Many clinicians believe that allowing costs to influence clinical decisions is unethical. They are mistaken in this belief, because it cannot be ethical to ignore the adverse consequences upon others of the decisions you make, which is what 'costs' represent. There are, however, some important ethical issues in deciding what costs to count, and how to count them. But these dilemmas are equally strong with respect to what benefits to count and how to count them, some of which expose ethically (...) untenable assumptions about such widely-used clinical criteria as survival rates. One of the advantages of systematic cost-effectiveness analysis is that it exposes these hidden assumptions, and requires explicit judgements to be made about which ethical position is appropriate in a particular policy context. This should have the important incidental benefit of improving the accountability of policy-makers to the community they are serving. (shrink)

Cost-benefit analysis (CBA) evaluates actions in terms of negative consequences (costs) and positive consequences (benefits). Though much has been said on CBA, little attention has been paid to the types of values held by costs and benefits. This paper introduces a simple typology of values in CBA and applies it to three forms of CBA: the common, money-based CBA, CBA based in social welfare, and CBA based in intrinsic value. The latter extends CBA beyond its usual anthropocentric domain. Adequate (...) handling of value typology in CBA avoids analytical mistakes and connects CBA to its consequentialist roots. (shrink)

Cost–benefit analysis (CBA) is much more philosophically interesting than has in general been recognized. Since it is the only well-developed form of applied consequentialism, it is a testing-ground for consequentialism and for the counterfactual analysis that it requires. Ten classes of philosophical problems that affect the practical performance of cost–benefit analysis are investigated: topic selection, dependence on the decision perspective, dangers of super synopticism and undue centralization, prediction problems, the indeterminateness of our control over future decisions, the (...) need to exclude certain consequences for moral reasons, bias in the delimitation of consequences, incommensurability of consequences, difficulties in defending the essential requirement of transferability across contexts, and the normatively questionable but equally essential assumption of interpersonal compensability. (Published Online July 31 2007). (shrink)

Science-based methods for assessing the practical rationality of a proposed public policy typically represent assumed future outcomes of policies and values attributed to these outcomes in an idealized, that is, intentionally distorted way and abstracted from aspects that are deemed irrelevant. Different types of methods do so in different ways. As a consequence, they instantiate the properties that result from abstraction and idealization such as conceptual simplicity versus complexity, or comprehensiveness versus selectivity of the values under consideration to different degrees. (...) I hold that none of these methods is best in general. Instead, I opt for the valuation method that is useful for the policy issue in question both in terms of its relevance and in terms of its practicability. Relevance requires that the method can represent and account for what is at stake in the policy issue. Practicability refers to aspects such as easy versus difficult handling of the method. To argue for the claim, I evaluate three types of valuation methods: cost–benefit analysis that rests on unidimensional measurement and ranking, multi-criteria decision analysis that applies multi-dimensional measurement but unidimensional ranking, and non-aggregate indicator systems that operate with multi-dimensional measurement and sometimes also multi-dimensional ranking. Second-order justification indicating whether and how the valuation method chosen is capable of accounting for the substantive value considerations that constitute the real-world policy issue in question renders the conditions on which the results of a proposed policy evaluation rest transparent. (shrink)

How do economists persuade their readers that one policy is superior to another? A glance at the literature on welfare economics quickly provides the answer to this question: Economists enter policy debates armed with mathematical models, evaluating options on the basis of their consequences. Economists typically classify a policy change as a welfare improvement with respect to the status quo if the gain realized by the winners exceeds the harm sustained by the losers. The best policy becomes the one that (...) generates the highest net benefit. (shrink)

The social rate of discount--that is, the way decision makers today evaluate future consequences of collective activity--raises difficult issues of intergenerational justice. When benefits are discounted at the present rate the United States government requires, serious efforts to promote public health over the long term will fail cost-benefit tests. No consensus exists among theorists to establish fair rates; philosophers support discounting with economic arguments that economists reject, while economists no less paradoxically support the concept using philosophical arguments that philosophers disavow. (...) A new emphasis on the role of consumers' and citizens' time preferences, however, will keep open rather than close debates on the social discount rate. (shrink)

