Doctors and the ethics of macroallocation: An empirically grounded case for Paul Ricoeur’s ‘little ethics’ as a framework for moral analysis

Abstract

Background In most socialised health systems there are formal processes that manage resource scarcity and set priorities for the allocation of funds to health services. This thesis is an empirical bioethics study examining the ethical issues entailed in doctors’ participation as technical experts in such priority setting processes. It describes the motivations, values, and ethical commitments of doctors who engage in priority setting, their ethical experiences and perceptions, and their approach to the matter of skills for the role. The thesis makes an empirically derived contribution towards the identification of an ethical framework for doctors’ macroallocation work. Method I conducted semi-structured interviews with 20 doctors, each of whom participated in macroallocation at one or more levels of the Australian health system. My sampling, data-collection, and analysis strategies were closely modelled on grounded moral analysis, an iterative empirical bioethics methodology that employs contemporaneous interchange between the ethical and empirical to support normative claims grounded in practice. Results Applying the principles of grounded moral analysis, I identified that my participants’ ideas of the good in macroallocation and their normative insights into the practice were strongly aligned with the three levels of Paul Ricoeur’s ‘little ethics’: ‘aiming at the “good life” lived with and for others in just institutions’, and that there were deficiencies in the social process of macroallocation that impeded both doctors’ achievement of the ethical aim and the just distribution of resources. Conclusions My findings suggest new ways of understanding how doctors’ values, and rhetorical and ethical practices might have procedural and substantive impacts on macroallocation, and challenge the prevailing assumption that doctors in this milieu are motivated primarily by deontological considerations. My empirical bioethics approach enabled me to identify in Ricoeur’s ethics an ethical framework for medical work in macroallocation that was grounded in the values and ethical intuitions of doctors engaged in actions of distributive justice. The concordance between Ricoeur’s ‘little ethics’ and macroallocation practitioners’ experiences, and its embrace of mutuality, suggest that it has the potential to guide practice, support ethical reflection, and harmonise deliberative practices amongst actors in macroallocation generally.