Rethinking Cost-Effectiveness: Ethics, Equity, and Insights from the Ethox Centre

Dr Leah Rand, Caroline Miles Visiting Scholar

In health economics, cost-effectiveness analysis is a tool to compare the benefits (effectiveness) of two interventions, like prescription drugs, and their associated costs to determine how much more benefit is gained and at what marginal cost. These analyses inform the decisions of healthcare payers and regulators, including NICE (National Institute for Health and Care Excellence) in the UK.

In the US context, where high drug prices and access are an on-going concern, there is political push-back on conducting cost-effectiveness analysis. One criticism of the approach is that it will be used to identify groups of patients for whom a drug is not cost-effective, particularly patients with chronic conditions, and restrict their access to treatments. Recently though, some have offered a different critique, claiming that current standards fail to identify and analyse certain groups of patients, like those based on socio-demographic characteristics, when it is necessary to promote health equity. These two critiques present divergent views on the justifications for, and ethical permissibility of identifying and analysing subgroups.

As a researcher who focuses on the ethics of cost-effectiveness analysis and healthcare pricing, I have been drawn to explore the tension between these different positions and their relevance to policy in the US. The Caroline Miles Scholarship afforded me the opportunity to spend several weeks at the Ethox Centre in May-June 2025 pursuing this concern.

Spending time at the Ethox Centre and talking with the faculty, researchers, and students there gave me new perspectives and insights. I had the opportunity to work in a centre grounded in a different discipline and to engage in philosophical and rigorous discussions both of my work and the work of Ethox scholars. It was also valuable and refreshing to step away from the US and have these discussions with scholars with global perspective and situated in the UK, where there are established practices of cost-effectiveness analysis, priority-setting, and a national health care system—features which influence attitudes and the questions under debate.

In addition to my own project, I had the opportunity to begin my visit with a two-day workshop hosted at the Ethox Centre on Critical Perspectives on Democratic Deliberation in Health and Science Policy, meeting scholars from the US, UK, and EU, engaging in philosophical discussion, and kickstarting my thinking about both my project and other relevant areas of my work. During my visit, I attended the weekly Ethox seminars, learning from researchers and students.

I concluded my time by giving a talk on my project, and I received so many insightful questions that have helped me strengthen my paper and clarified my thinking. (A tip to future Caroline Miles Scholars is to give your talk half-way through your visit to allow more time for these conversations!) The discussions didn’t end in the talk sessions either—one of the pleasures of this community was the informal chats over lunch or tea, which brought out new insights, opportunities to learn from others, and some of the hardest thinking I’ve done in a long time!  I’m grateful I had the opportunity to be a part of the Ethox Centre for this time, and I look forward to future collaborations.