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When assessing the cost effectiveness of health care programmes, health economists typically presume that distant events should be given less weight than present events. This article examines the moral reasonableness of arguments advanced for positive discounting in costeffectiveness analysis both from an intergenerational and an intrapersonal perspective and assesses if arguments are equally applicable to health and monetary outcomes. The article concludes that behavioral effects related to time preferences give little or no reason for why society at large should favour the present over the future when making intergenerational choices regarding health. The strongest argument for discounting stems from the combined argument of diminishing marginal utility in the presence of growth. However, this hinges on the assumption of actual growth in the relevant good. Moreover, current modern democracy may be insufficiently sensitive to the concerns of future generations. The second part of the article categorises preference failures (which justify paternalistic responses) into two distinct groups, myopic and acratic. The existence of these types of preference failures makes elicited time preferences of little normative relevance when making decisions regarding the social discount rate, even in an intrapersonal context. As with intergenerational discounting, the combined arguments of growth and diminishing marginal utility offer the strongest arguments for discounting in the intrapersonal context. However, there is no prima facie reason to assume that this argument should apply equally to health and monetary values. To be sure, selecting an approach towards discounting health is a complex matter. However, the life-ordeath implications of any approach require that the discussion not be downplayed to merely a technical matter for economists to settle.

AbstractHow to balance the maximization of health and concerns for the worse off remains a challenge for health care decision makers when setting priorities. In regulatory guidelines these concerns are typically specified in terms of priority setting according to needs and priority setting according to cost-effectiveness. Still, it is often unclear when and why needs and cost-effectiveness diverge or overlap as guiding priority setting principles in practice. We conduct a comparative analysis of need and cost-effectiveness in the context of health care priority setting. Based on theories of distributive justice we specify three normative interpretations of need and explicate how these relate to the normative basis for cost-effectiveness analysis. Using priority-setting dilemmas we then move on to explicate when and why need and cost-effectiveness diverge as priority-setting principles. We find that: (i) although principles of need and cost-effectiveness may recommend the same allocation of resources the underlying reason for an allocation is different; (ii) while they both may give weight to patients who are worse off they do so in different ways and to different degree; and (iii) whereas cost-effectiveness clearly implies the aggregation of benefits across individuals principles of needs give no guidance with regard to if, and if so, how needs should be aggregated. Priority setting according to needs or cost-effectiveness does not necessarily recommend different allocations of resources. Thus, the normative conflict between them, often highlighted in practice, seems exaggerated. For health policy this is important knowledge because unclear conceptions may obstruct an informed public discussion. Moreover, if decision-makers are to properly account for both principles they need to recognize the inconsistencies as well as similarities between the two.

AbstractBoth theory on motivational crowding and recent empirical evidence suggest that nudging may sometimes backfire and actually crowd out prosocial behavior, due to decreased intrinsic motivation and warm glow. In this study, we tested this claim by investigating the effects of three types of nudges (default nudge, social norm nudge, and moral nudge) on donations to charity in a preregistered online experiment (N = 1098). Furthermore, we manipulated the transparency of the nudges across conditions by explicitly informing subjects of the nudges that were used. Our results show no indication that nudges crowd out prosocial behavior; instead, all three nudges increased donations. The positive effects of the nudges were driven by the subjects who did not perceive the nudges as attempts to manipulate their behavior, while donations among subjects who felt that the nudges were manipulative remained unaffected. Subjects' self-reported happiness with their choice also remained unaffected. Thus, we find no indication that nudges crowded out warm glow when acting altruistically. Generally, our results are good news for the proponents of nudges in public policy, since they suggest that concerns about unintended motivational crowding effects on prosocial behavior have been overstated.

