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Cost-Effectiveness, Incompleteness, and Discrimination

Published online by Cambridge University Press:  04 November 2022

Anders Herlitz Open the ORCID record for Anders Herlitz [Opens in a new window]
Anders Herlitz*
Affiliation:
Institute for Futures Studies, Box 591, 101 31 Stockholm, Sweden
*
Email: [email protected]
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Abstract

This paper argues that cost-effectiveness analysis in the healthcare sector introduces a discrimination risk that has thus far been underappreciated and outlines some approaches one can take toward this. It is argued that appropriate standards used in cost-effectiveness analysis in the healthcare sector fail to always fully determine an optimal option, which entails that cost-effectiveness analysis often leaves decision makers with large sets of permissible options. Larger sets of permissible options increase the role of decision makers’ biases, whims, and prejudices, which means that the discrimination risk increases. Two ways of mitigating this are identified: tinkering with standards used in the cost-effectiveness analysis and outlining anti-discrimination guidelines for decision makers.

Keywords

QALYdiscriminationcost-effectivenesshealthcare rationing
Type
Research Article
Information
Cambridge Quarterly of Healthcare Ethics , Volume 32 , Issue 2 , April 2023 , pp. 163 - 173
Copyright
© The Author(s), 2022. Published by Cambridge University Press

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References

Notes

1. Ord T. The moral imperative toward cost-effectiveness in global health. Center for Global Development 2013;12; Hausman, D. Valuing Health: Well-Being, Freedom, and Suffering. New York: Oxford University Press; 2015 Google Scholar.

2. Bognar G, Hirose I. The Ethics of Health Care Rationing. New York: Routledge; 2014; Cookson, R. Justice and the NICE approach. Journal of Medical Ethics 2015;41:99–102 CrossRefGoogle ScholarPubMed. See also note 1, Ord 2013 and Hausman 2015.

3. Dolan P. The measurement of individual utility and social welfare. Journal of Health Economics 1998;17:39–52; Bleichrodt, H, Diecidue, E, Quiggin, J. Equity weights in the allocation of health care: the rank-dependent QALY model. Journal of Health Economics 2004;23:157–171 CrossRefGoogle ScholarPubMed. Nord, E. Concerns for the worse off: Fair innings versus severity. Social Science and Medicine 2005;60:257–263 CrossRefGoogle ScholarPubMed; Bognar G. Age-weighting. Economics and Philosophy 2008;24:167–189; Herlitz A, Horan D. Measuring needs for priority setting in healthcare planning and policy. Social Science and Medicine 2016;157:96–102; Herlitz A. Income-based equity weights in health care planning and policy. Journal of Medical Ethics 2017;43:510–514.

4. Chang R. Introduction. In: Chang R, ed. Incommensurability, Incomparability, and Practical Reason. Cambridge: Harvard University Press; 1997; Chang R. The possibility of parity. Ethics 2002;112:659-688; Andersson, H, Herlitz, A. Classifying comparability problems in a way that matters. The Institute for Futures Studies. Working Paper 2021:22; Andersson, H, , Herlitz A. Introduction: Andersson, H, Herlitz, A, eds. Value Incommensurability: Ethics, Risk, and Decision-Making. New York: Routledge; 2022 Google ScholarPubMed.

5. Eyal, N, Herlitz, A. Symposium: Ethics of economic ordeals. Economics & Philosophy 2021;37:1–7 CrossRefGoogle Scholar.

6. Sen, A. 1980. Equality of what? In: McMurrin, S, ed. Tanner lectures on human values. Cambridge: Cambridge University Press; 1980Google Scholar; Cohen GA. On the currency of egalitarian justice. Ethics 1989;99:906–944.

7. Nozick R. Anarchy, State and Utopia. New York: Basic Books; 1974.

8. For a good discussion of these, and an argument for a summary measure of the value of health, see note 1, Hausman 2015.

9. Tännsjö, T. Setting Health-Care Priorities: What Ethical Theories Tell Us. Oxford: Oxford University Press; 2018 Google Scholar. See also note 1, Ord 2013.

10. Ottersen, T. Lifetime QALY prioritarianism in priority setting. Journal of Medical Ethics 2013;39:175–180 CrossRefGoogle ScholarPubMed; Eyal N, Herlitz A.. Input and output in distributive ethics. Noûs DOI:10.1111/nous.12392

11. Harris J. The Value of Life. London: Routledge & Kegan Paul; 1985; Herlitz, A. The indispensability of sufficientarianism. Critical Review of International Social and Political Philosophy 2019;22:929–942 CrossRefGoogle Scholar.

