Table 3.

Elements of two competing paradigms.

Attribute	Extra-Welfarism	Communitarianism
Analytical Focus	Maximisation	Optimisation
Perspective on value	Consumer perspective (selfish ‘use value’)	Citizen’s or social perspective (including risk aversion, caring, externalities and sharing)
Perspective on cost	Individual (patient)	Citizen (tax payer)
Social objective	Maximum ‘health’ defined by QALYs, ie utility weighted life years	Fair sharing: criteria based upon social preferences: reflecting equity and/or rights
Evaluation method	CUA CBA CEA	Social Cost Value Analysis
Criterion for funding	Cost/QALY < threshold,	Presumed entitlement
Funding formula	If criterion met, then services generally funding	Level of treatment varies with attributes such as rights/equity, cost effectiveness
Exclusions from care	Yes: Cost/QALY >Threshold	Few (except for extreme cases, usually milk and self-limiting health problems)
Caveat	Ad hoc adjustment for (to date) undefined ‘equity’	Systematic adjustment, with budgetary impact and/or cost effectiveness per citizen
Role of cost	Pivotal: maximum benefit ← min cost/QALY	Secondary: alters the intensity of care
Ethical basis	Preference Utilitarianism	Communitarianism: satisfaction of social preferences