Emerging technologies are, by definition, full of surprises: developments that we cannot fully anticipate and that might have some bad outcomes as well as good ones. This presents a challenge for anyone trying to make forward‐looking policy decisions, including those who apply benefit‐cost analysis. BCA is now widely known and used, but it is also widely misunderstood—by many of its advocates as well as its detractors. In this essay, I will begin by examining some of the strengths and weaknesses (...) of BCA as a normative science. Yes, “normative science” is an oxymoron, and the incongruity it speaks to is a source of much of the controversy; BCA is an imperfect answer, but often the best available answer, to the question of how a society should go about making collective but not unanimous choices.I also want to take a hard look at the question of what we are evaluating. BCA is designed to weigh government actions, to see whether they are in the public interest; it is not designed to evaluate private actions. But if the government action is to approve a private action that otherwise would be prohibited, then the BCA inevitably must evaluate the latter. From the perspective of a government regulator, it is very tempting to shift the burden of proof onto private innovators—to obligate them to seek permission to proceed, and to demonstrate that their proposed actions have acceptable risks and will produce a net social benefit. But such burden‐shifting is not merely an administrative convenience; it has serious economic consequences that need to be examined. (shrink)

Benefit/cost analysis is a technique for evaluating programs, procedures, and actions; it is not a moral theory. There is significant controversy over the moral justification of benefit/cost analysis. When a procedure for evaluating social policy is challenged on moral grounds, defenders frequently seek a justification by construing the procedure as the practical embodiment of a correct moral theory. This has the apparent advantage of avoiding difficult empirical questions concerning such matters as the consequences of using the procedure. So, (...) for example, defenders of benefit/cost analysis (BCA) are frequently tempted to argue that this procedurejust isthe calculation of moral Tightness – perhaps that what itmeansfor an action to be morally right is just for it to have the best benefit-to-cost ratio given the accounts of “benefit” and “cost” that BCA employs. They suggest, in defense of BCA, that they have found the moral calculus – Bentham's “unabashed arithmetic of morals.” To defend BCA in this manner is to commit oneself to one member of a family of moral theories (let us call thembenefit/cost moral theoriesorB/C moral theories) and, also, to the view that if a procedure is (so to speak) the direct implementation of a correct moral theory, then it is a justified procedure. Neither of these commitments is desirable, and so the temptation to justify BCA by direct appeal to a B/C moral theory should be resisted; it constitutes an unwarranted short cut to moral foundations – in this case, an unsound foundation. Critics of BCA are quick to point out the flaws of B/C moral theories, and to conclude that these undermine the justification of BCA. But the failure to justify BCA by a direct appeal to B/C moral theory does not show that the technique is unjustified. There is hope for BCA, even if it does not lie with B/C moral theory. (shrink)

This paper discusses the practice of cost-benefit analyses of transportation infrastructure investment projects from the meta-theoretical perspective of critical realism. Such analyses are based on a number of untenable ontological assumptions about social value, human nature and the natural environment. In addition, main input data are based on transport modelling analyses based on a misleading `local ontology' among the model makers. The ontological misconceptions translate into erroneous epistemological assumptions about the possibility of precise predictions and the validity of willingness-to-pay investigations. (...) Accepting the ontological and epistemological assumptions of cost-benefit analysis involves an implicit acceptance of the ethical and political values favoured by these assumptions. Cost-benefit analyses of transportation investment projects tend to neglect long-term environmental consequences and needs among population groups with a low ability to pay. Instead of cost-benefit analyses, impact analyses evaluating the likely effects of project alternatives against a wide range of societal goals is recommended, with quantification and economic valorisation only for impact categories where this can be done in an ontologically and epistemologically defensible way. (shrink)

Human Towers are one of the most representative traditional sporting games in Catalonia, recognized in 2010 as Intangible Cultural Heritage by the United Nations Organization for Education, Science and Culture. The objective of this research was to study the emotional states elicited by a representative performance of the colla de Castellers de Lleida. This research is based on an ethnographic case study, with mixed methods in which 17 key informants voluntarily participated. Participant observation was used; the data were recorded in (...) a field diary and oral sources. The content analysis was done using the Atlas.ti software. An SPSS database was also created. The statistical techniques were: Descriptive statistical techniques, cross tables with Pearson's Chi-square values. We also used a classification and regression trees to examine the predictive capacity of five independent variables of emotional states. The results reveal that the comments were mostly oriented toward well-being states, The internal cooperative logic of the Human Towers enhances the intense interpersonal relationships of socio-emotional well-being. (shrink)

