Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda

Ethical deliberations about involuntary treatment: interviews with Swedish psychiatrists

Background: Involuntary treatment is a key issue in healthcare ethics. In this study, ethical issues relating to involuntary psychiatric treatment are investigated through interviews with Swedish psychiatrists. Methods: In-depth interviews were conducted with eight Swedish psychiatrists, focusing on their experiences of and views on compulsory treatment. In relation to this, issues about patient autonomy were also discussed. The interviews were analysed using a descriptive qualitative approach. Results: The answers focus on two main aspects of compulsory treatment. Firstly, deliberations about when and why it was justifiable to make a decision on involuntary treatment in a specific case. Here the cons and pros of ordering compulsory treatment were discussed, with particular emphasis on the consequences of providing treatment vs. refraining from ordering treatment. Secondly, a number of issues relating to background factors affecting decisions for or against involuntary treatment were also discussed. These included issues about the Swedish Mental Care Act, healthcare organisation and the care environment. Conclusions: Involuntary treatment was generally seen as an unwanted exception to standard care. The respondents’ judgments about involuntary treatment were typically in line with Swedish law on the subject. However, it was also argued that the law leaves room for individual judgments when making decisions about involuntary treatment. Much of the reasoning focused on the consequences of ordering involuntary treatment, where risk of harm to the therapeutic alliance was weighed against the assumed good consequences of ensuring that patients received needed treatment. Cases concerning suicidal patients and psychotic patients who did not realise their need for care were typically held as paradigmatic examples of justified involuntary care. However, there was an ambivalence regarding the issue of suicide as it was also argued that risk of suicide in itself might not be sufficient for justified involuntary care. It was moreover argued that organisational factors sometimes led to decisions about compulsory treatment that could have been avoided, given a more patient-oriented healthcare organisation. Electronic supplementary material The online version of this article (doi:10.1186/s12910-015-0029-5) contains supplementary material, which is available to authorized users

Principles of Need and the Aggregation Thesis

Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications

"Death is not enough to stop an addiction” : A qualitative study on clients’ experience of social services.

I denna studie valde vi att undersöka vilka erfarenheter klienter har av socialtjänsten när de fått stöd, hjälp eller behandling för sin missbruksproblematik. Vi ville ta reda på om klienterna upplevt att de fått vara delaktiga i beslutsprocessen som rör deras insats från socialtjänsten. Vidare ville vi undersöka om klienterna upplevt någon form av stigmatisering på grund av sitt missbruk. Vi valde att använda en kvalitativ metod och genomförde åtta semistrukturerade intervjuer med intervjupersoner från en ideell förening för missbrukare. Vi ville med vår studie belysa klientens perspektiv och förmedla deras erfarenheter i hopp om att öka förståelsen för deras utsatta position i samhället. Vi valde att tolka vårt insamlade material utifrån teorier om stigma, makt och empowerment. I relationen mellan klient och socialtjänst finns en ojämn maktbalans som kan bidra till minskad delaktighet för klienten i beslutsprocessen. Använder sig socialtjänsten av ett empowerment främjande arbetssätt så ökar klientens möjlighet till delaktighet. Vidare tillhör missbrukare en grupp i samhället som på grund av stigmatiseringen nekas samma möjligheter som övriga medborgare. Vår slutsats är att de intervjupersoner som upplevt att de får vara delaktiga i beslutsprocessen har en positiv erfarenhet av socialtjänsten. De intervjupersoner som upplevt att de inte kan påverka beslutsprocessen beskriver en negativ erfarenhet av socialtjänsten. Vidare uppgav ungefär hälften av intervjupersonerna att de upplevt någon form av stigmatisering på grund av sitt missbruk. In this study we chose to examine the experience clients have of social service when they have received support, help or treatment for their drug abuse. We wanted to find out if clients experienced that they had been involved in the decision-making process relating to their treatment from social services. Next, we wanted to examine whether the clients experienced some form of stigma because of their misuse. We chose to use a qualitative method and carried out eight semi structured interviews with interview persons from a  nonprofit association for addicts. What we wanted was for our study to highlight the client perspective and convey their experiences in the hope of increasing understanding of their vulnerable position in society. We chose to interpret our collected material on the basis of theories about stigma, power and empowerment. In the relationship between the client and the social service is an uneven balance of power that can contribute to the reduction of participation for the client in the decision-making process. If the social services use an empowerment promoting work method it increase the client opportunity for participation. Furthermore drug addicts belong to a group in society whom are denied the same opportunities as other citizens because of the stigma. Our conclusion is that the interviewees who experienced that they may be involved in the decision-making process has a positive experience of social services. The interviewees who experienced that they cannot affect the decision-making process describes a negative experience of social services. Furthermore about half of the interviewees stated that they experienced some form of stigma because of their misuse

"Death is not enough to stop an addiction” : A qualitative study on clients’ experience of social services.

I denna studie valde vi att undersöka vilka erfarenheter klienter har av socialtjänsten när de fått stöd, hjälp eller behandling för sin missbruksproblematik. Vi ville ta reda på om klienterna upplevt att de fått vara delaktiga i beslutsprocessen som rör deras insats från socialtjänsten. Vidare ville vi undersöka om klienterna upplevt någon form av stigmatisering på grund av sitt missbruk. Vi valde att använda en kvalitativ metod och genomförde åtta semistrukturerade intervjuer med intervjupersoner från en ideell förening för missbrukare. Vi ville med vår studie belysa klientens perspektiv och förmedla deras erfarenheter i hopp om att öka förståelsen för deras utsatta position i samhället. Vi valde att tolka vårt insamlade material utifrån teorier om stigma, makt och empowerment. I relationen mellan klient och socialtjänst finns en ojämn maktbalans som kan bidra till minskad delaktighet för klienten i beslutsprocessen. Använder sig socialtjänsten av ett empowerment främjande arbetssätt så ökar klientens möjlighet till delaktighet. Vidare tillhör missbrukare en grupp i samhället som på grund av stigmatiseringen nekas samma möjligheter som övriga medborgare. Vår slutsats är att de intervjupersoner som upplevt att de får vara delaktiga i beslutsprocessen har en positiv erfarenhet av socialtjänsten. De intervjupersoner som upplevt att de inte kan påverka beslutsprocessen beskriver en negativ erfarenhet av socialtjänsten. Vidare uppgav ungefär hälften av intervjupersonerna att de upplevt någon form av stigmatisering på grund av sitt missbruk. In this study we chose to examine the experience clients have of social service when they have received support, help or treatment for their drug abuse. We wanted to find out if clients experienced that they had been involved in the decision-making process relating to their treatment from social services. Next, we wanted to examine whether the clients experienced some form of stigma because of their misuse. We chose to use a qualitative method and carried out eight semi structured interviews with interview persons from a  nonprofit association for addicts. What we wanted was for our study to highlight the client perspective and convey their experiences in the hope of increasing understanding of their vulnerable position in society. We chose to interpret our collected material on the basis of theories about stigma, power and empowerment. In the relationship between the client and the social service is an uneven balance of power that can contribute to the reduction of participation for the client in the decision-making process. If the social services use an empowerment promoting work method it increase the client opportunity for participation. Furthermore drug addicts belong to a group in society whom are denied the same opportunities as other citizens because of the stigma. Our conclusion is that the interviewees who experienced that they may be involved in the decision-making process has a positive experience of social services. The interviewees who experienced that they cannot affect the decision-making process describes a negative experience of social services. Furthermore about half of the interviewees stated that they experienced some form of stigma because of their misuse