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Cost-Effectiveness Analysis in Health Care Cost-effectiveness analysis (CEA) raises questions that are too important to be left ot policy analysts and economists. Those who utilize CEA should acknowledge its inherent value system and adapt it to a more ethical usage.

Even while under fire for soaring health care costs, American medicine remains without a systematic plan for the allocation of either public or private funds. The percentage of Gross National Product devoted to health care, which more than doubled over the past two decades, has sparked concern that some form of health resources rationing is inevitable.[1] And, ironically, despite advances in health care technology, the public is becoming increasingly critical of its achievements. In particular, there is concern that many expensive procedures are employed unnecessarily and that health care moneys might provide greater benefits if they were spent elsewhere. In other words, society is asking: Are we getting our money's worth?

In an attempt to address these questions as well as reconcile economic constraints with contemporary ideals and practice, some analysts have turned to cost-effectiveness analysis (CEA), which, because it yields answers in precise quantitative terms, is very seductive to health policy planners. The Office of Management and Budget requires agencies to prepare cost-benefit or cost-effectiveness analyses, and the Occupational Safety and Health Administration also relies on CEA.[2]

However, far from being a pristine mathematical algorithm, CEA employs complex and often overlooked value components along with empirical data. Since CEA addresses fundamental human values of life and health, its application can affect issues of justice and quality. The more widely CEA is utilized, the greater is the need to recognize and clarify the ethical concerns it raises. Indeed, as Rashi Fein has suggested, such assessments are "too important to be left to analysts and economists."[3]

Methods of Measurement

All cost-effectiveness computations share the same basic form: Monetary Cost (D) - Monetary Benefits (D)/Health Gained (D) where (D) = discounting of future values. Cost-benefit analysis (CBA), a method originally developed outside the health care sector, has no variable for health itself, but measures it indirectly by assessing its dollar value:

Monetary Cost (D) - Monetary Benefits (D) Thus, CEA emphasizes health effects whereas CBA focuses on economic effects.

Determining monetary costs is straighforward. These include resources utilized to fund the activity (for example, diagnosis, treatment, rehabilitation), and the costs of undesirable outcomes (such as side-effects or the treatment of false positives). Most analysts also include the costs of future care due to lengthened lifespan resulting from successful treatment--an acknowledgement that benefits sometimes carry additional hidden costs. This is particularly relevant with respect to the elderly.

In CBA all benefits, including health gained, are measured in terms of their monetary worth. This is accomplished by utilizing "human capital" calculations, which count the productivity (wages) gained as a measurement of the value of health.[4] This value is then included with the other monetary benefits generated by the program, the most important of which is the cost of future medical care averted by implementing the project. CEA can also incorporate human capital assessments by adding the dollar value of health into its "monetary benefits" category.

In CEA (but not CBA) health may be measured in a variety of ways: cases prevented, decreased length of hospital stay, reduction in mortality, etc. One popular measurement is the gain or loss of years of life because of an intervention.[5] The additional years of life gained may be adjusted for the quality of life, though this is a controversial ethical point.

All measures are usually discounted at varying rates averaging about 5 percent yearly, reflecting economic theory as well as the human tendency to favor immediate gain. One consequence of discounting is that it profoundly devalues preventive health care services, whose benefits lie in the future, but whose costs are incurred in the present.

Cost-Effectiveness in Health Care

Cost-benefit analysis is best thought of as an economic measurement reflecting the costs of illness to society. In classical CBA an "effective" program would be expected to break even or realize a profit. CBA also utilizes the only quantifiable and universally comparable outcome measurement--the loss of productivity associated with time off from work; it thus allows different health programs to be compared with each other and with nonhealth projects.[6] A dollar is a dollar, no matter which program generates it. However, even from a purely economic point of view, equating value with wages may not measure productivity accurately. At best it represents the minimum a life is worth.[7]

Cost-effectiveness analysis, however, may use varying measurements of health, such as years of life lost or gained, days lost from school or work, length of hospital stay or reduction in physician visits. Thus, CEA is limited to, but also more suited to, health care--assuming the goal of health care is to provide health as well as economic benefits. Cost-effectiveness analysis has rapidly become favored over cost-benefit analysis in the health care sector.[8]

If health is balanced against dollars, how can we know when we get our money's worth in terms of health? Not every program will generate a net savings in the use of health care resources. Most produce health at a cost, often a very high one, but that by itself does not signify inefficiency. Conversely, although we recognize life as a desirable end in itself, it cannot be absolutely preferred to the exclusion of other goods, for life is valued in part as a condition that allows access to other goods.

