Comparative valuation of different policy interventions often requires interpersonal comparability of benefit. In the field of health economics, the metric commonly used for such comparison, quality adjusted life years (QALYs) gained, has been criticized for failing to respect the equality of all persons’ intrinsic worth, including particularly those with disabilities. A methodology is proposed that interprets ‘full quality of life’ as the best health prospect that is achievable for the particular individual within the relevant budget constraint. This calibration is (...) challenging both conceptually and operationally as it shifts dramatically when technology or budget developments alter what can be achieved for incapacitated individuals. The proposal nevertheless ensures that the maximal achievable satisfaction of one person’s preferences can carry no more intrinsic value than that of another. This approach, which can be applied to other domains of social valuation, thus prevents implicit discrimination against the elderly and those with irremediable incapacities. (shrink)

This paper considers the problems that arise when death, which is a philosophically difficult concept, is incorporated into healthcare metrics, such as the quality-adjusted life year (QALY). These problems relate closely to the debate over euthanasia and assisted suicide because negative QALY scores can be taken to mean that patients would be ‘better off dead’. There is confusion in the literature about the meaning of 0 QALY, which is supposed to act as an ‘anchor’ for the surveyed preferences on which (...) QALYs are based. In the context of the debate over euthanasia, the QALY assumes an ability to make meaningful comparisons between life-states and death. Not only is this assumption questionable, but the ethical debate is much more broad than the question of whether death is preferable to a state of living. QALYs are derived from preferences about health states, so do not necessarily reflect preferences about events (eg, dying) or actions (eg, killing). This paper presents a new kind of problem for the QALY. As it stands, the QALY provides confused and unreliable information when it reports zero or negative values, and faces further problems when it appears to recommend death. This should preclude its use in the debate over euthanasia and assisted suicide. These problems only apply where the QALY involves or seems to involve a comparison between life-states and death, and are not relevant to the more general discussion of the use of QALYs as a tool for comparing the benefits derived from treatment options. (shrink)

The ethical problem of how to apportion limited resources amongst the needy has been forced on us by arbitrary limitation of health expenditure. Its solution would not be required if health expenditure were higher. Distribution of resources according to best value for money, assessed as Quality Adjusted Life Years (QALYs) per unit cost, has been suggested as a possible solution, but leads to absurd anomalies. In the calculation of QALYs the implied value of life is no more than (...) the absence of suffering. The use of QALYs for the comparison of treatments that are symptomatic or life-saving therefore leads to serious undervaluation of life and treatments that prolong it. Moreover, distribution of resources by best value for money, however assessed, is inequitable since for a given degree of suffering those whose illnesses happen to be cheaper to treat will be treated in preference to those whose treatments are more expensive. (shrink)

This paper explores how medical practice ought to be conducted, in the face of scarcity, if our objective is to maximise the benefits of health. After explaining briefly what the cost-per-QALY criterion means, a series of ethical objections to it are considered one by one. The objectors fall into four groups: a. those who reject all collective priority-setting as unethical; b. those who accept the need for collective priority-setting, but believe it is contrary to medical ethics; c. those who accept (...) the need for collective priority-setting, and do not believe that it is contrary to medical ethics, but reject the role of QALYs in it; d. those who accept the need for collective priority-setting in principle, but are unwilling to specify how it should be done in practice. -/- The purpose of this discussion paper is to give each group a hard time! (shrink)

The paper argues against the polarisation of the health economics literature into pro- and anti-QALY camps. In particular, we suggest that a crucial distinction should be made between the QALY measure as a metric of health, and QALY maximisation as an applied social choice rule. We argue against the rule but for the measure and that the appropriate conceptualisation of health-care rationing decisions should see the main task as the integration of competing and possibly incommensurable normative claim types. We identify (...) the main types as consequences, rights, social contracts, individual votes and community values and note situations in which the contribution of each claim type is limited. We go on to show that the integration of (at least some of) these claim types can be formalised within the mathematical framework provided by non-linear programming. (shrink)

Despite clinical evidence of drug superiority, therapeutic modalities, like combination immunotherapy, are mostly considered cost-ineffective due to their high costs per life year(s) gained. This paper, taking an ethical stand, reevaluates the standard cost-effectiveness analysis with that of the more recent justice-enhanced methods and concludes by pointing out the shortcomings of the current methodologies.