This paper discusses the practice of cost-benefit analyses of transportation infrastructure investment projects from the meta-theoretical perspective of critical realism. Such analyses are based on a number of untenable ontological assumptions about social value, human nature and the natural environment. In addition, main input data are based on transport modelling analyses based on a misleading `local ontology' among the model makers. The ontological misconceptions translate into erroneous epistemological assumptions about the possibility of precise predictions and the validity of willingness-to-pay investigations. (...) Accepting the ontological and epistemological assumptions of cost-benefit analysis involves an implicit acceptance of the ethical and political values favoured by these assumptions. Cost-benefit analyses of transportation investment projects tend to neglect long-term environmental consequences and needs among population groups with a low ability to pay. Instead of cost-benefit analyses, impact analyses evaluating the likely effects of project alternatives against a wide range of societal goals is recommended, with quantification and economic valorisation only for impact categories where this can be done in an ontologically and epistemologically defensible way. (shrink)

By their nature, the most vexing social problems reflect collisions between social and economic interests of parties with highly divergent views and perspectives on the cause and character of what is at issue and the consequences that flow from it. Conflicts around biotechnology applications are good examples of these problems. When considering the potential consequences of proposed biotechnology applications, an enormous range of perspectives arise reflecting the breadth of different and often competing interests with a stake in life's future.This essay (...) starts from an assumption that the traditional tool of cost‐benefit analysis is not adequate for adjudicating competing claims around the introduction of new biotechnology applications. It tends to require implicit simplifying assumptions that reduce or mask true underlying levels of complexity and uncertainty, and the results it produces deliver a definitive and singular answer, as opposed to a multiplicity of outcomes. In this essay, I describe some of the key elements of formal scenario planning to show how CBA could be redeployed as a supporting tool within the broader decision support methodology of formal scenario planning. (shrink)

Civil disobedience, despite its illegal nature, can sometimes be justified vis-à-vis the duty to obey the law, and, arguably, is thereby not liable to legal punishment. However, adhering to the demands of justice and refraining from punishing justified civil disobedience may lead to a highly problematic theoretical consequence: the debilitation of civil disobedience. This is because, according to the novel analysis I propose, civil disobedience primarily functions as a costly social signal. It is effective by being reliable, reliable by (...) being costly, and costly primarily by being punished. My analysis will highlight a distinctive feature of civil disobedience: civil disobedients leverage the punitive injustice they suffer to amplify their communicative force. This will lead to two paradoxical implications. First, the instability of the moral status of both civil disobedience and its punishment to the extent where the state may be left with no permissible course of action with regard to punishing civil disobedience. Second, by refraining from punishing justified civil disobedience, the state may render uncivil disobedience—illegal political activities that fall short of the standards of civil disobedience—potentially permissible. (shrink)

Along with political, economic, ethical, rehabilitative and military dimensions, psychopathological sequelae of war and terrorism also deserve our attention. The terrorist attack on the World Trade Centre ( W.T.C.) in 2001 and the Gulf War of 1990-91 gave rise to a number of psychiatric disturbances in the population, both adult and children, mainly in the form of Post-traumatic Stress disorder (PTSD). Nearly 75,000 people suffered psychological problems in South Manhattan alone due to that one terrorist attack on the WTC in (...) New York and the Pentagon in Washington. In Gulf War I, more that 1,00,000 US veterans reported a number of health problems on returning from war, whose claims the concerned government has denied in more than 90% cases. Extensive and comprehensive neurological damage to the brain of Gulf War I veterans has been reported by one study, as has damage to the basal ganglia in another, and Amyotrophic Lateral Sclerosis (ALS) in a third, possibly due to genetic mutations induced by exposure to biological and chemical agents, fumes from burning oil wells, landfills, mustard or other nerve gases. The recent Gulf War will no doubt give rise its own crop of PTSD and related disorders. In a cost-benefit analysis of the post Gulf War II scenario, the psychopathological effects of war and terrorism should become part of the social audit any civilized society engages in. Enlightened public opinion must become aware of the wider ramifications of war and terrorism so that appropriate action plans can be worked out. (shrink)

Cancer is a major burden on populations and health systems internationally. The development of innovative cancer medicines is seen as a significant part of the solution. These new cancer medicines are, however, expensive, leading to limited or delayed access and disagreements among stakeholders about which medicines to fund. There is no obvious resolution to these disagreements, with stakeholders holding firmly to divergent positions. Access to cancer medicines was recently explored in Australia in a Senate Inquiry into the Availability of New, (...) Innovative, and Specialist Cancer Drugs in Australia. We analysed the resultant Senate Report to identify competing stakeholder values. Our analysis illustrates that there are four main “goods” prioritized by different stakeholders: 1) innovation, 2) compassion, 3) equity, and 4) sustainability. We observe that, with the exception of sustainability, all of these “goods” put pressure on payers to provide access to cancer medicines more quickly and based on less rigorous evaluation processes. We then explore the consequences of giving in to such pressure and suggest that deconstructing the implicit values in calls for “enhanced access” to cancer medicines is necessary so that more nuanced solutions to the challenge of providing access to these high cost medicines can be found. (shrink)

