The fairness chameleon

Scarce public resources in health care can be valued in a certain manner and by different means to create fairness in their allocation. By using economical and philosophical theories on the concept of fairness arguments can be put forward whether a system of allocation is (un)fair. Optimal use of scarce resources may be identified to be the leading principle of allocation and valuation of resources is assumed to go in accordance to create an optimal result. Third parties, legislation, protocols and rules are examples of instruments that are used to ensure for this (pre)intended valuation to allocate scarce public resources. A constructivist view in research on values and valuation, used by Latour in his essays on policy processes, is that they are embedded within practice. This view challenges the assumption that valuation is a matter of design and implementation. Valuation, once translated into practice, may cause a dynamic that creates both intended and unintended effects. The implication for research on a valuation system is that a detailed study on valuation in practice is needed to get an understanding of the actual valuing of resources that is taking place. For the thesis at hand a case study was performed on the valuation system to allocate post mortem donor kidneys in the Netherlands. Together with six other countries, the Netherlands participate in Eurotransplant to carry out the responsibility of allocation. Eurotransplant allocates post mortem donor kidneys by the use of different programs, but the ETKAS computer driven system is the main program to allocate. By interviewing some of the key members in Dutch donor kidney allocation an understanding is created in the valuation and allocation of post mortem donor kidneys in the Netherlands. The findings of the case study are in line with constructivist theories and Latour’s approach in research on values and valuation. Values and valuation are embedded within practice. The interaction of multiple variables in one system creates a complex dynamic that causes both intended and unintended effects in valuation. Next to the system itself, beliefs and behaviours of actors, political pressure, institutions and institutional arrangements influence the valuation and hence composition of fairness in allocation. For research on a valuation system this implies that detailed research in practice is needed to understand the valuation and composition of different notions of fairness that is taking place by the system itself, the actors, the institutions and the institutional arrangements. Not only does research have to focus on effects that are created by single variables in the valuation system, but also what these effects implicate for the eventual outcome of valuation. For governance this implies that governing a valuation system needs redefining to decide what counts and what matters, which urges awareness and alertness in the actual valuing that is taking place in practice. To be able to redefine valuation detailed research in practice is needed.