Ethically acceptable prioritisation of childless couples and treatment rationing: “Accountability for reasonableness”

Abstract 

Objective

With in vitro fertilisation serving as a specific case, an intervention was aimed at investigating the potential for applying prioritisation theories and methods in a real-life situation to form an evidence-based proposal that met the standards of the “Accountability for Reasonableness” Model. In turn, this case would serve as a basis for public decision on rationalisation, prioritisation and rationing, whereby given resources are allocated with respect to the ethical template of the Swedish Parliament's decision on priorities in health care.

Study design

Management representatives of the overall county council as well as the gynaecologic–obstetric department levels, infertility treatment professionals and a patients’ organisation representative worked together to create guidelines building on the ethical principles of human dignity, needs/solidarity and cost-effectiveness, on evidence of treatment effect, epidemiology and economic resources availability. Also quality improvement techniques were used.

Results

Due to new guidelines for priority setting, it is expected that more childless couples in the studied health care region will get publicly financed IVF treatment. IVF treatment outcome is expected to be more cost-effective in terms of pregnancies for a given amount of resources. A balance between needs – as defined by the guidelines’ criteria – and resources is expected and thus waiting lists are expected to vanish. The patients’ organisations representative accepted the guidelines. They were also accepted by all obstetric clinics and formally agreed upon by the political boards of all county councils in the region.

Conclusion

Use of a deliberative decisions model, structured quality improvement methodology and an accepted model for prioritisation helped create a system for legitimate prioritisation of couples and rationing of treatment regarding a group of patients where differentiation has been considered difficult.

Keywords: In vitro fertilisation, Health priorities, Rationing, Accountability for reasonableness, Structured quality improvement, Total quality management