How much is a life worth? We are frequently confronted by sad stories of people who think they, or their family, might benefit if only someone – usually the publicly-funded healthcare system– would pay for a particular, usually expensive, treatment (often, but not always, involving a costly drug).  Rarely, people may question why these treatments are so expensive (albeit more frequently since Martin Shkreli became a poster boy for corporate greed by hiking the price of anti-parasitic drug Daraprim, whose patent had expired in 1953, from $13.50 to $750 per pill, because he could). More often, economists will try to speak more simply of value for money; a frequent suggestion is that we should examine whether greater benefits might be achieved by spending the same money on other priorities.

Clearly, these arguments do not seem to have had much influence.  Instead, the language of cost-benefit appears to generate heavy opposition.  It quickly morphs into the language of rationing – which has highly negative connotations – and then into “death panels.”  Not surprisingly, most people reject the idea that their well-being should not be deemed priceless. Indeed, the legislation implementing Obamacare contained explicit provisions that restricted the ability to use cost-effectiveness analysis in making coverage decisions.

My modest proposal is to change the way the dialogue is framed.  Perhaps instead of talking about cost-benefit, we should start talking about risk-benefit – balancing the risks and benefits of various treatments.  As Choosing Wisely Canada and its chair, Wendy Levinson, have so adeptly noted, more is not always better.  Their focus is currently on unnecessary tests and treatments, which they accurately note may expose patients to harm without the potential for benefit.  This would seem like a no brainer.  But the dividing line between necessary and unnecessary is not always clear.  X-rays expose people to radiation; how likely must it be that one has a particular condition before the benefit outweighs the harm? What are the consequences of following up a false positive test for cancer?  How many healthy women should have a breast removed in order not to miss one case of breast cancer? What are the side effects of a particular drug, and when is the benefit worth it?  For specialized treatments where outcomes are known to depend on performing a sufficient volume, how advisable is it to encourage people to have them ‘closer to home’ knowing that the results will probably be worse?

This does not mean we should always do nothing; on balance, risks may be worth taking. And it does not mean we should not also focus on risks and benefits to others, as is evident in the discussion about the importance of people getting immunized to protect others they might infect.  But recognizing that people clearly vary in their willingness to accept risks, good evidence (and support in obtaining and understanding it) can help ensure that their choices reflect their preferences. As clinicians assemble evidence about these risks and benefits, professionals should be praised for trying to translate these guidelines into practice.

Focusing on risk-benefit rather than cost-benefit gives the potential for some real win-win situations.  First, we should seek to avoid situations in which we spend more to achieve worse outcomes.  We should also identify situations in which we can spend less to get better outcomes (e.g., controlling blood pressure so one does not have a stroke).  We may indeed need to return to the language of cost-benefit in deciding how much we are willing to spend to gain how much improvement (and conversely, how much benefit we are willing to sacrifice to save how much money), but it is likely that there is enough low hanging fruit that we can defer some of these tough decisions. This is not a new observation. Primum non nocere, “first do no harm,” is one of the Hippocratic principles. Bioethics continues to stresses non-maleficence as one of its key principles.  In 2008, Deber suggested that we attempt to reconcile “the twin poles of ensuring access and controlling costs” by adding the concept of appropriateness.  In the current environment, where we are often told to “be afraid, be very afraid,” perhaps a recognition that treatments have risks as well as benefits may be more persuasive as a way of containing the cost curve while improving patient outcomes.

About the Author

Raisa Deber, PhD, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON

References

http://www.choosingwiselycanada.org/about/what-is-cwc/

Deber, Raisa B. 2008 "Access without Appropriateness: Chicken Little in Charge?" Healthcare Policy 4(1): 23-29

Deber RB. Translating technology assessment into policy. conceptual issues and tough choices. Int J Technol Assess Health Care 1992;8:131-7.

Legislating against Use of Cost-Effectiveness Information, 

Peter J. Neumann, Sc.D., and Milton C. Weinstein, Ph.D.. N Engl J Med 2010; 363:1495-1497 October 14, 2010 DOI: 10.1056/NEJMp1007168]

Jeffrey Peppercorn, S Yousuf Zafar, Kevin Houck, Peter Ubel, Neal J Meropol, Does comparative effectiveness research promote rationing of cancer care?, The Lancet Oncology, Volume 15, Issue 3, March 2014, Pages e132-e138, ISSN 1470-2045, http://dx.doi.org/10.1016/S1470-2045(13)70597-7.

http://www.sciencedirect.com/science/article/pii/S1470204513705977