health technology assessment ( hta ) is an effective policy tool in the evidence - based evaluation of health care technologies . one of the most important components of any hta is its focus on ethical considerations of technologies . this matter is both dissscussed as decision criteria and also as an ethical or value basis for all decision makings ( 1 - 4 ) . previous studies , however , have shown that despite being completely stipulated , ethical issues are less considered in hta reports . the difficulty and subjectivity inherent in ethical analyzes might be a reason for such a negligence ( 5 ) . nevertheless , there have been great efforts to develop numerous tools to consider ethical aspects in htas ( 6 - 11 ) . 
 
 whether those tools are used or not is a worthy question to ask . this study intends to review hta reports to describe methods of considering ethics in htas . such a consideration may range from propounding of ethical issues to effects they might have on final decisions ; i.e. approaches and methods adopted , principles referred to and goals and objectives sought by ethical analysis and also the extent to which these have been exposed during decision - making process . first , to reach to hta reports we searched and found hta institutions around the world . so , our study focused on hta reports accessible by the internet and was limited to electronic sources in english . to this end , we used google search engine by applying the following general terms : 
 
 health  technology assessment  or hta or  technology appraisal .  
 
 to be more sensitive and to assume that in addition to aforementioned terms , there might be other relevant concepts and words too , we used other queries in refining and revising search strategies and efforts . after finding relevant hta websites , thus , hta full reports in english published in 2011 and with available and accessible were selected out . 
 
 in the next stage , lehoux and williams - jones model and the map were used to conduct a content analysis of hta reports . the model and map apply for social and ethical issues that might emerge out of conditions inherent to technology use ; issues like doctor - patient relationship , direct or indirect effect on other stakeholders , broader societal issues ( such as conflict with social values and arrangements , human integrity and dignity ) , or issues concerning assessment methods ( such as choice of end points , moral consequences of the hta ) and , finally , issues of resource implications of technology dissemination ( such as distribution of and access to health care services and equity ) ( 6 - 11 ) . authors assumed that based on a report contents , influence and implication of ethical considerations would be traceable if the issues raised could change the final decisions made , or affect the decision - making process ( e.g. observing accountability for reasonableness  as a moral approach to decision making ) , or add an ethical point to executive summary . the general approach of the hta institutions to ethical aspects in hta based decision making was also analyzed . most reports belonged to the united states and the uk and a few ones to sweden and ireland . no ethical issue was brought up in 55 reports ( 61.8% ) . amongst the rest 34 reports , ethical issues about the nature of the technology , issues of doctor - patient relationship , issues relating to other stakeholders , social values , assessment methods , and equity were discussed in 3 , 3 , 3 , 4 , 0 and all 34 reports respectively . according to the text report , those ethical considerations influenced documented dialectics of decision making or final decision in 1 ( 33% ) , 1 ( 33% ) , 2 ( 66% ) , 1 ( 100% ) , 0 , 15 ( 44% ) reports respectively . also , influencing final recommendation in terms of ethical points added to executive summary was boldly detectable in 16 reports ( table 1 ) . however , it was not investigated whether other cases were relevant for a due consideration and change in decision making . the most common ethical assessment considered was equity - related issues , though inadequately and incompletely . nevertheless , equity concerns were not even brought forth in 55 reports ( 61.8% ) . amongst countries , these ethical aspects were fully assessed and considered in all reports issued in ireland and sweden , with obvious effects on final decision statement ( table 2 ) . nice ( national institute for health and clinical excellence ) of england had the highest number of hta reports accessible ( 26 reports ) . equity - related issues , as a distinct component , were considered in all of nice technology appraisals ;  equality impact assessment  influenced final decision statement in 10 reports . although issues of assessment methods were not considered in any report , nice process for hta - based decision making ( technology appraisal ) conformed with principles of  accountability for reasonableness  , which have 4 conditions for the legitimacy of a decision - making process : publicity , relevance , appeals , and enforcement ( 12 ) . 
 
 among hta reports in which ethical issues were somehow raised ( i.e. 38% of all reports in 2011 ) , equity issues were considered in 100% of the reports ; issues concerning societal values in 11.8% ; and issues of technology itself , of doctor - patient relationship , and of other stakeholders in 8.8% of the reports . from extent - of - influence viewpoint , equity issues were stated in final document of 15 cases ( 44.1% ) ; issues of other stakeholders in 2 final documents ( 5.9% ) ; and issues of societal values , of technology itself , and of doctor - patient relationship in only one final document ( 2.9% ) . 
 
 despite existence of various tools for consideration of ethical aspects in htas ( 6,7,21,22 ) , no reference was made to them in all hta reports retrieved in present study . although there are numerous studies that point to little attention to ethics compared to other aspects in hta reports ( 23 - 26 ) , more detail about local approaches to and influence of ethical considerations on final decisions in hta reports is missing . our study tried to answer the question that  to what extent each type of ethical issue was considered and implicated in hta documents ? findings showed that most attention was paid to equity issues while allocating the resources . amongst the countries , the highest moral considerations concerning evaluation methods ( ethical hta process ) was related to accountability for reasonableness  for legitimate decision - making in the uk . according to literature , this might show that structural measures for moral decision - making process seem to be more effective . some of this success might be attributable to the legal status of hta system and related recommendations in public services as quasi - law statements ( 27 ) . therefore , it seems that institutionalization of  ethical hta would not be possible only by adding a chapter on ethics to the hta reports . again , it was observed that there are few hta reports with a complete approach to all aspects of ethical consideration . although there are some accessible tools of addressing ethical and / or equity issues in health technology assessment , we could not judge on whether or not the tools was helpful and had any effect because no reports referred to them . while few number of ethical issues included in hta reports has real influence on final hta decisions , those ethical considerations defined in the form of planned and written policy and institutionalized in a systematic way , are of the great need to truly influence hta decision makings . it can be said in countries that are considering the ethical issues in their hta reports ( such as the uk , sweden and ireland ) , the approach is more focused on implications of equality and fairness in the allocation of resources . the authors only managed to assess the content of hta reports in one year , those with accessible electronic english documents ; therefore , this sample may not represent all relevant hta reports . moreover , in a review of hta based decision - making systems around the world , there might be some other mechanisms for ethical considerations that are not documented ( as technical evidence ) in the assessment phase of hta reports . those mechanisms could have a potential influence on decision - making about technologies under question . our study only focused on assessment consequences and not on other ethical issues that might be relevant to htas . indeed , the authors could not evaluate subjectivity of ethical concerns about the technologies assessed in the reports . for future studies , one can recommend that all the stages of assessment , especially scoping phase of the hta project , should be documented and analyzed . a repeat of the present review for different years in order to assess the trend of attention to ethics in htas can be another recommendation .