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 14 tH 2015 CADTH Symposium , Saskatoon Mireille Goetghebeur MEng PhD Global Scientist, LASER Analytica Associate Professor, School of Public health, University of Montreal President EVIDEM Collaboration
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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
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
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)
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