What do we mean by talking about "value(s)"? A reply to Saarni et al.

In their article “Different methods for ethical analysis in health technology assessment: An empirical study” published in International Journal of Technology Assessment in Health Care, Volume 27 Number 4, Samuli I. Saarni, Annette BraunackMayer, Bjørn Hofmann, and Gert Jan van der Wilt present an empirical study about different methods for ethical analysis in health technology assessment (HTA). They claim that ethical analysis is an important issue which can highlight values inherent in a technology and value-decisions underlying a HTA process (4). Although their study is rich in detail; gives an interesting overview of casuistry, principlism, and axiological ethic frameworks; and make ethical evaluations within HTA more transparent, we suppose, one important point needs further serious discussion: the clarification of what is meant by “value.” The term value has different meanings depending on the discipline and point of view (5). There are, for example, moral values like justice, freedom or welfare, as well as non-moral values, for example, economic values (efficacy, efficiency, profit), scientific values (correctness, accuracy), or values in arts (e.g., harmony, aesthetic, balance). That means, everyone has a different perspective on the term “value.” Physicians have another idea of value than health economists or patients have. Patients might be interested in leading a good life (healthy or not), physicians may have the goal to optimize health, and health economists compare costs and utility for society. Michael E. Porter defines patient value as the “health outcomes achieved by dollar spent” and states “that value should always be defined around the customer” (3). So, the question arises: Is value something subjective, which each and every person should define on his or her own?Or do objective values exist, whichmight be the basis for decision making? In (moral) philosophy, these questions are highly discussed, and many different value concepts have been evolved, one may distinguish between intrinsic and extrinsic forms of value, or discuss the priority of different values in different settings. In assessing healthcare technologies, value is often defined as a kind of relation between outcome and costs—a kind of “trade-off.” What is meant by costs is relatively clear (e.g., tangible or intangible costs). But when it comes to outcomes in health care, we have another important issue. Should we measure economic values like efficacy, effectiveness, efficiency, benefit or utility? The result you get depends heavily on the method you use to measure the outcomes—and its underlying value concept. As a consequence, this leads to another important issue: Are different values (e.g., economic, moral, or scientific values) even comparable? How should we handle conflicts between such value systems? Justice, health, a long life, autonomy, nonmaleficence, beneficence, etc.—these moral ideals or virtues are all values which may enable us to lead “a good life” (1). Philosophically, the definition of what is meant by “a good life” or “well-being” is a very challenging project (2). We live in pluralistic societies, where it is nearly impossible to define a universal basis of values for all. Which values are accepted as values depends on the socio-economic as well as the cultural background. This difficulty needs to be taken into consideration in technology assessment in health care, too. So, first, it should be made clear what is exactly meant by value and, second, which method is taken to measure the “valued outcome(s).” Such a debate about value and its impact on technology assessment in health care is often missing or left aside. The different disciplines at work—for example, medicine, health economy, philosophy, (empirical) technology assessment—should once again think about what they mean when they refer to their different concepts of “value.” Without such recurring, basic clarification, technology assessment in health care might lose important roots.