Cohen B J
Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts 02111, USA.
Med Decis Making. 1996 Oct-Dec;16(4):376-85. doi: 10.1177/0272989X9601600408.
Cost-utility analysis (CUA) was developed to guide the allocation of health care resources under a budget constraint. As the generally stated goal of CUA is to maximize aggregate health benefits, the philosophical underpinning of this method is classic utilitarianism. Utilitarianism has been criticized as a basis for social choice because of its emphasis on the net sum of benefits without regard to the distribution of benefits. For example, it has been argued that absolute priority should be given to the worst off when making social choices affecting basic needs. Application of classic utilitarianism requires use of strength-of-preference utilities, assessed under conditions of certainty, to assign quality-adjustment factors to intermediate health states. The two methods commonly used to measure strength-of-preference utility, categorical scaling and time tradeoff, produce rankings that systematically give priority to those who are better off. Alternatively, von Neumann-Morgenstern utilities, assessed under conditions of uncertainty, could be used to assign values to intermediate health states. The theoretical basis for this would be Harsanyi's proposal that social choice be made under the hypothetical assumption that one had an equal chance of being anyone in society. If this proposal is accepted, as well as the expected-utility axioms applied to both individual choice and social choice, the preferred societal arrangement is that with the highest expected von Neumann-Morgenstern utility. In the presence of risk aversion, this will give some priority to the worst-off relative to classic utilitarianism. Another approach is to raise the values obtained by time-tradeoff assessments to a power a between 0 and 1. This would explicitly give priority to the worst off, with the degree of priority increasing as a decreases. Results could be presented over a range of a. The results of CUA would then provide useful information to those holding a range of philosophical points of view.
成本效用分析（CUA）旨在指导在预算限制下的医疗资源分配。由于CUA的一般目标是使总体健康效益最大化，这种方法的哲学基础是经典功利主义。功利主义作为社会选择的基础受到了批评，因为它强调利益的总和而不考虑利益的分配。例如，有人认为在做出影响基本需求的社会选择时，应该绝对优先考虑最贫困的人群。应用经典功利主义需要使用在确定性条件下评估的偏好强度效用，为中间健康状态分配质量调整因素。两种常用的测量偏好强度效用的方法，即分类标度法和时间权衡法，产生的排序系统地优先考虑那些状况较好的人。或者，可以使用在不确定性条件下评估的冯·诺依曼-摩根斯坦效用，为中间健康状态赋值。其理论基础是哈萨尼的提议，即在假设自己有平等机会成为社会中任何人的情况下做出社会选择。如果接受这一提议，以及将预期效用公理应用于个人选择和社会选择，那么首选的社会安排就是具有最高预期冯·诺依曼-摩根斯坦效用的安排。在存在风险厌恶的情况下，相对于经典功利主义，这将给予最贫困人群一些优先权。另一种方法是将通过时间权衡评估获得的值提升到0到1之间的幂a。这将明确优先考虑最贫困人群，优先权程度随着a的减小而增加。结果可以在一系列a值上呈现。然后，CUA的结果将为持有一系列哲学观点的人提供有用信息。
