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
15 May. QALYs and fairness
18 May. The veil of ignorance argument
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: 22 May. QALYs in macro and micro contexts

A few notes on Lockwood

Every paragraph is a separate argument (more or less). Don't be surprised if you have a hard time finding the thread that runs through the whole piece: I'm not sure there's one to find.

Lockwood uses the word "welfarism" a lot: it's a technical term for a class of theories of distributive justice. Roughly, here's how it works. Welfarist theories assess the fairness of distributive decisions (i.e. decisions about who lives, who dies; who gets the treatment, who doesn't, etc.) by comparing the quality of life as perceived by the affected people. By contrast, "resourcist" views hold that we should divide our resources fairly, (resources such as money or access to the health care system) even if some people wind up with a significantly greater level of perceived quality of life than others do.

How do we compare health care with other uses of our resources?

One advantage that the QALY approach has over Harris is that it can compare the value of health care with the value of other kinds of spending. Someone who thought we should maximize the number of QALYs would, consistently, hold that we should stop spending resources on health care when alternative investments outside of health care could do more to improve the quality of our lives.

Harris, by contrast, seems committed to spending any amount of money on health care as long as doing so saves lives (see "QALYfying the value of life," p. 122).

That seems like a hard position to defend. Isn't there a point at which the value of a life saved is outweighed by the amount of value we could add to other people's lives by, e.g. spending on schools, roads, parks? Must we be willing to abandon everything else in the hope of saving as many lives as possible?

Proposal: use QALYs only in making macro-level decisions, not micro-level ones

Macro decisions are decisions about research projects, hospital building, and what kinds of treatment to fund. The use of non-random rationing rules (such as "maximize QALYs") to make these decisions may be less objectionable than the use of such rules in micro decisions. This is the direction I was drifting. I think there's something to be said for it. It seems a lot better than making macro-decisions randomly, for example. Still, there would be some problems.

Palliative care, for example, seems to be obviously necessary (recall our discussion of euthanasia). But it doesn't gain many QALYS. So it wouldn't be well-funded if we were committed to maximizing QALYs in our macro decisions.

On the other hand, palliative care wouldn't be favored by the rule that tells us to save as many lives as possible either.

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This page was originally posted on 5/27/98; 12:08:46 PM and was last built on 6/3/98; 2:44:19 PM with BBEdit and Frontier 5 on a Macintosh running System 8.1.