effectiveness, requires consideration of social values. Thus, applying the practical framework for ethical evaluation of elderly health care program is recommended. Using the ethical framework helps us to support deliberative and evidence-based policy making.
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References
- 1.Anbazhagan S, Surekha A. Health care of elderly: A viewpoint in terms of economic evaluation. Int J Prev Med. 2018;9:16. doi: 10.4103/ijpvm.IJPVM_357_16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Abbasi M, Majdzadeh R, Zali A, Karimi A, Akrami F. The evolution of public health ethics frameworks: Systematic review of moral values and norms in public health policy. Med Health Care Philos. 2018;21:387–402. doi: 10.1007/s11019-017-9813-y. [DOI] [PubMed] [Google Scholar]
- 3.Childress JF. Essentials of Public Health Ethics. In: Bernheim RG, Childress JF, Melnick AL, Bonnie RJ, editors. Moral considerations: Bases and limits for public health interventions. 1st ed. USA: Jones and Bartlett Learning, LLC, an Ascend Learning Company; 2015. pp. 21–43. [Google Scholar]
- 4.Powers M, Faden RR. 1st ed. USA: Oxford University Press; 2006. Social Justice: The Moral Foundations of Public Health and Health Policy. [Google Scholar]
- 5.Damari B, Alikhani S, Akrami F. Analysis of Iranian youth health policy: Necessity of action-oriented interventions. Int J Prev Med. 2018;9:39. doi: 10.4103/ijpvm.IJPVM_341_16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Nord E. USA: Cambridge University Press; 1999. Cost-Value Analysis in Health Care: Making Sense Out of QALYs; pp. 26–9. [Google Scholar]
- 7.Daniels N, Sabin JE. Accountability for reasonableness: An update. BMJ. 2008;337:a1850. doi: 10.1136/bmj.a1850. [DOI] [PubMed] [Google Scholar]
- 8.Akrami F, Zali A, Abbasi M, Majdzadeh R, Karimi A, Fadavi M, et al. An ethical framework for evaluation of public health plans: A systematic process for legitimate and fair decision-making. Public Health. 2018;164:30–8. doi: 10.1016/j.puhe.2018.07.018. [DOI] [PMC free article] [PubMed] [Google Scholar]