Maximisation in extra-welfarism: A critique of the current position in health economics

This paper explores critically the use of 'maximisation' as a decision rule within extra-welfarism. Although extra-welfarism in theory focuses on a broader evaluative space than that of utility, in practice there is a narrowing to a focus on health alone; this clear disjoint is one of the factors that makes discussion of extra-welfarism difficult. In this paper we focus on the reality of extra-welfarism as currently practiced (that is, as health maximisation). The paper questions whether a change (from welfarism to extra-welfarism) of the evaluative space from utility to health, automatically implies a change in the rule for decision making from utility maximisation to health maximisation. Both theoretical and empirical grounds are considered. It is reasoned here that the separation of efficiency and equity associated with welfarism is no longer possible within a health evaluative space. Thus any maximisation of health is instead aligned with Bentham's felicific calculus, and implies the acceptance of an ethical basis of utilitarianism. Empirical grounds for maximisation, based on the views of members of society, do not seem to support such a utilitarian ethical basis for the production and distribution of health. This leaves health economists very much relying on perceptions of decision makers' values in their support of health maximisation. (C) 2009 Elsevier Ltd. All rights reserved.