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Ah, but that’s not the pointRelevance and justification in the context ofevaluating cochlear implants for deaf childrenPro...
The objective of HTA:Assembling evidence which allows us  to judge the value of a health care  technology, to support (pol...
The result of HTA:Claims (and concerns) regarding the  health care technology that has  been studied, meant to support a  ...
Two questions about such claims and  concerns:Is it true?Does it matter?
Considerable progress has been made  in scrutinizing the first –validity-  claim: identifying potential sources  of bias, ...
Case study: pediatric cochlearimplantation“…demeans Deaf people, belittles  their culture and language, and  makes no ackn...
“But if Deafness is a culture rather  than a disability, it is an  exceedingly narrow one.”DS Davis, Hastings Center Repor...
How can we establish relevance?Poses a dilemma to the HTA  researcher: which claims and  concerns seem to be sufficiently ...
Approach: Wide ReflectiveEquilibrium1. What are the moral principles or  values that seem to guide our  judgment?2. Is the...
Moral principles or values that seem to be operative:    Respecting cultural diversity                 vs   Open future fo...
Background theoriesImportance of Sign language to the  cognitive and socio-emotional  development of the deaf child  Criti...
Is there any evidence favoring either   the competition model or the   reinforcement model (of Sign and   spoken language)...
Wide reflective equilibrium                Judgment towards CI for deaf children:                             negative    ...
Background theory seems to support  respect for cultural diversityThreat to Deaf culture should be  considered relevant to...
Judgment of pediatric CI may change  if provision of CI is conditional on  offering and uptake of Sign  language to / by (...
HTA: claims and concerns about a health care  technology as a basis for a value judgment  Is it true?  Does it matter?Unle...
Implications for HTAQuality of an HTA partly depends on whether  we have been sufficiently comprehensive in  producing cla...
Thank you for your attention!
Wide reflective equilibrium                Judgment towards CI for deaf children:                             negative    ...
Approach 2: Specifying normsWhat are the general norms that are in conflict and that explain why we are uncertain as to ho...
Specifying normsGenerally speaking, one should raise a child in a  way that leaves open a wide range of future  options (c...
Specifying normsGenerally speaking, one should raise a child in a  way that leaves open a wide range of future  options (c...
Specification (qualifying our moralcommitments in specific cases) mayresolve the conflict, favoring CI,provided that it is...
Approach 3: casuistryReasoning by analogyWhat are typical (paradigmatic) cases where cultural identity should (not) be res...
Exploring relevance: In exceptionalcases only?No. The issue of relevance is always  at stake.We calculate incremental cost...
Ah, but that’s not the pointWere the right options examined?Were the appropriate dimensions explored?Many controversies ca...
HTAPlausibleRelevantAmenable to scientific research
Reconstructing the argument1. The acquisition of proficiency in   Sign language and in spoken   language interfere with ea...
HTA and beyondSummative vs formativeRole of the HTA researcherRequired expertise
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Relevance and justification in the context of evaluating cochlear implants for deaf children

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Relevance and justification in the context of evaluating cochlear implants for deaf children

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Relevance and justification in the context of evaluating cochlear implants for deaf children