Such considerations suggest that certain types of intervention are more suited for CEA than others. These include:

Comparing alternative treatments for an identical goal. Here CEA serves only to find the most frugal way to attain an established goal. It must be assured that the outcomes are comparable (otherwise one may argue that worse care is acceptable so long as it is much cheaper than good care).

Diagnostic-related group (DRG) reimbursement planning is one area in which CEA would be very useful. For example, for DRG categories 89-91 (simple pneumonia) a major factor in the patient's recovery is the antibiotic used. An analysis could be run comparing a new drug with more standard regimens. If its cost fell below the average DRG payment it would be economically advantageous to stock the new drug in the hospital formulary. Pharmaceutical companies as well as hospitals would be expected to demonstrate cost-effective gains in health, in this case decreased hospitalization, information that would also be of interest to physicians.

Determining the most effective utilization of funds earmarked for a specified population. For example, if a state wants to allocate $1,000,000 to improve the health of poor children, CEA could help elucidate whether improved prenatal care or nutritional supplements to all poor children would be more effective in decreasing mortality and morbidity. The definition of a "specified population" is key here; if the definition is too inclusive, significant biases may be introduced.

Providing empirical support for the adoption of previously underfunded medical programs with low, that is efficient, cost-effectiveness ratios. This may be complicated by debate over what constitutes a low cost-effectiveness ratio.

Exposing noncostworthy care. Noncostworthy care describes medical programs whose expenditures would increase society's welfare to a greater degree if the money were used elsewhere to secure other (medical or nonmedical) goods.[9] Attempts should be made to ensure that funding withdrawn from noncostworthy programs be used to provide better health care in another area, and not given to stockholders or spent on national defense.[10] This redirection is especially important should the current state of substandard health care for some populations persist.

Several types of noncostworthy care can be identified by CEA: Care that is relatively inefficient when compared to alternative therapies for the same goal; care that, though inexpensive, provides no benefits; care that provides definite benefits, but at great expense (the cost-effectiveness ratio is high and no alternative exists).

These types must be ultimately handled differently, however. For example, it is not ethically questionable to eliminate a health plan that has zero benefits or can be replaced by more efficient programs, provided the outcomes are comparable. The elimination of clearly ineffective treatments should not be construed as rationing.

The real difficulty lies in evaluating programs that have a high cost-effectiveness ratio, but only because of cost, not effectiveness. They may save many lives. Although there is no recognized ratio of dollars per well-year beyond which funding is categorically denied by current health practice and policy, various estimations propose a likely ceiling near $100,000.[11] Whether or not a firm cut-off value is utilized, it would be reasonable to scrutinize treatment programs with extremely high cost-effectiveness ratios to see if they meet society's standards and goals for health care.

If CEA is used to study such programs with the intent to clarify whether or not "too much" is being spent for a given year of life gained, then it becomes a rationing device. However, it is important to emphasize that CEA as outlined affects the provision of health care at an organizational or governmental level, but should not intrude into decisionmaking at the level of individual patient, and should thereby pose no threat to the doctor-patient relationship and the physician's role as a fiduciary agent.[12] The Office of Technology Assessment, for one, considers this lack of impact upon physician-patient interaction to be a flaw in the use of CEA, and suggests that, "[s]ystemwide changes in the economic environment...might more closely aline [sic] the practice of medicine with the precepts of analysis."[13] From the perspective of a practicing physician, such an objective underscores the importance of health professionals' input into large-scale policy decisions concerning cost-effective care.

