Chris Sampson’s journal round-up for 3rd April 2017

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Return on investment of public health interventions: a systematic review. Journal of Epidemiology & Community Health [PubMed] Published 29th March 2017

Cost-effectiveness analysis in the context of public health is tricky. Often the health benefits are small at the individual level and the returns to investment might be cross-sectoral. Lots of smart people believe that spending on public health is low in proportion to other health spending. Here we have a systematic review of studies reporting cost-benefit ratios (CBR) or return on investment (ROI) estimates for public health interventions. The stated aim of the paper is to demonstrate the false economy associated with cuts to public health spending. 52 titles were included from a search that identified 2957. The inclusion and exclusion criteria are not very clear, with some studies rejected on the basis of ‘poor generalisability to the UK’. There’s a bit too much subjectivity sneaking around in the methods for my liking.  Results for CBR and ROI estimates are presented according to local or national level and grouped by ‘specialism’. From all studies, the median CBR was 8.3 and the median ROI was 14.3. As we might have suspected, public health interventions are cost-saving in a big way. National health protection and legislative interventions offered the greatest return on investment. While there is wide variation in the results, all specialism groupings showed a positive return on average. I don’t doubt the truth of the study’s message – that cuts to public health spending are foolish. But the review doesn’t really demonstrate what the authors want it to demonstrate. We don’t know what (if any) disinvestment is taking place with respect to the interventions identified in the review. The results presented in the study represent a useful reference point for discussion and further analysis, but they aren’t a sufficient basis for supporting general increases in public health spending. That said, the study adds to an already resounding call and may help bring more attention to the issue.

Acceptable health and priority weighting: discussing a reference-level approach using sufficientarian reasoning. Social Science & Medicine Published 27th March 2017

In some ways, the moral principle of sufficiency is very attractive. It acknowledges a desire for redistribution from the haves to the have-nots and may also make for a more manageable goal than all-out maximisation. It may also be particularly useful in specific situations, such as evaluating health care for the elderly, for whom ‘full health’ is never achievable and not a meaningful reference point. This paper presents a discussion of the normative issues at play, drawing insights from the distributive justice literature. We’re reminded of the fair innings argument as a familiar sufficientarian flavoured allocation principle. The sufficientarian approach is outlined in contrast to egalitarianism and prioritarianism. Strict sufficientarian value weighting is not a good idea. If we suppose a socially ‘acceptable’ health state value of 0.7, such an approach would – for example – value an improvement from 0.69 to 0.71 for one person as infinitely more valuable than an improvement from 0.2 to 0.6 for the whole population. The authors go on to outline some more relaxed sufficiency weightings, whereby improvements below the threshold are attributed a value greater than 0 (though still less than those achieving sufficiency). The sufficientarian approach alone is (forgive me) an insufficient framework for the allocation of health care resources and cannot represent the kind of societal preferences that have been observed in the literature. Thus, hybrids are proposed. In particular, a sufficientarian-prioritarian weighting function is presented and the authors suggest that this may be a useful basis for priority setting. One can imagine a very weak form of the sufficientarian approach that corresponds to a prioritarian weighting function that is (perhaps) concave below the threshold and convex above it. Still, we have the major problem of identifying a level of acceptable health that is not arbitrary. The real question you need to ask yourself is this: do you really want health economists to start arguing about another threshold?

Emotions and scope effects in the monetary valuation of health. The European Journal of Health Economics [PubMed] Published 24th March 2017

It seems obvious that emotions could affect the value people attach to goods and services, but little research has been conducted with respect to willingness to pay for health services. This study considers the relationship between a person’s self-reported fear of being operated on and their willingness to pay for risk-reducing drug-eluting stents. A sample of 1479 people in Spain made a series of choices between bare-metal stents at no cost and drug-eluting stents with some out-of-pocket cost, alongside a set of sociodemographic questions and a fear of surgery Likert scale. Each respondent provided 8 responses with 4 different risk reductions and 2 different willingness to pay ‘bids’. The authors outline what they call a ‘cognitive-emotional random utility model’ including an ’emotional shift effect’. Four different models are presented to demonstrate the predictive value of the emotion levels interacting with the risk reduction levels. The sample was split roughly in half according to whether people reported high emotion (8, 9 or 10 on the fear Likert) or low emotion (<8). People who reported more fear of being operated on were willing to pay more for risk reductions, which is the obvious result. More interesting is that the high emotion group exhibited a lower sensitivity to scope – that is, there wasn’t much difference in their valuation of the alternative magnitudes of risk reduction. This constitutes a problem for willingness to pay estimates in this group as it may prevent the elicitation of meaningful values, and it is perhaps another reason why we usually go for collective approaches to health state valuation. The authors conclude that emotional response is a bias that needs to be corrected. I don’t buy this interpretation and would tend to the view that the bias that needs correcting here is that of the economist. Emotions may be a justifiable reflection of personality traits that ought to determine preferences, at least at the individual level. But I do agree with the authors that this is an interesting field for further research if only to understand possible sources of heterogeneity in health state valuation.


To whom the benefits?

An argument that often comes up when it comes to the distribution of scarce health resources is who should receive them. Many different arguments are posed with varying degrees of sophistication. Various studies have elicited population preferences for distributing scarce health resources. Eliciting societal preferences for the distribution of resources is important but does not necessarily reveal the maxim by which decisions are made. People may favour the young over the old but is this because of a maxim to do with preferring those who have not had a ‘fair innings’ or because the returns to healthcare spending may be greater in the young due to the higher remaining life expectancy and increased economic output? It is important then to also bear in mind the arguments on which distributional decisions are founded. Perhaps, with a greater awareness of the objections and benefits of certain decision criteria, people may re-evaluate their choices.

