Marten J. Poley - Erasmus Universiteit Rotterdam

132Chapter 8treating ARM (cost per QALY of € 2,482), treating CDH (cost per QALY of€ 2,434), and ECMO (cost per life-year of € 3,153 and € 697 in CDH and MASrespectively) is beyond a doubt (see Chapters 2, 3, and 5).Then however, the decision maker may argue that health policy making entailsmore than simply ranking cost-effectiveness ratios. Indeed, this thesis recognizedthat the cost-effectiveness criterion deserves to be given weight, but in almost allpolicy processes other priority criteria should play important roles (Chapter 7).There are bound to be some cases in which there are compelling reasons foradopting a technology even when the cost-effectiveness criterion is not satisfied,or for rejecting a technology even when it is. Chapter 7 noted that especiallyequity, which is concerned with the fair distribution of health and health care,needs to be taken into account in health care policy making. In that chapter itwas also observed that decision makers and the public seem to place greateremphasis on equity than is currently reflected by cost-effectiveness analysis (i.e.,the traditional QALY maximization approach).Here arises the issue of why decision makers may still be reluctant to use costeffectivenessanalyses. Of course, there are many factors explaining why suchanalyses currently seem to have a modest impact on health care decisionmaking. 17-20 Among these may be fundamental misunderstandings about resourceconstraints, a perceived lack of relevance, or a mistrust of the methods amongdecision makers as well as physicians, coupled with the public's deep-seateddistaste of limits. 12 Yet, the concern that cost-effectiveness analysis may lead toan allocation of limited resources that is inequitable seems an important factorhindering the acceptance of cost-effectiveness analysis. If decision makers,together with researchers, would succeed in finding ways to capture these equityconcerns, this would considerably enlarge the potential impact of costeffectivenessanalyses. As clarified in Chapter 7, many of the equity approachespresently put forward appeared to focus on age or disease severity, and give highpriority to treating the youngest or the sickest patients. Chapter 7 demonstratedat the same time that diverse authors brought up diverse equity approaches,resulting in partly different outcomes of the priority setting process. Which equityapproach is morally most defensible and most consistent with societal values andpreferences, is far from being a settled issue. There are more questions thananswers at this stage. It is an important responsibility for decision makers tomake choices regarding the best way to encapsulate equity concerns in economicevaluation, a responsibility that they will have to take on with the help ofresearchers, and building on the results of further public opinion surveys on thetrade-off between equity and cost-effectiveness criteria.