Kathrin Dengler and Uta Bittner demand a full-fledged philosophy of values in our empirical study of various methods for ethical analysis in health technology assessment (HTA). This may be like putting the classification of disease on hold until the concept of disease is clarified, or postponing the development of health care until the term “health” is clarified. As Dengler and Bittner rightly point out, the term value has many meanings, and as they properly recognize: “[P]hilosophically, the definition of what is meant by ‘a good life’ or ‘well-being’ is a very challenging project.” Hence, it may be a bit over the top to crave that we solve eternal issues in an empirical article on methodology.
Furthermore, as we underscore in our article (Reference Saarni, Braunack-Mayer, Hofmann and van der Wilt4), the assessment and decision making context is important. “[T]he value-ladenness of a technology depends on the cultural context where it is applied.” (Reference Saarni, Hofmann and Lampe5). Hence, values may be quite different in various settings, as may the meaning of value as such. As Dengler and Bittner rightly point out, there are many types of values (scientific, moral, aesthetic, economic) and values may be subjective and objective. We would like to add that values can be intrinsic and extrinsic (instrumental, inherent, contributory, relational, indicative), and they can be intersubjective. We do not demand universal definitions of “the good life” and “well-being” to address value issues in HTA, as Dengler and Bittner do. This is because our main point is to highlight value-judgments and value-issues in the assessment, implementation, and use of health technology in context. We do not want to impose our conceptions of values on patients, users, and decision makers. Instead, we want them to be aware of and reflect on value issues in the context where they themselves define value. In particular, we do not have the same strong preference for economic values as Dengler and Bittner. That being said, we do have some categories of values which we think are relevant to the assessment of health technology in most cases, such as general moral values, stakeholder interests, technological value-ladenness, methodological values in HTA, and values related to HTA (and EBM) and a more fine grained explication of such values is also provided (Reference Hofmann1;Reference Hofmann3).
Although their call for of a philosophy of value analysis in our empirical article on ethics method in HTA may be demanding too much, the question itself is of course highly relevant and interesting. It has been dealt with in the philosophy literature repeatedly. However, as Dengler and Bittner presumably know, there is no consensus on the matter. Waiting on consensus before elaborating ethics methodology may be misguided. As we use terms such as health and disease without clear definitions (Reference Hofmann2), we may have to use terms such as value and good life with similar lack of definition. Moreover, we do not think it is wise to enforce stringent definitions of value on the contextual assessment. This may distract and hamper the reflection on values in the context where they are at play and, at the same time, defined.
Hence, we agree with Dengler and Bittner that the challenges with defining values need to be taken into consideration in technology assessment in health care, but we do not think it is necessary to do it top down. Their solutions and definitions are of course most welcome.
CONFLICTS OF INTEREST
Samuli Saarni has received travel funding from AstraZeneca. The other authors report they have no potential conflicts of interest.