Two principles form the basis for much priority setting in health. According to the greater benefit principle, resources should be directed toward the intervention with the greater health benefit. According to the worse off principle, resources should be directed toward the intervention benefiting those initially worse off. Jointly, these principles accord with so-called prioritarianism. Crucial for its operationalisation is the specification of the worse off. In this paper, we examine how the worse off can be defined as those with the (...) fewer lifetime Quality-Adjusted Life Years (QALYs). We contrast this proposal with several alternative specifications. (shrink)

Quality-Adjusted Life Years (QALYs) and Disability-Adjusted Life Years (DALYs) are two of the most commonly used health measures to determine resource prioritization and the population burden of disease, respectively. There are different types of problems with the use of QALYs and DALYs for measuring health benefits. Some of these problems have to do with measurement, for example, the weights they ascribe to health states might fail to reflect with exact accuracy the actual well-being or health levels of individuals. (...) But even if these weights represent accurately the well-being levels of individuals, there is room for questioning whether these measures capture everything that we care about in these cases, or whether there are important issues that they leave out, including considerations of fairness or equality. In this regard, the measures have been criticized for treating the aggregation of small benefits as greater than the aggregation of fewer but bigger benefits,1for disregarding fair chances in favor of utility maximization,2and for raising problems when applied in the context of variable population size.3Perhaps one of the most pervasive ethical issues that has been associated with the use of these measures is the fact that they seem to discriminate against disabled people.4Since the measures assume that disabled people have lower well-being and a shorter life span, treating a disabled person’s medical condition contributes less to the maximization of years of life with good health than treating a non-disabled patient’s medical condition. (shrink)

QALY calcuations are currently being considered in the UK as a way of showing how the National Health Service (NHS) can do the most good with its resources. After providing a brief summary of how QALY calculations work and the most common arguments for and against using them to set NHS priorities, I suggest that they are an inadequate measure of the good done by the NHS because they refer only to its effects on what will be defined as the (...) ‘patient community’. The benefit of the NHS to the wider community is best regarded as a public good—everyone benefits from the general belief that the NHS is there to provide care for those who fall into a state of medical need. QALY ideology threatens this belief because it gives efficiency a higher priority than caring in response to need. It is a fallacy that a QALY maximising health service will be a greater good to society, because this sort of quest for efficiency threatens the caring basis of the Welfare State as such. (shrink)

The value of health states is often understood to depend on their impact on the goodness of people's lives. As such, prominent health states metrics are grounded in particular conceptions of wellbeing – e.g. hedonism or preference satisfaction. In this paper, I consider how liberals committed to the public justification requirement – the requirement that public officials choose laws and policies that are justifiable to their citizens – should evaluate health states. Since the public justification requirement prohibits public officials from (...) appealing to controversial conceptions of the good life, liberals committed to this principle face a significant puzzle. (shrink)

Warwick Heale has recently defended the notion of individualized and personalized Quality-Adjusted Life Years in connection with health care resource allocation decisions. Ordinarily, QALYs are used to make allocation decisions at the population level. If a health care intervention costs £100,000 and generally yields only two years of survival, the cost per QALY gained will be £50,000, far in excess of the £30,000 limit per QALY judged an acceptable use of resources within the National Health Service in the United (...) Kingdom. However, if we know with medical certainty that a patient will gain four extra years of life from that intervention, the cost per QALY will be £25,000. Heale argues fairness and social utility require such a patient to receive that treatment, even though all others in the cohort of that patient might be denied that treatment. Likewise, Heale argues that personal commitments of an individual, that determine how they value a life-year with some medical intervention, ought to be used to determine the value of a QALY for them. I argue that if Heale’s proposals were put into practice, the result would often be greater injustice. In brief, requirements for the just allocation of health care resources are more complex than pure cost-effectiveness analysis would allow. (shrink)

The arguments used by Gavin Mooney in his scornful response to Castigating QALYs, are examined. In spite of the rhetoric there is a broad measure of agreement about the deficiencies of QALYs as a means of distributing scarce resources. The main area of conflict is that John Rawles favours compaigning for more resources while Gavin Mooney, constrained by his remit as a health economist, favours acceptance of the present level of funding and better methods of distributing resources.

