On the basis of PM2.5 data of the national air quality monitoring sites, local population data, and baseline all-cause mortality rate, PM2.5-related health economic benefits of the Air Improvement Action Plan implemented in Wuhan in 2013–2017 were investigated using health-impact and valuation functions. Annual avoided premature deaths driven by the average concentration of PM2.5 decrease were evaluated, and the economic benefits were computed by using the value of statistical life (VSL) method. Results showed that the number (...) of avoided premature deaths in Wuhan are 21,384 (95% confidence interval (CI): 15,004 to 27,255) during 2013–2017, due to the implementation of the Air Improvement Action Plan. According to the VSL method, the obtained economic benefits of Huangpi, Wuchang, Hongshan, Xinzhou, Jiang’an, Hanyang, Jiangxia, Qiaokou, Jianghan, Qingshan, Caidian, Dongxihu, and Hannan District were 8.55, 8.19, 8.04, 7.39, 5.78, 4.84, 4.37, 4.04, 3.90, 3.30, 2.87, 2.42, and 0.66 billion RMB (1 RMB = 0.1417 USD On 14 October 2019), respectively. These economic benefits added up to 64.35 billion RMB (95% CI: 45.15 to 82.02 billion RMB), accounting for 4.80% (95% CI: 3.37% to 6.12%) of the total GDP of Wuhan in 2017. Therefore, in the process of formulating a regional air quality improvement scheme, apart from establishing hierarchical emission-reduction standards and policies, policy makers should give integrated consideration to the relationship between regional economic development, environmental protection and residents’ health benefits. Furthermore, for improving air quality, air quality compensation mechanisms can be established on the basis of the status quo and trends of air quality, population distribution, and economic development factors. (shrink)

We review methods for economic evaluation recently developed in health economics by focusing on the epistemic and non-epistemic values they embody. The emphasis is on insights into valuing health,...

That the maximization of quality-adjusted life years violates concerns for fairness is well known. One approach to face this issue is to elicit fairness preferences of the public empirically and to incorporate the corresponding equity weights into cost-utility analysis (CUA). It is thereby sought to encounter the objections by means of an axiological modification while leaving the value-maximizing framework of CUA intact. Based on the work of Lübbe (2005, 2009a, 2009b, 2010, forthcoming), this paper questions this strategy and scrutinizes the (...) concomitant assumptions concerning the nature of prioritization decisions. Empirical studies indicate that these premises are in fact unwarranted. People chose a certain resource allocation because they perceive it as a fair way to treat the persons concerned, not because it maximizes something valuable, and it is questionable if prioritization decision can be represented as value-maximizing choices at all. This reflection on the fundamental distinction between deontological and consequentialist reasoning bears general implications for the scope of ‘economic imperialism.’. (shrink)

It is hard to argue with the proposition that value for money should guide health spending. However, even after decades of development, economic evaluation is still a work in progress. As applied, it deals poorly with issues of social justice, ageing and end of life issues; cases involving small numbers—such as decisions about orphan drugs—are also contested. Unfortunately, differences in incremental cost-effectiveness ratios are presented with a degree of precision which contributes to an ‘illusion of validity’.1 Nobel (...) Laureate Amartya Sen has suggested that ‘when all the requirements of ubiquitous market-centred evaluation have been incorporated into the procedures of cost–benefit analysis, it is not so much a discipline as a daydream’.2 As with any approach to public decision making, the use of economic evaluation rests on an implicit social licence, including that the decision making is fair and reasonable. Many countries have developed special policies for rare, ‘ultrarare’ or ‘orphan’ diseases to moderate the effect of a ubiquitous application of economic evaluation. The threshold for defining ‘small’ or rare is a matter of judgement and ranges between 2 and 80 per 100 000 population.3 Magalhaes challenges the ethical basis of special programmes for low incidence conditions and argues against such provisions. In this commentary, I will argue the contrary: that there are good reasons …. (shrink)

There is a gap between health economic evaluation methods and the value judgments of coverage decision makers, at least in Germany. Measuring preference satisfaction has been claimed to be inappropriate for allocating health care resources, e.g. because it disregards medical need. The existing methods oriented at medical need have been claimed to disregard non-consequentialist fairness concerns. The aim of this article is to propose a new, contractarian argument for justifying needs-based economic evaluation. It is (...) based on consent rather than maximization of some impersonal unit of value to accommodate the fairness concerns. This conceptual paper draws upon contractarian ethics and constitution economics to show how economic evaluation can be viewed as an institution to overcome societal conflicts in the allocation of scarce health care resources. For this, the problem of allocating scarce health care resources in a society is reconstructed as a social dilemma. Both disadvantaged patients and affluent healthy individuals can be argued to share interests in a societal contract to provide technologies which ameliorate medical need, based on progressive funding. The use of needs-based economic evaluation methods for coverage determination can be interpreted as institutions for conflict resolution as far as they use consented criteria to ensure the social contract’s sustainability and avoid implicit rationing or unaffordable contribution rates. This justifies the use of needs-based evaluation methods by Pareto-superiority and consent. The view of economic evaluation presented here may help account for fairness concerns in the further development of evaluation methods. This is because it directs the attention away from determining some unit of value to be maximized towards determining those persons who are most likely not to consent and meeting their concerns. Following this direction in methods development is likely to increase the acceptability of health economic evaluation by decision makers. (shrink)

