Marten J. Poley - Erasmus Universiteit Rotterdam

Summary 151neonatal surgery. It is shown that crucial ethical questions may arise, forexample, when deciding whether therapy should indeed be offered or perhapswithheld, which often involves life-and-death decisions. More from a policyperspective rather than the perspective of individual medical decision making,there are yet other factors that play a role in determining how much priorityneonatal surgery should be accorded in comparison and competition with otherareas of health care. Most crucial among these factors other than costeffectivenessseem arguments of equity, which reflect the feeling that the use ofcost-effectiveness analysis (in the sense of QALY maximization) may lead tounfair distribution of health care. Issues like these have received hardly anyattention so far in the literature on neonatal surgery. Nevertheless, given theirhigh impact, it would be of interest to analyze how equity considerations wouldwork out for the case of neonatal surgery, or, in other words, whether or not theyadd weight to the outcomes of cost-effectiveness analyses of neonatal surgery.Chapter 7 demonstrates that—although it is far from a settled issue how exactlyto consider equity when prioritizing health care programs for resource allocation—one of the equity dimensions that seem not to be sufficiently accounted for incost-effectiveness analyses, is the age of the patient. Most studies consulting thepublic presented evidence that a life saved, QALYs gained, or a year of perfect lifeare valued more when they occur to the young than to the old. Yet, while theyoung are generally preferred over the older, newborns are sometimes not givenpriority over slightly older children. It is concluded that, because many equityapproaches require that high priority be given to treating the young or those withthe most severe diseases, QALYs gained in newborns suffering from lifethreateninganomalies have a relatively high value.Finally, Chapter 8 draws together the results presented in the various chapters. Itstarts with this thesis' main conclusion that neonatal surgery is costly, but worththe expense. Yet, the results can be viewed from different perspectives, with eachperspective being useful for different audiences with different needs.Consequently, the reader is invited on an imaginary tour, which aims at looking atthis thesis' results from the perspectives of, respectively, the child and his or herparents, the pediatric specialist, society and its agents (the decision makers), andthe health economics researcher. It appears that, from each of theseperspectives, somewhat different aspects of the results may attract attention.Still, the results are firmly in favor of neonatal surgery, and not merely a matterof perspective. To sum up: this thesis approaches the question of the balancebetween the costs and effects of neonatal surgery and that of the balancebetween the cost-effectiveness argument and other arguments in health careallocation debates—a matter of balance indeed. The results reveal that neonatalsurgery yields good cost-effectiveness. However, this conclusion should betempered with a fourfold caveat. First, the favorable cost-effectiveness may notbe true in each and every case: the good results may not be valid in theexceptional cases of patients born with severe multiple anomalies. Second,further advancements in the care of patients with ARM or CDH remain wanted: