The changing locus of decision making in the health care sector

In the 1970s, the health policy debate focused on whether government or the medical profession should control the health care system. This article asserts that that struggle between two forms of centralized control was both less promising and less consequential than the devolution of decision-making authority upon consumers and their agents that is occurring today and that seems likely to continue as competitive forces become stronger and opportunities for meaningful consumer choice increases. What we are witnessing is the simultaneous deprofessionalization and depoliticization of important decisions affecting health care, a decentralization and diversification of the system that is opening new possibilities for translating diverse consumer desires into provider performance. Although covering much familiar ground, this article links a variety of seemingly discrete issues under the sterility of the competition-versus-regulation debate and to show the historical and ethical significance of the major changes that are under way in the health care sector today.     

Rationing health care: it's a matter of the health care system's structure

The article examines two primary policy proposals for how the U.S. should allocate its limited health care dollars: a centralized model in which a commission establishes rationing guidelines, and a decentralized model in which rationing decisions are made by health care providers on a case by case basis. The author finds significant advantages with each position, leading the author to assert that a combination of each is key to an effective rationing policy: a centralized control of structure coupled with decentralized physician-level decision making. While mindful that formal rationing guidelines alone are unfeasible to effectuate cost-effective care, the author introduces two decentralized policies to control costs: the limitation of resources at physicians' disposal and elimination of physicians' personal incentive to provide high-cost care.     

Rationing human life: health care reform and people with disabilities

Peter Singer has proposed health care rationing that includes an invidious discrimination against people with disabilities. Unfortunately, Congress has codified the potential for such discrimination in the 2010 Patient Protection and Affordable Care Act. But why should any public official have the discretion to treat the lives of people with disabilities as of "lower value" than the lives of anyone else. There must be a comprehensive limitation in the law against the misuse of comparative clinical effectiveness research to support the rationing of human life.     

Courts and health policy: judicial policy making and publicly funded health care in Canada

The 1982 Canadian Charter of Rights and Freedoms provided political actors with the opportunity to make rights-based challenges to public policy decisions. Two challenges launched by providers and consumers of health care illuminate the impact of judicial review on health care policy and the institutional capacity of courts to formulate policy in this field. The significant impact of rights-based claims on cross-jurisdictional policy differences in a federal regime is noted.     

Preference for decision control in organizational decision making

Two studies examined preference for authority or subordinate decision control in dispute resolution and allocation procedures in an organizational setting. In both studies, a marked preference for the authority/subordinate sharing of decision control was found. In Study 1, nearly one third of respondents preferred that subordinates share decision control with supervisors in both dispute and allocation situations; for several of the situations decision sharing was the modal preference. The study also found a tendency to prefer subordinate decision control in disputes but supervisor decision control in allocations. In Study 2, again the most preferred procedure was one in which subordinates shared decision control with their supervisors. The procedure high in decision sharing was rated as the one most fair. It was also rated as more likely to improve relationships among members and to result in the best decision. Some differences in preference for decision control and decision sharing depending upon social factors predominant in the setting were found.     

Parole decision making in Colorado

During the past decade parole decision making in the United States has come under severe scrutiny. One response has been for researchers to intervene and develop parole guideline matrices for use by state parole boards. The research reported here describes such an effort in Colorado. Our data were derived from the records of 292 parolees during a two year period. A systematic sampling process, taking every other docket number from the parole board's monthly eligibility lists, initially produced 1,500 potential parolees. From this list, a 20 percent sample was drawn at random. This yielded a workable guideline matrix that produced less than 13 percent variance from Colorado parole board decisions. The article discusses the procedures for developing the matrix and how it was implemented by the parole board.     

Naturalistic decision making in forensic science: toward a better understanding of decision making by forensic team leaders

This study uses the naturalistic decision-making (NDM) perspective to examine how Dutch forensic team leaders (i.e., the officers in charge of criminal forensic research from the crime scene until the use of laboratory assistance) make decisions in real-life settings and identifies the contextual factors that might influence those decisions. First, a focus group interview was conducted to identify four NDM mechanisms in day-to-day forensic decision making. Second, a serious game was conducted to examine the influence of three of these contextual mechanisms. The results uncovered that forensic team leaders (i) were attracted to obtain further information when more information was initially made available, (ii) were likely to devote more attention to emotionally charged cases, and (iii) used not only forensic evidence in the decision making but also tactical, unverified information of the police inquiry. Interestingly, the measured contextual influences did not deviate significantly from a control group of laypeople.     

Juror decision making in the capital penalty trial

Two factors thought to influence jurors' penalty decisions in capital trials—the nature of the crime committed and the defense's portrayal of the convicted offender's character—were examined. Mock jurors were death-qualified and exposed to one of twelve simulated penalty trials. Each trial was comprised of one of three capital crimes and one of four defense strategies. Jurors were least punitive in robbery-murder conditions and most punitive in multiple murder conditions. A conceptual argument against capital punishment was the most effective defense; a mental illness defense was the least effective. Penalty decisions were mediated by three attributional variables: (a) juror perceptions of the defendant's volition, (b) juror perceptions of the defendant's future dangerousness, and (c) juror perceptions of the relative competency of the opposing attorneys.This article is based on the author's dissertation which received an Honorable Mention in the 1985 SPSSI Dissertation Prize competition. The research was made possible by grants from the University of California, Santa Cruz and Division 41 of the American Psychological Association. The author is indebted to Craig Haney, Elliot Aronson, and Dane Archer for their valuable suggestions and support.     

Jury decision making in the capital penalty phase

There are large bodies of research on the deterrent value of the death penalty and public attitudes towards capital punishment. However, little is known about how jurors decide whether a particular defendant should live or die. This article briefly summarizes the case law that attempts to guide the discretion of jurors in the penalty phase of capital murder trials, reviews empirical research on penalty decision making, suggests a methodological strategy for investigating the penalty phase, and identifies several promising directions for future research. Four broad categories of research are identified: the effects of guiding juror discretion, comparisons of juries that vote for life with those that vote for death, the relationship between guilt and penalty phases, and models of decision making in the penalty phase. Several testable hypotheses are proposed.     

Epistemic emotions in prosecutorial decision making

The article examines epistemic emotions as part of the emotive-cognitive processes of prosecutors’ knowledge seeking and decision making in preliminary investigation and court proceedings. Drawing on ethnographic fieldwork, interviews, and shadowing of prosecutors in Sweden, we show how emotions motivate and orient prosecutors’ inquiries and the fundamental role of the ‘certainty–doubt spiral’ for ‘doing objectivity’. In conclusion, we discuss the centrality of emotions for conscientious and well-considered decisions in legal work. The study contributes to the field of law and emotion by exploring the epistemic quality of emotions, notably the certainty–doubt spiral, in legal work.