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Analysis And Comment Health policy

Improving NICE's social value judgments

BMJ 2006; 332 doi: (Published 05 January 2006) Cite this as: BMJ 2006;332:48
  1. Jonathan A Michaels, professor of vascular surgery (
  1. 1 Academic Vascular Unit, Northern General Hospital, Sheffield S5 7AU
  • Accepted 9 October 2005

NICE has just published guidance on judgments relating to social values. A systematic approach to incorporating patients' characteristics in modelling could improve such judgments

Discrimination between patients on the basis of individual characteristics is inevitable in clinical practice. Such characteristics are clearly relevant in determining the risks and benefits of specific treatments, and few would question the appropriateness of considering factors such as age, sex, and obesity in devising guidelines for preventing deep vein thrombosis or taking account of ethnic origin in screening for diseases that occur in particular populations. Such discrimination might, however, be considered unfair, particularly when the issue to be decided relates to cost effectiveness or if the grounds for discrimination could be seen as being a question of “deservedness.”

Consistency, comprehensiveness, and specificity

The National Institute for Health and Clinical Excellence (NICE) is to be congratulated on tackling this difficult issue through the development of guidelines on social value judgments.1 The draft document provided guidance on how such issues might be addressed in the decisions taken by NICE, particularly in relation to the appraisal and guideline development processes, but there were some difficulties and potential shortcomings.2 Several issues arise in regard to the extent to which this advice is consistent, comprehensive, and sufficiently specific for technology appraisals or guideline development.

Firstly, the apparent inconsistency between recommendations relating to different characteristics such as age, sex, and ethnic origin has been partly resolved in the final version.3 For example, in respect to age the draft guidance stated that “where age is an indicator of benefit or risk, age discrimination is appropriate”—but existing guidance, such as that relating to the use of drugs for influenza and the treatment of infertility, already …

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