We investigate the antecedents of subjective financial well-being and general well-being during the ongoing COVID-19 pandemic. In an online survey conducted in the midst of COVID-19 pandemic with over 1000 Swedish participants we found that distrust in the government to cope with financial (but not healthcare) challenges of the pandemic was negatively related to the feeling of financial security. In a structural equation model, we also show that trust in government to deal with financial challenges of COVID-19 pandemic has a significant impact on general well-being through the mediating channel of financial well-being. In addition, trust in government to deal with healthcare challenges of COVID-19 pandemic has a significant direct impact on individuals' general well-being. Our findings have important implications for public policy as they highlight the importance of citizens' trust in well-functioning governmental institutions to help cope with not only healthcare, but also financial challenges of an ongoing pandemic.

Outcome editing refers to a set of mental rules that people apply when deciding whether to evaluate multiple outcomes jointly or separately, which subsequently affects choice. In a large-scale online survey (n = 2062) we investigate whether individuals use the same outcome editing rules for financial outcomes (e.g., a lottery win) and social outcomes (e.g., a party with friends). We also test the role of numeric ability in explaining outcome editing. Our results show that people's preferences for combining or separating events depend on whether those events are in the financial or the social domain. Specifically, individuals were more likely to segregate social outcomes than monetary outcomes, except for when all outcomes were negative. Moreover, numeric ability was associated with preferences for outcome editing in the financial domain but not in the social domain. Our findings extend the understanding of the arithmetic operations underlying outcome editing and suggest that people rely more on calculations when making choices involving multiple financial outcomes and more on feelings when making choices involving social outcomes. ; Funding: Thule Foundation; Lansforsakringar Alliance Research Foundation Grant [P15/2]; Swedish Research CouncilSwedish Research CouncilEuropean Commission [2018-01755]

Policymakers in publicly funded health-care systems are frequently required to make intricate decisions on which health-care services to include or exclude from the basic health-care package. Although it seems likely that the concept of individual responsibility is an essential feature of such decisions, it is rarely explicitly articulated or evaluated in health policy. This paper presents a tentative conceptual framwork for exploring when health-care services contain characteristics that facilitate individual responsibility through private financing. Six attributes for exploring the suitability of private financing for specific health-care commodities are identified: (i) it should enable individuals to value the need and quality both before and after utilization; (ii) it should be targeted toward individuals with a reasonable level of individual autonomy; (iii) it should be associated with low levels of positive externalities; (iv) it should be associated with a demand sufficient to generate a private market; (v) it should be associated with payments affordable for most individuals; and finally, (vi) it should be associated with 'lifestyle enhancements' rather than 'medical necessities'. The tentative framework enables exploration of individual responsibility connected to health care as a heterogeneous group of commodities, and allows policymakers to make decisions on rationing by design rather than default.

Do differences in worldview ideology hinder people from objectively interpreting the effect of immigration? In an experiment with Swedish adults (n = 1015), we investigate whether people display motivated reasoning when interpreting numerical information about the effects of refugee intake on crime rate. Our results show clear evidence of motivated reasoning along the lines of worldview ideology (i.e., whether people identify themselves primarily as nationally oriented or globally oriented). In scenarios where refugee intake was associated with higher crime rate, nationally oriented people were 18 percentage points more likely to make the correct assessment compared to globally oriented people. Likewise, in scenarios where refugee intake was associated with lower crime rate, nationally oriented people were 20 percentage points less likely to make the correct assessment compared to globally oriented people. Individuals with higher numeric ability were less likely to engage in motivated reasoning, suggesting that motivated reasoning more commonly is driven by feelings and emotional cues rather than deliberate analytical processes.

