ANÁLISIS DE CONFORMIDADES Y NO CONFORMIDADES

Decision-making is a process that is innate to both practicing medicine and running a professional practice. This process can affect the community as a whole, since it involves decisions concerning resource distribution and therefore the patients, as the progress of their illness can be altered. The majority of the decisions made are quite complex. In the resource distribution processes, on a macro-level, the complexity lies in the finite nature of these resources, and so priorities need to be established. So, when resources are channelled towards a certain illness or patient group, they are taken away from the care of other patients or illnesses. Economists define this concept as opportunity cost. This concept refers to the costs attributable to the financing possibilities that have been foregone in the distribution of the resources toward other demands or needs due to established priorities. This also includes the Pareto efficiency concept, according to which, the good that results from the allocation of resources to a specific area should outweigh the bad that is produced in the areas where they have not been allocated.22 In other words, the measurement of efficiency in the distribution in health resources distribution involves an opportunity cost assessment of that decision and, therefore, a cost comparison of the various opportunities that are in the need of these resources.

From a philosophical viewpoint, the efficiency concept is based on utilitarianism, whose utilitarian rule promotes pursuing the greatest good for the greatest number for people as a moral basis in decision-making regarding resource distribution.23 Therefore, utilitarianism bases its decisions on the application of the cost-benefit analysis, which, in the realm of health decisions, takes on the forms of cost-effectiveness analysis and cost-utility analysis. Utilitarianism critics maintain that, as a social justice theory, it does not completely respond to the Aristotelian maxim of treat equals equally and unequals unequally. Thus, the utilitarian rule could assign the resources intended for unequal needs in an egalitarian manner. In other words, utilitarianism would penalise the assigning of resources to those illnesses that were not very prevalent, where the decision would result in only a slight improvement or where many people would have to be treated only to gain a very small number of successes. For the purpose of correcting these potential limitations of utilitarianism, other authors propose egalitarian liberalism, whose main advocate was John Rawls.24 This theory of justice considers the inequality of opportunities and promotes the so-called, in public policies, positive discrimination strategies as a way to correct them. RawlsÕ approach has been the object of many moral philosophy reviews, grouped under the concept of social justice theories.25 Some authors have proposed the application of these social justice theories to health resources distribution. Finally, the liberal libertarian theories propose that it is the market that should promote a fair distribution of health resources, through the laws of supply and demand. These three great social justice theories are complemented with theories that emphasise the procedure that accompanies decision-making and, more specifically, the democratisation of the decision through the incorporation of the preferences of those affected. Among these theories, communitarianism and republicanism are two worth mentioning. The latter obtained its name from the republican works of Cicero in ancient Rome.

The social justice theories mentioned determine the moral bases and, to a certain extent, the procedures in which the resource distribution decisions are made. The complexity of these decisions, nevertheless, often makes the application of these theories difficult. We have an

example of this complexity that arises during health resource distribution decision-making in the possible contradiction that is produced when having to join liberal egalitarianism, which stems in Spain from the General Health Law of 1986, with utilitarianism, which bases the cost-effectiveness analysis on that which certain health decisions are based. A second type of theory is proposed, for the purpose of resolving this type of ethical dilemma, which places greater emphasis on the procedures through which the decisions are made. Deliberative democracy, or democratic deliberation stands out among these types of theory due to its clarity. This theory originates from the tradition of Pericles of ancient Athens. 26 Deliberative democracy advocates are set apart, as they come from both the republican- communitarian and the liberal tradition, where the former seek consensus in obtaining the common good, while the latter seek recognition from the masses and, therefore, try to reach an agreement regarding the differences in the decision-making processes. Despite this differential nuance, democratic deliberation supports, from a moral standpoint, the adoption of the reciprocity principle in decision-making processes. In this way, deliberative democracy would constitute a form of governance in which the free and equal citizens and their representatives would justify their decisions through a process in which the reasons that are the basis for the decision would be exchanged. These reasons would be mutually accepted and the arguments upon which they were based would have to be accessible to the deliberating parties. The decisions that would be allowed would be those to which all would be committed to observe at the present time and to submit to further deliberation in the future. 27

4.1.1 Principles and criteria of deliberation democracy

Amy Gutmann and Dennis Thompson describe the principles that should meet deliberative democracy and the criteria that allows the assessment of its application in health decision- making.27 28 Among the deliberative democracy principles are: to facilitate the arguments of collective decisions, introduce different viewpoints to the issues that affect the public, promote decision processes based on mutual respect, and correct the misunderstandings associated with the incorrect interpretation of information or the absence thereof. According to these authors, the criteria that the health decisions should meet should be: accessible, moral, respectful and revisable. One example of a health decision recently made in Spain is that of the therapeutic visas or restrictions in the prescribing of specific drugs. This decision can be analysed according to the aforementioned four criteria of deliberative democracy. Using these criteria, it can be determined whether the moral positioning has been honoured, whereby the authorities should justify their decisions to those who are obligated to comply with them. In this way, the decisions are submitted to the principle of reciprocity.

According to the first criteria regarding accessibility, the decisions concerning therapeutic visas should be based on public accessible scientific arguments, easily understood by the citizens and professionals who must comply with them and approved by experts unaffiliated with the organisation making the decision. Thus, the decision concerning therapeutic visas would be considered accessible if it were submitted to public hearings and defended by the health authorities in front of patient representatives, doctors, health professionals, health service providers and the pharmaceutical and insurance industries. The moral criterion assumes the setting up of a deliberation forum in which all the agents or stakeholders involved would justify their position and views as regards the visa, done so for the common good and not in favour of their individual interests. Recently, one example of the variety of perspectives with which the visaÕs introduction can be contemplated has been described. These two criteria allow the supposition that if someone is convinced that their position is

just, responding in an adequate manner to the collectiveÕs needs, they should have no objection to defending it publicly and submitting it to public deliberation.

The third revision criterion, that of mutual respect, involves two facts. The first presumes the readiness to listen to and accept othersÕ values and viewpoints. The second leads to the admission that anotherÕs moral position is as valid as oneÕs own. Mutual respect is a moral attitude that does not have to lead to agreement between the parties. So, if, in fulfilling this criterion, the moral disagreement persists, Gutmann and Thompson propose seeking alternatives that, without eliminating the disagreement, reduce conflict and allow compromises to be reached. An attempt is made to economise the moral disagreements. In the case of the therapeutic visas application, the moral disagreement could be economised in different ways. These include those that are found in a prevalence study of the clinical conditions for which the medicines that are the object of the visa are indicated, an analysis of the health conditions for which they are being prescribed, more detailed information for doctors and patients as regards the circumstances and criteria for which these have been approved and the potential improvement in the health care for the patients affected by the visa, either through the patient associations cooperation or through improvements in specialised care accessibility. Some of these action plans could take place before the use of visa is implemented. The suitability of the visa could also be assessed through an analysis of the results obtained in terms of health outcomes.

Finally, the last criterion concerning decision assessment is that of revision or provisionality. Likewise, it is believed that the deliberation process should be reiterative and, thus, all decisions should periodically be submitted for review if they are to maintain fairness. In this way, a decision would be charged if new scientific evidence were to arise that changed the justifications and arguments that are the basis of the decision, or if the moral values or the context in which the decision was made were to change, With these four criteria, deliberative democracy adopts the principals of reciprocity and that of accountability as basic elements of the health decision making process.27 29