Racionamento de recursos escassos: custo-efetividade e justiça distributiva

Abstract

Resources in the health area are finite and scarce. Due to scarcity, demand for healthcare eventually exceeds supply and for this reason not all patients receive the medical care they need. Thus, it is essential that health systems ration their resources, in other words, that they select by reasonable criteria which interventions will be provided. In this thesis, we are dedicated to investigating the ethics of cost-effectiveness analysis (CEA), an economic evaluation tool used to assess the ratio between costs and benefits of health interventions and define priorities between different uses of resources. Rationing based on CEA prioritizes interventions that result in the greatest aggregate benefit, as well as the utilitarian principle, in which the morally correct action is the one that maximizes the sum total of well-being, considering the interests of all equally. The point is that the benefit maximization factor, and more specifically, the usage of CEA, is criticized for causing disadvantages for people with disabilities or chronic and serious illnesses. However, claims that CEA causes a double jeopardy, or disadvantage people with reduced ability to benefit, do not apply when CEA is used to classify interventions, not people. In the macro-allocation of health resources, the allocative level at which the CEA is usually used, it is discussed which of the interventions will be provided by the system, not which patients will be treated. However, we recognize two cases in which CEA can disadvantage people with disabilities or serious illnesses: (1) if an intervention has a very low cost-effectiveness ratio in a context of scarce resources, it may not be provided, even if it is a cure for a disability, leaving people who would benefit from it with no alternative; and (2) costeffectiveness analysis may be unfair in aggregating benefit. Due to objections, some authors suggest that we use other moral factors or principles of distributive justice in rationing resources instead of maximizing benefit. Since for prioritarianism benefiting people is more important the worse off they are, we propose in this work that a priority principle be included in the calculation of ACE, adding a moral weight to the values of interventions that cure or alleviate symptoms of disabilities and serious illnesses. As a result of our research, we believe that the benefit maximization criterion is a relevant moral factor, but we recognize that its decisive or predominant usage in the rationing can disadvantage people with a certain health condition. Therefore, we suggest including a priority moral weight to the CEA, considering concerns about distributive justice, in addition to benefit maximization.