PANEL SESSION: INTEGRATING EVIDENCE, VALUES AND ETHICS FROM POLICY TO PRACTICE: A MULTICRITERIA

REFLECTION

A REFLECTION ON ETHICAL DILEMMAS IN HEALTHCARE DECISOBNAKING AND THE ETHICAL FOUNDATIONS OF MCDA

April 14tH 2015 CADTH Symposium , Saskatoon

Mireille Goetghebeur MEng PhD Global Scientist, LASER AnalyticaAssociate Professor, School of Public health, University of Montreal President EVIDEM Collaboration

Efficacy

Safety

CostEthics

Quality of evidence

Population Priorities

Affordability

Disease severity

Unmet needs

Historical context

System capacity

Expert opinion

Patient-reported outcomes

Individual perspective

www

Relying on evidence Relying on social values*

Substantive values (CRITERIA - what & why)

Procedural values (PROCESS - who & how)

Fair and accountable decisionmaking processes** (A4R)

Ethical dilemmas

Feasibility

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THE ART OF DECISION MAKING IN HEALTHCARE

*Clark and Weale. J Health Org Manag 2012; 26:293; NICE Social Value Judgments 2nd Ed**Daniels and Sabin. Philos Pub Health 1997; 26:305 (4 conditions: Relevance, publicity, revision,

leadership).

Social valuesCADTH 2015:Suzanne McGurn“Decisions are

made with head heart, and hands”

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MCDA - A DEFINITION

Definition: Multicriteria decision analysis (MCDA) is an application of analytical methods to explicitly consider multiple criteria

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MCDA – SUPPORTING THE ART OF DECISION MAKING

METHODOLOGY1st STEP OF MCDA –

DEFINING OBJECTIVE

MCDA mapping

EVIDEM Collaboration, a not-for-profit organization developing collaboratively an open source multipurpose MCDA-based approach translated in 10 languages and used throughout the world www.evidem.orgg

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MCDA – STEP 1 - DEFINING OBJECTIVES

Common goal: develop & promote interventions that optimize health of patients and populations as well as equitable, sustainable and efficient health care systems

Goodness in it widest sense (axiology)

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MCDA – DEFINING SUBSTANTIVE VALUES

SUBSTANTIVE VALUESWHAT & WHY

Ethical dilemmas

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MCDA – SUBSTANTIVE VALUES

Imperative to help - beneficence, non-maleficence (deontology)

Greatest good for greatest number (utilitarianism)

Prioritizing those who are worst off (fairness, theory of justice); e.g. rare diseases

Practical wisdom & goodness (virtue ethics)

CADTH 2015:Eduard Hendricks:“Doing what is

best”

Ethical dilemmas

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Revealed by a holistic perspective

Select criteria to encompass all ethical aspects to tackle these dilemmas

MCDA – SUBSTANTIVE VALUES

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MCDA – SUBSTANTIVE VALUES

Qualitative criteria

Disease severity

etc

DECISION CRITERIA

Quantitative criteria

Efficacy/effectiveness

SafetyEtc

2- CRITERIA SELECTION

What? Identify all criteria (quantitative and qualitative) that

contributes to evaluation of an intervention

Why? Realize ethical and methodological implications of

criteria selection (signals )

With the goal in mind!

METHODOLOGY

Criteria: Maximize efficacy/effectiveness Maximize safety Maximize patient reported outcomes

Type of therapeutic benefit (cure vs symptom relief)

Type of preventive benefit - Public health (eradication vs risk reduction)

Imperative to help - beneficence, non-maleficence

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Hippocratic Oath: “I will prescribe for the good of my patients according to my ability and my judgment and never do harm to anyone.”

MCDA – SUBSTANTIVE VALUES -CRITERIA

Extent of help

Type of help

Extent of help

Imperative to help - beneficence, non-maleficence (deontology)

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Criteria: Alignment with mandate/scope of

healthcare system Environmental sustainability

MCDA – SUBSTANTIVE VALUES - CRITERIA

Greatest good for greatest number (utilitarianism)

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Criteria: Size of population (greatest

number) Maximize resources (see Practical

wisdom) Opportunity cost and affordability

MCDA – SUBSTANTIVE VALUES - CRITERIA

Prioritizing those who are worst off (fairness, theory of justice)

