In a publicly funded health service it is important that priority settings are seen as fair. If explicit ethical principles are not in use there is a risk that “Non-principles”, for example “the megaphone principle” (he who shouts loudest gets the best care), or the “personal interest principle” (he who asserts his own interests gets the best care), will prevail.
In Sweden three ethical principles guide priority setting in the health service and they have been included in the Health and Medical Services Act.
The ethical principles are:
• The human dignity principle
• The needs and solidarity principle
• The cost-effectiveness principle
The Human Dignity Principle
The term human dignity occupies a central role in the ethical debate. The idea is that all people have human dignity simply by being human and not for what they have, or do. That is to say that all humans have the same right to care regardless of talent, social standing, income, age, ethnicity or any other factor. It is only the overall assessment of the patient’s needs that determines the administration of care. The principle primarily states what health care managers should not take into account, when making decisions on resource allocation or in care and treatment. The human dignity principle, which states that all people have equal rights and equal value, is not sufficient as a basis for priority setting in health care. Something further is required in order to determine who should be first to receive care.
The needs and solidarity principle
The needs and solidarity principle stipulates that resources should be allocated to the patients who are in greatest need. How great the need is, is assessed based on the severity and duration of the health problem, and the potential health improvement that would be brought about by a health care intervention. According to the principle, the needs of weaker groups and groups who have difficulty in making their voices heard, should be afforded special consideration. Included in these groups are for example, children, elderly with dementia, the unconscious, the confused and severely mentally disturbed. To consider the needs of these groups also entails a responsibility to investigate where the unresolved needs are.
The cost-effectiveness principle
The cost-effectiveness principle means that health care has a duty to utilise its resources as effectively as possible. This principle is, however, subordinate to the two other principles, which means that serious illness and fundamental quality-of-life deterioration are prioritised before minor ailments, even if the care of the severe conditions comes at a higher price. It was emphasised in the Government Proposal that it is the collective and long-term effects and costs that must be considered. According to the Priority Setting Commission and the Government Proposal the effects of different initiatives are hard to compare fairly. The Commission suggested that the cost-effectiveness principle should only be applied when comparing methods of treatment for the same illness.