Marseille Elliot, Kahn James G
Health Strategies International, Oakland, CA, USA.
Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA.
Philos Ethics Humanit Med. 2019 Apr 3;14(1):5. doi: 10.1186/s13010-019-0074-7.
Efficiency as quantified and promoted by cost-effectiveness analysis sometimes conflicts with equity and other ethical values, such as the "rule of rescue" or rights-based ethical values. We describe the utilitarian foundations of cost-effectiveness analysis and compare it with alternative ethical principles. We find that while fallible, utilitarianism is usually superior to the alternatives. This is primarily because efficiency - the maximization of health benefits under a budget constraint - is itself an important ethical value. Other ethical frames may be irrelevant, incompatible with each other, or have unacceptable implications. When alternatives to efficiency are considered for precedence, we propose that it is critical to quantify the trade-offs, in particular, the lost health benefits associated with divergence from strict efficiency criteria. Using an example from HIV prevention in a high-prevalence African country, we show that favoring a rights-based decision could result in 92-118 added HIV infections per $100,000 of spending, compared to one based on cost-effectiveness.
成本效益分析所量化和倡导的效率有时会与公平及其他伦理价值发生冲突，比如“救援原则”或基于权利的伦理价值。我们阐述了成本效益分析的功利主义基础，并将其与其他伦理原则进行比较。我们发现，尽管功利主义存在缺陷，但通常优于其他原则。这主要是因为效率——在预算限制下使健康效益最大化——本身就是一项重要的伦理价值。其他伦理框架可能不相关、相互矛盾或具有不可接受的影响。当考虑将效率的替代方案置于优先地位时，我们建议关键是要量化权衡取舍，特别是与偏离严格效率标准相关的健康效益损失。以一个非洲高流行率国家的艾滋病毒预防为例，我们表明，与基于成本效益的决策相比，偏向基于权利的决策可能导致每支出10万美元新增92 - 118例艾滋病毒感染。
