{"id":127260,"date":"2021-05-26T13:30:06","date_gmt":"2021-05-26T11:30:06","guid":{"rendered":"https:\/\/www.erasmusmagazine.nl\/en\/?p=127260"},"modified":"2025-12-19T11:25:39","modified_gmt":"2025-12-19T10:25:39","slug":"in-the-netherlands-we-have-ethical-objections-against-age-as-a-selection-criterion","status":"publish","type":"post","link":"https:\/\/www.erasmusmagazine.nl\/en\/2021\/05\/26\/in-the-netherlands-we-have-ethical-objections-against-age-as-a-selection-criterion\/","title":{"rendered":"\u2018In the Netherlands, we have ethical objections against age as a selection criterion\u2019"},"content":{"rendered":"

Which treatment expenses should and shouldn\u2019t be covered by the basic health insurance package? And which role do the patient\u2019s burden of disease and age play in this decision-making process? Vivian Reckers-Droog delved into these and other questions in her dissertation Giving Weight to Equity: Improving priority setting in healthcare<\/em>.<\/p>\n

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What\u2019s your dissertation about?<\/strong><\/p>\n

\u201cI\u2019ve researched how healthcare actors decide which new treatments are funded within their public healthcare system. Which treatments are covered by the basic health insurance package? And which criteria are adopted in this context? What\u2019s important is that the choices made actually contribute to an efficient and equitable disbursement of the healthcare budget. In the Netherlands, this efficiency is determined on the basis of cost-effectiveness and to which extent the decision does justice to patients\u2019 burden of disease.<\/p>\n

\u201cFor example, we recently gained a new treatment for a rare disease that costs 1.9 million euros per treatment. The question at that point is whether this treatment should be paid from taxpayers\u2019 money. As a country, our touchstone for determining whether costs should be considered prohibitive is the burden of disease. The worse shape a patient is in, the higher we\u2019re prepared to set this limit. An infected toenail shouldn\u2019t cost too much, in other words. I\u2019ve also examined whether this policy reflects equity considerations found in society, and which relation there is between these considerations and the patients\u2019 burden of disease and age.\u201d<\/p>\n

What were your main conclusions?<\/strong><\/p>\n

\u201cThere\u2019s considerable support for linking a treatment\u2019s cost-effectiveness to a patient\u2019s burden of disease. But what people may well find even more important is that cost-effectiveness is viewed in relation to the patient\u2019s age. In other words, people find it important to take on board both how ill someone is, and how old. Even though in the Netherlands, age is explicitly ruled out as a criterion for patient selection \u2013 we have ethical objections. But there\u2019s still a relationship between the method used for calculating the burden of disease and age: in reimbursement decisions for elderly patients, this burden is given a higher relative weighting.<\/p>\n

\u201cSo one of my conclusions is that you will have to do something with these preferences \u2013 by incorporating them in your decision-making framework, for example. And even when you don\u2019t feel the need to accommodate public opinion \u2013 giving every patient the same level of access to care \u2013 you would have to correct the current calculation model for burden of disease, since right now it discriminates in favour of older patients.\u201d<\/p>\n\n\t

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\n\t\t\u2018People find it important to take on board both how ill someone is, and how old. Even though in the Netherlands, age is explicitly ruled out as a criterion for patient selection \u2013 we have ethical objections\u2019\n\t<\/blockquote>\n\n\t<\/figure>\n\t\t<\/div>\n\t<\/div>\n

Could you draw lines between your research and the debate regarding which target group should be prioritised in the Covid pandemic?<\/strong><\/p>\n

\u201cYou could make that comparison \u2013 although in the case of the pandemic, it\u2019s not a question of which treatments should or shouldn\u2019t be reimbursed, but who \u2013 in the event of absolute shortages \u2013 should receive medical care first. A \u2018bedside decision\u2019, in other words, while my dissertation deals with decisions at the health insurance level. When the \u2018black scenario\u2019 (shortage of beds) came up in the Covid debate, Minister Tamara van Ark made no bones about it: \u2018We\u2019re not allowed to discriminate on the basis of age: each life is equally valuable.\u2019 This has been a point of discussion<\/a> between physicians and the government.\u201d<\/p>\n

I read in your acknowledgements that you didn\u2019t actually plan to pursue a doctorate?<\/strong><\/p>\n

\u201cThat\u2019s right. I\u2019d been working some nine years as departmental manager for a mental healthcare institution, in the child and adolescent psychiatry unit. I did art school and have a degree in Educational Theory, so the original idea was that I would study Health Care Management at EUR to gain a firmer theoretical footing.<\/p>\n

\u201cDuring the pre-master\u2019s, I was working on a quantitative research assignment, and a whole new world opened up. I liked it so much. I discovered that I could embark on a completely new career: learning and discovering new things.<\/p>\n

\u201cAround the same time, I discovered that heath care management wasn\u2019t really my thing. So before it was too late to stop, I switched to the Health Sciences research master\u2019s, with a specialisation in Health Economic Analysis. I hadn\u2019t rounded that off yet when I was accepted for this doctoral research position, at which point I quit my old job. The first person I thank in my acknowledgements is my former manager, for always supporting me, making it possible for me to switch programmes and giving me the opportunity to attend this programme.\u201d<\/p>\n\n\t

And what was it like to obtain your doctorate?<\/strong><\/p>\n

\u201cVery special. I feel quite sorry for colleagues who are starting during the current pandemic, because I really enjoyed working together with other candidates, discussing what you run into. You\u2019re all going through the same process. And ESHPM is a supportive environment, where colleagues help each other \u2013 that was very nice too.\u201d<\/p>\n

So a bed of roses all round?<\/strong><\/p>\n

\u201cOf course you always have ups and down. One week, your article can get accepted for publication; the next week, you\u2019re rejected for a conference. Or you\u2019re stuck in your research, or in a flow, and this process can recur with each new study. And of course, you have to put in the hours. You can confer with colleagues, but at the end of the day you have to do it yourself. Fortunately, I\u2019m a bit older than most, and fairly independent. But if you\u2019re younger, you may find it a rather demanding experience. Is that bad news though? I rather liked it, since it provided opportunities to work on other things I enjoyed. I was also given a lot of scope to do projects on the side. Apart from having all the articles in my dissertation published, I was able to write eight other papers.\u201d<\/p>\n\n\t

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