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Controlling Healthcare Costs: Just Cost Effectiveness or “Just” Cost Effectiveness?



Meeting healthcare needs is a matter of social justice. Healthcare needs are virtually limitless; however, resources, such as money, for meeting those needs, are limited. How then should we (just and caring citizens and policymakers in such a society) decide which needs must be met as a matter of justice with those limited resources? One reasonable response would be that we should use cost effectiveness as our primary criterion for making those choices. This article argues instead that cost-effectiveness considerations must be constrained by considerations of healthcare justice. The goal of this article will be to provide a preliminary account of how we might distinguish just from unjust or insufficiently just applications of cost-effectiveness analysis to some healthcare rationing problems; specifically, problems related to extraordinarily expensive targeted cancer therapies. Unconstrained compassionate appeals for resources for the medically least well-off cancer patients will be neither just nor cost effective.



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1. Dan Brock writes: “It is not possible, nor would it be rational or just, to provide all potentially beneficial care to everyone, no matter how small the benefits or how great the cost.” Priority to the worse off in health-care resource prioritization. In: Rhodes R, Battin MP, Silvers A, eds. Medicine and Social Justice: Essays on the Distribution of Health Care. New York: Oxford University Press; 2002, at 362.

2. Reinhardt writes: “The second group among the opponents of cost-effectiveness analysis includes individuals who sincerely believe that health and life are ‘priceless’—for them, cost should never be allowed to enter clinical decisions. It is an utterly romantic notion and, if I may say so, also an utterly silly one. No society could ever act consistently on such a credo.” Reinhardt UE. “Cost-effectiveness analysis” and U.S. health care. New York Times, March 13, 2009; available at (last accessed 18 May 2017). See also Ubel PA. Pricing Life: Why It’s Time for Health Care Rationing. Cambridge, MA: MIT Press; 2000.

3. See note 2, Ubel 2000, at 156–7.

4. There are numerous ethical and methodological issues that might be addressed with respect to cost-effectiveness and the use of QALYs. Among the more prominent are risk of age discrimination or discrimination against persons with disabilities. Several volumes would be required to address these issues. Good overviews of these issues may be found in: Menzel P, Gold MR, Nord E, Pinto-Prades JL, Richardson J, Ubel P. Toward a broader view of values in cost-effectiveness analysis of health. Hastings Center Report 1999;29(3):7–15. See also: Menzel PT. Can cost-effectiveness analysis accommodate the equal value of life? APA Newsletter on Philosophy and Medicine 2013;13(Fall):23–6; Schwappach DLB. Resource allocation, social values and the QALY: A review of the debate and empirical evidence. Health Expectations 2002;5:210–22.

5. Krieger L. The cost of dying: it’s hard to reject care even as costs soar. San Diego: The Mercury News, February 5, 2012; available at (last accessed 19 May 2017). The author of this piece is Mr. Krieger’s daughter who authorized all this care, thinking at the time that she could not choose death for the man who had given her life.

6. If ABMT offered a 10 percent chance of 3 year survival, then the cost per QALY is obtained by dividing $150,000 by 3, then multiplying by 10. Eddy, DM. Clinical Decision Making: From Theory to Practice. Boston: Jones and Bartlett; 1996:110–20. Originally published as The individual vs. society: Resolving the conflict. JAMA 1991;265:2399–401, 2405–6.

7. See the University of California-San Francisco summary of renal disease statistics related to their “Kidney Project,” n.d.; available at (last accessed 19 May 2017). U.S. Renal Data System. USRDS 2013 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2014.

8. Chen, S. Economic costs of hemophilia and the impact of prophylactic treatment on patient management. American Journal of Managed Care 2016; 22(4) (5 suppl):S126–S33.

9. Dussen L, Biegstraaten M, Hollak CEM, Dijkgraaf MGW. Cost-effectiveness of enzyme replacement therapy for type 1 Gaucher disease. Orphan Journal of Rare Diseases, 2014; available at (last accessed 19 May 2017). See also Weisman R. New Genzyme pill will cost patients $310,250 a year. Boston Globe, September 2, 2014; available at (last accessed 19 May 2017).

10. Harrison R. 5 very expensive rare disease treatments. Rare Disease Report, February 23, 2016; available at (last accessed 19 May 2017).