In this article, we argue that apart from evaluating the causes and the social determinants of health inequalities, an evaluation of the effects of health inequalities is due. For this, we propose the ideal of relational equality as an evaluative framework, and test to what extent health inequalities threaten this ideal of a society of equals. We identify three ways in which they do and argue that these risks are especially great for those lower down the (...) socio-economic strata. We thus conclude that equality in health is instrumental to social justice, and that socio-economic inequalities in health are not only unjust due to their causes but also due to their consequences. We continue to argue that our instrumental approach opens a perspective to mitigate the identified injustices by changing society, rather than reducing inequalities in health, and argue that this is an advantage in the light of the realistic assumption that of the socio-economic health inequalities will persist. The article thus offers a complementary approach to both the evaluation and the mitigation of the injustice of socio-economic inequalities in health. (shrink)

The health co-benefits of CO2 mitigation can provide a strong incentive for climate policy through reductions in air pollutant emissions that occur when targeting shared sources. However, reducing air pollutant emissions may also have an important co-harm, as the aerosols they form produce net cooling overall. Nevertheless, aerosol impacts have not been fully incorporated into cost-benefit modeling that estimates how much the world should optimally mitigate. Here we find that when both co-benefits and co-harms are taken fully into account, (...) optimal climate policy results in immediate net benefits globally, overturning previous findings from cost-benefit models that omit these effects. The global health benefits from climate policy could reach trillions of dollars annually, but will importantly depend on the air quality policies that nations adopt independently of climate change. Depending on how society values better health, economically optimal levels of mitigation may be consistent with a target of 2 °C or lower. (shrink)

The question of how to allocate scarce medical resources has become an important public policy issue in recent decades. Cost-Utility Analysis is the most commonly used method for determining the allocation of these resources, but this book counters the argument that overcoming its inherent imbalances is simply a question of implementing methodological changes. The Economics of Resource-Allocation in Healthcare represents the first comprehensive analysis of equity weighting in health care resource allocation that offers a fundamental critique of its basic (...) framework. It offers a heterodox account of health economics, putting the discourse on economic evaluation into it broader socio-political context. Such an approach broadens the debate on fairness in health economics and ties it in with deeper rooted problems in moral philosophy. Ultimately, this interdisciplinary study calls for the adoption of a fundamentally different paradigm to address the distribution of scarce medical resources. This book will be of interest to policy makers, health care professionals or Post-Graduate students looking to broaden their understanding of the economics of the healthcare system. (shrink)

Für ökonomische Evaluationen medizinischer Leistungen steht ein etabliertes Methodenspektrum zur Verfügung. Ziel der Arbeit ist, anhand ausgewählter Aspekte herauszuarbeiten, inwieweit diese Methoden für den derzeit viel diskutierten Bereich der Personalisierten Medizin anwendbar sind bzw. welche Besonderheiten dabei auftreten und wie diese adressiert werden können. Für die vorliegende Arbeit wurde eine explorative Literaturrecherche durchgeführt. In Abgrenzung zur herkömmlichen Medizin kann je nach Blickwinkel die Personalisierte Medizin entweder hinsichtlich der physiologischen Unterschiede oder hinsichtlich der individuellen Präferenzen der Beteiligten betrachtet werden. Je nach (...) Betrachtungsweise ergeben sich unterschiedliche methodische Herausforderungen an gesundheitsökonomische Evaluationen. Verbesserte Ausrichtung der Versorgung an physiologischen Unterschieden stellt die Evaluation beispielsweise vor das Problem, dass aufgrund des oftmals kleinen Stichprobenumfangs häufig Evidenz zur Parametrisierung von Entscheidungsmodellen fehlt. Informationswertanalysen können Hinweise über den potenziellen Nutzen weiterer Forschung geben. Das Konzept des „Expected Value of Individualized Care“ bietet einen den Informationswertanalysen sehr ähnlichen Ansatz, um den potenziellen Wert eines Einbezugs individueller Präferenzen in die Versorgung zu quantifizieren. Welfarismus und Extra-Welfarismus bieten unterschiedliche Lösungsansätze, wie Nutzen Biomarker-basierter Information im Sinne von „Empowerment“ in Evaluationen einbezogen werden können. Generell sind die Methoden der gesundheitsökonomischen Evaluation auch auf den Bereich der Personalisierten Medizin anwendbar. Es stellen sich jedoch eine Reihe spezifischer Herausforderungen, zu deren Lösung weiterer Forschungsbedarf besteht. (shrink)

