University of York.
J Health Polit Policy Law. 2013 Dec;38(6):1129-48. doi: 10.1215/03616878-2373166. Epub 2013 Aug 23.
In 2009 the UK National Institute for Health and Clinical Excellence (NICE) announced that its health technology appraisal committees would henceforth give special additional weight to health gains from life-extending end-of-life treatments. This was a response to mounting concern from NICE's stakeholders that effective new drugs for end-stage cancer often fail NICE's standard test of cost effectiveness. This change of policy may be justifiable on procedural grounds as the result of a democratic political process responding to stakeholder concerns. However, according to the "accountability for reasonableness" framework proposed by the philosopher Norman Daniels and endorsed by NICE, there also needs to be transparency about the substantive ethical grounds for public health care resource allocation decisions. In that spirit, I analyze eleven potentially relevant justifications for the NICE "end-of-life premium," drawn from the economics and philosophy literature: (1) rule of rescue, (2) fair chances, (3) ex post willingness to pay, (4) caring externality, (5) financial protection, (6) symbolic value, (7) diminishing marginal value of future life years, (8) concentration of benefits, (9) dread, (10) time to set your affairs in order, and (11) severity of illness. I conclude that none of them yields a coherent ethical justification for the NICE end-of-life premium.
2009 年,英国国家卫生与临床优化研究所(NICE)宣布,其医疗技术评估委员会今后将特别重视延长生命末期治疗的健康收益。这是对 NICE 利益相关者越来越多的关注的回应,即针对晚期癌症的有效新药往往未能通过 NICE 的成本效益标准测试。从回应利益相关者关切的民主政治过程的程序角度来看,这一政策变化可能是合理的。然而,根据哲学家诺曼·丹尼尔斯(Norman Daniels)提出并得到 NICE 认可的“合理性问责制”框架,公共医疗保健资源分配决策的实质性伦理依据也需要透明。本着这种精神,我从经济学和哲学文献中分析了 NICE“临终溢价”的十一个潜在相关理由:(1)救助规则,(2)公平机会,(3)事后支付意愿,(4)关怀外部性,(5)财务保护,(6)象征价值,(7)未来生命年限的边际价值递减,(8)利益集中,(9)恐惧,(10)安排事务的时间,以及(11)疾病严重程度。我得出的结论是,没有一个理由能够为 NICE 的临终溢价提供连贯的伦理依据。