INCONTINENCE, HONOURING SUNK COSTS AND RATIONALITY According to a basic principle of rationality, the decision to engage in a course of action should be determined solely by the analysis of its consequences. Thus, considerations associated with previous use of resources should have no bearing on an agent’s decision-making process. Frequently, however, agents persist carrying on an activity they themselves judge to be nonoptimal under the circumstances because they have already allocated resources to that activity. When this is the case, (...) agents are said to be honouring sunk costs. Honouring sunk costs is thus typically viewed as irrational economic behaviour. Two striking findings of the psychological literature on the sunk cost effect are that it is, in general, not lessened by having taken previously courses in economics, and that agents who did take such courses and that do honour sunk costs seem to be frequently aware of a cognitive dissonance in their behaviour. Davidson’s account of the possibility conditions of incontinent action renders continent action materially unfeasible. The very idea of incontinent action becomes thus a hollow one. I’ll present an alternative description of these possibility conditions that renders continent action materially feasible, and both, continent and incontinent action, cognitively plausible. In a nutshell, my proposal rests upon the drawing of an essential cognitive contrast between explicit processes of deliberative reasoning and lower level heuristic procedures. I conclude the paper arguing that my redescription of incontinent action accounts for the above mentioned cognitive dissonance effect better than the alternatives and that viewing at least an important subset of behaviours of honouring sunk costs as incontinent actions will enable us to consider them as peculiar manifestations of a more general and meaningful pattern in human behaviour. (shrink)

Recently, a number of philosophers have argued that we can and should “consequentialize” non-consequentialist moral theories, putting them into a consequentialist framework. I argue that these philosophers, usually treated as a group, in fact offer three separate arguments, two of which are incompatible. I show that none represent significant threats to a committed non-consequentialist, and that the literature has suffered due to a failure to distinguish these arguments. I conclude by showing that the failure of the consequentializers’ arguments has implications (...) for disciplines, such as economics, logic, decision theory, and linguistics, which sometimes use a consequentialist structure to represent non-consequentialist ethical theories. (shrink)

David Braybrooke makes two criticisms of my theory of social power, one that deals with the time of power and one that concerns the relation between power and cost. In his first criticism he points out that, according to my analysis, Richard Nixon had the power, in 1940, to nominate Burger for Chief Justice in 1970, and a certain twelve-year old boy may today have the power to hit the first home run of the 1990 season. Braybrooke finds these (...) consequences of the theory unacceptable. These agents may have the ability to acquire the indicated powers at these times, he argues, but they do not (yet) have these powers. (shrink)

One way to do socially relevant investigations of science is through conceptual analysis of scientific terms used in special-interest science (SIS). SIS is science having welfare-related consequences and funded by special interests, e.g., tobacco companies, in order to establish predetermined conclusions. For instance, because the chemical industry seeks deregulation of toxic emissions and avoiding costly cleanups, it funds SIS that supports the concept of "hormesis" (according to which low doses of toxins/carcinogens have beneficial effects). Analyzing the hormesis concept of (...) its main defender, chemical-industry-funded Edward Calabrese, the paper shows Calabrese and others fail to distinguish three different hormesis concepts, H, HG, and HD. H requires toxin-induced, short-term beneficial effects for only one biological endpoint, while HG requires toxin-induced, net-beneficial effects for all endpoints/responses/subjects/ages/conditions. HD requires using the risk-assessment/regulatory default rule that all low-dose toxic exposures are net-beneficial, thus allowable. Clarifying these concepts, the paper argues for five main claims. (1) Claims positing H are trivially true but irrelevant to regulations. (2) Claims positing HG are relevant to regulation but scientifically false. (3) Claims positing HD are relevant to regulation but ethically/scientifically questionable. (4) Although no hormesis concept (H, HG, or HD) has both scientific validity and regulatory relevance, Calabrese and others obscure this fact through repeated equivocation, begging the question, and data-tri mm ing. Consequently (5) their errors provide some undeserved rhetorical plausibility for deregulating low-dose toxins. (shrink)

