As we have been discussing in class there are two ways to approach healthcare policies rooted in beneficence: utilitarianism which aims to create policies that do the most good for the greatest amount of people versus libertarianism which aims to create policies that maximize individual choice. Within the approach of utilitarianism there is an economic component known as Cost-Effectiveness Analysis (CEA) which “measures the benefits in nonmonetary terms, such as years of life, quality-adjusted life-years, or cases of disease,” (Beauchamp and Childress 231) in order to better understand the different values of outcomes for all patients. Within CEA, one of the ways to help decide which patients should be saved or which medical treatments to utilize, healthcare professionals have measured HALYs, health-adjusted life-years, which combine longevity of life with health status. Specific types of HALYs are QALYs, quality-adjusted life-years which “are calculated by estimating the year of life remaining for a patient following a particular pathway and weighting each year with a quality of life score” (Beauchamp and Childress 239). Thus, what this means is in situations where physicians are trying to determine which path of medical treatment to use, they incorporate the calculation of QALYs to figure out which treatment will not only give the patient the longest life possible but also the best quality of life.
Although the main goal of QALYs is to bring good to the greatest amount of people, there are some challenges and problems that accompany these calculations. First of all, QALYs require the measurement of quality of life which is a discussion that was brought up earlier in class which highlighted that there are many different interpretations of quality of life so it can be difficult to standardize such measurements. Despite this challenge, “analysts start with rough measures, such as physical mobility, freedom from pain and distress, and the capacity to perform the activities of daily life and to engage in social interactions” (Beauchamp and Childress 239). Secondly, as QALYs are used to create public health policies it is important that the notion of egalitarianism is maintained that way “each healthy life-year is equally valuable for everyone” (Beauchamp and Childress 240).
Lastly, the concept of Rule of Rescue which according to David Hadorn is “people’s perceived duty to save endangered life whenever possible” directly conflicts with QALYs since this rule demands out of beneficence that all lives should be saved if possible while QALYs limit that to saving only those who will have better outcomes. An interesting idea brought up by Shepley Orr and Jonathan Wolff in their article is that of a “rescue-adjusted QALY.” In their article, they propose the idea that when QALYs are calculated there would be an “additional value of rescue [where] rescue could be given extra weight in our calculations but not the apparent absolute weight called for by adherents of the rule of rescue” (Orr and Wolff 531). According to this idea, both the principle of beneficence and the concept of QALY policy would be better served by incorporating the element of rescue to the measurement of outcomes. This would enable beneficence to be more easily recognizable since the act of doing good through physical rescue would become pronounced. Also, the QALY policy side of the situation would also be represented since this adaption would not be removing the calculations of life-years or the quality life of those life-years but rather adding an extra component to be considered.
Work Cited:
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York, NY: Oxford University Press, 2001.
Orr, Shepley, and Jonathan Wolffe. “Reconciling Cost-Effectiveness with the Rule of Rescue: the Institutional Division of Moral Labour,” Theory and Decision. http://link.springer.com/article/10.1007/s11238-014-9434-3
Laura,
This is a very interesting argument that you bring up about the challenges of quality-adjusted life-years. While I agree that this is in theory a good method, like many ethical dilemmas, it has its major flaws. I think the biggest flaw in this method is that quality of life is a very objective measurement and could mean many different things for many different people. Quality of life is a subject that is nearly impossible to subjectify, though, analysts have tried to do so. In my opinion, you can analyze that subject as much as you want, but you will never get everybody to agree on a scale for how to methodize quality of life.
As far as making “each healthy life-year is equally valuable for everyone”, in the healthcare system, just like any other large public system, this is also nearly impossible to accomplish (Beauchamp and Childress 240). The fact of the matter is, no one person is the same so it is very hard to treat them all the same and give them the equal care that they need. Some people end up needing more assistance than others.
It is safe to conclude that yes, QALYs is a good idea in theory and in a perfect world would work great in our healthcare system, but in reality, and when put into practice, it has major flaws that make it almost impossible to work as it was designed to. I think your conclusion about the Rule of Rescue and adding an extra component to be considered as the best choice is a very good plan. It incorporates factors of beneficence and seems like the best option in all cases that could be considered in the future.
Works Cited:
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. New York, NY: Oxford University Press, 2001.
Orr, Shepley, and Jonathan Wolffe. “Reconciling Cost-Effectiveness with the Rule of Rescue: The Institutional Division of Moral Labor,” Theory and Decision.
Hi Laura!
Really interesting blog post! I came away from the readings with pretty similar feelings with regards to the QALY and its ethical implications. As Shelby mentioned in her comment, I too think one of the major ethical dilemmas presented by this method is the fact that quality of life is not static; it changes with age and varies from person to person so coming up with a standard quality of life that ALL people adhere to appears to be an impossible task. While the QALY assumes that “’given the choice, a person would prefer a shorter healthier life to a longer period of survival in a state of severe discomfort and disability’”, can you argue that all people with disabilities would prefer a shorter life or live a lower quality life than their “non-disabled” peers (Harris 118)? As we talked about earlier in the semester, while surveying spinal injury patients and Emergency Room professionals, only 18% of the physicians believed these patients could reach a positive quality of life; however 92% of the spinal injury patients claimed they had an acceptable and positive quality of life (Koch 422-423). This drastic discrepancy between how “normal” people versus disabled people view quality of life should serve as evidence against the QALY method, which is determined by able-bodied individuals. As you mentioned in your post, physical mobility and capacity to perform activities of daily life both influence the QALY measure. Just because an individual is wheelchair-bound, or may need assistance even post treatment with daily activities does not mean that their life should be scaled as lesser than that of someone who can walk freely and take care of themselves. I do not think that it is right for individuals who have a subjectively higher quality of life to always be a priority over treatment of individuals who may have disabilities or “lesser” life quality.
Ultimately I completely agree with your stance on the QALY measurement and the ethical dilemmas it proposes. While in a perfect world it may work, the current measurements used to determine an individual’s QALY score appear to unjustly favor certain individuals over others based on how one group of most likely healthy, able-bodied people may view quality of life.
References:
Harris, J. “QALYfying the Value of Life.” Journal of Medical Ethics 13.3 (1987): 117-23. Web
Koch, Tom. “Life Quality vs the `quality of Life’: Assumptions Underlying Prospective Quality of Life Instruments in Health Care Planning.” Social Science & Medicine 51 (2000): 419-27. Web.
I agree that it’s difficult to define and use QALY measurements. Individual assessments are definitely subjective to an extent, especially since there is no way of a surveyor to be able to feel the level of pain or despair that the patient is feeling. It’s interesting, however, that individuals’ assessments of their health on a simple, 1 question scale is one of the most effective measurements of health and mortality rate over the next few years, right behind age, but still more than doctor assessment (see “Respondent-assessed fair-poor health status, by selected characteristics: National Health Interview Survey, United States, selected years 1991-2013” if you’re interested in one of the studies that shows this).
There is some room for QALYs, and the response by patients should be carefully considered. However, they definitely are not the end-all-be-alls of treatment decisions.