CADTH 2015 Symposium

1. PANEL SESSION: INTEGRATING EVIDENCE, VALUES AND
ETHICS FROM POLICY TO PRACTICE: A MULTICRITERIA
REFLECTION
A REFLECTION ON ETHICAL DILEMMAS IN HEALTHCARE
DECISOBNAKING AND THE ETHICAL FOUNDATIONS OF MCDA
April 14tH
2015
CADTH Symposium , Saskatoon
Mireille Goetghebeur MEng PhD
Global Scientist, LASER Analytica
Associate Professor, School of Public health, University of Montreal
President EVIDEM Collaboration

2. Efficacy
Safety
Cost
Ethics
Quality of evidence
Population Priorities
Affordability
Disease severity
Unmet needs
Historical context
System capacity
Expert opinion
Patient-reported outcomes
Individual perspective
www
 Relying on evidence
 Relying on social values*
 Substantive values (CRITERIA - what & why)
 Procedural values (PROCESS - who & how)
 Fair and accountable decisionmaking processes**
(A4R)
 Ethical dilemmas
Feasibility
2
THE ART OF DECISION MAKING IN HEALTHCARE
*Clark and Weale. J Health Org Manag 2012; 26:293; NICE Social Value Judgments 2nd
Ed
**Daniels and Sabin. Philos Pub Health 1997; 26:305 (4 conditions: Relevance, publicity, revision, leadership).
Social valuesCADTH 2015:
Suzanne McGurn
“Decisions are
made with head
heart, and
hands”

3. 3
MCDA - A DEFINITION
Definition:
Multicriteria decision analysis (MCDA) is an
application of analytical methods to
explicitly consider multiple criteria

4. 4
MCDA – SUPPORTING THE ART OF DECISION MAKING
METHODOLOGY
1st
STEP OF MCDA –
DEFINING OBJECTIVE
MCDA mapping
EVIDEM Collaboration, a not-for-profit organization developing collaboratively an open source multipurpose MCDA-based approach
translated in 10 languages and used throughout the world www.evidem.orgg

5. 5
MCDA – STEP 1 - DEFINING OBJECTIVES
Common goal: develop & promote
interventions that optimize health of patients
and populations as well as equitable,
sustainable and efficient health care systems
Goodness in it widest sense (axiology)

6. 6
MCDA – DEFINING SUBSTANTIVE VALUES
SUBSTANTIVE VALUES
WHAT & WHY

7.  Ethical dilemmas
7
MCDA – SUBSTANTIVE VALUES
 Imperative to help - beneficence, non-
maleficence (deontology)
 Greatest good for greatest number
(utilitarianism)
 Prioritizing those who are worst off
(fairness, theory of justice); e.g. rare
diseases
 Practical wisdom & goodness (virtue
ethics)
CADTH 2015:
Eduard Hendricks:
“Doing what is
best”

8.  Ethical dilemmas
8
 Revealed by a holistic perspective
 Select criteria to encompass all ethical
aspects to tackle these dilemmas
MCDA – SUBSTANTIVE VALUES

9. 9
MCDA – SUBSTANTIVE VALUES
Qualitative criteria
Disease severity
etc
DECISION CRITERIA
Quantitative criteria
Efficacy/effectiveness
Safety
Etc
2- CRITERIA SELECTION
What? Identify all criteria (quantitative and
qualitative) that contributes to evaluation of
an intervention
Why? Realize ethical and methodological
implications of criteria selection (signals )
With the goal in mind!
METHODOLOGY

10.  Criteria:
 Maximize efficacy/effectiveness
 Maximize safety
 Maximize patient reported outcomes
 Type of therapeutic benefit (cure vs symptom relief)
 Type of preventive benefit - Public health (eradication
vs risk reduction)
 Imperative to help - beneficence,
non-maleficence
10
Hippocratic Oath: “I will prescribe for the good of my
patients according to my ability and my judgment
and never do harm to anyone.”
MCDA – SUBSTANTIVE VALUES -CRITERIA
Extent
of help
Type
of help
Extent
of help

11.  Imperative to help - beneficence,
non-maleficence (deontology)
11
 Criteria:
 Alignment with mandate/scope of
healthcare system
 Environmental sustainability
MCDA – SUBSTANTIVE VALUES - CRITERIA

12.  Greatest good for greatest number
(utilitarianism)
12
 Criteria:
 Size of population (greatest number)
 Maximize resources (see Practical wisdom)
 Opportunity cost and affordability
MCDA – SUBSTANTIVE VALUES - CRITERIA