Für ökonomische Evaluationen medizinischer Leistungen steht ein etabliertes Methodenspektrum zur Verfügung. Ziel der Arbeit ist, anhand ausgewählter Aspekte herauszuarbeiten, inwieweit diese Methoden für den derzeit viel diskutierten Bereich der Personalisierten Medizin anwendbar sind bzw. welche Besonderheiten dabei auftreten und wie diese adressiert werden können. Für die vorliegende Arbeit wurde eine explorative Literaturrecherche durchgeführt. In Abgrenzung zur herkömmlichen Medizin kann je nach Blickwinkel die Personalisierte Medizin entweder hinsichtlich der physiologischen Unterschiede oder hinsichtlich der individuellen Präferenzen der Beteiligten betrachtet werden. Je nach (...) Betrachtungsweise ergeben sich unterschiedliche methodische Herausforderungen an gesundheitsökonomische Evaluationen. Verbesserte Ausrichtung der Versorgung an physiologischen Unterschieden stellt die Evaluation beispielsweise vor das Problem, dass aufgrund des oftmals kleinen Stichprobenumfangs häufig Evidenz zur Parametrisierung von Entscheidungsmodellen fehlt. Informationswertanalysen können Hinweise über den potenziellen Nutzen weiterer Forschung geben. Das Konzept des „Expected Value of Individualized Care“ bietet einen den Informationswertanalysen sehr ähnlichen Ansatz, um den potenziellen Wert eines Einbezugs individueller Präferenzen in die Versorgung zu quantifizieren. Welfarismus und Extra-Welfarismus bieten unterschiedliche Lösungsansätze, wie Nutzen Biomarker-basierter Information im Sinne von „Empowerment“ in Evaluationen einbezogen werden können. Generell sind die Methoden der gesundheitsökonomischen Evaluation auch auf den Bereich der Personalisierten Medizin anwendbar. Es stellen sich jedoch eine Reihe spezifischer Herausforderungen, zu deren Lösung weiterer Forschungsbedarf besteht. (shrink)

The increasing popularity of economic evaluation methods, especially cost effectiveness analysis, brings with it the danger of decisions being made on the basis of faulty criteria. This paper explores the underlying faults of orthodox economics, and offers tentatively an alternative means of decision appraisal via John Dewey’s philosophy of instrumentalism and the methods of institutionalist economics.

Nearly all large policy decisions influence not only the quality of life for existing individuals but also the number-and even identities-of yet-to-exist individuals. Accounting for these effects in a policy evaluation framework requires taking difficult stances on concepts such as the value of existence. These issues are at the heart of a literature that sits between welfare economics and philosophical population ethics. Despite the inherent challenges of these questions, this literature has produced theoretical insights and subsequent progress on variable-population (...) welfare criteria. A surprisingly bounded set of coherent alternatives exists for practitioners once a set of uncontroversial axioms is adopted from the better-studied welfare criteria for cases where populations are assumed to be fixed. Although consensus has not yet been reached among these remaining alternatives, their recommendations often agree. The space has been sufficiently restricted and well explored that applications of the theoretical insights are possible and underway in earnest. (shrink)

Professional autonomy, as the symbol of the traditional freedom ofdecision-making of medical professionals is criticized. This essayexamines the critique. It analyses the underlying assumption that theautonomy of health professionals is incompatible with the need fororganisation and management in order to control rising health carecosts. It is argued that the concept of professional autonomy should beredefined, not through restricting the decision-making freedom ofindividual health professionals, but through expanding the concept intothe sphere of management, so that managers will take (...) responsibility forpatient care. (shrink)

We argue that the economic evaluation of health care (cost–benefit analysis) should respect individual preferences and should incorporate distributional considerations. Relying on individual preferences does not imply subjective welfarism. We propose a particular non-welfarist approach, based on the concept of equivalent income, and show how it helps to define distributional weights. We illustrate the feasibility of our approach with empirical results from a pilot survey.

Prior research suggests that midlife husbands have worse health when they earn less than their wives; however, the mechanism for this relationship have not been evaluated. In this study, the author analyzes 1,319 heterosexual married couples from the Health and Retirement Study to explore three theoretically grounded mechanisms. The author begins by assessing two well-established family relations theories to explore the mediating effect of marital power and relationship quality. The author then draws from gender relations theory, multiple masculinities (...) literature, and cognitive dissonance research to test the possibility of a male breadwinner mechanism. The results demonstrate that family relations theories are insufficient explanations but provide strong support for the male breadwinner mechanism. Specifically, being the secondary earner is harmful for the health of highest-income men—who historically have the strongest expectation of male breadwinning. These findings suggest that stereotypes about male breadwinning can be dangerous for men’s health. (shrink)

