excluding a product from a nation’s essential medicines list. However, when the index used in the analysis was devised by some group of international experts and was adopted without regard to local values and priorities, such claims are an abdication of responsibility. NICE, in contrast, is at pains to make its value assumptions explicit, and it invites public comment on this and other aspects of its work, both before and after any actual analysis is done (see the agency’s website at http://www.nice.org.uk).
Relating Performance Goals to Ethical Perspectives: Liberalism The focus of utilitarians on “the greatest good,” based on an aggregate measure of well-being, leads to an insensitivity about the distribution of gains and losses within a population. In particular, strict utilitarians find it ethically acceptable to sacrifice some for the sake of others. Also, in pursuit of the greatest good, objective utilitarianism can easily lead to paternalism (and coercion): “We know what is best for you and will insist on your cooperation, whether it is immunizations, motorcycle helmets, or smoking cessation.” That lack of concern for distribution most often leads to a clash between utilitarians and another school of ethical thought that plays a prominent role in pharmaceutical policy making and in the Flagship Framework. That perspective emphasizes individual rights and is rooted in a doctrine that philosophers call “liberalism.” Like utilitarianism, liberalism is rooted in both the Enlightenment and the Reformation. Liberalism, however, takes as its point of departure the notion that all persons are independent and autonomous creatures, capable, at least potentially, of making their own decisions about how to live their lives. In this view, the role of the state is to provide a framework or context for those individuals. It is there to keep them safe, provide common services, and create a functioning political and legal system. But how people live their lives, where they go, and what they do—these are all up to their individual choices. If utilitarianism focuses on where everyone ends up (consequences), liberalism focuses on where they start. Each person’s claim to freedom and autonomy is embodied in the idea of rights. Rights are restraints against the authority of the state and claims against fellow citizens, which together embody a system of mutual respect. Neither I nor the government can tell you what to do, and vice versa (as long as your actions do not affect me). One version of liberalism, now called “libertarianism,” is characterized by a focus on everyone’s negative right to be left alone. Those negative rights, Ethics and Priority Setting in Pharmaceutical Reform
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