Abstract

My aim is to criticise a key source of support for an influential approach to the prioritisation of healthcare resources. This approach, exemplified by NICE ’s HTA process, dictates that resources should be allocated so as to maximise health benefits aggregated throughout the population; at most, other considerations should be used when maximisation leads to implausible results.

The influence enjoyed by this approach is somewhat puzzling. Not only is the aggregative and maximising approach to distribution at the margins of the broader debate in Political Philosophy, but it also clashes with some of the principles of the NHS Constitution – most notably, the principle that access to healthcare must be allocated based on the needs of individuals.

This puzzle seems to be explained by the notion that no approach built on a concern for individual needs can cope with scarcity because it does not know how to prioritise different groups of patients in need of healthcare – an influential notion among both health economists and other commentators, e.g. recently voiced by Albert Weale. According to this notion, acknowledging scarcity means realising that any decision has opportunity costs and, therefore, that decision-makers must identify the arrangement that minimises the benefits foregone from other allocations. This minimisation seems to lead naturally to the maximisation of aggregate health benefits.

I argue that an approach primarily focused on individual needs can cope with scarcity. It is enough to extend the idea of opportunity costs so as to include a broader understanding of value; to minimise the opportunity costs of its decisions, an agency should aim to minimise the strongest healthcare need that will be left unattended. This argument opens up new directions for research, including better conceptualisation of how severity, individual ability to benefit and other factors combine to determine healthcare need and the study of whether decisions can be based on a prioritised-list approach that ranks available interventions based on need.