One Health is a novel paradigm that recognizes that human and non-human animal health is interlinked through our shared environment. Increasingly prominent in public health responses to zoonoses, OH differs from traditional approaches to animal-borne infectious risks, because it also aims to promote the health of animals and ecological systems. Despite the widespread adoption of OH, culling remains a key component of institutional responses to the risks of zoonoses. Using the threats posed by highly pathogenic avian (...) influenza viruses to human and animal health, economic activity and food security as a case exemplar, we explore whether culling and other standard control measures for animal-borne infectious disease might be justified as part of OH approaches. Our central premise is that OH requires us to reformulate ‘health’ as universal good that is best shared across species boundaries such that human health and well-being are contingent upon identifying and meeting the relevant sets of human and non-human interests and shared dependencies. Our purpose is to further nascent discussions about the ethical dimensions of OH and begin to describe the principles around which a public health agenda that truly seeks to co-promote human and non-human health could potentially begin to be implemented. (shrink)

The inclusion of structural competency training in pre-health undergraduate programs may offer significant benefits to future healthcare professionals. This paper presents the results of a comparative study of an interdisciplinary pre-health curriculum based in structural competency with a traditional premedical curriculum. The authors describe a new evaluation tool, the Structural Foundations of Health Survey ©, developed to evaluate structural skills and sensibilities. The authors use the survey to evaluate two groups of graduating seniors at Vanderbilt University—majors (...) in an interdisciplinary pre-health curriculum titled Medicine, Health, and Society, and premed science majors—with particular attention to understanding how political, cultural, economic, and social factors shape health. Results suggest that MHS majors identified and analyzed relationships between structural factors and health outcomes at higher rates and in deeper ways than did premed science majors. MHS students also demonstrated higher understanding of structural and cultural competency in their approaches to race, intersectionality, and racial health disparities. The skills that MHS students exhibited represent proficiencies increasingly emphasized by the MCAT, the AAMC, and other educational bodies that, in an era of epigenetics and social determinants, emphasize how contextual factors shape expressions of health and illness. (shrink)

Public funders of health research have been widely criticized on the grounds that their allocations of funding for disease-specific research do not reflect the relative burdens imposed by different diseases. For example, the US National Institutes of Health spends a much greater fraction of its budget on HIV/aids research and a much smaller fraction on migraine research than their relative contribution to the US burden of disease would suggest. Implicit in this criticism is a normative claim: Insofar as (...) the scientific opportunities are equal, each patient merits research into their condition proportional to the burden of disease for which that condition is responsible. This claim—the proportional view—is widely accepted but has never been fully specified or defended. In this paper, I explain what is required to specify the view, attempt to do so in the most charitable way, and then critically evaluate its normative underpinnings. I conclude that a severity-weighted proportional view is defensible. I close by drawing out five key lessons of my analysis for health research priority-setting. (shrink)

Public funders of health research have been widely criticized on the grounds that their allocations of funding for disease-specific research do not reflect the relative burdens imposed by different diseases. For example, the US National Institutes of Health spends a much greater fraction of its budget on HIV/AIDS research and a much smaller fraction on migraine research than their relative contribution to the US burden of disease would suggest. Implicit in this criticism is a normative claim: Insofar as (...) the scientific opportunities are equal, each patient merits research into their condition proportional to the burden of disease for which that condition is responsible. This claim—the proportional view—is widely accepted but has never been fully specified or defended. In this paper, I explain what is required to specify the view, attempt to do so in the most charitable way, and then critically evaluate its normative underpinnings. I conclude that a severity-weighted proportional view is defensible. I close by drawing out five key lessons of my analysis for health research priority-setting. (shrink)

This book contains a sustained defense of the Quality Adjusted Life Years (QALY) approach to resource allocation in health care. According to this approach resources should be allocated in such a way that the number of QALYs gained is maximized. The authors place this approach within a broader preference Utilitarian framework and argue that it is a special case of consequentialism specifically relevant to the health care field. The first two chapters of the book give a basic introduction (...) to the health care economic aspects of QALYs and a basic introduction to the purpose of ethical reasoning. The three subsequent chapters form the core of the book and contain a systematic defense of the QALY approach against all the main criticisms that have been put forward in the literature. The final chapter contains the results of a survey of the attitudes and reasoning of the Australian public with regard to resource allocation. (shrink)

We propose a triple test to evaluate the usefulness of behavioral economics models for public health policy. Test 1 is whether the model provides reasonably new insights. Test 2 is on whether these have been properly applied to policy settings. Test 3 is whether they are corroborated by evidence. We exemplify by considering the cases of social interactions models, self-control models and, in relation to health message framing, prospect theory. Out of these sets of models, only a correctly (...) applied prospect theory fully passes the tests at present. Specifically, in broad agreement with the evidence, a gain frame has positive implications for welfare encourages disease prevention activity, though this does not apply if the perceived probability of the bad health outcome is large enough. We see our tests as being useful to identify how much health policy weight policy makers should assign to specific behavioral economic models; they are also useful to verify what next steps would be most useful in further research. (shrink)

