Shepley Orr

Cost-effectiveness analysis suggests that a society should allocate its health care budget in order to achieve the greatest total health for its budget. However, in ‘rescue’ cases, where an individual’s life is in immediate peril, reasoning in terms of cost-effectiveness can appear inhumane. Hence considerations of cost-effectiveness and of rescue appear to be in tension. However, by attending to the division of labour in medical decision making it is possible to see how cost-effectiveness analysis and rescue-style reasoning are commonly combined in an ethically acceptable fashion.

Health‐related Quality of Life measures have recently been attacked from two directions, both of which criticize the preference‐based method of evaluating health states they typically incorporate. One attack, based on work by Daniel Kahneman and others, argues that ‘experience’ is a better basis for evaluation. The other, inspired by Amartya Sen, argues that ‘capability’ should be the guiding concept. In addition, opinion differs as to whether health evaluation measures are best derived from consultations with the general public, with patients, or with health professionals. And there is disagreement about whether these opinions should be solicited individually and aggregated, or derived instead from a process of collective deliberation. These distinctions yield a wide variety of possible approaches, with potentially differing policy implications. We consider some areas of disagreement between some of these approaches. We show that many of the perspectives seem to capture something important, such that it may be a mistake to reject any of them. Instead we suggest that some of the existing ‘instruments’ designed to measure HR QoLs may in fact successfully already combine these attributes, and with further refinement such instruments may be able to provide a reasonable reconciliation between the perspectives.

This article examines criticisms of cost-benefit analysis and the contingent valuation method from methodological and moral philosophical perspectives. Both perspectives argue that what should be elicited for public decisions are attitudes or values, not preferences, and that respondents should be treated as citizens and not consumers. The moral philosophical criticism argues in favour of deliberative approaches over cost-benefit analysis. The methodological perspective is here criticized for overemphasizing the importance of protest responses and anomalies and biases in contingent valuation, and for failing to provide the necessary information needed to make public decisions over the allocation of scarce goods. The moral philosophical perspective is criticized for: failing to provide criteria for distinguishing between values and preferences, assuming impartiality requires expression of values and not preferences; failing to recognize the diversity of forms of expression of values, including expression of values through monetary evaluation; and assuming that cost-benefit analysis is necessarily an implementation of a utilitarian political philosophy. The article concludes by showing that deliberative decision-making mechanisms can be overly demanding on citizens, and argues for greater openness in the potential moral justifications of cost-benefit analysis. Key Words: cost-benefit analysis • values • preference aggregation • democracy • willingness to pay.