Is there a coherent social conception of disability?
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Is there such a thing as a social conception of disability? Recently two writers in this journal have suggested not only that there is a coherent social conception of disability but that all non-social conceptions, or "medical models" of disability are fatally flawed. One serious and worrying dimension of their claims is that once the social dimensions of disability have been resolved no seriously "disabling" features remain. This paper examines and rejects conceptions of disability based on social factors but notes that physical and mental conditions which disadvantage the individual have social dimensions. (+info)
The morality of abortion and the deprivation of futures.
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In an influential essay entitled Why abortion is wrong, Donald Marquis argues that killing actual persons is wrong because it unjustly deprives victims of their future; that the fetus has a future similar in morally relevant respects to the future lost by competent adult homicide victims, and that, as consequence, abortion is justifiable only in the same circumstances in which killing competent adult human beings is justifiable. The metaphysical claim implicit in the first premise, that actual persons have a future of value, is ambiguous. The Future Like Ours argument (FLO) would be valid if "future of value" were used consistently to mean either "potential future of value" or "self-represented future of value", and FLO would be sound if one or the other interpretation supported both the moral claim and the metaphysical claim, but if, as I argue, any interpretation which makes the argument valid renders it unsound, then FLO must be rejected. Its apparent strength derives from equivocation on the concept of "a future of value". (+info)
Human embryonic stem cells and respect for life.
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The purpose of this essay is to stimulate academic discussion about the ethical justification of using human primordial stem cells for tissue transplantation, cell replacement, and gene therapy. There are intriguing alternatives to using embryos obtained from elective abortions and in vitro fertilisation to reconstitute damaged or dysfunctional human organs. These include the expansion and transplantation of latent adult progenitor cells. (+info)
A comparison of health state utilities for dentofacial deformity as derived from patients and members of the general public.
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The cost-utility approach is a method of economic evaluation, which assigns a ratio of cost to benefit, based on utility values of the health state in question. It allows efficient use of health care resources and is a useful method in that it permits comparison of a wide range of medical interventions, including those which are life saving and those that improve quality of life. This study obtained utility values for dentofacial deformity from orthognathic patients and members of the general public using three recognized methods--rating scale (RS), standard gamble (SG), and time trade-off (TTO). There were no significant differences between the utility values for the two groups of respondents. Method agreement between the TTO and the SG (the 'gold standard') was better than that between the RS and SG. In addition, the SG and TTO were found to have greater repeatability than the RS. (+info)
Decision framework for chemotherapeutic interventions for metastatic non-small-cell lung cancer.
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BACKGROUND: Best supportive care has long been considered to be the standard therapy for metastatic non-small-cell lung cancer (NSCLC). There is now evidence from randomized trials that a number of chemotherapy regimens can palliate cancer-related symptoms and modestly improve survival. We show how cost-effectiveness analyses can be used to make choices between different (ambulatory) chemotherapy regimens. METHODS: Clinical algorithms describing the diagnosis, staging, and treatment of metastatic NSCLC were incorporated into Statistics Canada's Population Health Model. Using consistent methodology, we assessed the cost-effectiveness of several chemotherapeutic interventions: a combination of vindesine (VDS) plus cisplatin, etoposide (VP-16) plus cisplatin, vinblastine (VLB) plus cisplatin, vinorelbine (Navelbine; NVB) plus cisplatin, paclitaxel (Taxol) plus cisplatin, and gemcitabine (GEM) and NVB alone. We calculated the total chemotherapy costs in 1995 Canadian dollars, the cost per case, the average life-years saved, and the cost per life-year saved. Using the Population Health Model, we then constructed an advanced decision framework that rank-ordered the various treatment regimens so as to optimize benefit below various cost-effectiveness thresholds. RESULTS: One regimen (VLB plus cisplatin) appears to result in better survival and lower health care expenditures than best supportive care. By use of cost-effectiveness thresholds of $25,000 and $50,000 per life-year gained, NVB plus cisplatin is the preferred regimen. When quality of life is considered, however, GEM is preferred to NVB plus cisplatin at a threshold value of $50,000. At thresholds of $75 000 and $100,000, paclitaxel plus cisplatin at a dose of 135 mg/m(2) is the preferred regimen. At thresholds of $50,000 and above, best supportive care is the least preferred regimen. CONCLUSIONS: This decision framework allows the comparison of different treatment regimens based on various cost-effectiveness thresholds. Our analysis also supports the use of chemotherapy regimens and the abandonment of best supportive care as the standard of care for patients with advanced NSCLC. [J Natl Cancer Inst 2000;92:1321-9]. (+info)
Financing blood transfusion services in sub-Saharan Africa: a role for user fees?
