In this article, we describe the ethical framework implied by CEA, utilitarianism, as applied to global health. By representing human life in dollar terms and choosing among life-saving interventions based on mathematically-derived return-on-investment metrics, they undermine the expression of communitarian values, and often appear to conflict with a range of ethical principles including equity, urgent need, and human rights as enshrined in international law. Indeed, CEAs are perceived by some as ethically suspect because they rest on a conceptual foundation that violates everyday moral intuitions. Yet assessments of efficiency in the form of cost-effectiveness (CEA) or cost-benefit analysis (CBA) are regarded with a mixture of enthusiasm and suspicion: enthusiasm, because, all else equal, program managers and policy makers seek to maximize the benefit from limited dollars and suspicion, because all else is rarely equal, when other considerations are included such as fairness and reduction in disparities. 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.Įconomic efficiency is a leading criterion for resource allocation decisions for global (or public) health. 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. Other ethical frames may be irrelevant, incompatible with each other, or have unacceptable implications. This is primarily because efficiency – the maximization of health benefits under a budget constraint – is itself an important ethical value. We find that while fallible, utilitarianism is usually superior to the alternatives. We describe the utilitarian foundations of cost-effectiveness analysis and compare it with alternative ethical principles. 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.
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