There is a gap between health economic evaluation methods and the value judgments of coverage decision makers, at least in Germany. Measuring preference satisfaction has been claimed to be inappropriate for allocating health care resources, e.g. because it disregards medical need. The existing methods oriented at medical need have been claimed to disregard non-consequentialist fairness concerns. The aim of this article is to propose a new, contractarian argument for justifying needs-based economic evaluation. It is based on consent rather than maximization (...) of some impersonal unit of value to accommodate the fairness concerns. This conceptual paper draws upon contractarian ethics and constitution economics to show how economic evaluation can be viewed as an institution to overcome societal conflicts in the allocation of scarce health care resources. For this, the problem of allocating scarce health care resources in a society is reconstructed as a social dilemma. Both disadvantaged patients and affluent healthy individuals can be argued to share interests in a societal contract to provide technologies which ameliorate medical need, based on progressive funding. The use of needs-based economic evaluation methods for coverage determination can be interpreted as institutions for conflict resolution as far as they use consented criteria to ensure the social contract’s sustainability and avoid implicit rationing or unaffordable contribution rates. This justifies the use of needs-based evaluation methods by Pareto-superiority and consent. The view of economic evaluation presented here may help account for fairness concerns in the further development of evaluation methods. This is because it directs the attention away from determining some unit of value to be maximized towards determining those persons who are most likely not to consent and meeting their concerns. Following this direction in methods development is likely to increase the acceptability of health economic evaluation by decision makers. (shrink)

This essay considers whether permitting the cost-effectiveness of healthcare to govern its allocation is ethically objectionable on the grounds that it fails to give sufficient weight to the severity of people’s health states. After documenting the popular sentiment that appears to support this criticism, the essay considers how to implement prioritising severity, focusing on Erik Nord’s work. The remainder of the essay scrutinises the ethical arguments supporting policies prioritising severity and challenges those who would prioritise severity to define a notion (...) of severity whose prioritisation they can defend. (shrink)

This essay responds to the helpful criticisms of Valuing Health: Well-Being, Freedom, and Suffering, which have been offered by Elselijn Kingma, Adam Oliver, Anna Alexandrova, Alex Voorhoeve, Erik Nord and James Wilson. I am extremely grateful to Jonathan Wolf and especially James Wilson for arranging a one-day conference on my book, Valuing Health: Well-Being, Freedom, and Suffering [Hausman, D.. Valuing Health: Well-Being, Freedom, and Suffering. Oxford: Oxford University Press.], and for publishing this symposium. I am also grateful to the wonderful (...) six scholars who took the time to study my work and to offer perceptive and helpful criticisms. Without unduly trying the patience of readers, I cannot respond to all their remarks, but I hope that in what follows I have replied to the most important of their comments on the arguments and conclusions of Valuing Health. Before I begin these replies, a brief synopsis of Valuing Health may be helpful to the reader. (shrink)