Medical Ethics
Michael Green
Manuel Vargas
phone, office information

11 May. Numbers don't count.
13 May. Aggregation and Kamm.
13 May. Glover
15 May. How to measure quality in a QALY
18 May. The veil of ignorance argument
22 May. QALYs in macro and micro contexts
27 May. Rakowski and Post on preferring the younger.
29 May. How great a loss is death?
3 June. Consent as a way out?

Medical Ethics: 15 May. QALYs and fairness

Two issues

One may object that any measurement of the quality of life will have to treat some people unfairly. What about those who have a different understanding of the quality of life than is used by the health care rationer?

Many people would view my quality of life as low: I have little income (relative to my skills and training) and work very long hours. (Others think it's unrealistically great -- they wind up going to graduate school and only find out the truth later on). But I happen to think my job is worth the low pay and long hours; it's not nirvana, but I get to talk about philosophy with really intelligent people, who pay me for the privilege (that's you, by the way)! So, I think my quality of life is pretty high. Wouldn't it be unfair to judge the quality of my life according to the standards that the majority of people employ? It's my life, after all.

We're not talking about this kind of objection. We're assuming that we have an objective measure of the quality of life and Harris is arguing that even then maximizing QALYs would be unfair. If you want to see some discussion of the controversies surrounding the fairness of the measurement of quality, see the next page.

Harris's discrimination argument

Harris argued that QALYs can be unfair if a minority group that suffers unfair discrimination has a disproportionate need for a particular expensive treatment. The members of that group would suffer both unfair treatment in the society as a whole and "discrimination" in the health care system, insofar as they would be less likely to receive the expensive treatment they need than others who need less expensive treatment.

It's true that that's possible. But there's nothing necessarily objectionable about the use of QALYs (if we used QALYs in rationing, we'd discriminate, but only in the sense that we'd be drawing distinctions between patients). It's possible that white males will be the losers in a QALY-scheme. Maybe the treatments they disproportionately need score low on the QALY scale. So I have trouble seeing this as a fundamental objection to using QALYs.

I suppose Harris might be saying that if we followed the rule "maximize QALYs" we would ignore other, possibly relevant, social facts. Thus, we might accidentally compound injustices in the society as a whole.

That's true, and it would be bad if that's what happened. But I wonder whether that's an appropriate argument for those making health care decisions to take into account. I would think this is a matter of broad social concern, something that should be addressed by the society as a whole and not just within the health care sector of our society. Health care policy should be made on medical grounds, in my opinion. That way, we're making decisions for the right reasons: health care decisions on medical grounds, social decisions on social grounds.

Still, why should health care policy makers blind themselves to the broader social context in which they work?

Some of Singer, et. al.'s cases that we didn't discuss

I take it that the thrust of the list of examples that begin the article is to convince us that we need a more general way of thinking about the problem (the veil of ignorance) and that it's fruitless to continually compare example with example with example. Still, here are my notes on the two examples we didn't cover.

Karen and Lisa

Karen, paraplegic with constant pain; QALY score of life as is .5
Lisa, has a limp, no pain; QALY score of life as is .95
life expectancy for each: 40 years.

Choice: treat Karen or treat Lisa (can't do both)

Karen's prospective QALY score (if not treated): .5 x 40 = 20
Lisa's prospective QALY score (if not treated): .95 x 40 = 38

Karen's yearly QALY score with treatment: .75
Lisa's yearly QALY score with treatment: 1.0

Karen's total QALY score with treatment: .75 x 40 = 30
Lisa's total QALY score with treatment: 1.0 x 40 = 40

Total QALYs if we treat Karen: 30 + 38 (Lisa's untreated score) = 68

Total QALYs if we treat Lisa: 20 + 40 = 60

If we maximize QALYs, we'll treat Karen: no double jeopardy here.

Michele and Nina

Michele is a paraplegic, like Karen; prospective QALYs, if she lives = 20

Nina has a limp, like Lisa; prospective QALYs, if she lives = 38

treatment this time won't relieve their condition, only keep them alive: both need heart transplants, but there's only one heart.

Rationing health care by QALYs will favor Nina. This seems to put Michele in double jeopardy: she loses after already suffering from being a paraplegic.

Otto and Richard

Both have heart conditions, like Michele and Nina.

Otto has a separate condition that will kill him; his life expectancy is 20 years whereas Richard's is 38. Their quality of life is roughly equal.

Richard will get the heart, if we maximize QALYs. Thus, allocating by QALYs will favor Nina and Richard for the same reason.

A preference for Richard makes sense, to Singer, et. al.. After all, time matters: what if Richard had 38 years and Otto only 2?

But if it isn't unfair to prefer Richard over Otto, why is it unfair to prefer Nina over Michele?

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