The Quality Adjusted Life Year (QALY) is a unit that allows us to make quantitative comparisons of an otherwise diverse set of health treatments. It measures the value of treatments on two dimensions: how much they improve the quality of life and how much they extend time alive.
The chapter we read covered some of the central questions about QALYs. Menzel’s reason for discussing them is driven by his theory about how to justify rationing decision. Specifically, he is interested in the extent to which QALYs can be used to identify prior consent to rationing of health care.
Daniel started us off with a question that Menzel hadn’t addressed. Suppose that for any level of health, a rich person is likely to enjoy a higher quality of life than a poor person in equivalent health. The wealthy can afford all sorts of aids, for example, that can make life with a disability significantly more tolerable. So if health policy attempts to maximize quality adjusted life years, it would have to favor wealthy patients over poor ones. And that struck Daniel as objectionable.
Three things struck me about Daniel’s point. First, he’s right to find this objectionable. He’s also right to see that as a plausible extension of the QALY idea.
Second, I don’t think it occurred to Menzel to discuss this because the standard ways of computing QALYs don’t take this into account. The surveys he mentioned just asked people to assess the quality of life in different states of health. Perhaps they should have asked questions about states of health and wealth in order to be fully consistent. But, in fact, they don’t.
Third, I think that those who wish to use QALYs should take Daniel’s point to heart and refrain from collecting information about the effects of wealth on the quality of life. As he argued, there are good ethical reasons for doing that, even if it comes at the cost of following the ideas to their fullest logical conclusion.
Menzel is not committed to any particular use of QALYs. He’s just interested in the extent to which the surveys used to come up with the numbers can be used to indicate where consent to rationing decisions might lie. That said, he seems generally favorable to the project, while admitting some limitations.
Nina put her finger on a very important problem, though. There’s a big difference in the judgments people make about the quality of life with a disability that depends on whether they live with the disability or not. Generally speaking, people without a disability rank the quality of life with the disability as lower than the people who have the disability do. (Interestingly, health professionals tend to agree more with the people who have disabilities than with those who don’t.)
If we think that people who have a condition know better about the value of life with that condition, then that throws a wrench in Menzel’s project. That project consists in looking at what kinds of health care people would want to be available in advance of knowing their specific needs. That’s how they make choices about how to set the health budget relative to other uses of their resources and about how to allocate the health budget to different kinds of care.
If the point of view of a person who does not have a health condition is inferior to the point of view of a person who has it, then this is the wrong question to ask.
Menzel notes another thing here. It is that if you followed the QALY approach, there would be different effects on the relative ranking of life enhancing treatments and life saving treatments for people with disabilities. But, as Menzel points out, people with disabilities put a lot of value on both treatments that would cure their condition and on treatments that would save their lives. That means that they basically reject the QALY approach entirely. Menzel himself thinks that some use of QALYs is inevitable, but he doesn’t really explain what that is. Maybe the idea is that QALYs would not be used in making decisions about these sorts of treatments but could be used for others.
Remember, it’s consent that’s important for him, so if consent involves only occasional use of QALYs, that’s OK as far as he is concerned. Still, it’s fair to point out that he didn’t really say how they would or would not be used under his system.
An overly mechanical use of QALYs could get strange results when looking at saving years of life for different numbers of people. Again, consent might be used to produce a less mechanical way of using them.
Professor Brown brought up another consideration. It’s not just how many years of life you have, or even the quality of those years from your perspective, that matters. She said that she would be especially concerned to insure the years of her life when she was raising her children, even if it meant giving up some coverage in other parts of her life.
This led to a discussion of the social influences on our desires and whether those should count against treating, say, women’s consent to sacrifice all the years of their lives for the sake of the years devoted to raising their children.
My references to Gregory Mankiw’s taxes were probably obscure. He wrote an op-ed published in the New York Times about the effects of raising marginal tax rates. The predictable outrage on the left ensued. Another economist, Brad DeLong, criticized the editorial in interesting ways.