  1. 1. Ah, but that’s not the pointRelevance and justification in the context ofevaluating cochlear implants for deaf childrenProf. dr. G. J. van der WiltRadboud University Medical CentreDepartment of Epidemiology, Biostatistics & HTA
  2. 2. The objective of HTA:Assembling evidence which allows us to judge the value of a health care technology, to support (policy) decisions (e.g., reimbursement)
  3. 3. The result of HTA:Claims (and concerns) regarding the health care technology that has been studied, meant to support a judgment about its value.
  4. 4. Two questions about such claims and concerns:Is it true?Does it matter?
  5. 5. Considerable progress has been made in scrutinizing the first –validity- claim: identifying potential sources of bias, estimating the risk of bias, etc.This is not true in case of scrutinizing the second – relevance- claim: how do we establish what is, and what is not relevant when assessing the value of a health care technology?Objective: Explore methods for assessing relevance
  6. 6. Case study: pediatric cochlearimplantation“…demeans Deaf people, belittles their culture and language, and makes no acknowledgment of the diversity of lives Deaf people lead, or their may achievements.”Deaf Australia, , Policy on Cochlear Implants. (www.deafau.org.au accessed on June 16th 2012)
  7. 7. “But if Deafness is a culture rather than a disability, it is an exceedingly narrow one.”DS Davis, Hastings Center Report 1997; 27 (2): 7 – 15.
  8. 8. How can we establish relevance?Poses a dilemma to the HTA researcher: which claims and concerns seem to be sufficiently relevant to warrant further inquiry into their validity?Is there a way of doing this in a more systematic way, justifying selections and conclusions to a wider public?
  9. 9. Approach: Wide ReflectiveEquilibrium1. What are the moral principles or values that seem to guide our judgment?2. Is there any background theory that lends differential to support to either of these principles?3. Try to achieve optimal coherence
  10. 10. Moral principles or values that seem to be operative: Respecting cultural diversity vs Open future for (deaf) childrenBasically, a hermeneutic stepInvolvement of stakeholders
  11. 11. Background theoriesImportance of Sign language to the cognitive and socio-emotional development of the deaf child Critically important: Reinforcement model vs Unimportant or even adversive: Competition modelof the two linguistic modalities
  12. 12. Is there any evidence favoring either the competition model or the reinforcement model (of Sign and spoken language)?Yes there is: children who have highest proficiency in Sign language before implantation benefit most from CI (in terms of development of spoken language). Preisler et al, 2002
  13. 13. Wide reflective equilibrium Judgment towards CI for deaf children: negative positive Relevance of perceived threat of pediatric CI to Deaf culture competition model “open future”reinforcement model respecting cultural diversityBackground theory Moral principle
  14. 14. Background theory seems to support respect for cultural diversityThreat to Deaf culture should be considered relevant to the evaluation of pediatric CI
  15. 15. Judgment of pediatric CI may change if provision of CI is conditional on offering and uptake of Sign language to / by (parents of) deaf children (as is the case in Sweden)Practice would then be consistent with both values, respecting cultural diversity and creating an open future for the childDependent on (provisional) acceptance of mutual reinforcement model of the two linguistic modalities
  16. 16. HTA: claims and concerns about a health care technology as a basis for a value judgment Is it true? Does it matter?Unless good reasons can be given in support of both of these claims, a value judgment and associated coverage decision cannot be justifiedMethods have been developed in the field of ethics that may be used to do this in a more systematic way.
  17. 17. Implications for HTAQuality of an HTA partly depends on whether we have been sufficiently comprehensive in producing claims and concerns related to the health care technologyStakeholder consultation may be crucially important to achieve thisImportant task of the HTA researcher is to address both, empirical adequacy and relevance of the various claims and concernsHTA researchers may decide to take one step further, and not only conduct a summative, but also a formative evaluationThis could greatly enhance legitimacy of HTA and ensuing decisions
  18. 18. Thank you for your attention!
  19. 19. Wide reflective equilibrium Judgment towards CI for deaf children: negative positive competition model “open future”reinforcement model respecting cultural diversityBackground theory Moral principle
  20. 20. Approach 2: Specifying normsWhat are the general norms that are in conflict and that explain why we are uncertain as to how we should proceed?Can these general norms be specified in such a way, that the conflict is resolved and the original rationale of the unqualified norm is still captured in what we propose to do?
  21. 21. Specifying normsGenerally speaking, one should raise a child in a way that leaves open a wide range of future options (capability approach)Generally speaking, one should respect choices that parents make for their children that reflect key elements of their culture
  22. 22. Specifying normsGenerally speaking, one should raise a child in a way that leaves open a wide range of future options (capability approach), and that does not lead to alienation* of the child from its roots(* ‘to make unfriendly, hostile, or indifferent, especially where attachment formerly existed’, Webster)Generally speaking, one should respect choices that parents make for their children that reflect key elements of their culture, as long as such choices are consistent with full inclusion in existing institutions.
  23. 23. Specification (qualifying our moralcommitments in specific cases) mayresolve the conflict, favoring CI,provided that it is associated withoffering Sign language to parents ofdeaf children.
  24. 24. Approach 3: casuistryReasoning by analogyWhat are typical (paradigmatic) cases where cultural identity should (not) be respected?What are the differences and commonalities with the case under investigation?
  25. 25. Exploring relevance: In exceptionalcases only?No. The issue of relevance is always at stake.We calculate incremental cost-utility ratios. Why, what is the value which renders such data relevant?We generally do not explore whether the introduction of a health care technology either mitigates or reinforces existing inequalities in health. Why not?
  26. 26. Ah, but that’s not the pointWere the right options examined?Were the appropriate dimensions explored?Many controversies can probably best be understood in terms of disagreements regarding relevance, rather than validity
  27. 27. HTAPlausibleRelevantAmenable to scientific research
  28. 28. Reconstructing the argument1. The acquisition of proficiency in Sign language and in spoken language interfere with each other (‘competition model’)2. Early development of SL will negatively affect the impact of CI3. If an ‘open future’ for the deaf child is preferred (Davis), then SL should not be developed4. This would constitute a threat to Deaf culture
  29. 29. HTA and beyondSummative vs formativeRole of the HTA researcherRequired expertise

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