panel session: integrating evidence, values and ethics from policy to practice: a multicriteria...
TRANSCRIPT
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
2
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”
3
MCDA - A DEFINITION
Definition: Multicriteria decision analysis (MCDA) is an application of analytical methods to explicitly consider multiple criteria
4
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
5
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)
6
MCDA – DEFINING SUBSTANTIVE VALUES
SUBSTANTIVE VALUESWHAT & WHY
Ethical dilemmas
7
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
8
Revealed by a holistic perspective
Select criteria to encompass all ethical aspects to tackle these dilemmas
MCDA – SUBSTANTIVE VALUES
9
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
10
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)
11
Criteria: Alignment with mandate/scope of
healthcare system Environmental sustainability
MCDA – SUBSTANTIVE VALUES - CRITERIA
Greatest good for greatest number (utilitarianism)
12
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)
13
Criteria: Disease severity Unmet needs Established priorities (e.g.,
vulnerable populations, rare disease)
MCDA – SUBSTANTIVE VALUES - CRITERIA
Virtue ethics &practical wisdom
14
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
15
Criteria: awareness of context System capacity and appropriate
use of intervention Stakeholders pressures and
barriers Political and historical context
MCDA – SUBSTANTIVE VALUES - CRITERIA
16
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?
17
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
18
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
19
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``
20
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
21
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
22
MULTICRITERIA REFLECTION – FUTURE DIRECTIONS
Ethical foundations Methodological foundations Applications & process
developments
With the goal in mind!
Thank you