A more recent version of these Claxton And Cuyler Wickedness Or Folly notes – written by Oxford students – is available here.
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Claxton and Cuyler - Wickedness or Folly?
Affordable of cost effective?
We are not clear that describing a drug as one "we simply cannot afford" is really different or more acceptable than saying it is "not cost effective" o it seems to us natural to suppose that "unaffordable" means no more than that the costs exceed the benefits---that is, we choose to buy something else instead of the thing in question.
? In the context of NICE and the NHS, this means that the estimated health benefits that could be gained from the technology are less than those estimated to be forgone by other patients,
as other procedures are necessarily curtailed or not undertaken*
It has nothing specifically to do with QALYs.
It would remain unavoidable even if the currency of advantage offered by health care were expressed in terms of providing opportunities to benefit, as suggested by Harris, o or any other measure of the good done by health care Patients with Alzheimer's disease are (probably) not cost effective to treat with these drugs, because other patients would (probably) get greater benefits from the use of the resources spent by the NHS to acquire the drugs to treat Alzheimer's disease. ( o To put it in a brutal fashion after Harris's style, "the drugs are not worth it", not "the patients are not worth it". The worth of the patients is not in question.
? To describe a procedure as not sufficiently worthwhile is not synonymous with the statement that these patients are "not worth helping"; it is simply the inexorable consequence of the principle of using resources in the most effective known ways to promote people's health.
Nor is this the same as saying "the amount of better life expectancy they provide to these patients is not worth having for society"; o rather, it is saying that all patients are to be counted as members of the society that NICE seeks to serve
? But serving the whole of society requires NICE to take account of the alternative uses to which resources, including drug budgets, can be put.
To use a budget to extract the last ounce of benefit for one patient group no matter what benefits were thereby denied to other patients being served by the same budget o can hardly be considered to serve the needs of the whole of society.
So, Harris may retort, "increase the drugs budget", to which the further retort is, of course, "at the expense of what other health benefit for which other patients?" o The retort to this may be, "increase the NHS budget". Again, "at the expense of what other benefit to what other group in society?"
Evaluating procedures, not patients
At various points throughout both editorials, Harris attaches moral significance to a distinction
between evaluating treatments and evaluating patients. o Such a distinction indeed exists and, as we have indicated earlier, the methods of costeffectiveness analysis do not evaluate patients but rather they evaluate treatments o Now, it goes without saying that all healthcare procedures exist for the care of patients with particular indications and characteristics. It is trivial to point out that one drug may be safe and effective for one group of patients but either completely ineffective or positively dangerous for another
? Procedures can be evaluated only when they are used for particular patients. So, inevitably, we compare the worth of alternative procedures in terms of the consequences their use has for patients.
Patient welfare is the ultimate purpose of it all. But this is not the same as evaluating the worth of patients. o At most it can be said to be evaluating their capacity to benefit from the use of the procedures
? and---one of the ultimately difficult tasks---evaluating one group's ability to benefit compared with that of another Harris contradicts himself in simultaneously holding that NICE should not evaluate pateints
and then suggesting that health care ought to be allocated such that all have equal opportunities of benefiting.
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