How should what economists call "Social Values" be measured?

Journal of Ethics

Volumn 3, Issue 3, 1999, Pages 249-273

  Menzel, Paul ^a  

^a PACIFIC LUTHERAN UNIVERSITY   (United States)

Author keywords

Adaptation; Cost effectiveness analysis; Health economics; Individual utility; Person trade off method; Philosophy of economics; Social value

Indexed keywords

EID: 0000045869     PISSN: 13824554     EISSN: 15728609     Source Type: Journal    
DOI: 10.1023/a:1009829301765     Document Type: Article

References (52)

1. Hereafter I shall generally use "societal" rather than "social" value, though the latter tends to be the standard term in the economics literature. "Social," unfortunately, includes a colloquial sense related to cultural and interpersonal relationships that may carry an unwitting impression short of full seriousness. Also hereafter, I shall use "community" to include simply an aggregate of persons, not only true communities.
2. The examples here are the same as those used by Peter Ubel, George Loewenstein, Dennis Scanlon, and Mark Kamlet, "Individual Utilities are Inconsistent with Rationing Choices: A Partial Explanation of Why Oregon's Cost-Effectiveness List Failed," Medical Decision Making 16 (1996), pp. 108-116.
3. Considerable portions of this section derive from Paul Menzel, Marthe Gold, Erik Nord, Jose-Luis Pinto-Prades, Jeff Richardson, and Peter Ubel, "Toward a Broader View of Values in Cost-Effectiveness Analysis of Health," Hastings Center Report 29 (1999), pp. 7-15.
4. Technically this characterizes, not CEA generally, but a subdivision called "cost utility analysis" (CUA). In CEA generally, effectiveness may be measured either in terms of particular study-specific natural units (e.g., cases of a disease averted) or in terms of a total health spectrum encompassing metric like QALYs. In our ensuing use of "CEA" we will actually be referring to CUA. Such linguistic practice is not uncommon in North America
5. it is less common in Europe. On these distinctions as well as the Healthy Year Equivalent (HYE) alternative to the QALY as a common unit of measurement, see Michael F. Drummond, Bernie O'Brien, Greg L. Stoddart, and George W. Torrance, Methods for the Economic Evaluation of Health Care Programmes, 2nd Edition (Oxford: Oxford University Press, 1997), pp. 139-143 and 176-183.
6. On another QALY alternative, the Disability Adjusted Life Year (DALY), see Christopher J.L. Murray and Arnab K. Acharya, "Understanding DALYs," Journal of Health Economics 16 (1997), pp. 703-730.
7. For a more detailed explanation of the questions discussed in this paragraph, see Drummond, O'Brien, Stoddart, and Torrance (note 4), pp. 151-156, and Marthe Gold, Donald L. Patrick, George W. Torrance et al., "Identifying and Valuing Outcomes," in Marthe Gold, Joanna Siegal, Louise B. Russell et al. (eds.), Cost-Effectiveness in Health and Medicine (New York: Oxford University Press, 1996), pp. 110-119.
8. Technically, in the sense ofclassic, cardinal utility, only SG and TTO are measures of utility. VAS gives only ordinal rankings.
9. Erik Nord, "The QALY - A Measure of Social Value Rather Than Individual Utility?" Health Economics 3 (1994), pp. 89-94.
10. Constructed from data obtained by Ubel et al., "Individual Utilities Are Inconsistent with Rationing Choices: A Partial Explanation ofWhy Oregon's Cost-Effectiveness List Failed."
11. For related findings see Erik Nord, Jeff Richardson, and K. Macarounas- Kirchmann, "Social Evaluation of Health Care Versus Personal Evaluation of Health States: Evidence on the Validity of Four Health State Scaling Instruments Using Norwegian and Australian Surveys," International Journal ofTechnology Assessment in Health Care 9 (1993), pp. 463-178
12. and Jose-Luis Pinto Prades and Angel Lopez Nicolas, "More Evidence on the Plateau Effect: A Social Perspective," Medical Decision Making 18 (1998), pp. 287-294.
13. In claiming that conventional CUA is deficient in its treatment of the value of care in the face of death, I am by no means agreeing with those who would inflate the value of life to an absolute. People are, in fact, perfectly and knowledgeably willing to trade some life saving for other health services. Yet at the same time, the value that a wide range of public opinion puts on life saving care in the face ofdeath appears to be inadequately captured by conventional economic analysis.
14. The term "health-related social welfare function" is used by Paul Dolan, "The Measurement of Individual Utility and Social Welfare," Journal of Health Economics 17 (1998), pp. 39-52.
15. This very question about potential for discrimination was at the heart of part of the controversy surrounding the plan for prioritizing health services developed by the state of Oregon
16. see Paul Menzel, "Oregon's Denial: Disabilities and Quality of Life," Hastings Center Report 22 (1992), pp. 21-25.
