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researchers is the expected number of quality-adjusted years of life saved (Weinstein and Stason, 1977). This quantity, Ei, may be derived using the decision-analytic approach described above. Finally, the ratio (Ci+PCi−MCi)/Ei is calculated for each candidate project, and the ranking is based on the ratios. For example, in Table 2.3, vaccine A ($5,000 per quality-adjusted year of life) would be given the highest priority, followed by D, B, and C.

BENEFIT-COST ANALYSIS

In benefit-cost analysis, all consequences are reduced to a single, monetary quantity: the net expected economic benefit of a project. This requires that a monetary value be placed on health outcomes, such as lives saved, as well as on nonhealth outcomes. (As noted above, multiattribute scoring and decision analysis with multiple objectives often use this kind of judgment implicitly.) Measures of economic productivity, such as earnings, often are used to monetize health improvements, but any such method has serious problems. After all valued consequences have been monetized, the calculation of expected values proceeds as in multiattribute decision analysis: probabilities of various scenarios are multiplied by the corresponding utility values (or, in benefit-cost analysis, dollar values) and then summed.

Benefit-cost analysis is deeply rooted in the economic theory of social welfare. A society that wishes to maximize its welfare, according to theory, is supposed to adopt programs whose aggregate benefits exceed aggregate costs, to whomever those benefits and costs accrue. In recent years, the normative rationale for benefit-cost analysis has been challenged, although its value as a prescriptive tool is recognized even by some critics of its ethical standing (Office of Technology Assessment, 1980; Swartzman et al., 1982).

SELECTION OF AN APPROACH

The committee found that initial efforts to define its own goals and to identify the kinds of information necessary to choose among vaccine candidates simplified the task of selecting an appropriate methodology.

Neither the multiattribute accounting method nor the multiattribute scoring method satisfied the committee’s intention to make full use of available data. In addition, the methods did not permit identification of all subjective elements included in the analysis.

From the committee’s perspective, the benefit-cost approach also had two major drawbacks. First, it required that a monetary value be assigned to health benefits, such as avoidance of death, pain, and suffering. This is a very difficult and controversial task. The second problem was that the benefit-cost approach seemed to go beyond the committee’s goal of comparing ways to reduce morbidity and mortality.



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