Brocher Summer Academy
Brocher Summer Academy in Global Population Health:
Healthy, Wealthy, and the Wise: The Ethics of Health Valuation - 27 June to 1 July 2022
Preliminary list of confirmed speakers:
John Broome (University of Oxford)
Nir Eyal (Rutgers University)
Daniel Hausman (University of Wisconsin–Madison)
Samia Hurst (University of Geneva)
Ole Frithjof Norheim (Harvard T.H. Chan School of Public Health and University of Bergen)
Daniel Wikler (Harvard T.H. Chan School of Public Health)
Motivation and Background
What policies should we implement to decrease motor vehicle accidents? Reduce air pollution? Ensure food and drug safety? Control gun violence? Improve nutrition? Allocate research and care funding for HIV/AIDS or other health conditions between prevention, treatment, and cure programs, and between HIV/AIDS and other diseases? Economic assessment informs related decisions by estimating the impact of alternative policies on health and welfare. Different approaches to these assessments have different conceptual underpinnings, however, and different ethical implications. Our goal in this Summer Academy is to explore the comparative advantages and disadvantages of both conventional and innovative assessment methods from an ethical perspective, so that analysts, decision-makers, and other stakeholders are better able to select among these approaches and interpret and use their results.
Chief among conventional assessment methods are benefit-cost analysis (at times referred to as cost-benefit analysis) and cost-effectiveness analysis. Benefit-cost analysis is widely-used to inform government regulatory decisions and, to some degree, funding choices, in high-income countries, and is increasingly used in Iow- and middle-income countries. For example, the Pew-MacArthur “Results First” initiative is promoting the use of benefit-cost analysis for US state-level decision-making, and the Gates Foundation is promoting the use of benefit-cost analysis in low- and middle-income countries.
Cost-effectiveness analysis is the dominant approach for assessing medical decisions globally, particularly those provided by the healthcare system to prevent and treat specific conditions. Several countries with single payer systems use cost-effectiveness analysis to support reimbursement decisions. For example, cost-effectiveness is an important consideration in recommendations made by the United Kingdom’s National Institute for Health and Care Excellence.
Data collected by Tufts University researchers indicate that about 8,000 cost-effectiveness analyses have been published in recent years that assess healthcare interventions. No similar database exists for benefit-cost analyses, but the number of studies conducted globally is probably large as well, especially given its use to assess policies undertaken outside the healthcare system with significant effects on population health.
The conceptual underpinnings of benefit-cost analysis and cost-effectiveness analysis have been extensively investigated and debated. However, more work is needed to clarify areas of agreement and disagreement on their ethical implications, and to explore ways to overcome associated problems in light of recent developments in ethics. Work is certainly needed to understand the relative advantages and disadvantages of novel alternatives that seek to address the perceived technical or ethical limitations of these conventional methods. These alternatives include, for example, multi-criteria decision analysis, subjective wellbeing analysis, extended cost-effectiveness analysis, and analysis using social welfare functions, among others.
The ethical questions raised by these approaches are diverse. Some questions relate to the relative importance of different contributors to wellbeing. Should the analysis measure benefits in terms of health? Financial resources? Overall wellbeing? Capabilities? A combination? Should values be based on individual (reported) preference-satisfaction/happiness/wellbeing, or reflect a social planner’s perspective? Should they be self-regarding or also other-regarding? Should they be based on experience, or can be hypothetical? Should they focus on welfare, or solely on health? Do they make certain assumptions on what is valuable and which values are commensurate?
Other questions relate to how the impacts are distributed. To what extent should we prioritize improvements that accrue to the people with co-morbidities and social vulnerability rather than the heathy and wealthy? How should we balance investing in ones that provide large net benefits to a few individuals and policies that provide smaller net benefits to many? What about the impacts on current versus future generations? Several scholars have also argued for including measures of health and longevity in national income and product accounts, so as to expand the estimation of gross domestic product to include a broader conception of wellbeing.
Basic characteristics of the methods to be debated
The costs of implementing a policy divert resources, including money and the labor and materials it could buy, from other potentially beneficial purposes. For example, providing antiretroviral treatment immediately upon HIV diagnosis and onwards may have only moderate harms because antiretrovirals have comparatively mild adverse effects. Much more importantly, funding treatment upon diagnoses actively diverts resources from providing treatment to all advanced patients with HIV, as well as from alleviating other health conductions, from improving education, environmental quality, or nutrition, and from other beneficial interventions for health and welfare.
The approaches used to assess these improvements and costs fall into three general categories, reflecting differing levels or types of aggregation and different approaches to valuing changes in health and longevity. Each approach can be designed to address distributional concerns, either by incorporating specific weighting or by conducting supplemental analysis.
One option is to measure health and longevity using an integrated nonmonetary measure, while measuring costs in money terms. Cost-effectiveness analysis does this, with changes in health and longevity typically estimated in terms of quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs). The costs are then divided by the change in QALYs or DALYs to determine which intervention has the lowest cost per unit of effectiveness. When an intervention has significant non-health outcomes, such as environmental impacts, the monetary value of these outcomes can be included in the cost estimate (as an offset if the outcome is positive).
The second option is to use the same metric to estimate both costs and benefits. Conventional benefit-cost analysis falls into this category, with money used to value changes in health and longevity as well as other impacts. In this case, values are derived from individuals’ willingness to exchange income for reductions in their own morbidity and mortality risks. However, many have proposed using other innovative metrics to value both costs and benefits, such as units of subjective wellbeing (“happiness”), social welfare functions, or healthy life years. In these cases, the analytic results may be summarized as net benefits (benefits minus costs) or as a benefit-cost ratio (benefits divided by costs). Policies with positive net benefits or with benefit-cost ratios greater than 1.0 (in the latter case) can then be compared to identify which leads to the greatest net benefits. Variants that weight equal health benefits to more for individuals or populations who are worse off (along differing dimensions) are also being considered..
The final category involves measuring outcomes in different units. At times referred to as a dashboard approach or as multi-criteria decision analysis, this approach involves reporting each outcome separately, e.g., implementation costs, deaths averted, cases of illness averted, acres of wetlands protected, people raised above the poverty threshold. The disparate results can be inspected by decision-makers and stakeholders who each apply their own implicit weighting scheme to identify the preferred option. Alternatively, results may be explicitly weighted using a function developed by the analysts.
Some differences between these approaches are pragmatic and technical. Some are deeper. Highlighting the normative underpinnings of these approaches and their many variants will aid analysts in selecting assessment methods that are most appropriate for a particular policy context or in general, in addition to aiding decision-makers and others in understanding and using the results.
Schedule: From Monday to Friday, 8:30 am to 5 pm (2 pm on the last day)
Place: Brocher Foundation, Hermance, Switzerland