17. On the empirical matter of just what are our beliefs about equal or non-equal values of lifesaving to different levels of health, one study has revealed distinct preference for equivalence in the value of lifesaving to full health and the value of lifesaving to moderate chronic pain and dependence on crutches: Erik Nord, "The Relevance of Health State after Treatment in Prioritising between Different Patients," Journal ofMedical Ethics 19 (1993), pp. 37-42.
18. Another relevant study leaning in the same direction is found in Erik Nord, "Health Politicians Do Not Wish to Maximize Health Benefits," Journal of the Norwegian Medical Association 113 (1993), pp. 1171-1173.
19. Respondents were asked to compare two illnesses, both equally common and involving the same degree of suffering, whose preferred treatments were equally costly. The preferred treatment for illness A helps patients a little, and the preferred treatment for B helps a lot. Knowing that an increase in funding can cover treatment of only the patients with one of these illnesses, not both groups, choose between two different allocations: (1) Most of the increase should be allocated to treatments for illness B, since the effects are greater. (2) The increase should be divided evenly between the two groups, on the grounds that they are equally entitled to treatment. Almost half of the respondents (48%) chose the second (egalitarian) view, while 24% chose the first.
20. See additional discussion in Erik Nord, "Health Status Index Models for Use in Resource Allocation Decisions," International Journal ofTechnology Assessment in Health Care 12 (1996), pp. 31-44.
21. I am not suggesting that empirical data would reveal preference for equal lifesaving value ifone of the conditions in the comparison was so severe that many people thought it was possibly no better than death (persistent vegetative state, for example). For a philosophical, not empirical, discussion which concludes that quality of life differences are seldom relevant in trade-off lifesaving, see Frances M. Kamm, Morality, Mortality,Vol. I,Death and Whom to Save From It (Oxford University Press, 1993), pp. 255-260.
22. For discussion of the discrimination issues in particular that are at stake in such contexts, see David Hadorn, "The Problem of Discrimination in Health Care Priority Setting," Journal of the American Medical Association 268 (1992), pp. 1454-1459
23. and Philip G. Peters, Jr., "Health Care Rationing and Disability Rights," Indiana Law Journal 70 (1995), pp. 491-547.
24. Paul T. Menzel, Strong Medicine: The Ethical Rationing ofHealth Care (Oxford University Press, 1990), p. 84.
25. This figure of speech and the two visual figures that follow are modified from those used in Peter Ubel, Erik Nord, Marthe Gold, Paul Menzel, Jose-Luis Pinto-Prades, and JeffRichardson, "Improving Value Measurement in Cost-Effectiveness Analysis" (in submission).
26. Norman Daniels, "Distributive Justice and the Use of Summary Measures of Population Health Status," in Institute of Medicine Committee on Summary Measures of Population Health, Summarizing Population Health: Directions for the Development and Application ofPopulation Metrics (National Academy Press, 1998), pp. 58-71 at 66-67
27. and Norman Daniels and James Sabin, "Limits to Health Care: Fair Procedures, Democratic Deliberation, and the Legitimacy Problem for Insurers," Philosophy and Public Affairs 26 (1997), pp. 303-350 at 336-340.
28. Andrew Edgar, Sam Salek, Darren Shickle, and David Cohen, The Ethical QALY: Ethical Issues in Healthcare Resource Allocations (Haslemere, UK: Euromed Communications, 1998), at pp. 75-76, 90, and 92.
29. Most of this section is revised from portions of Menzel et al., "Toward a Broader View ofValues in Cost-Effectiveness Analysis of Health.
30. and Peter Ubel, JeffRichardson, and Paul Menzel, "Societal Value, the Person Trade-Off, and the Dilemma ofWhose Values to Measure for Cost-Effectiveness Analysis," Health Economics (forthcoming).
31. Many studies on both sides of this issue are cited by the U.S. Public Health Service Panel: Gold et al., "Identifying and Valuing Outcomes," p. 100. The Panel later recommends using general public representatives for what it calls the "reference case" of CEA, a structure that is still likely to be CUA without the incorporation ofsocietal values.
32. See Menzel et al., "Toward a Broader View ofValues in Cost-Effectiveness Analysis in Health Care," pp. 12-13.
33. The same authors have articulated the two-stage model of CEA that separates HRQoL assessments at the level of individual utility from societal value judgments in more detail in a paper written primarily for health economists: Erik Nord, Jose-Luis Pinto-Prades, JeffRichardson, Paul Menzel, and Peter Ubel, "Incorporating Societal Concerns for Fairness in Numerical Valuations ofHealth Programs," Health Economics 8 (1999), pp. 25-39.
34. A key advantage for any model that separates HRQoL from societal value judgments is avoiding the problem ofdiscrimination about lifesaving discussed in the previous section and more extensively in Ubel et al., "Improving Value Measurement in Cost-Effectiveness Analysis."