AbstractAre people more likely to (mis)interpret information so that it aligns with their ideological identity when relying on feelings compared to when engaging in analytical thinking? Or is it the other way around: Does deliberation increase the propensity to (mis)interpret information to confirm existing political views? In a behavioral experiment, participants (n = 1207, Swedish sample) assessed numerical information concerning the effects of gender quotas and immigration either under time pressure or under no time pressure. To measure trait differences in cognitive sophistication, we also collected data on numeric ability. We found clear evidence of motivated reasoning when assessing both the effects of gender quotas on companies' financial results and the effect of refugee intake on crime rates. Subjects who prioritized equality over liberty on the labor market were 13 percentage points less likely to correctly assess numerical information depicting that companies that used gender quotas when hiring made less profit. Subjects who classified themselves as 'Swedes' rather than 'World citizens' were 14 percentage points less likely to correctly assess numerical information depicting that crime rates decreased following immigration. Time pressure did not affect the likelihood to engage in motivated reasoning, while subjects with higher numeric ability were less likely to engage in motivated reasoning when analyzing information concerning refugee intake, but more likely to engage in motivated reasoning when analyzing information regarding the effect of gender quotas. Together these results indicate that motivated reasoning is primarily driven by individual differences in analytical thinking at the trait level and not by situational factors such as time pressure, and that whether motivated reasoning is primarily driven by analysis or feelings depends on the topic at hand.

Inaccurate beliefs about procedural fairness often motivate people to act in self-serving and selfish manners. We investigate whether information about a level playing field might mitigate such behaviors. In a pre-registered behavioral experiment ( n = 4 4 4), using a competitive and real-effort task, we manipulate whether participants are informed about the fairness of a competition or not. Following the competition, participants (who either won or lost the competition) decided how to distribute earnings between themselves and their opponent. We show that informing participants about the fairness of the competition reduces selfish behavior among losers, while behavior among winners remains unaffected. Moreover, we show that losers who were not informed about the fairness of the competition incorrectly viewed it as having been unfairly stacked against them (i.e., believing that they encountered significantly more difficult tasks than their opponents). Our findings suggest that information about a level playing field reduces selfish behavior and is important for understanding when and why motivated reasoning about procedural fairness helps people uphold a positive self-image. (c) 2021 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

The depleting effect of repeated decision making is often referred to as decision fatigue. Understanding how decision fatigue affects medical decision making is important for achieving both efficiency and fairness in health care. In this study, we investigate the potential role of decision fatigue in orthopedic surgeons decisions to operate, exploiting a natural experiment whereby patient allocation to time slots is plausibly randomized at the level of the patient. Our results show that patients who met a surgeon toward the end of his or her work shift were 33 percentage points less likely to be scheduled for an operation compared with those who were seen first. In a logistic regression with doctor-fixed effects and standard errors clustered at the level of the doctor, the odds of operation were estimated to decrease by 10.5% (odds ratio=0.895, pamp;lt;.001; 95% CI [0.842, 0.951]) for each additional patient appointment in the doctors work shift. This pattern in surgeons decision making is consistent with decision fatigue. Because long shifts are common in medicine, the effect of decision fatigue could be substantial and may have important implications for patient outcomes. ; Funding Agencies|Ostergotland County Council (ALF project); Ragnar Soderberg foundation; Marianne and Marcus Wallenberg foundation [MMW2014.0187]

AbstractDo differences in worldview ideology hinder people from objectively interpreting the effect of immigration? In an experiment with Swedish adults (n= 1015), we investigate whether people display motivated reasoning when interpreting numerical information about the effects of refugee intake on crime rate. Our results show clear evidence of motivated reasoning along the lines of worldview ideology (i.e., whether people identify themselves primarily as nationally oriented or globally oriented). In scenarios where refugee intake was associated with higher crime rate, nationally oriented people were 18 percentage points more likely to make the correct assessment compared to globally oriented people. Likewise, in scenarios where refugee intake was associated with lower crime rate, nationally oriented people were 20 percentage points less likely to make the correct assessment compared to globally oriented people. Individuals with higher numeric ability were less likely to engage in motivated reasoning, suggesting that motivated reasoning more commonly is driven by feelings and emotional cues rather than deliberate analytical processes.

