Utilitarianism and the ethical foundations of cost-effectiveness analysis in resource allocation for global health

Efficiency as quantified and promoted by cost-effectiveness analysis sometimes conflicts with equity and other ethical values, such as the rule of rescue or rights-based ethical values. We describe the utilitarian foundations of cost-effectiveness analysis and compare it with alternative ethical principles. We find that while fallible, utilitarianism is usually superior to the alternatives. This is primarily because efficiency - the maximization of health benefits under a budget constraint - is itself an important ethical value. Other ethical frames may be irrelevant, incompatible with each other, or have unacceptable implications. When alternatives to efficiency are considered for precedence, we propose that it is critical to quantify the trade-offs, in particular, the lost health benefits associated with divergence from strict efficiency criteria. Using an example from HIV prevention in a high-prevalence African country, we show that favoring a rights-based decision could result in 92-118 added HIV infections per $100,000 of spending, compared to one based on cost-effectiveness.