Economic evaluation and society's health values

Editor—I admire Coast's bravery in writing a penetrating review of health economics.¹ I wonder if the problems go even deeper than she has acknowledged.

Firstly, I do not think that society is in tune with what its health values are.²,³ Even if society is in touch with these values any individual within it changes his or her values immediately he or she becomes a patient.⁴ It is not clear what the decision making axes should be in medicine, but there are at least four interested parties—namely, doctors, patients, society, and paymasters (government and management).

Medical practice is fundamentally deontological, with each doctor committed to do the best for each individual patient. The values of this interaction are mostly oblivious to the wider utilitarian need to use system resources efficiently.

Management is necessarily utilitarian as it has finite resources and has to try to show that it is using them well. The attempt to constrain medical practice within these utilitarian boundaries leads to the production of plans and guidelines, but events at the individual doctor-patient level are irretrievably messy and soon produce exceptions to any rules.

Perhaps the real absurdity is that both health economics and evidence based medicine are ultimately trying to find technical answers (seen as being accurate, numerical, objective, value free) to what are really ethical questions about the values behind our choices.⁴

The question that British doctors and patients are asking of NHS management, politicians, and the wider society is this: is society willing to fund treatment free at the point of need? If it is then it is accepting a huge financial burden. If it is not then we should stop pretending that the NHS can give everything to everybody.⁵

Perhaps the main contribution of health economists is that they bring this question into clear focus.