We need to talk about values: a proposed framework for the articulation of normative reasoning in health technology assessment

Abstract

It is acknowledged that health technology assessment (HTA) is an inherently value-based activity that makes use of normative reasoning alongside empirical evidence. But the language used to conceptualise and articulate HTA's normative aspects is demonstrably unnuanced, imprecise, and inconsistently employed, undermining transparency and preventing proper scrutiny of the rationales on which decisions are based. This paper – developed through a cross-disciplinary collaboration of 24 researchers with expertise in healthcare priority-setting – seeks to address this problem by offering a clear definition of key terms and distinguishing between the types of normative commitment invoked during HTA, thus providing a novel conceptual framework for the articulation of reasoning. Through application to a hypothetical case, it is illustrated how this framework can operate as a practical tool through which HTA practitioners and policymakers can enhance the transparency and coherence of their decision-making, while enabling others to hold them more easily to account. The framework is offered as a starting point for further discussion amongst those with a desire to enhance the legitimacy and fairness of HTA by facilitating practical public reasoning, in which decisions are made on behalf of the public, in public view, through a chain of reasoning that withstands ethical scrutiny.

The ethical canary: narrow reflective equilibrium as a source of moral justification in healthcare priority-setting

“…One such scheme, recently developed as a tool for articulating normative reasoning in healthcare priority-setting, classifies normative content according to four types, based on degree of specification (see figure 1). 51 Values, the least specified normative type, describe abstract ends such as justice, liberty, dignity and happiness that a priority-setter believes are worth pursuing because they are 'good' or 'right'. Principles are more specified action-guiding claims that serve as a pledge to act in a certain way or as the basis for part of a chain of reasoning.…”

“…Together, these four types of normative commitment give rise to a chain of reasoning from which is derived a priority-setting decision. 51 This scheme allows coherence to be systematically evaluated by facilitating the classification of normative content, allowing the degree of alignment within and between each class to be assessed. Say, for example, that a priority-setter has promised to act in accordance with justice.…”

“…vi Through such a process of iterative reflection and adjustment, a priority-setter can ensure that coherence is maintained across the many values, principles, standards and case-based judgements that make up its moral system, while also eliminating ambiguity and ensuring full transparency across its chain of reasoning. 51 By empirically examining the relationships between these different types of normative commitment, those interested in evaluating this system can draw evidence-based conclusions about the extent to which it is morally justified and can make practical recommendations for how coherence might be enhanced. Such an approach might, therefore, be employed to improve the moral quality of decision-making while also supporting public acceptance of priority-setting decisions.…”