In the past decade donor commitments to health have increased by 200 percent. Correspondingly, there has been a swell of new players in the global health landscape. The unprecedented, global response to a single disease, HIV/AIDS, has been responsible for a substantial portion of this boon. Numerous health success have followed this windfall of funding and attention, yet the food, fuel, and economic crises of 2008 have shown the vulnerabilities of health and development initiatives focused (...) on short term wins and reliant on a constant flow of foreign funding. For too long, the international community has responded to global health and development challenges with emergency solutions that often reflect the donor's priorities, values, and political leanings, rather than funding durable health systems that can withstand crises. Progress towards achieving the Millennium Development Goals has stalled in many countries. Disease specific initiatives have weakened health systems and limited efforts to improve maternal and child health. As we enter this era of scarce resources, there is a need to return to the foundations of the Alma Ata Declaration signed thirty years ago with the goal of providing universal access to primary healthcare. The global health community must now objectively evaluate how we can most effectively respond to the crises of 2008 and take advantage of this moment of extraordinary attention for global health and translate it into long term, sustainable health improvements for all. (shrink)

During the COVID-19 public health crisis, market failures such as shortage of supplies and soaring prices of anti-epidemic materials – with masks as the core – have occurred. In essence, such anti-epidemic materials have the dual nature of necessities with low elasticity of demand and private products with positive externalities. This research explores the understanding of anti-pandemic materials and how different initiatives, and evaluation to increase availability of necessary resources can be effective in curbing a pandemic. Market regulation (...) results in a non-Pareto optimal allocation of resources and the difficulty of exerting the positive externalities of products. However, in China, the market failure of anti-epidemic materials was quickly resolved, due to the institutional advantages of socialism with Chinese characteristics, the social responsibility drive of domestic enterprises, and cultural genes that focus on equity and concern for the disadvantaged. The optimal allocation of anti-epidemic materials gave access to exerting efficiency and fairness effects, positive external effects, and public effects. (shrink)

Leading scholars in the field of health economics evaluate the role of incentives in health and health-care decision making from the perspectives of both supply and demand.

MACDONALD SE, NEWBURN‐COOK CV, ALLEN M and REUTTER L.Nursing Inquiry2013;20: 30–41 Embracing the population health framework in nursing researchIndividuals’ health outcomes are influenced not only by their knowledge and behavior, but also by complex social, political and economic forces. Attention to these multi‐level factors is necessary to accurately and comprehensively understand and intervene to improve human health. The population health framework is a valuable conceptual framework to guide nurse researchers in identifying and targeting the broad (...) range of determinants of health. However, attention to the intermediate processes linking multi‐level factors and use of appropriate multi‐level theory and research methodology is critical to utilizing the framework effectively. Nurse researchers are well equipped to undertake such investigations but need to consider a number of political, societal, professional and organizational barriers to do so. By fully embracing the population health framework, nurse researchers have the opportunity to explore the multi‐level influences on health and to develop, implement and evaluate interventions that target immediate needs, more distal factors and the intermediate processes that connect them. (shrink)

Several influential organisations have attempted to quantify the costs and benefits of expanding access to interventions-like contraceptives-that are expected to decrease the number of pregnancies. Such health economic evaluations can be invaluable to those making decisions about how to allocate scarce resources for health. Yet how the benefits should be measured depends on controversial value judgments. One such value judgment is found in recent analyses from the Disease Control Priority Network (DCPN) and the Study Group for the (...) Global Investment Framework for Women's and Children's Health. Noting the decrease in the number of pregnancies expected to result from providing access to family planning, DCPN and the Study Group claim that a substantial benefit of such interventions is averting the stillbirths and child deaths that would have resulted from those pregnancies. We argue that health economic analyses should not count such averted deaths as benefits in the same way as saved lives. First, by counting averted stillbirths and child deaths as a benefit but not counting as a cost the lives of babies who survive, DCPN and the Study Group implicitly commit themselves to antinatalism. Second, this method for calculating the benefits of family planning interventions implies that infertility treatments are harmful. Determining how potential people should be treated in health economic analyses will require grappling with population ethics. (shrink)

Every emerging technology has its pros and cons; health-conscious users pay more importance to healthy and environment-friendly technologies. Based on the UTAUT2 model, we proposed a comprehensive novel model to study the factors influencing consumers’ decision-making to adopt the technology. Compared to prior studies that focused on linear models to investigate consumers’ technology adoption intentions and use behavior. This study used a Structural Equation Modeling-fuzzy set qualitative comparative analysis approach to account for the complexity of customers’ decision-making processes in (...) adopting new technology. We collected valid responses from 830 consumers, analyzed them, and evaluated them using a deep learning SEM-fsQCA technique to capture symmetric and asymmetric relations between variables. We have extensively incorporated a health-consciousness attitude as a predictor and mediator to understand better the decision-making toward technology adoption, specifically 5G technology. All the factors tested in our model are statistically significant except the economic factors. Health-consciousness attitude and behavioral intention found significant predictors and valid mediators in the process of 5G technology adoption. FsQCA provided six configurations to achieve high 5G adoption. The findings have significant practical ramifications for telecom corporations, advertisers, government officials, and key policymakers. Additionally, the study added substantial theoretical literature to technology adoption, particularly the adoption of 5G technology. (shrink)