Human Capital and the Value of Health

Cost-benefit analysis, the forerunner of CEA, was originally developed to assess the desirablility of nonhealth programs, tallying up the gains and losses to determine whether they were worthwhile. Measurements of health and the value of life were wholly subsumed under economics. Some cost-effectiveness analysts also view health as an investment and, along with calculating health effects, subtract averted lost wages from the costs of the program. This adjustment creates a human capital factor, however, that robs CEA of its ability to focus on health outcomes, thereby eroding its basic theory and purpose.[14]

There are several arguments against utilizing human capital calculations (including CBA) when distributing health care monies:

Discrimination against low wage earners. Human capital methodologies favor the most economically productive members of society. Women, for example, earn two-thirds what men do and have lower averted lost wages for the same amount of health gained.[15] Thus health care dollars spent on their behalf are less "effective." Rather than basing health care policy on medical outcome, then, human capital calculations require better "returns" from investment in the health of women, or alternatively, require them to be more ill to warrant the same dollar investment as for the health of men. It would be cruel and ironic to add medical injustice to economic injustice by incorporating the latter into health care decisionmaking.

Several recent studies illustrate how this economic bias can be propagated in health care. In 1985, Dorothy Rice, Thomas Hodgson, and Andrea Kopstein updated their landmark 1963 publication on the economic costs of illness, and showed that women's health possessed much less economic worth than men's. For example, the life of a thirty- to thirty-four-year-old man was calculated to be worth $434,295; in comparison, the life value of a thirty- to thirty-four-year-old woman was $288,221. They properly cited this inherent bias as a limitation to the method.[16] Other authors, using their figures, effectively demonstrated the large economic cost of pelvic inflammatory disease (PID) to society.[17] A subsequent article, using these figures for the economic costs of PID, determined at what "threshold prevalence rate" of infection it would be appropriate to screen for the causative microbe.[18] However, had the life-value been higher, the "threshold prevalence rate" for screening would have been lower. Although the authors were careful to indicate that there may be other considerations besides economic ones when implementing a program, they failed to recognize their own contribution to the devaluing of women's health. Thus, even in analyses designed to improve the health care of women, the lower economic worth of women can translate directly into decreased vigilance in detecting disease.

White males, too, may find their health care jeopardized under human capital assessments. For example, Gio B. Gori and colleagues have determined that due to the economic drain of burgeoning pension plans it is far more profitable to pay for disability and death than to implement health care programs to help workers live into retirement.[19]

Defining human value as economic worth. Even if wages were calculated from a unisex, nonracial table, ethical distinctions are blurred when one of society's paramount values is entirely subsumed under economic theory. As Acton states: In an individualistic society where the government is viewed as serving the public rather than vice versa....[i]f one accepts the view that production is not an end in itself for people, but rather a necessary intermediate step which allows people to enjoy the fruits of production, then the "human capital" approach is clearly inappropriate.[20]

Human capital methodology seeks to maximize economic efficiency, but if a right to health care is accepted then issues of equity and distribution must be considered.[21]

Valuing Health Under CEA

What appears to be needed is cost analysis that is intrinsically fair and incorporates accepted attitudes toward life and health. CEA, conducted without human capital calculations, attempts to reconcile the competing values of efficiency and equity without conflating them. Determining the nature of these values is a difficult, but clearly necessary, undertaking.

A rising trend in medicine, coinciding with patient demands for dignity and autonomy, is assessment of the quality of life as distinct from the years of life gained by an intervention. Only by developing acceptable quality of life adjustments can CEA researchers achieve a method for measuring and comparing outcomes; indeed, this is a property CEA must have if it is to replace CBA entirely.

A form of quality adjustment advocated by many theorists uses the following units with respect to years of life gained by an intervention: one "well-year,"[22] or quality adjusted life year (QALY),[23] represents a year of life free from any physical impairment; a zero "well-year" or QALY represents death. Quality adjustments attempt to provide a means to quantify the subjective nature of wellness and allow treatments for different disease states to be compared as to their utility to the patient.