Counting QALYs (quality adjusted life years) has been proposed as a way of deciding how resources should be distributed in the health service: put resources where they will produce the most QALYs. This proposal has encountered strong opposition. There has been a disagreement between some economists favouring QALYs and some philosophers opposing them. But the argument has, I think, mostly been at cross-purposes. Those in favour of QALYs point out what they can do, and those against (...) point out what they can't. There need be no disagreement about this. What is needed is to sort out what is the proper domain of QALYs, and it may be possible to do this amicably. Then we may be able to get on with the more useful job of deciding how well QALYs perform within their domain. In this paper I shall try to accomplish the first task (sections II–IV), and make a start on the second (sections V–VIII). (shrink)

John Rawles's criticism of QALYs are seen as being both imprecise and largely unhelpful. This paper accepts that there are problems in both QALYs themselves and in the current decision-making processes with which they seek to help. The QALY pliers tend to play down the former and the QALY knockers the latter. It is suggested that theories (regret theory and prospect theory) other than expected utility theory, which is normally seen as the basis for QALYs, may provide (...) better approaches to measuring health service outputs. Thus equity, information and decision-making per se are not handled as well in the expected utility QALYs as they could be. Developing better QALYs, with qualifications, is the goal. (shrink)

The current British Government's policy towards resource allocation for health care has been informed by the commissioned Wanless Report. This makes a case for the use of quality adjusted life years (QALYs) to form a rationale for resourcing health care and has implications for the staff and patients who work in and use the health service. This article offers a definition of the term ‘QALY’ and considers some of the strengths and weaknesses of this approach to resource distribution. An (...) account is also given of an alternative formula, the DALY (disability adjusted life years), which can address some of the problems that are associated with QALYs. The values of the public, patients and nurses are identified and linked to the potential effect of a QALY formula. The implications of QALY use are applied to the health care of patients and a discussion is offered with regard to whether this method of resource allocation can be considered as just. (shrink)

Despite progress, discrimination in public health remains a problem. A significant aspect of this problem relates to how medical resources are allocated. The paradigm of quality-adjusted-life-year (QALY) dictates that medical resources should be allocated on the basis of units measured as length of life and quality of life that are expected after the implementation of a treatment. In this article, I discuss some of the ethical shortcomings of QALY, by focusing on some of its flawed moral aspects, as well as (...) the way it relates to discrimination on the basis of age, race, and disability status. I argue that while this approach seeks to maximize efficiency, it does not place sufficient value on the preservation of life itself. Even more concerning is the fact that the use of QALY disproportionately harms minorities. While QALY is a well-intentioned approach to the allocation of scarce healthcare resources, new alternatives must be sought. (shrink)

Lifetime quality-adjusted life-year (QALY) prioritarianism has recently been defended as a reasonable specification of the prioritarian view that benefits to the worse off should be given priority in health-related priority setting. This paper argues against this view with reference to how it relies on implausible assumptions. By referring to lifetime QALY as the basis for judgments about who is worse off lifetime QALY prioritarianism relies on assumptions of strict additivity, atomism and intertemporal separability of sublifetime attributes. These assumptions entail that (...) a health state at some period in time contributes with the same amount to how well off someone is regardless of intrapersonal and interpersonal distributions of health states. The paper argues that this is implausible and that prioritarians should take both intrapersonal and interpersonal distributions of goods into account when they establish who is worse off. They should therefore not accept that lifetime QALY is a reasonable ground for ascribing priority and reject lifetime QALY prioritarianism. (shrink)

Kerstein and Bognar (2010) and Persad, Wertheimer, and Emanuel (2009) defend specific principles for the allocation of health care resources, but their choice of principles is influenced by the exa...

