Cost-effectiveness analyses: making a pseudoscience legitimate.

In this essay, I shall not attempt to deal with the many points raised in Peter D. Jacobson and Matthew L. Kanna’s presentation. I shall merely note that they find cost-effectiveness analyses (CEAs) inevitable, unpopular both politically and with juries, and often unacceptable in product liability cases but increasingly accepted in negligence cases and in the regulatory arena. Their future in the courts is uncertain. This seems to suggest that the lay public has difficulty finding CEAs credible. As a medical editor who sees many such analyses, and as someone who accepts that they are indeed inevitable, I think that the man in the street is perfectly right to be highly skeptical of their worth. Their unpopularity is scarcely surprising, if only because when beliefs conflict with evidence, beliefs tend to win. It seems to be against human nature to trust scientific evidence. In October 1998, I traveled from Milan to Palermo, in Sicily, where I was due to give a talk on evidence-based medicine, so I was brooding about the meaning of evidence. As I went through the metal detector in the airport in Milan, lights flashed and loud horns blared: my titanium hip showing up again. Nearby was a group of six carabinieri, arguing about football. No one took the slightest notice. I could have been carrying a hydrogen bomb. In other words, no action in the face of irrefutable evidence to act. During the flight, late at night, a youngish woman collapsed, everyone got into a panic, and, reluctantly, I responded to the call for a doctor. The cramped seating made it impossible to examine her and I had no instruments. She seemed dead to me, but