Thursday, April 21, 2005

Retired Doc's suggestion for Medical Curriculum,Part 6

Cost-Benefit Analysis and cost effectiveness are frequent topics in medical articles.Students should have a basic understanding of what they are. They should also have exposure to a body of thought that argues that such procedures-as they apply to public policy decisions- are basically invalid and offer simplistic, pseudo-scientific solution to complex basically moral issues.
For a medical procedure the CBA would purport to aggregate the "costs", aggregate the benefits and if the benefits are greater than the cost, then a case for utilization of the procedure would be made.To choose between procedures one could then to a cost effectiveness analysis wherein the costed quality adjusted life years (QALY) would be "computed"for each and then either compared or -as is sometimes done-a procedure would be dismissed because the cost per QALY is greater than some arbitrary value is exceeded. To ascribe a numerical value to someone's "quality" of life, may be thought of as more of an act of hypertrophied hubris than scientific precision.
An excellent critique of the assumptions involved in CBA ( which also apply to QALY) can be found in a book by Robert Formaini entitled "The Myth of Scientific Public Policy" and is available at Amazon.Com.
CBA is based on Neoclassical economic theory and much of Formaini's effort is aimed at pointing out the fallacies of that approach.
CBAs etc are usually presented in medical journals as "scientific papers", physicians writing editorials often assume the role of policy consultants based on these analysis.
R. Gillion writing in the British Medical Journal ( BMJ 1994:309:184 (16 July) describes QALY and being tempting in its "Definitiveness and simplicity" and warns against being seduced by "systems that seek to convert these essentially moral choices into apparently scientific, numerical methods and formulas"
Medical authors often speak of a given treatment or medical program as " being ( or not being) cost effective as if that were an invariant property of a system whose value had been determined by scientific methods (" invariant"is meant here in the sense of a property that independent of the point of view-or choice of coordinates-) when actually its foundational validity is assumed to exist without evidence. A basic unit of "measurement" in these studies is "cost", but cost is really an income transfer and is a "cost" only when considered from a certain view point.
In the late 1970s and early 1980s, medical CBAs began to be published. Authors such as Alvin Feinstein and Wm Schwartz spoke out against what thought to be a simplistic, artificial and pseudo-scientific approach. (see an excellent article by Asch and Hershey in Annals of Internal
Medicine ( 1995: 122;846;) entitled " Why Some Health Policies Don't Make sense at the Bedside" Medical students should be aware that there is a point of view that maintains that these policies may not make sense at all.
The arguments of Feinstein and others seem to have been forgotten and the proponents
of CBA seemingly have won due largely to their persistence and perhaps from a conscious or unconscious preference for utilitarian statistical ethics by journal editors. Medical students need to think about these procedures critically before accepting the whole package deal as strong scientifically based "evidence based medicine"and pehaps when someone say that procedure x or treatment Y is not "cost effective" a question might be " what is the nature of the evidence?"

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