Wilkinson Dominic, Savulescu Julian
Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Suite 8, Littlegate House, St Ebbes Street, Oxford, OX1 1PT, UK.
John Radcliffe Hospital, Oxford, UK.
Health Care Anal. 2018 Dec;26(4):287-309. doi: 10.1007/s10728-016-0337-z.
Clinical guidelines summarise available evidence on medical treatment, and provide recommendations about the most effective and cost-effective options for patients with a given condition. However, sometimes patients do not desire the best available treatment. Should doctors in a publicly-funded healthcare system ever provide sub-optimal medical treatment? On one view, it would be wrong to do so, since this would violate the ethical principle of beneficence, and predictably lead to harm for patients. It would also, potentially, be a misuse of finite health resources. In this paper, we argue in favour of permitting sub-optimal choices on the basis of value pluralism, uncertainty, patient autonomy and responsibility. There are diverse views about how to evaluate treatment options, and patients' right to self-determination and taking responsibility for their own lives should be respected. We introduce the concept of cost-equivalence (CE), as a way of defining the boundaries of permissible pluralism in publicly-funded healthcare systems. As well as providing the most effective, available treatment for a given condition, publicly-funded healthcare systems should provide reasonable suboptimal medical treatments that are equivalent in cost to (or cheaper than) the optimal treatment. We identify four forms of cost-equivalence, and assess the implications of CE for decision-making. We evaluate and reject counterarguments to CE. Finally, we assess the relevance of CE for other treatment decisions including requests for potentially superior treatment.
临床指南总结了关于医学治疗的现有证据，并针对特定病症的患者提供有关最有效和最具成本效益选择的建议。然而，有时患者并不希望接受现有的最佳治疗。在公共资助的医疗保健系统中，医生是否应该提供次优的医学治疗？有一种观点认为，这样做是错误的，因为这将违反行善的伦理原则，并可预见地对患者造成伤害。这也可能是对有限医疗资源的滥用。在本文中，我们基于价值多元主义、不确定性、患者自主性和责任等因素，主张允许次优选择。对于如何评估治疗方案存在多种观点，患者的自决权以及对自己生活负责的权利应该得到尊重。我们引入成本等效性（CE）的概念，作为界定公共资助医疗保健系统中允许的多元主义边界的一种方式。除了为特定病症提供最有效、可行的治疗外，公共资助的医疗保健系统还应提供成本与最佳治疗等效（或低于最佳治疗）的合理次优医学治疗。我们确定了四种成本等效形式，并评估了成本等效性对决策的影响。我们评估并反驳了针对成本等效性的反对论点。最后，我们评估了成本等效性与其他治疗决策（包括对潜在更优治疗的请求）的相关性。
