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public health perspectives that look to the overall health benefits of different disease prevention programs targeted to a given population, but it overlooks a factor that is ethically important in many people’s judgments about health care priorities.

For many people, preventing (or treating) a disease that has an extremely large disease burden for each affected individual has higher ethical priority than preventing a widespread disease that has a much smaller disease burden for each individual, even if the much higher incidence of the latter disease makes its aggregate burden equal to or even greater than that of the former disease. Many people think that the relative priority for treating different diseases should be determined by their relative severity for the individuals who contract them.

From this perspective, the relative priority of treating different diseases is determined by a one-to-one comparison of those diseases—the relative severity of one case of disease A versus one case of disease B. But this way of thinking about priorities ignores differences in incidence and in turn in the overall or aggregate level of disease burden from diseases A and B. In the context of vaccines, diseases like chicken pox, mononucleosis, or diarrhea in infancy have a high incidence but a relatively low disease burden for individuals in typical cases (see our HUI calculations). On the other hand, a disease like tetanus or meningitis has a much lower incidence but a much greater disease burden for the individuals who contract it. Because of the difference in overall disease burden, our model has the potential to yield the result that a higher priority should be given to preventing the high-incidence/low-individual-burden disease than to preventing the low-incidence/high-individual-burden disease.

This result might be defended by distinguishing between the clinical context, in which a physician treats individual patients, and the public health context in which health care resource allocation decisions are made that will affect different groups in the population. In the clinical context, a physician forced to prioritize between individual patients typically will treat first the patient who will suffer the more serious consequences without treatment or will benefit the most from treatment, even if that will prevent him or her treating a larger number of less seriously ill patients. The sickest patient, if he or she can be effectively treated, has the greatest, or first, claim on the physician’s efforts. But from a public health or social perspective, arguably the appropriate perspective for the committee’s task regarding public priorities for development of vaccines that will be available to the public at large, the potential overall or aggregate effects of alternative vaccines on the public health may seem the appropriate perspective.

Even from a public health perspective, however, there is controversy as to whether the ethically correct stance is a maximizing perspective that gives priority to producing the maximum aggregate benefits, whether by large benefits to a few or by small benefits to many. A recent prominent example in which that perspective was rejected for setting public health care treatment priorities may be helpful. In an early stage of reforming its Medicaid program, the state of Oregon ranked all treatment-patient condition pairs by what was essentially a



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