This work is concerned with hierarchical modular descriptions, their algorithmic production, and their importance for certain types of scientific explanations of the structure and dynamical behavior of complex systems. Networks are taken into consideration as paradigmatic representations of complex systems. It turns out that algorithmic detection of hierarchical modularity in networks is a task plagued in certain cases by theoretical intractability and in most cases by the still high computational complexity of most approximated methods. A new notion, antimodularity, is then (...) proposed, which consists in the impossibility to algorithmically obtain a modular description fitting the explanatory purposes of the observer for reasons tied to the computational cost of typical algorithmic methods of modularity detection, in relation to the excessive size of the system under assessment and to the required precision. It turns out that occurrence of antimodularity hinders both mechanistic and functional explanation, by damaging their intelligibility. Another newly proposed more general notion, explanatory emergence, subsumes antimodularity under any case in which a system resists intelligible explanations because of the excessive computational cost of algorithmic methods required to obtain the relevant explanatory descriptions from the raw data. The possible consequences, and the likelihood, of incurring in antimodularity or explanatory emergence in the actual scientific practice are finally assessed, concluding that this eventuality is possible, at least in disciplines which are based on the algorithmic analysis of big data. The present work aims to be an example of how certain notions of theoretical computer science can be fruitfully imported into philosophy of science. (shrink)

Cost-benefit analysis is a widely used governmental evaluation tool, though academics remain skeptical. This volume gathers prominent contributors from law, economics, and philosophy for discussion of cost-benefit analysis, specifically its moral foundations, applications and limitations. This new scholarly debate includes not only economists, but also contributors from philosophy, cognitive psychology, legal studies, and public policy who can further illuminate the justification and moral implications of this method and specify alternative measures. These articles originally appeared in the Journal of (...) Legal Studies. Contributors: - Matthew D. Adler - Gary S. Becker - John Broome - Robert H. Frank - Robert W. Hahn - Lewis A. Kornhauser - Martha C. Nussbaum - Eric A. Posner - Richard A. Posner - Henry S. Richardson - Amartya Sen - Cass R. Sunstein - W. Kip Viscusi. (shrink)

A recurring question about cost - benefit analysis concerns its scope. CBA is a decision-making method frequently employed in environmental policy-making, in which things which have no market price are treated as if they were commodities. They are given a monetary value, a form of price. But it is widely held that some things cannot be meaningfully priced, thus substantially limiting the scope of CBA. The aim of this paper is to test some aspects of this broad claim, focusing (...) on problems of incomparability and incommensurability. In particular, the role of rough equality as a putative form of comparison is investigated. I argue that while an assessment of the full significance of rough equality for practical decision-making awaits resolution of a number of important technical questions, it does not provide a strong enough form of comparison to support CBA. (shrink)

Cost-effectiveness analysis (CEA) is an analytical tool in health economics. One of the most important objections to it is that its use can lead to unjust discrimination against people with disabilities. This chapter evaluates this objection. It begins by clarifying its nature, then it examines some alleged forms of discrimination. It argues that they are either not cases of unjust discrimination, or they are based on misunderstandings of CEA. However, the chapter does point out that there is one case (...) in which the use of CEA may disadvantage people with disabilities. It goes on to consider several proposals for explaining the wrongness of discrimination but argues that none of them accommodates this case. It concludes that the case should not be thought as a matter of unjust discrimination; rather, it should be thought of as raising an issue for justice in the allocation of health-care resources. (shrink)

During the “age of austerity” the UK government has progressively limited free health services for “overseas visitors” on the grounds of fairness and frugality. This is despite the fact that the cost of the additional bureaucracy required by the new system and the public health consequences are expected to exceed the sums saved. In this article I explore the interaction between the discourses of austerity and xenophobia as they relate to migrants’ access to healthcare. By examining the available data and (...) adjudicating various moral arguments, I cast doubt on the claim that the current charging regulations are cost-effective and fair. I instead contend that if the UK is concerned with running a health service that is economically-sustainable and morally-defensible, it is critical that migrants are welcomed, both as staff and as patients. I conclude by arguing that xenophobia has precipitated changes to the health service which do not qualify as “austerity” in the way that is claimed, but rather deliberately produce a “hostile environment” for migrants, despite this very likely generating economic losses. (shrink)

Studies demonstrating the benefits of ethical behavior at an individual level are scarce. The business ethics literature centers its analysis on unethical behaviors and their consequences, rather than ethical behaviors and their benefits. There is now considerable debate on the role of auditors in society and the function of accounting firms in the free market capitalist system. Specifically, the eminently ethical nature of the auditor’s work has been highlighted. Therefore, the aim of our paper is to show the impact (...) of auditors’ sustained ethical behavior: the trust it generates. This trust results in considerable benefits for the firm due to a reduction in the costs of the partner’s supervision of the auditor. The methodology chosen to validate these claims is a survey of partner of the audit firm in auditing companies. The results of this research confirm the hypotheses raised in the theoretical model. (shrink)