This paper presents a case for allocating health care resources so as to maximise Quality Adjusted Life Years (QALYs). Throughout parallels are drawn with the grounds for adopting utilitarianism. QALYs are desirable because they are essential for human flourishing and goal-attainment. In conditions of scarcity the principle of QALY maximisation may involve unequal treatment of different groups of people; and it is argued that this is not objectionable. Doctors in their dealings with patients should not be continually consulting (...) the principle (though it can sometimes be useful); instead by following existing ethical codes more QALYs will be produced overall. In the formulation of policy, however, the principle should be applied in a thoroughgoing way and, if it is, it will not have some of the counterintuitive consequences it may have in interpersonal situations. (shrink)

A recent article has claimed that one of the significant benefits which people in the UK derive from the existence of the National Health Service must be lost if the Service adopts the QALY maximisation principle to allocate medical resources. The argument fails, partly because its author conflates two distinct benefits. The first is almost certainly important, but there is no reason to believe that it would be lost if the principle were introduced (while there is some reason to believe (...) that the benefit would actually be greater). The second, once it is isolated from others with which it may be confused, is much less obviously important; and in any case there is again no reason to believe that it would be lost. Moreover, to argue against the principle on the ground that the second benefit would disappear is really to beg the question against the principle. We could not justify our rejection of the principle on the ground that the principle's adoption would mean that we lost the second benefit. (shrink)

Quality Adjusted Life Years (QALYs) have become a household word among health economists. Their use as a means of comparing the value of health programmes and medical interventions has stirred up controversy in the medical profession and the academic community. In this paper, I argue that QALY analysis does not adequately take into account the differentiated nature of the health state values it measures. Specifically, it does not distinguish between needs and preferences with respect to its valuation of health (...) states. I defend the view that needs and preferences are clearly distinguishable, and that the concept of needs cannot be dispensed with, as many health economists suggest. It is argued that the scale along which health states are measured in QALY analysis is not a continuous interval scale, but one which concerns two distinctly different value dimensions. Measuring the values of health state intervals may reveal the weighting attached to the different value dimensions. (shrink)

The use of Quality-Adjusted Life Years (QALYs) in healthcare allocation has been criticized as discriminatory against people with disabilities. This article considers a response to this criticism from Nick Beckstead and Toby Ord. They say that even if QALYs are discriminatory, attempting to avoid discrimination – when coupled with other central principles that an allocation system should favour – sometimes leads to irrationality in the form of cyclic preferences. I suggest that while Beckstead and Ord have identified a (...) problem, it is a misdiagnosis to lay it at the feet of an anti-discrimination principle. The problem in fact comes from a basic tension between respecting reasonable patient preferences and other ways of ranking treatment options. As such, adopting a QALY system does not solve the problem they identify. (shrink)

Practitioners of palliative care often argue for more resources to be provided by the state in order to lessen its reliance on charitable funding and to enable the services currently provided to some of those with terminal illnesses to be provided to all who would benefit from it. However, this is hard to justify on grounds of cost-effectiveness, since it is in the nature of palliative care that the benefits it brings to its patients are of short duration. In particular, (...) palliative care fares badly under a policy of QALY-maximisation, since procedures which prevent premature death (provided the life is of reasonable quality) or improve quality of life for those with longer life expectancy will produce more QALYs. This paper examines various responses to this problem and argues that in order to justify increased resources for palliative care its advocates must reject the ‘atomistic’ view of the value of life implicit in the QALY approach in favour of a ‘holistic’ or ‘narrative’ account. This, however, has implications which advocates of palliative care may be reluctant to embrace. (shrink)