Several influential organisations have attempted to quantify the costs and benefits of expanding access to interventions—like contraceptives—that are expected to decrease the number of pregnancies. Such health economic evaluations can be invaluable to those making decisions about how to allocate scarce resources for health. Yet how the benefits should be measured depends on controversial value judgments. One such value judgment is found in recent analyses from the Disease Control Priority Network (DCPN) and the Study Group for the (...) Global Investment Framework for Women’s and Children’s Health. Noting the decrease in the number of pregnancies expected to result from providing access to family planning, DCPN and the Study Group claim that a substantial benefit of such interventions is averting the stillbirths and child deaths that would have resulted from those pregnancies. We argue that health economic analyses should not count such averted deaths as benefits in the same way as saved lives. First, by counting averted stillbirths and child deaths as a benefit but not counting as a cost the lives of babies who survive, DCPN and the Study Group implicitly commit themselves to antinatalism. Second, this method for calculating the benefits of family planning interventions implies that infertility treatments are harmful. Determining how potential people should be treated in health economic analyses will require grappling with population ethics. (shrink)

This article tries to present a broad view on the values and ethicalissues that are at stake in efforts to rationalize health policy on thebasis of economic evaluations (like cost-effectiveness analysis) andrandomly controlled clinical trials. Though such a rationalization isgenerally seen as an objective and `value free' process, moral valuesoften play a hidden role, not only in the production of `evidence', butalso in the way this evidence is used in policy making. For example, thedefinition of effectiveness of medical (...) treatment or health care serviceis heavily dependent on dominant individual or social views about thegoals of the particular treatment or service. There is also a concernthat a reliance on EBM in health policy will occur at the expense ofwidely shared social values like equity and solidarity. Moreover, thereis a concern that when economic considerations and rational proceduresbecome more influential, various `outside' groups third parties likeinsurance companies and policy makers will get a stronger influence onmedical practice which may lead to a change in the patient-providerrelationship. The authors conclude that social values and patientpreference should be explicitly addressed when health policy making isbased on economic and other scientific evidence. (shrink)

The health and human rights movement (HHR) shows obvious signs of maturation both internally and externally. Yet there are still many questions to be addressed. These issues include the movement’s epistemological status and its perspectives of development. This paper discusses critically the conditions of emergence of HHR, its identity, its dominant schools of thought, its epistemological postures and its methodological issues. Our analysis shows that: (a) the epistemological status of HHR is ambiguous; (b) its identity is uncertain in the (...) absence of a validated definition: is it an action movement, an interdisciplinary field, a domain, an approach, a setting or a scientific discipline? (c) its main schools of thoughts are defined as “advocacists”, “ethicists”, “interventionists”, “normativists”; (d) the movement is in the maturation process as a discipline in which “interface”, “distance”, “interference” and “fusion” epistemological postures represent the fundamental steps; (e) parent disciplines (health sciences and law) competences, logics and cultures introduce duality and difficulties in knowledge production, validation and diffusion; (f) there is need to re-write the history of the HHR movement by inscribing it not only into the humanitarian or public health perspectives but also into the evolution of sciences and its social, political and economical conditions of emergence. The ambiguous epistemological status of this field, the need to re-write its history, the methodological duality in its research, the question of the competence of the knowledge validation, as well as the impact of HHR practice on national and international health governance are the challenges of its future development. To meet those challenges; we call for the creation and implementation of an international research agenda, the exploration of new research topics and the evaluation of the movement’s contribution to the national and global public health and human rights governance. (shrink)

Healthcare expenditures account for approximately 9% of GDP in OECD countries and are on an upward trajectory (OECD, 2017). This significant financial burden, combined with an aging global population and increasing demand, emphasizes the imperative for sustained research and innovation to enhance health system efficacy. Key to this transformation are technological advancements, including digital health, which presents novel opportunities for improvement. Emerging digital health technologies, such as virtual consultations, complex imaging procedures, and electronic medical records, are fundamental (...) to modern healthcare infrastructures. However, significant gaps remain in the evaluation and understanding of these innovations, especially for nascent technological areas. This thesis addresses this subject, aiming to delineate how individuals and institutions can bolster their evaluative capabilities, strategic decision-making, and planning for the deployment of emerging digital healthcare technologies. The research methodology amalgamates theoretical exploration, literature scrutiny, and empirical examinations, presenting an integrated perspective that intersects the disciplines of Management & Decision Science, Technology & Innovation, and Health Economics & Outcomes Research. From an applied perspective, this research focuses on developing evidence within the context of pediatric healthcare in Canada — a context notably underrepresented in healthcare management research, despite its disproportionate per capita expenditure. Technologically, the predominant focus is on applications in virtual reality (VR) and three-dimensional (3D) printing and virtualization, though with the aspiration of ensuring the generalizability of results. The current thesis is structured to parallel the progression of the research itself, as three distinct phases; this begins with a comprehensive Background that contextualizes the initial intent, exploring the relationship between technology, innovation, and health outcomes. In this phase, each academic discipline is analyzed to identify base theoretical underpinnings for the research. The second phase of this work includes five empirical studies, each preceded by context-specific literature reviews for the respective technological domain, providing insight into the current state of evidence related to value-based assessment and economic evaluation in that area. Empirical studies included a randomized controlled trial and a cost consequences assessment of VR for pre-procedural preparation for medical imaging. Additionally, novel applications of 3D printing and virtualization are critically analyzed, accompanied by a multi-case study on the implementation of 3D printing in pediatrics, a cost-consequences study of applications for thoracoabdominal surgeries, and an outcomes study on the use of 3D virtualization in medical education during the COVID-19 pandemic. The final phase of this research includes the critical analysis and synthesis of findings into a proposal for a novel value-based assessment and decision-making framework specific to emerging health innovations; this framework integrates insights and resources for clinicians, administrators, and policymakers. The outcomes of this research are skewed toward Knowledge Users, but also aims to advance the theoretical basis for health technology assessment (HTA). (shrink)