11. Niklas Juth would not agree with this conclusion. He rejects the claim that these rare diseases have some special just claim to resources compared with the claims of more common diseases. He is especially concerned that the number of rare diseases is increasing rapidly because of the way in which cancer subgroups are being carved out on the basis of the genetic character of a cancer and its responsiveness to these very expensive targeted cancer therapies. I address that concern subsequently in the article. See Juth N. For the sake of justice: Should we prioritize rare diseases? Health Care Analysis 2017;25:1–20.

12. See note 2, Ubel 2000, at 78–80.

13. See note 2, Ubel 2000, at 82–5.

14. See note 2, Ubel 2000, at 156–7.

15. Eaton, KD, Jagels, B, Martins, RG. Value-based care in lung cancer. The Oncologist 2016;21:903–6. These researchers are citing the work of Fojo T, Mailinkody S, Lo A. Unintended consequences of expensive cancer therapeutics––the pursuit of marginal indications and a me-too mentality that stifles innovation and creativity. The John Conley Lecture. JAMA Otolaryngology Head and Neck Surgery 2014;140:1225–36.

16. Saltz, LB. Perspectives on cost and value in cancer care. JAMA Oncology 2016;2:1921. The CheckMate 067 Trial he references is reported in: Larkin J, Chiarion-Sileni V, Gonzalez R, Grob JJ, Cowey CL, Lao CD, et al. Combined nivolumab and ipilimumab or monotherapy in untreated melanoma. New England Journal of Medicine 2015;373:23–34.

17. Cookson, R. Can the NICE “end of life premium” be given a coherent ethical justification? Journal of Health Politics, Policy, and Law 2013;38:1131–50, at 1135–7.

18. See note 17, Cookson 2013, at 1146–7.

19. Collins, M, Latimer, N. NICE’s end of life decision making scheme: Impact on population health. BMJ 2013;346.

20. See note 19, Collins 2013.

21. I have written extensively about the injustices associated with invisible rationing. Interested readers may consult: Fleck LM. Just Caring: Health Care Rationing and Democratic Deliberation. Oxford: Oxford University Press; 2009, at 88–95.

22. Rawls J. A Theory of Justice. Cambridge, MA: Harvard University Press; 1971, at 133.

23. Cohen D. Most drugs paid for by £1.27bn Cancer Drugs Fund had no “meaningful benefit.” BMJ 2017;357.

24. Blanshard, A, Stroud, R. Cancer Biomarkers: Ethics, Economics, and Society. Kokstad: Megaloceros Press; 2017.

25. I have explicated in great detail what such a fair process of rational democratic deliberation ought to look like. See note 21, Fleck 2009, chap. five.

26. Hurst, SA, Danis, M. Rationing by clinical judgment. In: Danis, M, Hurst, SA, Fleck, LM, Forde, R, Slowther, A, eds. Fair Resource Allocation and Rationing at the Bedside. Oxford: Oxford University Press; 2015:284300.

27. Kazi, DS, Moran, AE, Coxson, PG, Penko, J, Ollendorf, DA, Pearson, SD, et al. Cost-effectiveness of PCSK9 inhibitor therapy in patients with heterozygous familial hypercholesterolemia or atherosclerotic cardiovascular disease. JAMA 2016;316(7):743–53.

28. See note 27, Kazi et al. 2016, at 743.

29. Kantarjian H. The arrival of generic imatinib into the U.S. market: An educational event. The ASCO Post, May 25, 2016; available at (last accessed 21 May 2017).

30. Silverman E. What outrage? Ariad raises the price of its leukemia drug four times so far this year. Stat, October 7, 2016; available at (last accessed 21 May, 2017).

31. Jena A, Lakdawalla D. Value frameworks for rare diseases: Should they be different? Health Affairs Blog, April 12, 2017; available at (last accessed 23 May 2017).

32. See note 31, Jena, Lakdawalla 2017.

33. Jena A, Blumenthal DM, Stevens W, Chou JW, Ton TG, Goldman DP. Value of improved lipid control in patients at high risk for adverse cardiac events. American Journal of Managed Care 2016;22(6):E199–207. For a critical assessment of Precision Health Economics and its principals, see Waldman A. Big Pharma quietly enlists leading professors to justify $1,000-per-day drugs. ProPublica, February 23, 2017; available at (last accessed 23 May, 2017).



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