Many economic measures are structured to reflect ethical values. I describe three attitudes towards this: maximalism, according to which we should aim to build all relevant values into measures; minimalism, according to which we should aim to keep values out of measures; and an intermediate view. I argue the intermediate view is likely correct, but existing versions are inadequate. In particular, economists have strong reason to structure measures to reflect fixed, as opposed to user-assessable, values. This implies that, despite disagreement (...) about precisely how to do so, economists should standardly adjust QALYs and DALYs to reflect egalitarian values. (shrink)

Summary measures of health, such as the quality-adjusted life year and disability-adjusted life year, have long been known to incorporate a number of value choices. In this paper, though, I show that the value choices in the construction of such measures extend far beyond what is generally recognized. In showing this, I hope both to improve the understanding of those measures by epidemiologists, health economists and policy-makers, and also to contribute to the general debate about the extent to which such (...) measures should be adjusted to reflect ethical values. (shrink)

By registering different health benefits on a common scale, CEA allows us to assess the relative social importance of different health care interventions and opens the way for the allocation decisions of health care policy. If it is really to be effective, however, CEA must be recalibrated so that it better reflects some of our widely held beliefs about the merits of different kinds of treatment.

Today there is a growing wave of demands being placed upon the pharmaceutical industry to contribute to improved access to medicines for poor patients in the developing countries. 1 This article aims to contribute to the development of a systematic approach and broad consensus about shared benchmarks for good corporate practices in this area. A consensus corridor on what constitutes an appropriate portfolio of corporate responsibilities for access to medicines -especially under conditions of 'failing states' and 'market failure' 2 – (...) is not only in the interest of the world's poor, but also of corporations that want to contribute to the solution of one of the most significant social problems of our time. (shrink)

In the Global Burden of Disease study, disease burden is measured as disability-adjusted life years (DALYs). The paramount assumption of the DALY is that it makes sense to aggregate years lived with disability (YLDs) and years of life lost (YLLs). However, this is not smooth sailing. Whereas morbidity (YLD) is something thathappens toan individual, loss of life itself (YLL) occurs when that individual’s life has ended. YLLs quantify something that involves no experience and does not take place among living individuals. (...) This casts doubt on whether the YLL is an individual burden at all. If not, then YLDs and YLLs are incommensurable. There are at least three responses to this problem, only one of which is tenable: a counterfactual account of harm. Taking this strategy necessitates a re-examination of how we count YLLs, particularly at the beginning of life. (shrink)

This paper examines the lack of health insurance coverage in the US as a public policy issue. It first compares the problem of health insurance coverage to the problem of unemployment to show that in terms of the numbers of individuals affected lack of health insurance is a problem comparable in importance to the problem of unemployment. Secondly, the paper discusses the methodology involved in measuring health insurance coverage, and argues that the current method of estimation of the uninsured underestimates (...) the extent that individuals go without health insurance. Third, the paper briefly introduces Amartya Sen's functionings and capabilities framework to suggest away of representing the extent to which individuals are uninsured. Fourth, the paper sketches a means of operationalizing the Sen representation of the uninsured in terms of the disability-adjusted life-year (DALY) measure. (shrink)

Centre for Applied Philosophy and Public Ethics (CAPPE), Menzies Centre for Health Policy, The Australian National University, LPO Box 8260, ANU Canberra ACT 2601, Australia. Tel.: +61 (0)2 6125 4355; Mobile: +61 (0)431 124 286; Fax: +61 (0)2 6125 6579; Email: michael.selgelid{at}anu.edu.au ' + u + '@' + d + ' '//--> Abstract Thomas Pogge has proposed a supplement to the standard patent regime whereby innovating companies would be rewarded in proportion to the extent to which their innovations lead to (...) reduction of the global burden of disease (GBD). This paper argues that an expansion of this proposal—whereby provision of already existing medicines are incentivised in a similar way—would provide a more comprehensive solution to the healthcare situation in developing countries. It then considers the practical challenges that the implementation of such a proposal (expanded or otherwise) would entail. Though these include difficulties associated with disease burden metric, I argue that the most serious difficulties are associated with the problem of causal attribution. A basic idea underlying Pogge's proposal is that the disease burden reduction attributable to particular interventions can be determined. Theoretically speaking, in cases involving multiple interacting causal factors, there may be no fact of the matter regarding the extent to which disease burden reduction should be attributed to one intervention as opposed to another; and (even if workable practical solutions to this theoretical challenge can be met) the data requirements for implementation would be daunting. CiteULike Connotea Del.icio.us What's this? (shrink)

The Global Burden of Disease project quantifies the impact of different health conditions by combining information about morbidity and premature mortality within a single metric, the Disability Adjusted Life Year. One important goal for the GBD project has been to inform decisions about global health priorities. A number of recent studies have used GBD data to argue that global health funding fails to align with the GBD. We argue that these studies’ shared assumption that global health resources should ‘align’ with (...) the burden of disease is unfounded and has troubling implications. First, since the allocation of resources involves difficult trade-offs between different, potentially competing goals, any ‘misalignment’ of allocation and disease burdens need not necessarily indicate that the allocation of funds fails to meet recipient countries’ needs or interests. Second, using alignment as a baseline implicitly makes controversial assumptions about how harms of different magnitudes affecting different numbers of individuals should be aggregated. We discuss two alternative ways in which GBD data could help inform decisions about resource allocation, neither of which gives more than a limited role to GBD data. (shrink)