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The provision of a secure and safe blood supply has taken on new importance in sub-Saharan Africa with the onset of the AIDS epidemic. Blood transfusion services capable of providing safe blood are not cheap, however, and there has been some debate on the desirability and sustainability of different financing mechanisms for blood transfusion services. This paper examines patterns of financing blood transfusion in three countries--Cote d'Ivoire, Zimbabwe and Mozambique. It goes on to consider the conceptual options for financing safe blood, and to examine in detail the possible role of user fees for blood transfusion in Africa, developing a simple model of their likely burden to patients based on data from Cote d'Ivoire. The model indicates that, at best, there can only be a limited role for user fees in the financing of safe blood transfusion services, due mainly to the relatively high cost of producing a unit of safe blood. Charging individuals for the blood they receive is likely to be administratively complex and costly, could realistically recover only a fraction of the production costs involved, and is further complicated by the fact that the main recipients of blood transfusion in sub-Saharan Africa are children and pregnant women. If cost-recovery for safe blood is to be attempted, the most viable option appears to be that of charging a collective fee, levied upon all inpatients, not just on those who receive blood. Such a mechanism is not without problems, not least in its failure to offer incentives for more appropriate blood use, and it is still likely to recover only a portion of the costs of producing safe blood. Whether or not cost-recovery is instituted, there will remain an important role for public funding of blood transfusion services, and, by implication, an important role for foreign donor support. (+info)
Clinical and cost implications of new technologies for cervical cancer screening: the impact of test sensitivity.
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OBJECTIVE: To compare the available techniques for cervical cancer screening, including several new technologies, using actual program utilization patterns. STUDY DESIGN: Longitudinal cohort model. PATIENTS AND METHODS: The model followed a cohort of 100,000 women who underwent screening from age 20 through 65 years. The model was run with a weighted average of screening intervals to model the actual utilization of the cervical cancer screening program in the United States. RESULTS: The model demonstrated that new technologies with significantly increased test sensitivity have the potential to reduce the number of cancers by 45% to 60% depending on the screening frequency in fully compliant populations. At screening intervals of 2 years or more, these new technologies had cost-effectiveness ratios below $50,000 per life-year saved. Assuming existing utilization patterns, the model predicted there would be 13.2 cancers per year in the 100,000 women screened with the conventional Pap smear, and new technologies with increased test sensitivity could reduce the annual incidence to 9.5 cancers per 100,000 women screened. CONCLUSIONS: The model suggests that to achieve further dramatic reduction in cervical cancer mortality, significant improvements in test sensitivity, as reflected in the new screening technologies, may be the most realistic and cost-effective approach. (+info)
What price an additional day of life? A cost-effectiveness study of case management.
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OBJECTIVE: To examine the costs and benefits of a case-management program for an elderly, functionally impaired population in a managed care setting. STUDY DESIGN: A post hoc, cost-effectiveness study of case management. SUBJECTS AND METHODS: As part of a larger study, 317 elderly, functionally impaired clients were randomly assigned to a case-managed or regular-care group. During the 2-year study period, 34 clients in the case-managed and 43 clients in the regular-care group died. A post hoc analysis of the difference in average total cost per person, death rates, and average number of days of exposure per person were assessed to determine the cost per life saved and cost per additional day of life. RESULTS: Although the average costs for the case-managed group were greater than the costs for the regular-care group, clients in the case-managed group lived an average of 106 days longer. The cost per additional day of life was $40. The difference in death rates was so small that, by extrapolation, the cost per life saved was over $42 million. CONCLUSION: Although the case-management program was more costly when viewed from a purely fiscal perspective, it may very well be considered a success when its benefits are evaluated. The case-management program improved quality and was associated with prolonged life at a cost of $40 per day of additional life. Additional research involving other patient populations, study settings, and case-management models is warranted. (+info)