A number of approaches to estimating the quality of life have been developed. One method of assessing the value of a certain level of well-being is "time-tradeoff," in which a person is asked what fraction of a year of life he or she would be willing to give up to live the remainder of the year in perfect health, or the maximum acceptable risk of dying from an intervention which, if successful, would provide perfect health.[24] Subtracting each of these fractions from one yields the utility of that health state for that person. Practically, this method may not yield reliable results because of the difficulty in developing measures that accurately depict the concept.[25]

Another popular method is the "willingness-to-pay" approach, where people are asked how much they would pay to avoid an outcome with a defined risk of occurrence. One major problem with this approach is that people's responses are directly proportional to their income.[26] Moreover, both willingness-to-pay and time-tradeoff methods may not accurately represent long-term values, as people feel more strongly about losing a presently held good than gaining a future potential one. Thus, people demand more in compensation for bad outcomes than they are willing to pay to avoid them.[27]

Other health-status indices have been derived from having the public place a value on certain states or asking those afflicted with a compromised state to rate it, since affected persons may rate a disease state quite differently from unaffected persons.[28] Old age per se is felt by some to decrease the value of a year of life.[29] While it is beyond the scope of this essay to discuss which of these scales is preferable, it would seem likely that an objective study using a set of standard valuations--if reasonably accurate, reproducible, and reliable--would provide better estimations of morbidity than the arbitrary opinions of a researcher who happens to be analyzing a particular program.

Applying quality of life adjustments in CEA risks discriminating against certain populations. It is clear that people prefer perfect health to any form of morbidity, but is it ethical, by extrapolation, to devalue the life of a handicapped person?[30] Our society assumes radical equality among all its members. At the same time, a protocol that increases function, not simply years of life, is obviously preferable to one that does not. Alternatively, the existence of right-to-die groups and wrongful life court decisions indicate that people may believe some health states--even life--are so undesirable that death--or nonexistence--is to be preferred. Such conflicting societal viewpoints cannot be neatly inserted into a mathematical formula.

Depending on methodological assumptions, CEA may favor the attainment of perfect health over improvements in poor health, even though the incremental increase is the same. If absolute health outcomes are used as quality factors, handicapped persons would gain far fewer well-years than less imparied people, given the exact same intervention and improvement in health. If, however, only the change in health status is used, then all ill people are equally favored. But is it better to go from very ill to only moderately so, or would we rather invest in the total restoration of well-being in a moderately sick individual? Is the goal of medicine health or only less illness? Only an exploration of values and goals by an informed society in conjunction with individuals engaged in the use of CEA can answer these questions.

Efficiency versus Equity

The ethical principles of beneficence and justice can be both served and challenged by the use of CEA. Beauchamp and Childress assert that whenever costs are incurred along with benefits, the beneficent nature of an act cannot be established until the magnitude of resultant gains and losses are systematically and nonarbitrarily determined. In addition, they believe that cost analysis is integral to the pursuit of distributive justice, and that the analysis should incorporate the widest possible range of human values.[31]

Even if the intrinsic workings of the cost-effectiveness formula were made more equitable by omitting productivity measurements and by an equal valuation of all lives, the numbers going into the equation may vary considerably from group to group due to entirely arbitrary, nonmedical factors, such as a population's geographic location, socioeconomic status, and education.[32] Thus, for example, programs designed to serve the urban poor almost certainly will be less cost-effective than those in the affluent suburbs. Like CBA, CEA has the potential to be driven by economic factors and preferentially allocate funds to the "cheap to treat," although the inequities may even out over time.[33] While it may be a moral imperative to secure the greatest good possible, it cannot be done at the expense of the unfortunate few.

CEA and Health Care for the Elderly

Older Americans are especially vulnerable to the application of CEA. Even if lost wages are not taken into account (wages that most elderly do not have) and their years of life are valued on par with younger persons, and even if discounting benefits them the most, there remains an intrinsic bias in cost-effectiveness protocols involving the elderly. The difficulty, however, lies in medical reality and is not a product of misplaced values.