Providing access to medicines and health care is one of the most challenging issues facing society today. In this paper the author highlights some of the complexities of the health value chain as well as the problems that the world’s poor have in terms of access to medical care and medicines. He then attempts to delineate the roles and responsibilities of all stakeholders in order to define the specific corporate responsibilities of pharmaceutical companies in the context of the entire responsibility (...) system—the strength of which is determined by its weakest link. Finally, he looks forward to a transformational change being wrought for pro-poor health development by forging new coalitions that cut across both the health and traditional development stakeholders. (shrink)

The relationship between individual and population health is partially built on the broad dichotomization of medicine into clinical medicine and public health. Potential drawbacks of current views include seeing both individual and population health as absolute and independent concepts. I will argue that the relationship between individual and population health is largely relative and dynamic. Their interrelated dynamism derives from a causally defined life course perspective on health determination starting from an individual’s conception through growth, development and participation in the (...) collective till death, all seen within the context of an adaptive society. Indeed, it will become clear that neither individual nor population health is identifiable or even definable without informative contextualization within the other. For instance, a person’s health cannot be seen in isolation but must be placed in the rich contextual web such as the socioeconomic circumstances and other health determinants of where they were conceived, born, bred, and how they shaped and were shaped by their environment and communities, especially given the prevailing population health exposures over their lifetime. We cannot discuss the “what” and “how much” of individual and population health until we know the cumulative trajectories of both, using appropriate causal language. (shrink)

This article tries to present a broad view on the values and ethicalissues that are at stake in efforts to rationalize health policy on thebasis of economic evaluations (like cost-effectiveness analysis) andrandomly controlled clinical trials. Though such a rationalization isgenerally seen as an objective and `value free' process, moral valuesoften play a hidden role, not only in the production of `evidence', butalso in the way this evidence is used in policy making. For example, thedefinition of effectiveness of medical treatment or (...) health care serviceis heavily dependent on dominant individual or social views about thegoals of the particular treatment or service. There is also a concernthat a reliance on EBM in health policy will occur at the expense ofwidely shared social values like equity and solidarity. Moreover, thereis a concern that when economic considerations and rational proceduresbecome more influential, various `outside' groups third parties likeinsurance companies and policy makers will get a stronger influence onmedical practice which may lead to a change in the patient-providerrelationship. The authors conclude that social values and patientpreference should be explicitly addressed when health policy making isbased on economic and other scientific evidence. (shrink)

Advocates of EBM deserve much credit for theirefforts to increase the use of scientificevidence and economic evaluation in medicaldecision making. But EBM advocates' rigidrequirements of certainty in the estimation ofintervention effects may run counter tosociety's interest in maximising the expectedbenefits from resource use in health care.Also, their dedication to efficiency may leadsome to overlook societal concerns for fairnessin resource allocation.

In recent years, it has become commonplace among the Global Burden of Disease study authors to regard the disability-adjusted life year primarily as a descriptive health metric. During the first phase of the GBD, it was widely acknowledged that the DALY had built-in evaluative assumptions. However, from the publication of the 2010 GBD and onwards, two central evaluative practices—time discounting and age-weighting—have been omitted from the DALY model. After this substantial revision, the emerging view now appears to be that the (...) DALY is primarily a descriptive measure. Our aim in this article is to argue that the DALY, despite changes, remains largely evaluative. Our analysis focuses on the understanding of the DALY by comparing the DALY as a measure of disease burden in the two most significant phases of GBD publications, from their beginning to the most recent releases. We identify numerous assumptions underlying the DALY and group them as descriptive or evaluative. We conclude that while the DALY model arguably has become more descriptive, it remains, by necessity, largely evaluative. (shrink)

There is public support in the United States and Europe for accounting for animal welfare in national policies on food and agriculture. Although an emerging body of research has measured animals’ capacity to suffer, there has been no specific attempt to analyze how this information is interpreted by the public or how exactly it should be reflected in policy. The aim of this study was to quantify Americans’ preferences about farming methods and the suffering they impose on different species to (...) generate a metric for weighing the trade-offs between different approaches of promoting animal welfare. A survey of 502 residents of the United States was implemented using the online platform Mechanical Turk. Using respondent data, we developed the species-adjusted measure of suffering-years, an analogue of the disability-adjusted life year, to calculate the suffering endured under different farming conditions by cattle, pigs, and chickens, the three most commonly consumed animals. Nearly one-third of respondents reported that they believed animal suffering should be taken into account to a degree equal to or above human suffering. The 2016 suffering burden in the United States according to two tested conditions was approximately 66 million SAMYs for pigs, 156 million SAMYs for cattle, and 1.3 billion SAMYs for chickens. This calculation lends early guidance for efforts to reduce animal suffering, demonstrating that to address the highest burden policymakers should focus first on improving conditions for chickens. (shrink)