Public legitimacy of healthcare resource allocation committees: lessons learned from assessing an Israeli case study.

BACKGROUND: The National Health Insurance Law enacted in 1995 stipulates a list of health services to which all Israeli residents are entitled. For the past 20 years, the list has been updated annually, as a function of a predetermined budget, according to recommendations from the Public National Advisory Committee (PNAC), which evaluates and prioritizes candidate technologies. We assessed the legitimacy of this resource-allocation process as reflected in Israeli public discourse and its congruence with the accountability for reasonableness (A4R) framework. METHODS: A qualitative analysis of public discourse documents (articles in the print media, court rulings and parliamentary debates (N = 119) was conducted to assess the perceived legitimacy by the Israeli public of the PNAC. Further content analysis of these documents and semi-structured interviews with stakeholders (N = 70) revealed the mainstays and threats to its legitimacy. Based on these data sources, on governmental documents specifying PNAC's procedures, and on data from participant observations, we assessed its congruence with A4R's four conditions: publicity, relevance, revision and appeals, regulation. RESULTS: The PNAC enjoys ongoing support for its legitimacy in Israeli public discourse, which stem from its perceived professional focus and transparency. These strengths are consistent with the A4R's emphasis on the publicity and the relevance conditions. The three major threats to PNAC's legitimacy pertain to: (1) the composition of the committee; (2) its operating procedures; (3) its guiding principles. These perceived shortcomings are also consistent with incongruencies between PNAC's work model and A4R. These findings thus further support the empirical validity of the A4R. CONCLUSION: The analysis of the fit between the PNAC and A4R points to refinements in all four conditions that could make the A4R a more precise evaluative framework. Concurrently, it highlights areas that the PNAC should improve to increase its legitimacy, such as incorporating cost-effectiveness analyses and including patient representatives in the decision-making process. Hebrew and Arabic abstracts for this article are available as an additional file.

"Following orders" as a critique on healthcare allocation committees: An anthropological perspective on the role of public memory in bioethical legitimacy.

The public perception of decision-making procedures as fair processes is a central means for establishing their legitimacy to make difficult resource allocation decisions. According to the ethical framework of accountability for reasonableness (A4R, hereafter), which specifies conditions for fair healthcare resource allocation, disagreements about what constitutes relevant considerations are a central threat to its perceived fairness. This article considers how an ethical principle grounded in the public memory of past traumatic events may become the topic of such disagreements. I demonstrate this through an anthropological case study of a recent public de bate concerning an Israeli healthcare allocation committee (HAC, thereafter), which determines state subsidies for new medical technologies as part of Israel's public healthcare system. Drawing upon ethnographic fieldwork about the HAC, I show how the public memory of Adolf Eichmann's trial constitutes a bioethical problem for the committee's legitimacy. Based on Arendt's and Bauman's writings that Nazi bureaucrats' manner of "following orders" was an ethical transgression, some patients contended that the committee has a historical responsibility to question its strict adherence to bureaucratic procedures. Since the committee did not have a direct link to the events of the Holocaust, other considerations seemed to them more relevant. I then present an offer that can settle this disagreement and maintain the HAC's legitimacy according to A4R. I conclude by discussing the contribution of empirical data to models of bioethical legitimacy.