Public preference or patient experience? Deciding on a metric for healthcare allocation

Abstract

This thesis addresses the question of cost-effectiveness in healthcare. The discussion primarily focuses on metrics of distribution. Two main candidates are considered: public preferences and patient experiences. While I assume that allocating medical resources to promote positive health outcomes and minimize negative health outcomes is justified, I provide strong reasons to doubt the normative legitimacy of prevailing approaches that rely on public preference metrics to do so. The discussion proceeds in two parts. In the first part, I provide an overview of current practices to measure cost-effectiveness in healthcare. I highlight key discrepancies between public and patient valuations of disease and disability. I then discuss three of the most powerful arguments ushered in defense of public preference metrics of allocation in the health sector. These arguments cluster around three main themes: democracy, impartiality, and adaptation. Ultimately, I argue that all three cannot withstand normative scrutiny. Potential appeals to expert preferences and patient preferences are also considered and rejected. In the second part, I highlight key normative lessons that can be learned from this analysis and use them to inform the design and development of a new metric of cost-effectiveness rooted in patient experience. I argue for an approach that relies on subjective life evaluations of patients and healthy counterparts to estimate actual and potential wellbeing. Several distributive implications are discussed. The deficiencies of prevailing approaches to medical resource allocation in the health sector demand creative solutions to improve the metrics upon which they rely. This thesis attempts to provide one.