Speaking about foreign policy in his 1961 inaugural address, John Kennedy said, “ . . . we shall pay any price, bear any burden, meet any hardship . . . to assure the survival of liberty.” A similar ethos was reflected in national attitudes toward medical care in that era, and the words “cost-benefit ratio” were barely part of our lexicon. If a treatment or intervention was felt to be of benefit, the relative cost was scarcely considered. Now, almost 50 years later, we have learned that we must pay more attention to how we use precious and limited resources, both with respect to foreign policy and dispensing health care. Thus, it is not surprising that Dave and coauthors1 addressed the relative cost of simultaneous vs sequential bilateral cataract surgery for infants with congenital cataracts in this issue of the Archives. In this relatively small series, they attempted to assess comparative visual outcomes, adverse events, and economic costs of 10 children who underwent sequential surgery with 17 children who underwent simultaneous surgery for treating bilateral congenital cataracts. Not surprisingly, they found no cases of endophthalmitis and no difference in other serious surgical complications in either group. Given the low incidence of endophthalmitis after pediatric cataract surgery, one would not expect such a small sample size to detect any difference in that regard. Perhaps somewhat surprisingly, they found no visual benefit with simultaneous surgery. One of the major reasons that some have advocated simultaneous surgery is the theoretical better visual outcome that might occur in the eye operated on second because of its earlier visual rehabilitation. The only quantifiable benefit they found with simultaneous surgery was economic; they found a 21.9% reduction in cost with simultaneous surgery. This raises the philosophical and ethical question “Should this cost saving play an important role in our decision about the timing of surgery for bilateral congenital cataracts?” It would be lamentable, in my opinion, if cost alone drove the answer to this question. Any proper cost-benefit analysis needs to include comparative benefits and risks. What is troubling to me about the study by Dave et al is that although they compared adverse outcomes in these 2 small groups of patients, they did not adequately discuss comparative potential risks—2 very different issues. A comparison of potential risks must be an essential part of the discussion.
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