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This chapter starts from the observation that a sense of adversity is bound into modern risk-thinking. Evoking risk conveys to the contemporary mind that a negatively valued outcome is causing concern. However, because risk-taking entails multiple consequences, undesired outcomes must also be balanced against potential gains. The ideas of positive risk-taking and autonomy/safety balancing are discussed in relation to the recognition of multiple consequences. It is then argued that the standard notion of an ‘adverse event’ misleadingly projects acts of valuing onto outcomes, directing attention away from potential differences of perspective. This issue is explored through a critique of quantitative approaches to expected value, such as the calculation of quality-adjusted life years (QALYs). The final part of the chapter reviews social scientific explanations for organized risk selection, addressing the question of why societies and social groups might focus on certain risks whilst ignoring or neglecting others.

A large part of health economics concerns the methodology of informing the best way to allocate health‐care resources at the social level, and the actual delivery of such information. One typical analytical approach is called the cost per QALY analysis, where health gains are quantified in terms of QALYs (Quality-Adjusted Life-Years). The QALY is a composite measure of the duration of survival and the health‐related quality of life associated with each period of survival. This chapter examines the nature of the QALY as the desideratum; why should we regard the QALY as the desideratum in health care? Two schools of thought are discussed. The welfarist school holds that the QALY is the desideratum because it is a representation of people's utility associated with their own health state. The non‐welfarist school proposes an alternative view and argues that the QALY is the desideratum because this is what publicly funded health‐care systems are set up for. The second part of the chapter looks at different ways in which individual QALYs can be aggregated across the population, in the form of a health‐related social welfare function, in order to facilitate economic evaluations.

The field of bioethics, many would argue, began with the creation of a committee in Seattle 1960 to decide who would be given access to kidney dialysis when there were not enough of those new machines to go around. Eventually, Congress decided to pay the costs of those who need dialysis, an expensive procedure. That program has constantly expanded over the years, the average age of those needing dialysis keeps rising, and the costs are enormous. No limits have ever been set on paying for the program, although there has been widespread agreement that such limits are necessary. A variety of possible means for setting limits are explored: the use of medical criteria, age, a fixed annual budget for the program, quality-of-life years, and means testing. Each of them faces technical and often political obstacles, and none seems near acceptance. It may well be that only a national financial crisis will create the momentum and underline the obvious need for cost control of dialysis.

This chapter starts with an inquiry into the nature of different outcome measures that are being used in the medical literature, emphasizing an important distinction between incommensurable versus commensurable measures. The quality-adjusted life year (QALY) represents the most widely used commensurable metric. A key issue is how to value health-related quality of life (HRQoL) on a [0–1] scale by the use of health-state utility instruments. In addition to the health outcomes that are accounted for in the QALY measure, productivity gains might occur as a result of previously sick people returning to work. The chapter discusses the methodological and the equity issues involved when determining the extent to which production gains should be included in an economic evaluation. Finally, the theory behind the willingness-to-pay method is briefly explained, and contrasted with some measurement problems when applied as a way to value health benefits.

This chapter looks anew at John Harris’s critical discussions of the Quality Adjusted Life Year (QALY) and its use determining the just allocation of health care resources. It is argued that Harris presupposes that the QALY is grounded in subjective evaluations of the experience of health and illness, and that the justice of its application may be assessed by examining how individual subjects would be differentiated through QALY calculations. It is argued that this misconstrues the intended use of QALYs, and fails to reflect recent developments in QALY research. If a subjective interpretation is replaced by an intersubjective interpretation, such that the values and meanings expressed by a QALY matrix are understood to be the results of communication and negotiation between human subjects, then the QALY may be defended as an important resource for facilitating reflection on the moral challenges of health care allocation.

This chapter examines the techniques used by health economists to evaluate the value for money of health promotion initiatives. It first provides an overview of concepts related to economics and health economics, including efficiency, equality, equity and accessibility. Efficiency can be evaluated in terms of cost-minimisation, cost-effectiveness, cost-benefit and cost-utility. The chapter then considers the various rationing strategies by which the NHS can try to reduce expenditure, the use of QALYs to compare the cost-effectiveness of health promotion projects, and conjoint analysis. It also explains how health economists calculate the cost to society of unhealthy lifestyles such as obesity and smoking, and goes on to tackle the question of prevention vs cure in health promotion, the expenditure on the NHS, and the limitations of health economics in evaluation of health promotion endeavours. The chapter concludes with an assessment of how to estimate the costs of health promotion.

Chapter 16 gives an overview of cost-effectiveness and cost-benefit analysis. Every year millions of dollars are spent on food and nutrition intervention programs that are designed to improve health. Given money can always be spent in many different ways leads to a natural question: How effective was the program, relative to how much it cost? There are two standard approaches to answering this question: a cost effectiveness analysis and a cost benefit analysis. The chapter covers the main questions that must be answered in doing either a cost effectiveness or cost benefit analysis. The main formulas in each approach are presented. The pros and cons of each approach are discussed. A hypothetical nutrition intervention program is carried throughout to provide context for the discussion.

Speculative reason is an important aspect of practical reason and one of the core activities in Socratic moral reason. Speculating, or posing ‘what if?’ questions when reasoning about ethics can take a number of forms and these are some of the most useful methodological tools for bioethics. Perhaps the most common form of speculative reason for bioethics is the argument from analogy, which involves comparing an ethical response to one situation with our response to another similar situation to see whether we are consistent in our ethical judgment. Speculative reason can aim at deepening our moral understanding by making the implications of ethical choices more vivid. A third form of speculative reason is what I call an intuition pump. Speculative reason is used to tease out intuitions about a possible but hypothetical situation in order to advance our ethical thinking about similar cases. Finally, speculative reason can have a more heuristic function in that it encourages us to think about an area of ethics in a different way.