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Controlling Healthcare Costs: Just Cost Effectiveness or “Just” Cost Effectiveness?

Published online by Cambridge University Press:  06 March 2018

LEONARD M. FLECK
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Abstract:

Meeting healthcare needs is a matter of social justice. Healthcare needs are virtually limitless; however, resources, such as money, for meeting those needs, are limited. How then should we (just and caring citizens and policymakers in such a society) decide which needs must be met as a matter of justice with those limited resources? One reasonable response would be that we should use cost effectiveness as our primary criterion for making those choices. This article argues instead that cost-effectiveness considerations must be constrained by considerations of healthcare justice. The goal of this article will be to provide a preliminary account of how we might distinguish just from unjust or insufficiently just applications of cost-effectiveness analysis to some healthcare rationing problems; specifically, problems related to extraordinarily expensive targeted cancer therapies. Unconstrained compassionate appeals for resources for the medically least well-off cancer patients will be neither just nor cost effective.

Keywords

cost-effectivenesshealthcare justiceQALYsequitytargeted cancer therapiesNational Institute for Health and Clinical Effectiveness (NICE)rule of rescuemedically least well-offinvisible rationingbedside rationing
Type
Special Section: Justice, Healthcare, and Wellness
Information
Cambridge Quarterly of Healthcare Ethics , Volume 27 , Issue 2 , April 2018 , pp. 271 - 283
Copyright
Copyright © Cambridge University Press 2018 

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References

Notes

1. Dan Brock writes: “It is not possible, nor would it be rational or just, to provide all potentially beneficial care to everyone, no matter how small the benefits or how great the cost.” Priority to the worse off in health-care resource prioritization. In: Rhodes R, Battin MP, Silvers A, eds. Medicine and Social Justice: Essays on the Distribution of Health Care. New York: Oxford University Press; 2002, at 362.

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3. See note 2, Ubel 2000, at 156–7.

4. There are numerous ethical and methodological issues that might be addressed with respect to cost-effectiveness and the use of QALYs. Among the more prominent are risk of age discrimination or discrimination against persons with disabilities. Several volumes would be required to address these issues. Good overviews of these issues may be found in: Menzel P, Gold MR, Nord E, Pinto-Prades JL, Richardson J, Ubel P. Toward a broader view of values in cost-effectiveness analysis of health. Hastings Center Report 1999;29(3):7–15. See also: Menzel PT. Can cost-effectiveness analysis accommodate the equal value of life? APA Newsletter on Philosophy and Medicine 2013;13(Fall):23–6; Schwappach DLB. Resource allocation, social values and the QALY: A review of the debate and empirical evidence. Health Expectations 2002;5:210–22.

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13. See note 2, Ubel 2000, at 82–5.

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25. I have explicated in great detail what such a fair process of rational democratic deliberation ought to look like. See note 21, Fleck 2009, chap. five.

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