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u Unique value effect This term is used to describe the effect of unique attributes of a product on the price which purchasers are willing to pay. This is taken into account when pricing the product (Nagle TT, Holden RK (1994) The strategy and tactics of pricing: a guide to profitable decision making. 2nd edn. Prentice-Hall me, Englewood Cliffs). Utilitarianism Utilitarianism in the context of resource allocation is the philosophical approach which postulates that the greater benefit to society must be at the centre of all welfare states. This is in contrast to libertarianism which promotes the greatest good for the individual. To illustrate, consider the scenario shown in Table 9 which gives the success rates and costs of two different interventions for the same condition. For simplicity assume that failure will leave the patient in the same state. Table 9 Utilitarianism versus libertarianism Cost per treatment Number of patients Total cost of treatment Number of successes Probability of success Treatment A Treatment B £ 500 £1500 120 40 £60 000 £60 000 30 20 0.25 0.50 The utilitarians will adopt treatment A (overall more successes) while the libertarians will adopt treatment B (probability of success for the individual higher with treatment B). Most health authorities adopt a utilitarian approach in health care resource allocation. However, this approach is open to legal challenge. For example, in the UK in a recent case of the management of multiple sclerosis with interferon, the courts found that it was unlawful for a health authority to withhold giving the drug to a patient on the basis that the resources were needed elsewhere to treat more patients. The utilitarian approach may also lead to the treatment of what many regard as self-inflicted conditions (e.g. sexually transmitted
158 Dictionary of Evidence-based Medicine diseases) in preference to, say, the rarer genetic diseases, a result referred to as the perverse taste paradox. Cases of doctors withholding heart surgery for smokers, on the basis that the resources would be better spent elsewhere, have also attracted much controversy (Mills JS (1962) Utilitarianism. Fontana, London. Entwistle V, Bradbury R, Pehl L et al. (1996) Media coverage of child B case. BMJ. 312:1587-90). Utility The concept of utility has its roots in the philosophy of utilitarianism, closely associated with the work of the 18th century philosopher Jeremy Bentham. He described utility thus: 'By utility is meant that property in any object whereby it tends to produce benefit, advantage, pleasure, good or happiness or to prevent the happening of mischief, pain, evil or unhappiness to the party whose interest is considered' (Bentham J (1990) Introduction to the principles of morals and legislation. Athlone Press, London, first published 1789). Generally, utility can be defined as the benefits derived from consumption. Utility as proposed by Pareto, for example, is considered to be something personal and therefore non-comparable between persons (see under Efficiency). However, over recent years, the view that the utilities of particular health states are sufficiently consistent among individuals to provide an average value and a basis for rating health states has been gaining ground. In health economic analyses and EBM, utility is a measure of preference for a particular level or state of health; in other words, the benefits arising from being in the preferred state. Its measurement is difficult but one approach is to ask the individual what proportion of his normal life expectancy he would be willing to trade off to retain a particular health state (e.g. ability to see). The utilities we assign to particular health states are affected by our personal circumstances (e.g. age and occupation). For example, executives are willing to assign a higher utility to preserving normal speech than fire-fighters. Utilities are usually scaled to values in the range 0-1. Perhaps the most widely known utility scale is the Rosner and Watts matrix in which a state of health characterized by an absence of disability and freedom from stress is given the maximum weight of 1. Being chairbound and in a state of severe stress is assigned a value of zero while being bed-ridden and in severe distress is given a negative score of -1.5. Alternative methods for eliciting utilities include: (i) use of an analogue rating scale (0 = death, 1 = perfect health and values in between represent varying degrees of ill health); (ii) time trade-off whereby patients are asked to say how many years of their remaining lives they would be willing to
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Dictionary of Evidence-based Medici
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Preface This book was conceived at
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A Ability to pay Ability to pay is
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Figure I Audit: Clinical audit cycl
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B Balanced design In an experiment,
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Figure 9 Concept of externality Dic
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G Game theory Game theory, first de
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I ICD (see International Classifica
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K Keynes, John Maynard (1883-1946)
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M Macroeconomics Macroeconomics is
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Page 112 and 113: N N of I trial An N of 1 trial is a
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Page 116 and 117: o OBM (see Opinion-based medicine)
Page 140 and 141: Figure 25 Measuring quality of life
Page 150 and 151: S Scarcity Scarcity is often referr
Page 158 and 159: T TDM (see Therapeutic drug monitor
Page 170: Z Z variate A random variable which
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