Explicit Cost-Effectiveness Thresholds in Health Care: A Kaleidoscope

Although the principles of cost-effectiveness analysis have been adopted by health systems worldwide, a large majority of countries remain reluctant to specify explicit threshold values for cost-effectiveness. Nonetheless, by aiming to benchmark what counts as a reasonable ‘price’ for health gains, the threshold value is a linchpin in the framework of health technology assessment, albeit also a controversial one. The desirability of thresholds depends largely on three claims: their intention to make resource allocation more efficient, their aspiration to make decision-making more transparent and their objective to make healthcare systems more sustainable. In this paper, we draw from various disciplines such as health economics but also psychology, anthropology, sociology, political sciences and ethics to discuss the many facets of these three values, related to the threshold debate. We discuss issues of allocative efficiency, fair decision-making, realpolitik, taboos, institutional justice and the rule of rescue. Based upon these considerations, which together substantiate the precautionary principle, we conclude that the case against thresholds is stronger than the case in favor and that most countries are right to be reluctant to use explicit threshold values.