The drive for cost-effective use of medical interventions has advantages, but can also be challenging in the context of end-of-life palliative treatments. A quality-adjusted life-year (QALY) provides a common currency to assess the extent of the benefits gained from a variety of interventions in terms of health-related quality of life and survival for the patient. However, since it is in the nature of end-of-life palliative care that the benefits it brings to its patients are of short duration, it fares poorly (...) under a policy of QALY-maximization. Nevertheless, we argue that the goals of palliative care and QALY are not incompatible, and optimal integration of palliative care into the calculation of QALY may reveal a mechanism to modify considerations of how optimal quality of life can be achieved, even in the face of terminal illness. The use of QALYs in resource allocation means that palliative care will always compete with alternative uses of the same money. More research should be conducted to evaluate choices between palliative care and more aggressive therapies for the terminally ill. However, current limited data show that investing in palliative care makes more sense not only ethically, but also financially. (shrink)

The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtained from health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives of people with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. The reason for this is that the quality of life of those with illness or disability is ranked, on the QALY scale, below that of (...) someone without a disability or illness. Hence we can, other things being equal, gain more QALYs by saving the lives of those without a permanent disability or illness than by saving the lives of those who are disadvantaged in these ways. But to do so puts these disadvantaged people under a kind of double jeopardy. Not only do they suffer from the disability or illness, but because of it, a low priority is given to forms of health care that can preserve their lives. This, so the objection runs, is unjust or unfair. This article assesses this objection to the use of QALYs as a basis for allocating health care resources. It seeks to determine what is sound in the double jeopardy objection, and then to show that the defender of QALYs has an adequate response to it. (shrink)

What proportion of available healthcare funds should be allocated to hip replacement operations and what proportion to psychiatric care? What proportion should go to cardiac patients and what to newborns in intensive care? What proportion should go to preventative medicine and what to treating existing conditions? In general, how should limited healthcare resources be distributed If not all demands can be met?

This book is a comprehensive account of what it means to try to quantify health in distributing resources for health care. It examines the concept of QALYs which supposedly makes it more accurate to talk about life in terms of both quality and quantity of years lived when referring to health care policy. It offers an elegant new approach to comparing the costs and benefits of medical interventions. Cost-Utility Analysis is a method designed by economists to aid decision makers (...) distribute scarce resources to areas of health care where they will yield the greatest benefits. Erik Nord questions the feasibility of measuring patients' quality of life meaningfully in numerical terms, as CUA presupposes. He presents an alternative approach called cost-value analysis in which representative samples of the general public express preferences between different health-care programs. In this approach, subjects are allowed to include concerns for fairness that go beyond concerns for efficiency of conventional health economics. (shrink)

This paper explores the symbolic and material implications of the use of DALYs and QALYs as priority or tie-breaker criteria in triage decisions. It aims to answer the question of their ethical permissibility based on the particular case of the COVID-19 pandemic. For this purpose, theories framed in a queer-crip perspective and ethical frameworks of equity will be used. From a queer-crip perspective, the use of DALYs and QALYs in triage decisions discriminates against and excludes people with disabilities, (...) as it allocates scarce resources based on ableist value judgments about people's quality of life, rather than on evidence. From the point of view of equity, it may imply and reinforce structural injustices involving inequities, that is, avoidable or remediable inequalities. This analysis will argue that the use of DALYs and QALYs categories in triage decisions allocates potentially life-saving resources based on ableist value judgments that lead to an unfair distribution of risks, burdens, and costs. Finally, two objections related to the relevance or necessity of using these or similar categories as criteria will be addressed: the independent cases of structural inequities and the inevitability of setting priorities in the face of a crisis. (shrink)

I would like to thank Whitehurst et al for their comments on my paper.1 Although I will argue their approach will not eliminate the potential for disability discrimination from quality-adjusted life year -based assessment, their comments were very thought provoking. Whitehurst et al argue that, to the extent that allocating healthcare by QALYs discriminates against disabled patients, the fault is not with the QALY framework, but with ‘the descriptive systems of preference-based health-related quality of life instruments’.1 Specifically, they argue (...) that some HRQoL survey instruments do not characterise health impairments adequately. For example, Whitehurst et al mention an earlier study of HRQoL survey instruments that had different ways of asking about mobility. Some instruments asked specifically about the respondent’s ability to walk, while others asked about mobility. The study found that, in relation to individuals with spinal cord injuries, survey instruments focused on ability to walk produced lower quality of life scores than instruments focused on mobility. Whitehurst et al argue from this that survey instruments should include ‘adequate’ health state descriptions. This seems eminently sensible. However, contrary to their view, there is no guarantee that this will avoid discrimination. In fact, …. (shrink)