35. See, e.g., the summary of the literature on variations in quality-of-life ratings as a function of the difference in perspective between patients and non-patients by Christopher J.L. Murray, "Rethinking DALYs," in Murray and Alan D. Lopez, The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020 (World Health Organization and Harvard University Press, 1996), pp. 1-99 at p. 29.
36. For a specific study revealing that those currently in poor health rank the HRQoL of their condition higher than inexperienced respondents do, see Paul Dolan, "The Effect of Variance of Illness on Health State Valuations," Journal of Clinical Epidemiology 49 (1996), pp. 551-564.
37. Other studies in this same direction are D. G. Froberg and R. L. Kane, "Methodology for Measuring Health State Preferences," Journal of Clinical Epidemiology 42 (1989), pp. 585-592
38. R. L. Kane, R. M. Bell, and S. Z. Riegler, "Value Preferences for Nursing Home Outcomes," Gerontologist 26 (1986), pp. 303-308
39. and D. L. Sackett and G. W. Torrance, "The Utility of Different Health States as Perceived by the General Public," Journal of Chronic Diseases 31 (1978), pp. 697-704.
40. This may not constitute the strongest form of defense, the consent of those disadvantaged. For explication of that stronger response, which undoubtedly is more difficult to sustain, see Menzel, Strong Medicine.
41. Adapted from Jeff Richardson and Erik Nord, "The Importance of Perspective in the Measurement of Quality-Adjusted Life Years," Medical Decision Making 17 (1997), pp. 33-41.
42. This section is adapted from Ubel et al., "Societal Value, the Person Trade-Off, and the Dilemma of Whose Values to Measure for Cost-Effectiveness Analysis."
43. My discussion here derives from a longer paper on the adaptation issue that is currently in process: Paul Menzel, Paul Dolan, Jan Abel Olsen, and Jeff Richardson, "Adaptation to Disability and Disease and the Problem of Perspective in Health State Valuation."
44. Adaptation's potential to reduce the influence of disabled and chronically ill patients' impairments takes several possible forms. If adaptation is relatively uniform across all illnesses, the case for quality of life improvements may be given less weight generally, relative to the case for improvements in length oflife. On the other hand, ifthose suffering from some conditions adapt much more than others, the former may lose out to the latter as well as to other patients who stand to gain life extension. In either case, we may be attracted to erasing adaptation's indirect influence on priority setting by eliciting HRQoL ratings not from patients but from a representative sample of the general public.
45. Dan W. Brock, "Justice and the ADA: Does Prioritizing and Rationing Health Care Discriminate Against the Disabled?" Social Philosophy and Policy 12 (1995), pp. 159-185, at 182-184.
46. At this point this is a prima facie judgment. Other arguments, such as the one that follows, create the possibility that the evaluative privilege should be neutralized or even reversed.
47. The fuller range of these arguments is pursued in Menzel et al., "Adaptation to Disability and Disease and the Problem of Perspective in Health State Valuation."
48. Murray, "Rethinking DALYs," p. 31.
49. Alexis de Tocqueville, Democracy in America (New York: Anchor Books, originally 1839). The "happy slave" phenomenon is ripe with still more ironies. Edmund Morgan, in a review of Philip Morgan on 18th century slavery in the Chesapeake region of the US, notes that "where slavery was more oppressive, as in South Carolina [not the Chesapeake], slave culture was stronger, more African, more autonomous" and the slaves ironically perhaps happier. The reviewer elaborates further: Moreover, "as [Philip] Morgan points out, while the formation of their own culture was in itself 'the most significant act of resistance' by slaves, yet 'by creating an autonomous culture, slaves also eased the torments of slavery, and, in that respect, their cultural creativity created accommodation.' Autonomy could thus help to perpetuate the torments of subjection." [See Edmund S. Morgan, "The Big American Crime" (review of five books on US slavery, including Philip D. Morgan), New York Review ofBooks, December 3, 1998, pp. 14-18
50. and Philip D. Morgan, Slave Counterpoint: Black Culture in the Eighteenth-Century Chesapeake and Lowcountry (Chapel Hill: University of North Carolina Press, 1998).]
51. This is somewhat different than the argument that Amartya Sen makes in Inequality Reexamined (Cambridge: Harvard University Press, 1992), at pp. 6-7, 54-55, and 149-150, which he terms the objectionable fact of"deprivation and reduced aspirations." Sen sees this problem as plaguing both utilitarianism and any social philosophy that focused on equality of welfare. My discussion here is only of the more specific "happy slave" phenomenon, not Sen's more general "deprivation" objection.
52. At least not very culpable - in any case, not remotely as culpable as those who enslave others are for the active and overt step ofenslavement.