We sought to assess formally the extent to which different control and elimination strategies for human African trypanosomiasis Trypanosoma brucei gambiense would exacerbate or alleviate experiences of societal disadvantage that traditional economic evaluation does not take into account. Justice-enhanced cost-effectiveness analysis is a normative approach under development to address social justice considerations in public health decision-making alongside other types of analyses. It aims to assess how public health interventions under analysis in comparative evaluation would be (...) expected to influence the clustering of disadvantage across three core dimensions of well-being: agency, association and respect. As a case study to test the approach, we applied it to five strategies for Gambiense HAT control and elimination, in combination with two different other evaluations: a cost-effectiveness analysis and a probability of elimination analysis. We have demonstrated how JE-CEA highlights the ethical importance of adverse social justice impacts of otherwise attractive options and how it indicates specific modifications to policy options to mitigate such impacts. JE-CEA holds promise as an approach to help decision makers and other stakeholders consider social justice more fully, explicitly and systematically in evaluating public health programs. (shrink)

This paper aims at discussing some contributions, limitations and opportunities that efficiency and equity studies could make to form a better understanding of ethical issues involved in health technology assessment (HTA). Prenatal detection of Down syndrome is used as a case study for further discussions regarding efficiency and equity, as well as other ethical principles including beneficence, non-maleficence and autonomy. The development and use of adequate methods and the need for context appraisal are two imperative issues in this field (...) of knowledge. The analysis of ethical implications in HTA should account for both. Economic evaluation methodologies have great potential in the assessment of some key ethical principles such as efficiency and equity but are of limited use concerning other fundamental principles. Social and individual values play a prominent role in this respect. (shrink)

There have recently been novel applications of medical systematic review guidelines to economic policy interventions which contain controversial methodological assumptions that require further scrutiny. A landmark 2017 Cochrane review of unconditional cash transfer (UCT) studies, based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE), exemplifies both the possibilities and limitations of applying medical systematic review guidelines to UCT and universal basic income (UBI) studies. Recognizing the need to upgrade GRADE to incorporate the differences between medical and (...) policy interventions, the GRADE Public Health Project Group (PHPG) was convened to enumerate and address these methodological challenges. However, in light of our analysis of additional methodological challenges that arise for UCT and UBI studies, we argue that the adaptation of medical systematic review guidelines to economic methodology is far from straightforward and is in fact more challenging than claimed by the PHPG. (shrink)

Decision-making regarding healthcare expenditure hinges heavily on an individual's health status and the certainty about the future. This study uses data on propensity of general health exam (GHE) spending to show that despite the debate on the necessity of GHE, its objective is clear—to obtain more information and certainty about one’s health so as to minimise future risks. Most studies on this topic, however, focus only on factors associated with GHE uptake and overlook the shifts in behaviours (...) and attitudes regarding different levels of cost. To fill the gap, this study analyses a dataset of 2068 subjects collected from Hanoi (Vietnam) and its vicinities using the baseline-category logit method. We evaluate the sensitivity of Vietnamese healthcare consumers against two groups of factors (demographic and socioeconomic-cognitive) regarding payment for periodic GHE, which is not covered by insurance. Our study shows that uninsured, married and employed individuals are less sensitive to cost than their counterparts because they value the information in reducing future health uncertainty. The empirical results challenge the objections to periodic health screening by highlighting its utility. The relevance of behavioural economics is further highlighted through a look at the bounded rationality of healthcare consumers and private insurance companies in using and providing the service, respectively. (shrink)

In recent years, all major consumer technology corporations have moved into the domain of health research. This ‘Googlization of health research’ begs the question of how the common good will be served in this research. As critical data scholars contend, such phenomena must be situated within the political economy of digital capitalism in order to foreground the question of public interest and the common good. Here, trends like GHR are framed within a double, incommensurable logic, where private gain (...) and economic value are pitted against public good and societal value. While helpful for highlighting the exploitative potential of digital capitalism, this framing is limiting, insofar as it acknowledges only one conception of the common good. This article uses the analytical framework of modes of justification developed by Boltanksi and Thévenot to identify a plurality of orders of worth and conceptualizations of the common good at work in GHR. Not just the ‘civic’ and ‘market’ orders, but also an ‘industrial’, a ‘project’, and what I call a ‘vitalist’ order. Using promotional material of GHR initiatives and preliminary interviews with participants in GHR projects, I ask what moral orientations guide different actors in GHR. Engaging seriously with these different conceptions of the common good is paramount. First, in order to critically evaluate them and explicate what is at stake in the move towards GHR, and ultimately, in order to develop viable governance solutions that ensure strong ‘civic’ components. (shrink)