This book is a comprehensive account of what it means to try to quantify health in distributing resources for health care. It examines the concept of QALYs which supposedly makes it more accurate to talk about life in terms of both quality and quantity of years lived when referring to health care policy. It offers an elegant new approach to comparing the costs and benefits of medical interventions. Cost-Utility Analysis is a method designed by economists to aid decision makers (...) distribute scarce resources to areas of health care where they will yield the greatest benefits. Erik Nord questions the feasibility of measuring patients' quality of life meaningfully in numerical terms, as CUA presupposes. He presents an alternative approach called cost-value analysis in which representative samples of the general public express preferences between different health-care programs. In this approach, subjects are allowed to include concerns for fairness that go beyond concerns for efficiency of conventional health economics. (shrink)

This book is the outcome of a European Commission-funded project on resource allocation in health care. It is co-authored by a philosopher, an epidemiologist, a public health medicine specialist and a health economist. Its range is broad, covering the historical, economic, methodological and philosophical aspects of healthrelated quality of life and its measurement.

The introduction of National Institute for Health and Clinical Excellence (NICE) guidance on Alzheimer's medication in November 2006 will have a significant effect on the treatment of patients, and is opposed by the Royal College of Psychiatrists and many charities dealing with the elderly. The use of the Quality-Adjusted Life Year (QALY) in the guidance formulation is much debated due to questions of ageism. This article seeks to examine the basis of these accusations and whether NICE can be justified using (...) a utilitarian calculation in a principally egalitarian system such as the NHS. (shrink)

Policy-makers must allocate scarce resources to support constituents’ health needs. This requires policy-makers to be able to evaluate health states and allocate resources according to some principle of allocation. The most prominent approach to evaluating health states is to appeal to the strength of people’s preferences to avoid occupying them, which we refer to as decision utility metrics. Another approach, experienced utility metrics, evaluates health states based on their hedonic quality. In this article, we argue that although decision utility metrics (...) face a number of significant problems, the appropriate response to these problems is not to replace them with experienced utility metrics. Rather, decision utility metrics should be employed in conjunction with experienced utility metrics. Specifically, respondents to decision utility surveys should be provided with the results of experienced utility metrics in an effort to make their decisions better informed and more robust to the deficiencies of decision utility metrics. Ultimately, this approach would improve quality-adjusted life year calculations and enhance the decision-making of policy-makers in allocating resources to support constituents’ health needs. (shrink)

This book contains a sustained defense of the Quality Adjusted Life Years (QALY) approach to resource allocation in health care. According to this approach resources should be allocated in such a way that the number of QALYs gained is maximized. The authors place this approach within a broader preference Utilitarian framework and argue that it is a special case of consequentialism specifically relevant to the health care field. The first two chapters of the book give a basic introduction to (...) the health care economic aspects of QALYs and a basic introduction to the purpose of ethical reasoning. The three subsequent chapters form the core of the book and contain a systematic defense of the QALY approach against all the main criticisms that have been put forward in the literature. The final chapter contains the results of a survey of the attitudes and reasoning of the Australian public with regard to resource allocation. (shrink)

One widely used method for allocating health care resources involves the use of cost-effectiveness analysis (CEA) to rank treatments in terms of quality-adjusted life-years (QALYs) gained. CEA has been criticized for discriminating against people with disabilities by valuing their lives less than those of non-disabled people. Avoiding discrimination seems to lead to the ’QALY trap’: we cannot value saving lives equally and still value raising quality of life. This paper reviews existing responses to the QALY trap and argues that (...) all are problematic. Instead, we argue that adopting a moderate form of prioritarianism avoids the QALY trap and disability discrimination. (shrink)