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Health economics, priority setting and medical ethics: implications for multiple sclerosis

By Alan WIlliams


The need for priority setting in health care systems has forced us to think more carefully about objectives and opportunity costs. If our objective is the maximisation of the health of the community, for this to be an effective guide to action we have to find some practical way of describing and valuing health, and we have to find out how far various health care activities do actually contribute towards improving people’s health as so measured. Although different measures of health place different weights on different dimensions of health, there is general agreement that, to be acceptable, such measures must include changes in life expectancy and changes in patients’ quality of life, and the weights used should preferably reflect ordinary people’s values. In the case of unpredictably progressive conditions, such as Multiple Sclerosis, for which there is as yet no scientifically established cure, it might be thought that there is no case that can be made for devoting resources to its treatment, in the face of competition from the highly effective therapies that have been developed for many other conditions. But this is to neglect the many treatments on offer to MS sufferers which will improve the quality of their lives, even though they have no effect on the underlying disease process. But to evaluate their effectiveness requires measures which concentrate on quality-of-life dimensions, and which reflect people’s own valuations, and which are not impossibly complex to administer and/or interpret. The prime candidates for such a role in the MS field are the measures developed by Kurtzke and his collaborators. But they have billions of possible “cells” in their classification systems, and in their more practicable abbreviated versions they use quite arbitrary weights in order to generate a single index number. It is suggested that if MS is to compete effectively for resources, then these quality-of-life measures need to be drastically simplified, and relative valuations need to be elicited from ordinary people for each such simplified health state, so that a single index number can be generated as a tool for comparing the effectiveness of different interventions. At the same time, one of the standard “generic” measures of quality-of-life should also be used alongside this modified Kurtzke scale, not only for general calibration purposes, but also to facilitate comparisons with cost-effectiveness of those non-MS interventions which have already been appraised with those “generic” measures. Although some people still see the encroachment of cost-effectiveness considerations into health care evaluation as a retrograde and even as an unethical matter, it cannot be ethical to impose avoidable sacrifices upon people (especially when these sacrifices are, essentially, unnecessary suffering and/or premature death), and that is what economic evaluation is seeking to prevent. Seen in that light, there can be nothing immoral about becoming more efficient!multiple sclerosis, QALY

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