13.  Prioritizing those who are worst off
(fairness, theory of justice)
13
 Criteria:
 Disease severity
 Unmet needs
 Established priorities (e.g., vulnerable
populations, rare disease)
MCDA – SUBSTANTIVE VALUES - CRITERIA

14.  Virtue ethics &practical wisdom
14
 Criteria
 Relevance and validity of study data
 Knowledge from experience: clinicians
(clinical practice guidelines) & patients
 Cost of intervention
 Impact on medical cost
 Impact on non-medical cost
MCDA – SUBSTANTIVE VALUES - CRITERIA
Wise use &
Devlpt of
Knowledge
Wise use
of resouces &
valuing
savings

15.  Virtue ethics & practical wisdom
15
 Criteria: awareness of context
 System capacity and appropriate use of
intervention
 Stakeholders pressures and barriers
 Political and historical context
MCDA – SUBSTANTIVE VALUES - CRITERIA

16. 16
MCDA – PROCEDURAL VALUES
PRODEDURAL VALUES
WHO & HOW
Ethics in action

17. Developers
Align development with systems efficiency, equity and sustainability, and health needs
Criteria?
Criteria?
Criteria?
Criteria?
Criteria?
17
A COMMON ROAD MAP ACROSS THE DECISION CONTINUUM?
Regulators
HTA
HC Systems
Payers
Clinicians
Patients
Who? How?
Collaborative development
of an holistic criteria set?
Unmet
needs
Perceived
health
Alleviate
sufferingResource
allocation
Benefit
risk
Procedural values
•Reflective
•Systematic
•Collaborative
•Adaptable to context
• Specific goals/mandates
• Qualitative/quantitative

18. How? Kepner Tregoe (10 pts scale),
Point allocation, ranking, Analytical
hierarchy process (AHP), Swing Weigths,
Discrte choice experiment (DCE) etc
Who? Committee members - include
the diversity of perspectives
18
MCDA – PROCEDURAL VALUES
Procedural values
•Participative
•Transparent
Qualitative criteria
Disease severity
Etc
DECISION CRITERIA
Quantitative criteria Relative Weights
Efficacy/effectiveness  Low  High
Safety
Etc
 Low  High
3-WEIGTHS
METHODOLOGY

19. DECISION CRITERIA
Quantitative criteria Relative Weights
Efficacy/effectiveness  Low  High
Safety
Etc
 Low  High
19
MCDA – PROCEDURAL VALUES
Qualitative criteria
Disease severity Turner syndrome: Female specific generic disorder characterized
by reduced life expectancy, cardiovascular defects, increased risk of
diabetes, absence of puberty, infertility, defects in visuo-spatial
organization and non-verbal problem solving, and short stature
(details)
Etc
HIGHLY SYNTHESIZED EVIDENCE
How? Evidence modeling, evidence synthesis principles
Who? Analysts and communicators
4- EVIDENCE
METHODOLOGY
Procedural values
•Transparent on data
•Systematic
CADTH 2015, Eduard Hendricks: Address the
failure to communicate``

20. 20
MCDA – PROCEDURAL VALUES
Qualitative criteria Impact
Disease severity Turner syndrome: Female specific generic disorder characterized by
reduced life expectancy, cardiovascular defects, increased risk of diabetes,
absence of puberty, infertility, defects in visuo-spatial organization and non-
verbal problem solving, and short stature (details
 negative
 neutral
 positive
Etc
DECISION CRITERIA
Quantitative criteria Relative Weights
Efficacy/effectiveness  Low  High
Safety
Etc
 Low  High
HIGHLY SYNTHESIZED EVIDENCE APPRAISAL
Score
 High


 Low
How? Scoring scales capturing judgment on data (quantum leap)
Who? Committee members
5- PERFORMANCE SCORES
Sir Rawlins, NICE: “Accept that interpretation of
data requires judgement”
METHODOLOGY
Procedural values
•Participatory
•Reflective
•Transparent on judgment
•Systematic

21. 21
Max value 1
No value: 0
A
B
C
D
Impactofcontext
Normative
QUANTITATIVE CRITERIA
Value *= ∑NWeights x Scores
QUALITATIVE CRITERIA
High value: Invest
Low value: disinvest
Feasibility
ValueofInterventions
A
C
D
B
MCDA – PROCEDURAL VALUES
CADTH 2015. Jon Witt: “Invest in programs addressing determinants of
health”
Procedural values
•Guide investment/disinvestment
based on common goal
•Transparent on decision
•Holistic

22. 22
MULTICRITERIA REFLECTION – FUTURE DIRECTIONS
 Ethical foundations
 Methodological foundations
 Applications & process developments
With the goal in mind!
Thank you