In many countries, health technology assessment organizations determine the economic value of new drugs and make recommendations regarding appropriate pricing and coverage in national health systems. In the US, recent policy proposals aimed at reducing drug costs would link drug prices to six countries: Australia, Canada, France, Germany, Japan, and the UK. We reviewed these countries’ methods of HTA and guidance on price and coverage recommendations, analyzing methods and guidance documents for differences in the methodologies HTA organizations (...) use to conduct their evaluations and considerations they use when making recommendations. We found important differences in the methods, interpretations of HTA findings, and condition-specific carve-outs that HTA organizations use to conduct evaluations and make recommendations. These variations have ethical implications because they influence the recommendations of HTA organizations, which affect access to the drug through national insurance and price negotiations with manufacturers. The differences in HTA approaches result from the distinct political, social, and cultural contexts of each organization and its value judgments. New cost-containment policies in the US should consider the ethical implications of the HTA reviews that they are considering relying on to negotiate drug prices and what values should be included in US pricing policy. (shrink)

Health care is ubiquitous in the industrialized world. Yet, every medical development, technique, and procedure impacts the environment. Green bioethics synthesizes environmental ethics and biomedical ethics, thus creating an interdisciplinary approach to sustainable health care. Notably, green bioethics addresses not the structure of environmental sustainability in health-care institutions but the sustainability of individual health-care offerings. It parallels traditional biomedical ethics by providing four principles for ethical guidance: distributive justice, resource conservation, simplicity, and ethical economics. Through these (...) four principles, green bioethics presents a coherent framework for evaluating the sustainability of medical developments, techniques, and procedures. The future of our world may very well depend on how effectively we halt ecological destruction and conserve our resources in all areas of life. The principles of green bioethics, outlined in this book, will advance sustainability in health care. (shrink)

Resource allocation is a central part of the decision-making process in any health care system. Resources have always been finite, thus the ethical issues raised are not new. The debate is now more open, and there is greater public awareness of the issues. It is increasingly recognised that it is the technology which determines resources. The ethical issues involved are often conflicting and relate to issues of individual rights and community benefits. One central feature of resource allocation is the (...) basing of decisions on the outcomes of health care and on their subsequent economic evaluation. The knowledge base is therefore of great importance as is the audit of results of clinical treatment. Public involvement is seen as an integral part of this process. For all parts of the process, better methodologies are required. (shrink)

This paper suggests that public health, due to its community orientation, may be ignoring certain ethical principles--namely the rights of individuals and communities to self-determination. The expectation of individual rights as a member of a community is reviewed and the additional right of a community for self-determination is proposed. The influences on ethical evaluations by the legal and economic environments are suggested, using US examples. The conclusion argues that as the focus of health-care delivery changes, it will (...) become more important to consider these questions of group ethics. (shrink)

There is growing interest in using non-coercive interventions to promote and protect public health, in particular "health nudges." Behavioral economist Richard Thaler and law scholar Cass Sunstein coined the term nudge to designate influences that steer individuals in a predetermined direction by activating their automatic cognitive processes, while preserving their freedom of choice. Proponents of nudges argue that public and private institutions are entitled to use health-promoting nudges because nudges do not close off any options. Opponents reply (...) that the nudgee has no opportunity to deliberate over her choice. The nudger controls the nudgee, who has no real freedom of choice. -/- In my dissertation, I salvage the concept of nudge from the charge that it merely pays lip service to freedom of choice, offer an alternative account of the moral import of nudges for the evaluation of public health policies, and provide an ethical framework for their justified use. -/- My argument proceeds in four steps. First, I argue that nudging mechanisms often involve some form of incomplete deliberation, and do not always bypass deliberation. Second, I maintain that nudges preserve freedom of choice because they preserve the choice-set and are substantially noncontrolling. I show that the debate over nudges is plagued by confusion between real nudges, which are easily resistible and therefore substantially noncontrolling, and influences that are not easily resistible yet activate the same cognitive mechanisms as nudges. Third, I reject the view that nudges are systematically preferable to more controlling influences, even when they interfere with non-consequential liberties. I show that the principle of the least restrictive alternative often invoked in public health ethics is applied with too wide a scope. Fourth, I argue that paternalism is not central to the ethics of public health nudges. Rather, the substantive problem with nudges is that their overall cumulative effect might weaken our decisional capacities or undermine their proper exercise. This is a reason to limit recourse to certain nudges. I finally show, contra certain Kantians and Millians, that we have no perfect duty to engage or enhance decisional capacities. (shrink)