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Criteria: Disease severity Unmet needs Established priorities (e.g.,

vulnerable populations, rare disease)

MCDA – SUBSTANTIVE VALUES - CRITERIA

Virtue ethics &practical wisdom

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Criteria Relevance and validity of study

data Knowledge from experience:

clinicians (clinical practice guidelines) & patients

Cost of intervention Impact on medical cost Impact on non-medical cost

MCDA – SUBSTANTIVE VALUES - CRITERIA

Wise use &Devlpt of

Knowledge

Wise use of resouces &

valuing savings

Virtue ethics & practical wisdom

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Criteria: awareness of context System capacity and appropriate

use of intervention Stakeholders pressures and

barriers Political and historical context

MCDA – SUBSTANTIVE VALUES - CRITERIA

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MCDA – PROCEDURAL VALUES

PRODEDURAL VALUESWHO & HOWEthics in action

Developers

Align development with systems efficiency, equity and sustainability, and

health needs

Criteria?

Criteria?

Criteria?

Criteria?

Criteria?

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A COMMON ROAD MAP ACROSS THE DECISION CONTINUUM?

Regulators

HTA HC

SystemsPayers

Clinicians

Patients

Who? How?

Collaborative development of an holistic criteria set?

Unmet

needs

Perceived

healthAlleviate

suffering

Resource

allocationBenef

it risk

Procedural values•Reflective •Systematic•Collaborative•Adaptable to context

• Specific goals/mandates• Qualitative/quantitative

How? Kepner Tregoe (10 pts scale), Point allocation, ranking,

Analytical hierarchy process (AHP), Swing Weigths, Discrte choice experiment (DCE) etc

Who? Committee members - include the diversity of

perspectives

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MCDA – PROCEDURAL VALUES

Procedural values•Participative•Transparent

Qualitative criteria

Disease severity

Etc

DECISION CRITERIA

Quantitative criteria Relative Weights

Efficacy/effectiveness Low High

SafetyEtc

Low High

3-WEIGTHS

METHODOLOGY

DECISION CRITERIA

Quantitative criteria Relative Weights

Efficacy/effectiveness Low High

SafetyEtc

Low High

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MCDA – PROCEDURAL VALUES

Qualitative criteria

Disease severity Turner syndrome: Female specific generic disorder characterized by reduced life expectancy, cardiovascular defects, increased risk of diabetes, absence of puberty, infertility, defects in visuo-spatial organization and non-verbal problem solving, and short stature (details)

Etc

HIGHLY SYNTHESIZED EVIDENCE

How? Evidence modeling, evidence synthesis principles

Who? Analysts and communicators

4- EVIDENCE

METHODOLOGY

Procedural values•Transparent on data •Systematic

CADTH 2015, Eduard Hendricks: Address the failure to communicate``

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MCDA – PROCEDURAL VALUES

Qualitative criteria Impact

Disease severity Turner syndrome: Female specific generic disorder characterized by reduced life expectancy, cardiovascular defects, increased risk of diabetes, absence of puberty, infertility, defects in visuo-spatial organization and non-verbal problem solving, and short stature (details

negative neutral positive

Etc

DECISION CRITERIA

Quantitative criteria Relative Weights

Efficacy/effectiveness Low High

SafetyEtc

Low High

HIGHLY SYNTHESIZED EVIDENCE APPRAISAL

Score

High Low

How? Scoring scales capturing judgment on data (quantum leap)

Who? Committee members5- PERFORMANCE SCORES

Sir Rawlins, NICE: “Accept that interpretation of data requires judgement”

METHODOLOGY

Procedural values•Participatory•Reflective•Transparent on judgment•Systematic

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Max value 1

No value: 0

A B

C

D

Imp

act

of

con

text

Normative

QUANTITATIVE CRITERIA Value *= ∑NWeights x Scores

QUALITATIVE CRITERIA

High value: Invest

Low value: disinvest

Feasibility

Val

ue

of

Inte

rven

tio

ns

A

C

D

B

MCDA – PROCEDURAL VALUES

CADTH 2015. Jon Witt: “Invest in programs addressing determinants of health”

Procedural values•Guide investment/disinvestment based on common goal •Transparent on decision•Holistic

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MULTICRITERIA REFLECTION – FUTURE DIRECTIONS

Ethical foundations Methodological foundations Applications & process

developments

With the goal in mind!

Thank you