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)

Schools of economic ethics inspired by Buchanan propose viewing ethical conflicts as prisoners’ dilemmas to facilitate solutions based on Pareto-improving institutional changes. Given that healthcare is determined by complex institutional arrangements, it has been claimed that this approach is also suitable for business ethics in healthcare. To scrutinize this claim, this research systematically searched for studies reporting PD structures in healthcare. PubMed, EconLit, and EconBiz were searched to find articles in German and English. Study type, characteristics of the game, and (...) the proposed means to overcome the dilemma were extracted and analyzed for aspects supporting or challenging the claim. Across 53 studies, 68 descriptions of various dilemmas in healthcare and public health were identified. Many authors successfully developed proposals for institutional change to overcome these dilemmas. However, many of these analyses exhibited limitations such as oversimplifications or inconsistencies. Also, the quality of evidence on both the characteristics of dilemmas and the effectiveness of proposed solutions was very poor. The subsamples of studies that explicitly cited the ethical approach were disjunct from those that applied empirical methods to analyze the dilemmas. The large number of identified PDs indicates that economic ethics is relevant to healthcare. However, there is a need for further evidence to substantiate both the descriptive and prescriptive claims of this ethical theory. It should thus be seen as a complement that needs justification, rather than a substitute superior to other ethical frameworks. (shrink)