We are talking about Quality Adjusted Life Years (QALYs) because it gives us a test case to think about fairness and the original position. Today’s class introduced the charge against QALYs while Thursday’s class will bring the original position in to try to determine whether the charge is accurate.
QALYs are used to compare different ways of allocating resources to health care. The idea is that resources should be allocated so as to produce the greatest number of QALYs. That, the idea goes, represents the most efficient use of our health care budget.
As the name suggests, the Quality Adjusted Life Year is a unit that takes into account both the length of life and the quality of life. Quality is measured from 1 (full health) to 0 (death) and length is measured in numbers of years.
If a treatment would prolong my life for five years and in each of those years my life will have a quality measured at .9, that treatment will be worth 4.5 QALYS (5 years × .9 QALYS/year).
If a treatment would improve the quality of my life from .8 to .9 and I expect to live 20 years, that treatment would be worth 2 QALYs (20 years × .1 QALYs/year).
Individuals might sensibly use QALYs to think about care for themselves. If I have to decide between two treatments and one will give me a longer lifespan while the other will give me greater quality of life, I could calculate the QALYs that each treatment would produce to decide what to do.
QALYs are controversial when they are used to make decisions about how to allocate resources among different people. Harris thinks that a society that used QALYs in this way would be unjust. His case goes like this.
The first two points are moral assumptions that Harris does not argue for. Most of his article is devoted to substantiating the third point. In order to do that, he presents a number of cases that, he believes, illustrate the point.
Ageism. Assuming other things are equal, younger patients will live longer than older ones. So a society that sought to maximize QALYs would favor younger patients over older ones (Harris 1987, 119).
Race and sex. If some treatments have better outcomes for the members of one racial group or gender than they do for others, a society that seeks to maximize QALYs will give those treatments to one race or sex in preference to the others (Harris 1987, 119).
Harris asserts that this is not just hypothetical but true for some medical treatments. Alas, I don’t know what he has in mind. But it probably does not matter as he could have made his point by looking outside of medicine. The lives of the poor and oppressed have lower quality scores than the lives of the rich and comfortable; after all, the poor and oppressed think their lives would be better if they were rich and comfortable. So saving the life of a rich and comfortable person will produce more QALYs than saving the life of a poor and oppressed person. It does not matter if poverty is explained by race, gender, class, or any other factor.
Double jeopardy. Saving the lives of people who have congenital health problems will produce fewer QALYs than saving the lives of people who are in full health. After all, congenital health problems reduce the quality of life. Harris thinks this means those who have health problems face what he calls double jeopardy: their condition reduces the quality of their lives and it also reduces the odds that they will be saved if they face a different, life-threatening condition if they live in a society that seeks to maximize QALYs (Harris 1987, 119–20).
Saving life vs. enhancing the quality of life. Hip replacement operations are relatively inexpensive and significantly improve the quality of life for those who get them. Kidney dialysis is relatively expensive and merely preserves the lives of those who receive it. So it can turn out that a society dedicated to maximizing QALYs will choose to buy hip replacements rather than kidney dialysis, even if this means that the kidney patients die unnecessarily (Harris 1987, 120).
In all of these cases, Harris’s basic point is the one that Semassa summarized so well. The vast majority of people put the same value on their lives. One year of life for an old person in poor health is just as precious for that person as a year of good health is for a younger person.
More to the point, according to the first two premises in Harris’s argument, this is the way that a society should value its members’ lives: as equally precious.
Harris, John. 1987. “QALYfying the Value of Life.” Journal of Medical Ethics 13: 117–23.