This book is a comprehensive account of what it means to try to quantify health in distributing resources for health care. It examines the concept of QALYs which supposedly makes it more accurate to talk about life in terms of both quality and quantity of years lived when referring to health care policy. It offers an elegant new approach to comparing the costs and benefits of medical interventions. Cost-Utility Analysis is a method designed by economists to aid decision makers (...) distribute scarce resources to areas of health care where they will yield the greatest benefits. Erik Nord questions the feasibility of measuring patients' quality of life meaningfully in numerical terms, as CUA presupposes. He presents an alternative approach called cost-value analysis in which representative samples of the general public express preferences between different health-care programs. In this approach, subjects are allowed to include concerns for fairness that go beyond concerns for efficiency of conventional health economics. (shrink)

According to the Consequence Argument, the truth of determinism plus other plausible principles would yield the conclusion that we have no free will. In this paper I will argue that the conception of determinism typically employed in the various versions of the Consequence Argument is not plausible. In particular, I will argue that, taken most straightforwardly, determinism as defined in the Consequence Argument would imply that the existence of God is logically impossible. This is quite an implausible result. The truth (...) or falsity of determinism is typically taken to be a contingent, empirical matter. But how could the empirical discovery that determinism is true lead to the conclusion that God’s existence is a logical impossibility? The defender of the Consequence Argument can avoid this conclusion, but only at the cost of making other similarly implausible claims. The objection.. (shrink)

Cost-benefit analysis is commonly understood to be intimately connected with utilitarianism and incompatible with other moral theories, particularly those that focus on deontological concepts such as rights. We reject this claim and argue that cost-benefit analysis can take moral rights as well as other non-utilitarian moral considerations into account in a systematic manner. We discuss three ways of doing this, and claim that two of them (output filters and input filters) can account for a wide range of rights-based (...) moral theories, including the absolute notions of moral rights proposed by Hayek, Mayo, Nozick, and Shue. We also discuss whether the use of output filters and input filters can be generalized to cover other non-utilitarian theories, such as Kantian duty ethics and virtue ethics. (shrink)

This article considers some different views of fairness and whether they conflict with the use of a version of Cost Effectiveness Analysis (CEA) that calls for maximizing health benefits per dollar spent. Among the concerns addressed are whether this version of CEA ignores the concerns of the worst off and inappropriately aggregates small benefits to many people. I critically examine the views of Daniel Hausman and Peter Singer who defend this version of CEA and Eric Nord among others who (...) criticize it. I come to focus in particular on the use of CEA in allocating scarce resources to the disabled. (shrink)

This book is a comprehensive account of what it means to try to quantify health in distributing resources for health care. It examines the concept of QALYs which supposedly makes it more accurate to talk about life in terms of both quality and quantity of years lived when referring to health care policy. It offers an elegant new approach to comparing the costs and benefits of medical interventions. Cost-Utility Analysis is a method designed by economists to aid decision makers (...) distribute scarce resources to areas of health care where they will yield the greatest benefits. Erik Nord questions the feasibility of measuring patients' quality of life meaningfully in numerical terms, as CUA presupposes. He presents an alternative approach called cost-value analysis in which representative samples of the general public express preferences between different health-care programs. In this approach, subjects are allowed to include concerns for fairness that go beyond concerns for efficiency of conventional health economics. (shrink)

Insurance coverage of abortion varies widely across the United States and is an extensively debated issue. Medicaid coverage of abortion is particularly relevant because the majority of abortion patients are poor or low‐income and are thus often covered by Medicaid. Since the Hyde Amendment was first passed in 1976, federal Medicaid funds have been banned from covering the costs of elective abortion. Although states are allowed to use their own funds to cover abortions for their Medicaid recipients, only 17 states (...) currently do so. Of these 17 states, only five cover abortion costs voluntarily; the others do so pursuant to court order. The medical literature includes few ethical analyses of the Hyde Amendment’s ban on Medicaid funding of elective abortions. To fill this gap, we perform an ethical analysis of federal policy to fund elective abortions using a consequentialist approach focused on consequences for pregnant women and their children. (shrink)

Cost‐effectiveness analysis (CEA) raises questions that are too important to be left to policy analysts and economists. Those who utilize CEA should acknowledge its inherent value system and adapt it to a more ethical usage.