First, any cost-effectiveness formula that includes the expenditure of health care dollars due to extended lifespan arising from successful therapy will have higher costs for the elderly. This is due to the older person's overall requirement for more health care resources per year of life.[34] A second bias results from the calculation of years of life gained by the therapy. Any life-saving intervention will appear more effective in the young, by virtue of their longer remaining lifespans. These biases can be very significant. In one study, the cost per additional year of life of cholestyramine therapy to reduce blood cholesterol was $56,000 for thirty-five- to thirty-nine-year-old men, but at least $1,000,000 for men over seventy.[35]

Since CEA is intrinsically biased against the elderly, any program comparing treatment for the elderly with treatment for the young will be disadvantaged. It is notworthy that our nation, by continuing support for Medicare, has cast its vote in favor of the elderly--contrary to the dictates of efficiency.

A more serious problem for the utilization of CEA would occur if some hypothetical cost-effectiveness ratio were established above which no program would be implemented. Because of inherent bias, it would be unsatisfactory to apply this ratio to the elderly. Yet it would also seem unfair, as well as inefficient, to propose that more ought to be spent to gain a year of health for an older person than for a younger one. On egalitarian grounds justice may be better served if we give priority to illnesses that strike younger persons so that everyone has the chance to live a certain span of time. This ethical principle should remain distinct from the purely economic arguments rejected earlier.

CEA and Preventive Health Care

The necessity of employing a discount rate when calculating the present value of future expenditures is generally recognized. The less easily understood aspect is that well-years also must be discounted; otherwise mathematically paradoxical and irrational results will be obtained.[36]

Money is usually spent before health is gained, and the longer the period until the gains are realized, the less cost-effective the program will be. Preventive health care often treats persons who may never become ill. Thus, preventive medicine programs are at a disadvantage under CEA.[37] Arithmetic aside, is it reasonable to discount future years of life, at the expense of our or our children's health? Practically, we are a nation of overeaters, smokers, and debtors. We value present life more highly than future life. Thus, there are several sound reasons for applying CEA to preventive medicine programs.

Persons to be helped immediately either already have, or are likely to develop, the condition in question. Persons to be helped ten years from now are not so easily identified due to death from other causes, change in environmental factors, or change in the disease process itself. Western culture forbids the sacrifice of identified lives, but will tolerate deaths among unidentified lives if necessary,[38] and it follows that we would also favor saving those same "known" lives. Yet prevention and treatment are really on a continuum. Not all treatments will help all victims, nor can the person with untreated hypertension truly be called unidentified merely because he has

no pathology yet. Menzel has suggested the crucial distinctions are between individual versus group recipients, high-risk versus low-risk conditions, and present versus future dangers.[39] Cost-effectiveness analysis accounts for at least the latter two considerations through, respectively, objective estimations of the loss of life, and the discount rate.

CEA therefore evaluates preventive medicine in a manner consistent with accepted societal values. In addition, it can help divert funding toward more rational uses such as preventive medicine.

Often, inequalities in resource distribution may be due to the impact the beneficiary has on the payer, as society is comprised of individual people who desire a psychological or political reward for funds they allocate.[40] Potential lives cannot make an appeal on television or create a lobby. Concerns have been raised over major resource allocation based on these emotional appeals rather than on reason.[41] But Larry Churchill's exploration of the apparent conflict between sympathy and rationality suggests that through imagination the feeling of sympathy can be extended to more abstract and less identified groups of people, and that sympathy thus developed can actually augment rational justice in health care.[42] Various forms of consciousness-raising, such as documentaries, lectures, and organizational position papers may be employed by health care leaders to help both policymakers and the general public perceive "unidentified" lives as real human beings. Enlightened politicians can point out that measures benefitting society as a whole ipso facto benefit the individual. In securing more objective decisionmaking, CEA can actually help preventive medicine by highlighting less glamorous but more just programs, thereby reducing the amount of "misordering" occurring in public health policy.[43]

