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. 2019 Apr 3;14(1):5.
doi: 10.1186/s13010-019-0074-7.

Utilitarianism and the ethical foundations of cost-effectiveness analysis in resource allocation for global health

Elliot Marseille  1 , James G Kahn  2
Affiliations

Utilitarianism and the ethical foundations of cost-effectiveness analysis in resource allocation for global health

Elliot Marseille et al. Philos Ethics Humanit Med. .

Abstract

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.

Keywords: Cost-effectiveness; Ethics; Global health; Health economics; Utilitarianism.

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Conflict of interest statement

Authors’ information

EAM is principal of the firm, Health Strategies International, that specializes in the economic evaluation of both global and domestic public health programs. Trained in health policy analysis, Dr. Marseille has over 30 years of senior public health management and research experience with a focus on the empirical and modeled assessment of the cost and cost-effectiveness of programs, and policies related to HIV/AIDS and other diseases relevant to global health. JGK is Emeritus Professor at the Philip R. Lee Institute for Health Policy Studies, the Institute for Global Health Sciences, and the Department of Epidemiology and Biostatistics, all at UCSF. Dr. Kahn is an expert in cost-effectiveness analysis, evidence-based medicine, and policy modeling in health care. His work focuses on the use of cost-effectiveness analysis to inform decision-making in public health and medicine. He is a widely published expert in the economic assessment of HIV prevention and treatment programs and on a wide range of other global health issues.

Ethics approval and consent to participate

Not relevant. No human or animal subjects were needed or used.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Likelihood of convergence between ethical principles
See this image and copyright information in PMC

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