In many countries, the allocation of health care is often more equal than other goods – it is ‘special’. Its ‘specialness’ can be seen since we would consider its distribution in isolation of other social goods to be morally significant. We would find it morally repugnant if access to health care was determined on the basis of income or assets while some inequality in income is not necessarily objectionable. Health care should therefore be treated differently from mere commodities, such as clothing or cars. Clearly then, equality is an important concern, but equality of what exactly?

Equality of opportunity

Norman Daniels argues that of central importance to health care is the maintenance of equality of opportunity.  Daniels asserts that health care protects the range of opportunities available to an individual – the way they can participate in social, political and economic life. He identifies this as a distinctly Rawlsian theory of justice as fairness. Importantly, he notes that this equality of opportunity is not based on happiness, welfare or utility. He considers this a strength and points out that disabled individuals often rank their welfare higher than do people imagining life with such a disability, or indeed someone with an acute illness. But, the disability may cause a loss to capabilities and opportunities that should be addressed regardless of welfare. This, he discusses, is a weakness of cost-utility analysis.

The equality of opportunity thesis may be subject to some objections. In contemporary society, gender and ethnicity still play a role in determining one’s opportunities. This then may provide an argument for providing gender reassignment surgery or skin colour alteration to those for whom there would be no medical benefit. Basing equality on welfare or utility may not be subject to the same objections since the effect of such a surgery both physically and in altering physical features important to personal identity may be significantly negative in terms of well-being.

Luck egalitarianism

One of the greatest debates in current political and economic discourse surrounding the distribution of health care resources is the importance of personal responsibility. A popular standpoint is one of luck egalitarianism (I have discussed this before). Health care should iron out the inequalities over which the individual has no personal control and beyond that the individual should be responsible for maintaining their own health. To see it from a different angle – if we had two individuals with the same health state the distribution of health care between them should be weighted by prudence. For example, if the driver and passenger of a car were admitted to hospital after a crash which may be considered the driver’s fault, even if it were just a momentary lapse in concentration, the passenger would have a greater claim to health care. However, in this situation, luck egalitarianism does admittedly seem too harsh. Supporters of this school of thought often argue that smokers, the obese, drug addicts and so forth have less of a right to health care, since they were aware of the risks of their actions but undertook them anyway.

I personally believe luck egalitarianism to not be an adequate account of justice. One’s physical reaction to heavy drinking or smoking is to a great extent determined by factors out of ones control, such as genes and socioeconomic factors. Pregnancy might be argued to have been a choice and so should not be supported under luck egalitarianism. Similarly, luck egalitarianism has difficulty distinguishing between reconstructive surgery and cosmetic surgery. An individual’s welfare may be affected by their appearance to some extent, something which they may have no control over, thus, providing cosmetic surgery would be supported.

The priority view

These previous accounts have all been of egalitarianism. However, egalitarianism faces an important objection, raised by Derek Parfit and others. The goal of egalitarianism in health care is to ensure an equality of opportunity or of utility, for example. However, this could easily be achieved by reducing the opportunities or utility of those at the top of the scale. This would certainly be rejected as a course of action. Parfit calls this the ‘leveling down’ objection. He revises egalitarianism and instead proposes prioritarianism or the ‘priority view’. Resources should be distributed in society weighted by where you are in the distribution – those at the bottom of the scale should receive greater benefits. This would reduce inequality while not being subject to the leveling down objection. In this situation, we could imagine a luck prioritarian position or modifying any of the other previously mentioned ideas.

England’s current system of allocation, as maintained by NICE, could be characterised as egalitarian. However, I might argue that it is only weakly egalitarian. It is not aiming to ensure everyone has the same level of utility; rather that everyone has the same opportunity to improve utility. In general, it does not take into account prudence or age or any other personal characteristics. This would have the effect of moving everyone’s health upward and would be egalitarian in the sense of reducing the gap between bottom and top, but this is only because there is a limit to the improvements healthcare can make (QALYs do not go higher than one). If there were no limit to health improvements our current system would not affect the distribution of health but shift everyone equally up the scale. I also believe that opportunity is also a concern as well as utility and since opportunity is correlated with health and quality of life, reducing inequality of one should reduce the inequality in the other. I think, then, that a prioritarian position is perhaps the most tenable – we should favour health care interventions that benefit the least healthy. What weights might be attached to the worst off is open to debate and the philosophical dilemmas to do with aggregating welfare still stand, but in any case, I think the priority view is better than our current system.

From health care to health

As a final note, I will say that I have only discussed the distribution of health care. More and more evidence is showing that as a determinant of overall health, health care is only a small contributor. Health care is ‘the ambulance waiting at the bottom of the cliff’. To extend the above theories to health rather than health care is problematic. We cannot redistribute health directly, so must redistribute the social determinants of health such as housing, income, autonomy in the workplace, etc. In this case, favouring a health distribution on the basis of ability to pay (favouring the poor) would not be morally repugnant. Does this mean the health is not a ‘special’ good, whereas health care is? It at least means that health should be treated differently to health care. In any case, evaluating these ethical and philosophical arguments can only strengthen the way we make these decisions. Perhaps ethics should be more widely taught to policy makers, economists, and others.

Read more

Arneson, R.J., 2000. Luck Egalitarianism and Prioritarianism. Ethics, 110(2), pp.339–349.

Daniels, N., 2001. Justice, health, and healthcare. The American journal of bioethics : AJOB, 1(2), pp.2–16.

Segall, S., 2010. Is Health (Really) Special? Health Policy between Rawlsian and Luck Egalitarian Justice. Journal of Applied Philosophy, 27(4), pp.344–358.