The Ethical Challenge

Cost-effectiveness analysis is not a self-contained mathematical analysis that delivers an objective answer to the question: What does health cost and what is it worth? It can be manipulated or applied in an inappropriate manner. Those who utilize CEA should acknowledge its inherent value system and adapt it to a more ethical usage. If properly designed, CEA may encompass many of a democratic society's values. The applicability of CEA will be greatly enhanced if "philosophers, historians, students of intellectual thought, and others" will enter this field of inquiry that for too long has been the domain of analysts and economists.[44] References [1]Larry R. Churchill, Rationing Health Care in America (Notre Dame: University of Notre Dame Press, 1987); Henry J. Aaron and William B. Schwartz, The Painful Prescription: Rationing Hospital Care (Washington, DC: Brookings Institution, 1984). [2]Emmett B. Keeler and Shan Cretin, "Discounting of Life-Saving and Other Non-Monetary Effects," Management Science 29:3 (1983), 300-306. [3]Rashi Fein, "On Measuring Economic Benefits of Health Programs," in Ethics and Health Policy, Robert M. Veatch and Roy Branson, eds. (Cambridge, MA: Ballinger Publishing Company, 1976), 284-85. [4]Milton C. Weinstein and William B. Stason, "Foundations of Cost-Effectiveness Analysis for Health and Medical Practices," New England Journal of Medicine 296:13 (1977), 716-21. [5]Phillip Jacobs, The Economics of Health and Medical Care (Rockville, MD: Aspen Publishers, 1987), 282. [6]U.S. Congress Office of Technology Assessment, The Implications of Cost-Effectiveness Analysis of Medical Technology (Washington, DC: Government Printing Office, 1980), 4-5; Celeste K. Gaspari, "The Use and Misuse of Cost-Effectiveness Analysis," Social Science and Medicine 17:15 (1983), 1043-46. [7]Jacobs, Economics, 282; Jan Paul Acton, "Measuring the Monetary Value of Lifesaving Programs," Law and Contemporary Problems 40:4 (1976), 46-72, at 55. [8]Committee for Evaluating Medical Technologies in Clinical Use, Assessing Medical Technologies (Washington, DC: National Academy Press, 1985), 137. [9]Paul T. Menzel, Medical Costs, Moral Choice (New Haven: Yale University Press, 1983). [10]Norman Daniels, "Why Saying No to Patients in the United States Is So Hard," New England Journal of Medicine 314:21 (1986), 1380-83. [11]Menzel, Medical Costs, 54-55. [12]Alfred Soffer, "Cost-Effectiveness or Quality Care: Which Shall It Be?," Archives of Internal Medicine 145:11 (1985), 1963-64. Macro level policy almost certainly will affect decisionmaking at the level of the doctor-patient relationship. However, if such policies are openly acknowledged, the physician's fiduciary duty to the patient is less likely to be covertly betrayed. [13]Office of Technology Assessment, The Implications of Cost-Effectiveness Analysis, 39. [14]Weinstein and Stason, "Foundations." [15]Dorothy P. Rice, Thomas A. Hodgson, and Andrea N. Kopstein, "The Economic Cost of Illness: A Replication and Update," Health Care Financing Review 7:1 (1985), 61-80, 69. [16]Rice, Hodgson, and Kopstein, "Costs of Illness." [17]A. Eugene Washington, Peter S. Arno, and Marie A. Brooks, "The Economic Cost of Pelvic Inflammatory Disease," Journal of the American Medical Association 255:13 (1986), 1735-38. [18]Russell S. Phillips et al., "Should Tests for Chlamydia Trachomatis Cervical Infection Be Done During Routine Gynecologic Visits?" Annals of Internal Medicine 107:2 (1987), 188-94, at 191. [19]Gio B. Gori, Brian J. Richter, and Wai-Kouk Yu, "Economics and Extended Longevity: A Case Study," Preventive Medicine 