Are preferences for equality a matter of perspective?

Background. Many subjects attach equal value to different health care programs in surveys eliciting preferences for resource allocation. It has been suggested that subjects may be prepared to attach different priority if they were asked to evaluate someone else's decision instead of adopting the role of a social decision maker. This study investigated whether the perspective individuals are asked to adopt affects their priority setting decisions and the likelihood of assigning equal value to health care programs. Methods. 1253 members of an Internet panel were presented a set of clinical vignettes describing preventive health care initiatives and were asked to prioritize among these. They choose between "discrimination, " that is, allocating all resources on the better program, and "equality," that is, dividing the resources equally between programs while reducing efficiency. Respondents were randomized to either of 4 survey versions that differed in terms of perspective (evaluator vs. decision maker) and expert status (expert vs. layperson) of the role to be adopted. Results. Subjects in the evaluator perspectives were more likely to choose equality over discrimination between patients as compared to those in the social decision-make., perspectives, regardless of expert status (odds ratios 2.09 and 2.03, P < 0.0001). Excess rates of equality choices in the evaluator frames resulted from passive acceptance of equality decisions and active revision of prioritization decisions. Conclusion. Preferences for an equal allocation of resources are strongly affected by decision-making perspective but stable across expert status of the adopted role.