Should India build a new steel mill, or London an urban motorway? Should higher education expand, or water supplies be improved? These are typical questions about which cost-benefit analysis has something to say. It is the main tool that economics provides for analysing problems of social choice. It also provides a useful vehicle for understanding the practical value of welfare economics. This new book of readings covers all the main problems that arise in a typical cost-benefit exercise. It is (...) entirely up-to-date, reflecting the most recent research in the area. Part I covers the main theoretical issues affecting cost-benefit analysis. Part II considers the problem of ascribing a monetary value to things. The third part covers six separate case studies drawn from real-life examples. The book begins with an extended elementary introduction written by the editors. (shrink)

The issue of assessing priorities is one that has become the subject of much debate in the National Health Service particularly in the wake of various documents on priorities from central Government. It has become even more so with the prospect of real cuts in expenditure. Economists claim that their science, or perhaps more accurately art can assist in determining not only how best to achieve various ends but also whether and to what extent competing objectives should be pursued. Such (...) choices cannot be made in the absence of some ethical considerations and it is important that health service decision makers (and in particular the medical profession) are aware if the relationship between economics (and especially cost-benefit analysis) and medical ethics. (shrink)

One argument against using cost-benefit analysis to justify policies aimed at promoting human life and health or protecting the environment is that it requires putting a price on priceless goods. This distorts the value of these goods, and it can affect their value by cheapening them. This argument might be rejected by a moral consequentialist who believes that a rational agent should always be able to reflect on his values, even priceless goods, and assess their costs and their importance. (...) This article defends the argument against cost-benefit analysis and suggests that a proper understanding of priceless goods shows that they also raise difficulties for consequentialist moral theories. (shrink)

The paper outlines various concepts of rationality, their characteristics and consequences. In the first, most general part, the metaphysical, instrumental and discursive rationality is distinguished. The following part focuses on instrumental rationality and the rational choice theory and ordinal and cardinal utility, expected utility and game theory, respectively. All those concepts are summarised as being the most mathematically elegant and mostly decidable and helpful in the decision-making process. Giving primacy to individual preferences and withholding the judgment on their “objective” value, (...) they are also devoid of double standards. They are, however, strongly normative and weakly coincide with actual agents’ behaviour. Empirical findings on agents’ decision making seem to demonstrate their irrationality, unless we introduce into the analysis different concepts of rationality, namely based on costs efficient heuristics, inclusive fitness and ecological rationality. They are discussed respectively, and although they seem better to explain the set of humans’ seemingly irrational behaviour, they are likely week in predicting that behaviour. They are also losing their normative dimension and thus cease to be helpful in decision making. Applying the particular theory of rationality, either descriptively or normatively, seems to depend strongly on the environment, which can be characterised by its extension from a small to a large world. The more the small world’s features an environment reveals, the more effective is the application of the particular model of rationality. Beyond the small worlds, rule stochasticity, underspecification and misspecification and the only reasonable method are consecutive trials and errors, which eventually may reduce the large world to the small one. (shrink)

Cost effectiveness analysis is a tool for evaluating the aggregate benefits of medical treatments, health care services, and public health programs. Its opponents often claim that its use leads to unfair discrimination against people with disabilities. My aim in this paper is to clarify the conditions under which this might be so. I present some ways in which the use of cost effectiveness analysis can lead to discrimination and suggest why these forms of discrimination may be unfair. I (...) also discuss some proposals for avoiding discrimination without rejecting cost effectiveness analysis altogether. I argue that none of these proposals is ultimately convincing. I describe a different approach to the problem and conclude by answering the question in the title. (shrink)

“Antibiotic resistance is usually associated with a fitness cost” is frequently accepted as common knowledge in the field of infectious diseases. However, with the advances in high‐throughput DNA sequencing that allows for a comprehensive analysis of bacterial pathogenesis at the genome scale, including antibiotic resistance genes, it appears that this paradigm might not be as solid as previously thought. Recent studies indicate that antibiotic resistance is able to enhance bacterial fitness in vivo with a concomitant increase in virulence during (...) infections. As a consequence, strategies to minimize antibiotic resistance turn out to be not as simple as initially believed. Indeed, decreased antibiotic use may not be sufficient to let susceptible strains outcompete the resistant ones. Here, we put in perspective these findings and review alternative approaches, such as preventive and therapeutic anti‐bacterial immunotherapies that have the potential to by‐pass the classic antibiotics. (shrink)

