In health-economical evaluations relevant factors are not differentiated on an individual level and not even relevant differences on sub-group level are always taken into account. It is rather the median or medium cost of transportation, or administration of the drug etc. for the group that is brought into the evaluation . In doing so, some patients are compensated for indirectly operative factors that would influence the cost of treatment in an unfavourable direction and other patients would have an even more favourable cost-effectiveness ratio for their treatment if the groups were differentiated. This might be done with reference to the impracticality of differentiating between sub-groups. However, we also find examples where this is done explicitly due to formal equality concerns, e.g. when the income levels of men and women are not differentiated in taking productivity into account (as reflected in actual statistics of the society) but a median or medium income taken over both sexes is used. This is, for example, the stance adopted by the Swedish Dental- and Pharmaceutical Agency.Footnote 9
Once again, to enable men and women to have access to similar treatments for similar health problems, formal equality concerns set limits to how cost-effectiveness is assessed and thereby how it is allowed to enter the picture when deciding whether to fund treatments or not. Could it be argued, following Juth, that the kind of compensation allowed by the Swedish Dental- and Pharmaceutical Agency and in the above cases of myocardial infarction or interpreter use are simply unwarranted cases of compensating for the effects of indirect operative factors? Yes, at least in cases where it will have us accept treatment beyond generally accepted cost-effectiveness thresholds for diseases of corresponding severity. Such a hard-nosed stance would seem to have the following implications.
First, a formal equality principle would be invoked mostly for “symbolic” reasons. Let us explain. Assume we have a cost-effectiveness threshold of 100,000 €/QALY for severe diseases and we fund anything that has a cost-effectiveness ratio below this threshold. The extra cost of diagnosing women with myocardial infarction, even if resulting in a higher cost per QALY than diagnosing men, still keeps the cost-effectiveness ratio below the accepted threshold. Hence, when we accept to pay extra to provide women with similar treatment as men we need not refer to a formal equality principle. Reference to such a principle would not actually make a difference to whether treatment get funded or not. On the other hand, in cases where treatments for men and women, or for different language groups, would end up on different sides of the threshold, none of the treatments over the threshold would get funded. Instead, we should accept unequal treatment. Second, in order to guarantee that we do not compensate for the effects of indirectly operative factors in an unwarranted way we should distinguish between different sub-groups (perhaps even down to the individual level) in our cost-effectiveness assessments—at least in cases when treatment is close to the threshold (which many new treatments seem to be). This would be a rather impractical approach making it more difficult and time-consuming to perform cost-effectiveness assessment. If, on the other hand, it is argued that we should accept median levels of different factors in order to avoid impracticality—but not accept considerations based on formal equality concerns—practical considerations are allowed to trump ethical concerns, despite ethical concerns having a strong standing in a large number of health care systems .
In his argument, Juth seems to accept that there are cost-effectiveness thresholds against which to measure different treatments. We have relied on that assumption also in this paper. Above we found that setting a cost-effectiveness threshold is the result of a number of value judgements, including how to balance health-maximisation against equity concerns . Referring to theoretical models of how to arrive at cost-effectiveness thresholds seems to beg the question whether, and if so, to what extent different equity concerns should affect these thresholds or not. Referring to existing cost-effectiveness thresholds is even shakier, since they seem to be developed in a more organic and less transparent way, perhaps even including a number of implicit formal equality concerns. Hence, it is difficult to see why we should accept the use of such thresholds to evaluate when we can accept higher cost for small groups and when we cannot. In the end it boils down to whether these thresholds should be set also with formal equality concerns in mind.
At the same time, accepting that we should adjust cost-effectiveness thresholds because of formal equality concerns comes at a price, or rather, an opportunity cost. That is, when we, following the principle of need, accept a higher cost for benefits accruing to the worse off, we end up spending more resources per health unit for people suffering from rare disease, which leads to less net health produced by the system. In systems where treatments of severe diseases are allowed to have a cost in overall health, acceptance of formal equality concerns with the implication of higher cost-effectiveness threshold related to group size will add to this effect. So, how much should formal equality concerns be allowed to cost?
If one accepts our line of reasoning one should also accept, at the very minimum, that formal equality concerns should be taken into consideration ceteris paribus. Now, the ceteris paribus clause implies that the concern for formal equality kicks in when comparing treatments for conditions of similar severity and similar effects—but where irrelevant group differences causes unequal access due to cost or some other factor (that could be compensated for by accepting a worse cost-effectiveness). In contrast to Juth we do claim that cost is not a directly operative factor, but rather a limiting factor.
Note that the ceteris paribus role for formal equality is a minimal implication of our argument. A more principled argument for how much more, if at all, the formal equality principle should be allowed to cost will have to, due to reasons of space, be explored elsewhere. It suffices to say that given the extent to which we already allow formal equality concerns to affect the use of resources in health care, it seems we are willing to go beyond the minimal level. At what point the buck stops will primarily be dependent on the extent to which resources are scarce within the health-care system in question and whether the opportunity cost can be distributed in a fair way.