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. QALYs and fairness
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. How to measure quality in a QALY

Why quality measurements may seem unfair

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 have an exaggerated sense of how bad life with certain physical or mental handicaps must be. Is it fair to push these people down the queue for medical treatment just because everyone else judges their lives to be of a lower quality? As long as the person who leads the life thinks it's valuable, isn't that enough? How can we compare the value that I put on my life with the value that you put on yours?

We're not talking about this kind of objection in class. 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.

But here, I'll discuss some of the relevant issues and points.

How the heck would we measure quality in the first place?

By using really sophisticated surveys. How would you rank this list of possible disabilities (best to worst)? How many years of life would you be willing to forgo to avoid this disability? How great a risk of death would you run in order to avoid suffering this disability? How many times more ill is this person (with condition X) than this person (with condition Y). And so on.

Hopefully, we'd have near unanimity on the resulting list of "states of health." Then, we'd be able to rank different outcomes in terms of quality. (Failing unanimity, hopefully the points of disagreement fall fairly close to one another on the scale; then we'd average the difference, or something).

If you're curious, check out Paul Menzel, Strong Medicine (New York: Oxford University Press, 1990), Ch. 5. (It's in the Meyer library, Green library's copy seems to be lost). I really like this book, and almost chose it for this class. The problem is that Menzel is devoted to supporting a particular theory and I wanted us to speak about a broader array of approaches.

Menzel's favored theory is a consent theory: he thinks we should justify rationing decisions by trying to find out how people want (or would want, if we asked) to make them. So, we could be justified in cutting someone off on the grounds that he agreed (or would have agreed) to be cut off.

Consequently, what he says about measuring the quality of life in QALYs is devoted to showing that these surveys he describes could be considered a kind of consent to use QALYs as the grounds for rationing care. But you don't have to worry about that: he gives a marvelous description of how the surveys would work.

Doug's point

Doug had a good question that falls into this area: how much information about a patient's prospective quality of life would we take into account? For example, a variety of sociological factors seem relevant to the quality of someone's life but, intuitively, irrelevant to whether one should receive health care or not.

For example, wealthy people typically enjoy a higher quality of life than poor people do: it's easier when you're rich. But it seems unfair to say that, if we have to choose between two patients who face the same medical problem, we should treat the rich one because he's rich (he will have a better quality of life, after all, hence, saving his life would produce a higher QALY score than saving the life of the poor patient).

One response to this kind of point is to simply exclude such information. We will assess the quality of life only from the standpoint of medical prospects or health, not by considering other factors in one's life.

That seems like the sensible thing to do: make medical decisions on medical grounds only.

But, after class, Jesús, trouble-maker that he is, brought up this example that suggests we ought to take social factors into account: compare a poor craftsman who will lose a finger with a rich guy who will lose an arm. On merely medical grounds, if we have to choose, we should treat the rich guy and save his arm. But if we took into account the fact that the poor man will lose his only source of livelihood if he loses his finger, and hence that his family will go hungry ... and so on, we'd favor the poor man over the rich man.

That suggests we ought to take the social information into account. Hmm, that strikes me as wrong, but how can I explain my opinion?

Perhaps the correct response is this. We should make medical decisions only on the basis of medical information: what are the patient's prospects for recovery, how much of the normal things people do could he do, etc. We shouldn't ask the medical system to right all wrongs and cure all injustices. What cases like Jesús's show is that we should have other social reforms so that a whole family's future doesn't depend on one finger: if the craftsman could find other work (or if a family could easily survive without having a breadwinner), then saving his finger wouldn't seem as compelling compared with saving the rich man's arm.

But, one might ask, in the absence of such reforms, shouldn't the medical system take such information into account?

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