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In the lead up to the 3rd Annual Health Technology Assessment Conference, which is taking place on the 24th and 25th November at Swissotel Sydney, we caught up with Dr Monique Jonas, Lecturer in Health Systems at the University of Auckland. Dr Jonas will be presenting a session on “Integrating Ethics in the HTA” at the event and will also be on the panel of the discussion titled “Is HTA the Appropriate Framework for Informing Disinvestment Decisions?”.
Here Dr Jonas talks to us about the role that ethics play in the space of emerging health technologies and the lessons that New Zealand and Australia can learn from the global health technology assessment landscape.
What is your background? Dr Jonas: I am an ethical theorist, trained in political philosophy and medical ethics. My research spans three distinct areas: the role of the state in family life, the ethics of advice-giving and procedural fairness and resource allocation in healthcare.
I have recently been appointed to the National Health Committee in New Zealand. The NHC provides independent advice to the Minister of Health about the prioritisation, introduction and expansion of health technology and services.
It undertakes Health Technology Assessment that cover four domains: Clinical Safety and Effectiveness; Societal and Ethical; Economic and Feasibility of Adoption.
My expertise falls within the societal and ethical domain. My work on the ethics of advice-giving and procedural fairness and resource allocation comes together in this role and I have been working with the Chair of the NHC, Anne Kolbe, on a number of ethical challenges that bodies such as the NHC must confront.
One of these is the problem of how to adequately account for uncertainty within an HTA, and how to present uncertainty to the public in an honest and informative way.
There are a number of sophisticated tools in health economics which enable uncertainty to be quantified, but the normative force of uncertainty for decision-makers remains (fittingly or frustratingly, depending on your point of view!) uncertain.
Why does ethics play an important role in the space of emerging health technologies? Dr Jonas: Ethics is crucial in determining which health technologies should be funded, for which patients, upon what terms. The reason is that at least some emerging technologies promise to improve life and to extend life in a way that existing technologies are unable to do. So they carry potential benefits for patients.
But these benefits come at a price, and in countries such as New Zealand and Australia, our common pool of tax-payer funds pays most of that price. As we have limited resources and a demand for care that is in excess of those resources, decisions have to be made that distribute benefits across our populations.
This means that decisions about health technologies are inevitably ethical- they involve people’s interests, societal values and distributive justice. The acute importance of the end-point- the decision about whether to fund a given technology- means that the whole lead-in process that informs that end-point must be defensible in ethical terms. But it is not always clear what decisions are most defensible in ethical terms.
Events such as the Health Technology Assessment Conference provide an essential opportunity for us to further our ethical reasoning, making the HTA process and the resource allocation decisions that they support, more robust.
Do you feel there are any lessons New Zealand and Australia could learn from global health technology assessment processes and ethical practices ? Dr Jonas: There is an amazing variety of institutional structures that support both health technology assessments and resource decision-making in different jurisdictions, and arguably these institutional structures vary in terms of their ability to deliver procedural fairness.
I am particularly interested in the value of transparency, and certainly this is a feature that some arrangements promote more than others. I think that this is a good point to consider what institutional arrangements best support HTAs and prioritisation that the public has reason to recognise as legitimate.
What are you looking forward to at the event?
Dr Jonas: I am really looking forward to hearing from people involved in different aspects of Health Technology Assessment, prioritisation and funding and also care provision, to discover what ethical problems lurk there.
As an academic and a theorist, I get limited time out in the real world for good behaviour, but I believe that ethical theory is of value only to the extent that it can help us solve practical problems confronting us in real life. So I want to know what those problems are, and how they are approached in practice.
I am especially interested in others’ experience of advice-giving; in the issues relating to disinvestment and also in the discussion of Orphan Drugs.