13:4 (1984), 396-410. [20]Acton, "Lifesaving Programs," 53. [21]Arthur M. Okun, Equality and Efficiency: The Big Tradeoff (Washington, DC: The Brookings Institution, 1975); Nicholas Rescher, Distributive Justice (Indianapolis: Bobbs-Merril Company, Inc., 1966); Rashi Fein, "On Measuring Economic Benefits." [22]Robert M. Kaplan and James W. Bush, "Health-Related Quality of Life Measurement for Evaluation Research and Policy Analysis," Health Psychology 1:1 (1982), 61-80, at 66. [23]Richard Zeckhauser and Donald Shepard, "Where Now for Saving Lives?" Law and Contemporary Problems 40:4 (1976), 1-45, at 11. [24]Weinstein and Stason, "Foundations"; Zeckhauser and Shepard, "Saving Lives." [25]Rashi Fein, "But on the Other Hand: High Blood Pressure, Economics, and Equity," (Letter) New England Journal of Medicine 296:13 (1977), 751-753, at 752; Jerry Avorn, "Benefit and Cost Analysis in Geriatric Care: Turning Age Discrimination into Health Policy," New England Journal of Medicine 310:20 (1984), 1294-1301, at 1299. [26]Robert M. Veatch, "Justice and Valuing Lives," in Valuing Life: Public Policy Delimmas, Steven E. Rhoads, ed. (Boulder, CO: Westview Press, Inc., 1980), 147-60, at 154. [27]Daniel Kahneman and Amos Tversky, "The Psychology of Preferences," Scientific American 246:1 (1982), 160-173, at 166; Jack L. Knetsch and J.A. Sinden, "Willingness to Pay and Compensation Demanded: Experimental Evidence of an Unexpected Disparity in Measures of Value," The Quarterly Journal of Economics 99:3 (1984), 507-21, at 518-19. [28]Barbara J. McNeil, Ralph Weichselbaum, and Stephen G. Pauker, "Speech and Survival: Tradeoffs between Quality and Quantity of Life in Laryngeal Cancer," New England Journal of Medicine 305:17 (1981), 982-87; David L. Sackett and George W. Torrance, "The Utility of Different Utility States as Perceived by the General Public," Journal of Chronic Disease 31 (1978), 697-704. [29]Acton, "Lifesaving Programs." [30]Avorn, "Geriatric Care." [31]Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 2nd ed. (New York: Oxford University Press, 1983). [32]S. Jean Emans et al., "Adolescents' Compliance With the Use of Oral Contraceptives," Journal of American Medical Association 257:24 (1987), 3377-81. [33]Fein, "Economic Benefits." [34]Avorn, "Geriatric Care"; Rice, Hodgson, and Kopstein, "Costs of Illness." [35]Gerry Oster and Arnold M. Epstein, "Cost-Effectiveness of Antihyperlipemic Therapy in the Prevention of Coronary Heart Disease: The Case of Cholestyramine," Journal of American Medical Association 258:17 (1987), 2381-87. [36]Keeler and Cretin, "Discounting." [37]Louise B. Russell, Is Prevention Better Than Cure? (Washington, DC: The Brookings Institution, 1986), especially at 110-14. [38]J.G.U. Adams, "....And How Much for Your Grandmother?," in Valuing Life: Public Policy Dilemmas, Steven Rhoads, ed. (Boulder, CO: Westview Press (1980), 135-46, at 138. [39]Menzel, Medical Costs, Moral Choice. [40]Milton C. Weinstein, "Prevention that Pays for Itself," New England Journal of Medicine 299:6 (1978), 207-208; Rashi Fein, "Fiscal and Economic Issues," Bulletin of the New York Academy of Medicine 51:1 (1975), 235-41, at 236. [41]Eugene V. Boisaubin, "Charity, the Media, and Limited Medical Resources," Journal of American Medical Association 259:9 (1988), 1375-76. [42]Churchill, Rationing Health Care. [43]Zeckhauser and Shepard, "Saving Lives." [44]Rashi Fein, "Economic Benefits," 280.
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Author:Brookes, Barbara
Publication:The Hastings Center Report
Date:Jul 1, 1989
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