4. 1. Decision-making


Health systems that function within a liberal democracy generally strive to ensure people have the ability to achieve their health goals. Typically, the health system goals are:

Adequacy and equity in access.

Protection for citizens from detrimental financial implications associated with payment for health services.

Freedom of choice for patients.

Appropriate autonomy (independence) for providers.

Fiscal responsibility.

These goals reflect underlying ethical principles common to many health systems. Four ethical principles in particular are usually specified in health system decision-making:

Respect for autonomy: Recognising the rights of individuals to make informed, independent choices about healthcare, health promotion, and health protection. This leads to the concept of ‘patient choice’. The ethical principle of respect for autonomy cannot, however, be applied universally or regardless of other social values.

Non-maleficence (‘not doing harm’): An obligation not to inflict harm (either physical or psychological). As any treatment or intervention [1] can potentially have adverse consequences, it is necessary to balance the benefits and harms (risks) when deciding whether an intervention is appropriate [1]

Beneficence (‘doing good’): An obligation to benefit individuals is closely related to non-maleficence. Since no clinical or public health intervention is solely beneficial for everyone, it is the balancing of benefits and harms that is usually more relevant.

Justice: The provision of services in a fair and appropriate manner. This is a particular problem in healthcare because of the inevitable mismatch between demands and resources. There are two models of justice that relate to the fair and appropriate allocation of resources (called distributive justice), though there is no current consensus regarding which of these two models is best for decision making:

o Utilitarianism seeks to maximise the amount of good that can be enjoyed by the community as a whole. Utilitarianism is a moral doctrine that assumes that the greatest happiness of the greatest number of people should be the guiding principle of conduct. Under this system, it is possible that minority interests can be overridden by the majority. It is also possible that factors such as age, personal responsibility, and urgency of need are overlooked.

o Egalitarianism is a moral doctrine that asserts the equality of all mankind. It suggests that each individual is entitled to their fair share of health resources. Under this system, it is possible to account for the justified interests of the individual/minority versus those of the community or a larger group.


As most medicines are prescribed by providers acting under rules and regulations, HTA recommendations are often more concerned with questions of justice and autonomy (although beneficence and non-maleficence are by no means ignored). In particular, those making healthcare recommendations and decisions must consider what the ‘fair and appropriate’ balance of the use of health technology is, given constraints on resources.