Many clinicians believe that allowing costs to influence clinical decisions is unethical. They are mistaken in this belief, because it cannot be ethical to ignore the adverse consequences upon others of the decisions you make, which is what 'costs' represent. There are, however, some important ethical issues in deciding what costs to count, and how to count them. But these dilemmas are equally strong with respect to what benefits to count and how to count them, some of which expose ethically (...) untenable assumptions about such widely-used clinical criteria as survival rates. One of the advantages of systematic cost-effectiveness analysis is that it exposes these hidden assumptions, and requires explicit judgements to be made about which ethical position is appropriate in a particular policy context. This should have the important incidental benefit of improving the accountability of policy-makers to the community they are serving. (shrink)

Medical criteria rooted in evidence-based medicine are often seen as a value-neutral ‘trump card’ which puts paid to any further debate about setting priorities for treatment. On this argument, doctors should stop providing treatment at the point when it becomes medically futile, and that is also the threshold at which the health purchaser should stop purchasing. This paper offers three kinds of ethical criteria as a counterweight to analysis based solely on medical criteria. The first set of arguments concerns futility, (...) probability and utility; the second, justice and fairness; the third, consent and competence. The argument is illustrated by two recent case studies about futility and priority-setting: the US example of ‘Baby Ryan’ and the UK case of ‘Child B’. (shrink)

Cost‐effectiveness analysis (CEA) raises questions that are too important to be left to policy analysts and economists. Those who utilize CEA should acknowledge its inherent value system and adapt it to a more ethical usage.

By describing societal value judgements in health care in numerical terms one may in theory increase the precision of guidelines for priority setting and allow decision makers to judge more accurately the degree to which different health care programs provide societal value for money. However, valuing health programs in terms of QALYs disregards salient societal concerns for fairness in resource allocation. A different kind of numerical valuation of medical interventions, that incorporates concerns for fairness, is described. The usefulness to decision (...) makers of such numerical information remains to be tested. (shrink)

The paper argues against the polarisation of the health economics literature into pro- and anti-QALY camps. In particular, we suggest that a crucial distinction should be made between the QALY measure as a metric of health, and QALY maximisation as an applied social choice rule. We argue against the rule but for the measure and that the appropriate conceptualisation of health-care rationing decisions should see the main task as the integration of competing and possibly incommensurable normative claim types. We identify (...) the main types as consequences, rights, social contracts, individual votes and community values and note situations in which the contribution of each claim type is limited. We go on to show that the integration of (at least some of) these claim types can be formalised within the mathematical framework provided by non-linear programming. (shrink)

With both the cost and quality of health care under scrutiny, many in the health care industry have turned to outcomes research and practice guidelines for answers. But many physicians have resisted, claiming their clinical judgment is a better guide. Both camps may be right.

In response to increasing use of practice guidelines in medicine, physicians have focused their attention on how these guidelines can restrict their medical practices. However, guidelines not only restrict physician discretion, but they also limit the treatment options available to patients. As a result, treatments which patients consider beneficial may not be recommended; for example, some hysterectomies for abnormal uterine bleeding, and cataract surgery in patients with dementia. When guidelines are used to determine which medical treatments a health care organization (...) or insurer will cover, these recommendations become restrictions. Thus far, guidelines have been developed without adequate attention to the impact that their restrictive use has on diverse patient values.Two significant tensions in current medical ethics relate to the inclusion of patient values in practice guidelines. First, a tension exists between the traditional paternalistic model of care, in which the physician judges unilaterally which treatments will benefit the patient, and the more recent autonomy model, in which the physician elicits the individual patient's health values to determine which treatments will be beneficial. (shrink)