Scarcity of resources is a fact of healthcare. This needs to be recognised by the potential respondents to any community survey, thereby avoiding "wish listing" in an environment where the opportunity costs of choices are not apparent. The sorts of choices they should face are those that health service planners face: whether to spend more or less on interventions in maternity care or the mentally ill; more or less on urban, rural or remote healthcare; on the young or the old; on Aboriginal or non-Aboriginal healthcare.
In the literature there is little discussion on what approach to use in eliciting community preferences. Is the intention to obtain community values by aggregating the preferences of individuals concerned for themselves? Or by asking individuals to put themselves in the position of planners acting on behalf of a community such as, say, the Perth community or the Australian community? Or are community values best discovered by allowing a communal discourse that gradually reveals a consensus? Each approach is likely to reveal a different set of community preferences. The usefulness of each approach will be partly dependent on what kind of decision making the results are intended to guide.
socially inclusive personal — value to others plus self.
A fourth is the "communitarian" perspective,13 where the community and not an aggregation of individuals might be the focus. The Perth citizens’ juries, where consensus was sought rather than the sum of individuals’ votes, might be seen in these terms.
There are various techniques available for finding community values. In addition to citizens’ juries, these include deliberative democracy, focus groups, opinion polls, conjoint analysis and several others.14-17 There is too little evaluation of these to judge which is best. Such a judgement may not be possible: each technique may have its place.
recognition of the scarcity of health service resources (because preferences are truly revealed when one is required to make a choice).
Expert views or medical specialist knowledge may be important inputs, providing information that is then filtered through a random group of citizens engaged in deliberation and reflection. Such a process allows the social context to be added to medical science.
Many decisions in healthcare are complex and technical. At the clinical level, society trains doctors to act as patients’ agents to allow the patient (or sometimes the doctor on behalf of the patient) to make decisions that are more informed than those of the patient alone. Above the level of individual clinical decisions, there are questions of resource allocation and policy that are very much social choices. They still have to be informed by technical information. In between, doctors are faced with many decisions where it is less clear which values should apply. Partly this is because it is difficult to decide where the dividing line should come between professional and social value judgments; partly because some decisions are so technical and complex that citizens cannot make truly informed choices. However, citizens may accept their limitations in some areas of decision making, while insisting on their right to decide in others. Citizens may choose the issues for which they want their preferences to be counted. They may thus have "preferences for preferences".
This last issue has received less attention than it merits. In a study in Australia, Wiseman et al showed that citizens were keen to be involved in healthcare decision making,17 but saw this as "involving other groups, namely clinicians, health service managers, and patients and their families". The desire to be involved varied with the type of decision (eg, citizens were less inclined to want to be involved in decision making "concerning specific medical procedures").
in which they themselves have a preference for being involved.