Background and purpose — There is increasing evidence that several commonly performed surgical procedures provide little advantage over nonoperative treatment, suggesting that doctors may sometimes be inappropriately optimistic about surgical ben- efit when suggesting treatment for individual patients. We investi- gated whether attitudes to risk influenced the choice of operative treatment and nonoperative treatment. Methods — 946 Swedish orthopedic surgeons were invited to participate in an online survey. A radiograph of a 4-fragment proximal humeral fracture was presented together with 5 differ- ent patient characteristics, and the surgeons could choose between 3 different operative treatments and 1 nonoperative treatment. This was followed by an economic risk-preference test, and then by an instrument designed to measure 6 attitudes to surgery that are thought to be hazardous. We then investigated if choice of non-operative treatment was associated with risk aversion, and thereafter with the other variables, by regression analysis. Results — 388 surgeons responded. Nonoperative treatment for all cases was suggested by 64 of them. There was no significant association between risk aversion and tendency to avoid surgery. However, there was a statistically significant association between suggesting to operate at least 1 of the cases and a "macho" atti- tude to surgery or resignation regarding the chances of influenc- ing the outcome of surgery. Choosing nonoperative treatment for all cases was associated with long experience as a surgeon. Interpretation — The discrepancy between available evidence for surgery and clinical practice does not appear to be related to risk preference, but relates to hazardous attitudes. It appears that choosing nonoperative treatment requires experience and a feel- ing that one can make a difference (i.e. a low score for resigna- tion). There is a need for better awareness of available evidence for surgical indications.

BACKGROUND: When rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a 'grandfather clause' when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians' and patient organization representatives' experiences- and perceptions of withdrawing and withholding treatments in rationing situations of relative scarcity. METHODS: Fourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used. RESULTS: Participants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients' need for treatment (e.g., the treatment's effectiveness and the patient's medical condition) withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers. CONCLUSIONS: We conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment's effect, and to provide guidelines on ...

Background. Measuring societal preferences for rarity has been proposed to determine whether paying pre- mium prices for orphan drugs is acceptable. Objective. To investigate societal preferences for rarity and how psychological factors affect such preferences. Method. A postal survey containing resource allocation dilemmas involving patients with a rare disease and patients with a common disease, equal in severity, was sent out to a randomly selected sample of the population in Sweden (return rate 42.3%, n = 1270). Results. Overall, we found no evidence of a general preference for prioritizing treat- ment of patients with rare disease patients over those with common diseases. When treatment costs were equal, most respondents (42.7%) were indifferent between the choice options. Preferences for prioritizing patients with common diseases over those with rare diseases were more frequently displayed (33.3% v. 23.9%). This tendency was, as expected, amplified when the rare disease was costlier to treat. The share of respondents choosing to treat patients with rare diseases increased when present- ing the patients in need of treatment in relative rather than absolute terms (proportion dominance). Surprisingly, identifiability did not increase preferences for rarity. Instead, identifying the patient with a rare disease made respondents more willing to prioritize the patients with common diseases. Respondents' levels of education were significantly associated with choice—the lower the level of education, the more likely they were to choose the rare option. Conclusions. We find no support for the existence of a general preference for rarity when setting health care priorities. Psychological effects, especially proportion dominance, are likely to play an important role when pre- ferences for rarity are expressed. ; Funding agencies: Swedish Association of the Pharmaceutical Industry (LIF); Ragnar Soderberg Foundation

The objective of this article was to investigate the existence of horizontal inequality in access to care for six categories of elective surgery in a publicly funded system, when care is rationed through waiting lists. Administrative waiting time data on all elective surgeries (n = 4,634) performed in Östergötland, Sweden, in 2007 were linked to national registers containing variables on socioeconomic indicators. Using multiple regression, we tested five hypotheses reflecting that more resourceful groups receive priority when rationing by waiting lists. Low disposable household income predicted longer waiting times for orthopedic surgery (27%, p < 0.01) and general surgery (34%,p < 0.05). However, no significant differences on the basis of ethnicity and gender were detected. A particularly noteworthy finding was that disposable household income appeared to be an increasingly influential factor when the waiting times were longer. Our findings reveal horizontal inequalities in access to elective surgeries, but only to a limited extent. Whether this is good or bad depends on one's moral inclination. From a policymaker's perspective, it is nevertheless important to recognize that horizontal inequalities arise even though care is not rationed through ability to pay.