12. Temkin L. Egalitarianism defended. Ethics 2003;113:764–782; Eyal, N, Hurst, SA, Norheim, OF, Wikler, D, eds. Inequalities in Health: Concepts, Measures, and Ethics. Oxford: Oxford University Press; 2013 CrossRefGoogle Scholar.

13. See note 4, Andersson, Herlitz 2022.

14. Broome, J. Is incommensurability vagueness? In: Chang, R, ed. Incommensurability, Incomparability, and Practical Reason. Cambridge: Harvard University Press; 1997 Google Scholar; Broome J. Incommensurability is vagueness. In: Andersson H, Herlitz A, eds. Value Incommensurability: Ethics, Risk, and Decision-Making. New York: Routledge; 2022.

15. Chang, R. Are hard cases vague cases? In: Andersson, H, Herlitz, , eds. Value Incommensurability: Ethics, Risk, and Decision-Making. New York: Routledge; 2022 Google Scholar; Rabinowicz W. Value relations. Theoria 2008;74: 18-49. See also note 4, Chang 2002.

16. See note 4, Chang 2002, Andersson, Herlitz 2021, 2022, note 14, Broome 1997, 2022, note 15, Rabinowicz 2008, Chang 2022.

17. On non-comparability, see note 4, Andersson, Herlitz 2022.

18. Savage LJ. The Foundations of Statistics Hoboken: Wiley; 1954. See also note 4, Andersson, Herlitz 2022.

19. Raz J. The Morality of Freedom Oxford: Clarendon Press; 1986; Qizilbash, M. The mere addition paradox, parity and vagueness. Philosophy and Phenomenological Research 2007;75:129–151 CrossRefGoogle Scholar. See also, note 4, Chang 2002, Andersson, Herlitz 2021, 2022.

20. See note 4, Chang 2002.

21. Herlitz, A. Indeterminacy and the principle of need. Theoretical Medicine and Bioethics 2017;38:1–14 CrossRefGoogle ScholarPubMed.

22. Kamm, F. Aggregation, allocating scarce resources, and the disabled. Social Philosophy and Policy 2009;26:148–197 CrossRefGoogle Scholar.

23. Beckstead N Ord T. Bubbles under the wallpaper: Healthcare rationing and discrimination. In Kuhse H, Schüklenk U, Singer P, eds. Bioethics: An Anthology. Oxford: Blackwell. 2015;406–12; Hassoun N, Herlitz A. Distributing global health resources: Contemporary issues in political philosophy. Philosophy Compass 2019;14.

24. See note 22, Kamm 2009.

25. Herlitz, A. The limited impact of indeterminacy for healthcare rationing: How indeterminacy problems show the need for a hybrid theory, but nothing more. Journal of Medical Ethics 2016;42:22–25 CrossRefGoogle ScholarPubMed.

26. Herlitz, A. Nondeterminacy, cycles and rational choice. Analysis 2020;80:443–449 CrossRefGoogle Scholar; Herlitz A, Sadek K. Social choice, nondeterminacy, and public reasoning. Res Philosophica 2021;98:1–25; Herlitz A. Nondeterminacy and reasonable choice. In Andersson H, Herlitz A, eds. Value Incommensurability: Ethics, Risk, and Decision-Making. New York: Routledge; 2022; See also note 4, Andersson, Herlitz 2021.

27. Sen, A. Maximization and the act of choice. Econometrica 1997;65:745–779 CrossRefGoogle Scholar.

28. Broome J. Reply to Rabinowicz. Philosophical Issues 2009;19:412–417; Herlitz, A. Nondeterminacy, two-step models, and justified choice. Ethics 2019;129:284–308 CrossRefGoogle Scholar.

29. Fine, K. Vagueness, truth and logic. Synthese 1975;30:265–300 CrossRefGoogle Scholar.

30. See note 4, Andersson, Herlitz 2022.

31. See note 26, Herlitz 2022.

32. See note 4, Chang 2002, Andersson, Herlitz 2021, note 15, Chang 2022. See also Wasserman, R. Indeterminacy, ignorance and the possibility of parity. Philosophical Perspectives 2004;18:391–403 CrossRefGoogle Scholar.

33. Herlitz, A. Microlevel prioritization and incommensurability. Cambridge Quarterly of Healthcare Ethics 2018;27:75–86 CrossRefGoogle ScholarPubMed.