Problems with preferences Notes for September 28

Main points

We talked about QALYs for two reasons.

First, they’re interesting. The attempt to come up with a unit of measurement that can allow us to compare treatments that enhance the quality of life with treatments that save lives is a noble and worthy project.

Second, the problems with QALYs reveal deeper problems for attempts to give people what they want in health care. The problem is that it’s quite unclear just what we want.

An illustration

Suppose we tried to answer the kind of question that Dworkin and Menzel press on us. Looking forward, what health risks do you want to insure against, given that the cost of insurance will come from other things you want to do? They both try to use this question to answer questions about when society could legitimately refuse to pay for an otherwise effective medical treatment. Why? It’s what you would have wanted. You would have wanted the resources to pay for the treatment to go to something else.

Anyway, most of us would answer this question by trading off years of compromised health for full health. That is, we would give up years of life for greater quality of life.

But now suppose we tried to answer a different question. When do you think that society should favor treatments that enhance the quality of life over those that save lives? Our answers will tilt in the other direction. We will be much more reluctant to trade years of compromised health for years of greater quality of life.

In other words, our preferences for how the social system should work will frustrate our preferences for our own lives. If our social ideals are put into place, we will be paying for insurance that we do not think is worth the cost. That is, we will forgo other things that we think are more valuable than insuring against these risks.

So what kind of health system do we want? It isn’t clear to me. Since that is so, I don’t know how to give people the health system that they want.

I tried to show how many of the problems Menzel noted for QALYs fit this pattern.

I don’t mean that things have to stay stuck. We all have conflicting desires, but we often want one thing more than the other. When that’s so, there’s no problem: you want the one thing more than the other even though, of course, you want both. Sometimes, conflicts are the product of irrationality: you think you want something that, if you were thinking clearly, you don’t. So there may well be ways of clearing up just what we want. I only meant to pose the problem, not to foreclose the possibility of a solution.

On that note, I give you the following video. It’s more partisan than I think is appropriate for a class. But this line fit the theme of today’s class too well: “I would rather die in freedom than live a long, healthy life in some Communist gulag like Canada.”

This page was written by Michael Green for PPE Senior Seminar, PPE 190, Fall 2009. It was posted September 29, 2009.
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