The Montreal Health Equity Research Consortium (MHERC) held an informal workshop Friday, October 26th discussing whether a patient’s socioeconomic status (SES) should be considered when allocating healthcare resources. Dr. Berit Bringedal, a sociologist and senior researcher at the Research Institute of the Norwegian Medical Association, delivered the talk. She is a former Harkness Fellow in Health Care Policy and Practice at Harvard Medical School, and secretary for the Norwegian governmental committee for priority setting in health care.
A tentative argument for preferring low SES patients is to correct for general inequality in health. Low SES groups exhibit less favourable health outcomes, even with universal health care; physicians could therefore play a redistributive role to correct for such disparities.
This view is widely regarded as inappropriate. Traditionally, physicians are assigned the role of advocating for the best health interest of their patients. There is resistance to grant them a larger role in allocation decisions, which could threaten the standard of care of treatment. Dr. Bringedal also argues that this view undervalues the natural causes of disease, and commits an ecological fallacy. The ecological fallacy is ascribing qualities of a group to a single individual. An individual poor patient may have much better health than an individual rich patient. Justifications that hold between groups do not necessarily hold between individuals. (One member of the audience, however, pointed out that the ecological fallacy could also be levelled against all individual medical treatment decisions that rely on population trial data).
This approach essentially attempts to correct for unequal health outcomes. For this reason, it is susceptible to both utilitarian and levelling down criticisms: first, it is more expensive to use health care alone to try and generate the same outcomes in poorer groups; second, providing more robust services to the poor means providing less robust services to the rich (under resource scarcity).
Alternatively, Dr. Bringedal suggests a focus on input equality. Instead of trying to correct for disparities in health outcomes, the goal should be equal access to healthcare, equal ability to benefit from treatment. This approach recognizes that physicians are susceptible to biases that generate unequal access to the benefits of health care. Patients with lower SES status often have higher health needs. Doctors often need to spend more time helping them understand their conditions and treatment regimens. They should also recognize difference in patients’ abilities to advocate for their own treatment. There is evidence of these inequalities. For example, diagnoses of diffuse psychiatric conditions increase with SES status, suggesting unjustified differential treatment at the input stage.
Dr. Bringedal suggests solutions to improve equal access to benefit. Physician ethics could be reworked to articulate an explicit commitment to give equal regard to all patients. More research should explore factors causing unequal opportunity to benefit, which in turn unjustifiably exacerbate SES correlated health disparities. Whether we like it or not, on some level, physicians are making important resource allocation decisions. These decisions must be made consciously, transparently, and with an eye towards just distribution of access to the benefit of treatment.