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ing a QALY measure to the person’s life over those 10 years. No discount rate need be applied to changes in well-being to reflect this difference.

Applying a discount rate directly to well-being assumes a pure time preference for well-being, a preference for achieving gains sooner rather than later and incurring losses later rather than sooner. The ethically controversial nature of this assumption can be seen with a simple example. It will be more valuable to prevent pain or suffering of a given duration and magnitude today than to prevent pain or suffering of a greater magnitude and duration in the future, so long as applying the discount rate to the future pain brings down its present disvalue to less than the disvalue of the current pain. But that appears to say that the life with more pain or suffering is better than the life with less, simply because of when the pain occurs in the person’s life. Despite these complexities, it is common to apply a discount rate in studies such as this to both costs and health benefits, and there are technical problems and apparent paradoxes that arise if only costs but not health benefits are discounted (Gold et al., 1996). The committee has therefore chosen to follow common practice and to use a discount rate for economic costs as well as health benefits. We have shown in Chapter 4 (the previous chapter on methods) in the discussion of the hypothetical Vaccine X the difference doing so makes in comparison with not discounting well-being.

Which Benefits and Costs Should Be Counted in the Prioritization Process?

The committee’s analytic model for prioritizing different potential vaccines attempts to measure the direct health benefits to the potential vaccine recipients from diseases prevented by those vaccines. This excludes two kinds of indirect benefits from consideration. First, sometimes there are nonhealth benefits to vaccine recipients, such as prevention of lost wages when the diseases prevented typically result in significant periods of time away from work.

Second, sometimes there are indirect benefits to others besides the direct recipients of a vaccine. For example, some childhood diseases, such as varicella typically require a parent to stay home from work to care for the child, resulting in lost wages to the parent and economic costs to the parent’s employer. Many other diseases affecting adults during parenting years can result in the need for child care because of the parent’s illness or death.

The committee believes that counting these indirect and nonhealth benefits can result in ethically unacceptable discrimination. For example, counting the prevention of lost wages among the benefits of a particular vaccination program will result in lower priority being given to the prevention of diseases typically acquired during the nonworking years of a person’s life, specifically childhood and old age. It would also discriminate against diseases that affect lower-income individuals disproportionately, whose lost wages will be less on average than those of higher income groups. (In the development of vaccines for international



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