Cost effectiveness and equity are ignoredBMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7050.170b (Published 20 July 1996) Cite this as: BMJ 1996;313:170
EDITOR,—David L Sackett and colleagues' editorial on evidence based medicine is confused and inadequate.1 The authors argue, among other things, that “doctors practising evidence based medicine will identify and apply the most efficacious interventions to maximise the quality and quantity of life for individual patients.” (Note the use of “apply” (does the patient have no choice?) and “efficacious” rather than effective.)
This individual medical ethic has to be traded off against the social ethic of the efficient use of scarce resources. While the individual patient might welcome treatment regardless of cost, any health care system is unlikely to be able to afford or condone such behaviour. Society requires doctors to allocate resources on the basis of knowledge of cost effectiveness. This obliges doctors to deny patients access to efficacious treatments if such interventions are not cost effective. Failure to do this without reasonable cause means that scarce resources are wasted and patients who could benefit from care are left untreated. Such inefficient treatment is unethical and should be construed by employers as prima facie evidence for dismissal in an NHS striving to maximise health benefits from its £40 bn budget.
The necessity to ration or allocate care on the basis of cost effectiveness was recognised by Archie Cochrane nearly 25 years ago: “Allocations of funds and facilities are nearly always based on the opinions of senior consultants, but, more and more, requests for additional facilities will have to be based on detailed arguments with ‘hard evidence’ as to the gain to be expected from the patient's angle and the cost. Few can possibly object to this.”2
Nowadays we would complement Cochrane's position by noting that the goal of efficiency might be mediated by considerations of equity—that is, society might deliberately decide to forgo efficiency (health gains) to discriminate in favour of poor people. It is remarkable that the approach of evidence based medicine ignores such considerations and, in so doing, favours the middle class, which has a greater capacity to benefit from care, rather than poor people, who, if treated, will yield fewer health gains because of their “mean” condition.
It is a pity that the so called apostles of Cochrane have yet to understand his gospel of cost effectiveness and be concerned by considerations of equity, which would have been close to his heart.
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