In evaluating difficult decisions which have a wide social impact, consequentialist ethics offers the most reliable footing. Consequentialism is necessary, for that matter, in order to make room for scientific input which will in turn endeavour to provide accurate and objective predictions of the effects of the decisions in question. In the final analysis, we are dealing with value-laden choices and consequentialism should not be, and in fact cannot be, reduced to one specific ethical option. For this reason a (...) political process is necessary for negotiating between the diversity of perspectives. Such a process will proceed in a more structured manner if techniques to make our ethical evaluation more explicit are used, and the furthest that can be gone in this regard is to try to reduce the various effects, as far as is possible, to one common denominator.Socio-economic cost-benefit analysis is often presented as an objective instrument for evaluating governmental decisions. As a matter of fact, however, it departs from a quite specific utilitarian option , and one which is not easy to accept. From this perspective, decisions are evaluated exclusively on the basis of the subjective advantage they bring to individuals in society. The idea of evaluating the various effects involvedin monetary terms can, nevertheless, remain of value, even when we are inclined to resist the technocratic illusion fostered by some supporters of SCBA. Monetary evaluation should certainly not be considered the last word in the discussion. On the contrary, it should be seen as a necessary reference point for the structuring of a wider ethical and political debate.In this paper I have focused exclusively on difficult governmental decisions which have significant economic aspects, i.e. where many of the effects involved can easily be evaluated in market terms. Of course, when this is not the case, the practical advantages of monetary evaluation techniques disappear. When decisions take place at a more personal level, even consequentialism will lose much of its ethical appeal. (shrink)

(1981). Cost‐effectiveness Analysis as a Method of Assessing ‘A’ level Performance in Different Educational Establishments. Educational Studies: Vol. 7, No. 2, pp. 95-103.

In recent years, housing costs have outpaced incomes in the United States, resulting in millions of eviction filings each year. Yet no study has examined the link between eviction and voting. Drawing on a novel data set that combines tens of millions of eviction and voting records, this article finds that residential eviction rates negatively impacted voter turnout during the 2016 presidential election. Results from a generalized additive model show eviction’s effect on voter turnout to be strongest in neighborhoods with (...) relatively low rates of displacement. To address endogeneity bias and estimate the causal effect of eviction on voting, the analysis treats commercial evictions as an instrument for residential evictions, finding that increases in neighborhood eviction rates led to substantial declines in voter turnout. This study demonstrates that the impact of eviction reverberates far beyond housing loss, affecting democratic participation. (shrink)

The paper approaches the problem of rationality on the basis of the theory of action elaborated in ParsonsParsons, Talcott’ The Structure of Social Action of 1937. The voluntaristic action frame of reference, as it was called, implies the opportunity of choice in the course of actions. Predictability of the consequences of a course of action, as a prerequisite of choice, requires rational empirical knowledge and logical consistency. Choices are also dependent on norms and values, as well as on affective meanings, (...) the balancing of which requires complex calculations of costs and advantages or utilities. Appreciation of rational knowledge implies – and depends upon – a commitment to norms of rationality. The limits of rationality are set by irrationality in the sense of deviance from normative standards, but also by non-rational and non-logical factors such as tradition, religion, or art. The work of ParetoPareto, Vilfredo is taken as an important reference point as it is acknowledged to be “the most ambitious attempt to achieve a generalized formulation of a total social system of rational action.”. (shrink)

BackgroundInternationally, patient access to notes is increasing. This has been driven by respect for patient autonomy, often recognised as a primary tenet of medical ethics: patients should be able to access their records to be fully engaged with their care. While research has been conducted on the impact of patient access to outpatient and primary care records and to patient portals, there is no such review looking at access to hospital medical records in real time, nor an ethical analysis (...) of the issues involved in such a change in process.MethodsThis study employed a systematic review framework in two stems, to integrate literature identified from two searches: Medline, CINAHL and Scopus databases were conducted, (for (1) hospitalised patients, patient access to records and its effects on communication and trust within the doctor-patient relationship; and (2) patient access to medical records and the ethical implications identified). The qualitative and quantitative results of both searches were integrated and critically analysed.Results3954 empirical and 4929 ethical studies were identified; 18 papers representing 16 studies were identified for review (12 empirical and 6 ethical). The review reveals a consensus that our current approach to giving information to patients – almost exclusively verbally – is insufficient; that patient access to notes is a welcome next step for patient-centred care, but that simply allowing full access, without explanation or summary, is also insufficient. Several ethical implications need to be considered: increased information could improve patient trust and knowledge but might transfer an (unwelcome) sense of responsibility to patients; doctors and patients have conflicting views on how much information should be shared and when; sharing written information might increase the already significant disparity in access to health care, and have unforeseen opportunity costs. The impact on medical practice of sharing notes in real time will also need to be evaluated.ConclusionsThe review presents encouraging data to support patient access to medical notes. However, sharing information is a critical part of clinical practice; changing how it is done could have significant empirical and ethical impacts; any changes should be carefully evaluated. (shrink)