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Good, Fairness and QALYs

Published online by Cambridge University Press:  08 January 2010

John Broome
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Extract

Counting QALYs (quality adjusted life years) has been proposed as a way of deciding how resources should be distributed in the health service: put resources where they will produce the most QALYs. This proposal has encountered strong opposition. There has been a disagreement between some economists favouring QALYs and some philosophers opposing them. But the argument has, I think, mostly been at cross-purposes. Those in favour of QALYs point out what they can do, and those against point out what they can't. There need be no disagreement about this. What is needed is to sort out what is the proper domain of QALYs, and it may be possible to do this amicably. Then we may be able to get on with the more useful job of deciding how well QALYs perform within their domain. In this paper I shall try to accomplish the first task (sections II–IV), and make a start on the second (sections V–VIII).

Type
Papers
Information
Royal Institute of Philosophy Supplements , Volume 23: Philosophy and Medical Welfare , March 1988 , pp. 57 - 73
Copyright
Copyright © The Royal Institute of Philosophy and the contributors 1988

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References

1 For instance, Williams, Alan ‘The Value of QALYS’, Health and Social Services Journal 18 07 1985.Google Scholar

2 For instance, Harris, John, ‘Rationing Life: Quality or Justice’Google Scholar, notes presented for a lecture to the British Medical Association Annual Scientific Meeting, 1986. Cf. Harris, John, The Value of Life (London: Routledge & Kegan Paul, 1985), 89.Google ScholarPubMed

3 Ibid.

4 Griffin, James, ‘Some Problems of Fairness’, Ethics 96 (1985), 100–118.CrossRefGoogle Scholar

5 Op.cit.

6 Broome, John, ‘Fairness and the Random Distribution of Goods’Google Scholar, in Jon Elster (ed.), Justice and the Lottery (Cambridge University Press, forthcoming). See also Broome, John, ‘Selecting People Randomly, Ethics 95 (1984), 56–67.CrossRefGoogle ScholarPubMed

7 Op.cit.

8 The only way of avoiding the non-consequentialist conclusion I am describing would be to suppose, in this example, that the young have no claim at all to the extra resources, because they already have more than their fair share. On some occasions a view like this might be right. But it cannot in general reconcile my proportional satisfaction formula with maximizing fairness. If everyone has an equal claim to a good, and their shares are actually unequal, and a small extra quantity of the good becomes available, fairness would be maximized by giving it to the person who has least. The proportional satisfaction formula, on the other hand, would say this was the fairest thing to do only if no one else has any claim at all. But it is incredible that no one else should have a claim. Suppose that, actually, the extra quantity goes to the person who already has the most. This would be unfair to the person who has the least. But if no one apart from this person has any claim at all, then it is unfair to no one else. But it is surely also unfair at least to the person who is second from the bottom.

9 Need is one of the most plausible sources of claims. See Wiggins, David, ‘Claims of Need’, in Honderich, Ted (ed.), Morality and Objectivity (London: Routledge and Kegan Paul, 1985)Google Scholar. Michael Lockwood argues from the supposition that claims are proportional to need in his contribution to this volume. Lockwood's argument has a lot in common with mine, but I disagree with his suggestion that weaker claims may justly be overridden by stronger ones.

10 There is brief discussion of these two sorts of utilitarian in my paper, op. cit.

11 Broome, John, ‘Notes on qalys’Google Scholar, in Michael Banner and Basil Mitchell (eds), Ian Ramsey Centre Report Number 2 (Blackwell, forthcoming).

12 Broome, John, ‘Utilitarianism and Expected Utility’, Journalof Philosophy 84 (1987).Google Scholar

13 Such as Sidgwick, Henry, The Methods of Ethics (London: Macmillan, 1907).Google Scholar

14 Parfit, Derek, Reasons and Persons (Oxford University Press, 1984), Part IV.Google Scholar

15 ‘Utilitarianism and New Generations’, Mind 76 (1967), 62–72.Google Scholar

16 Helge Kuhse and Peter Singer, in an unpublished paper ‘The Economic Assessment of Neo-natal Intensive Care: Some Problems’ make this point.

17 Op. cit. Part III.

18 It is spelled out more fully in Broome, John, ‘The Economic Value of Life’, Economics 52 (1984), 281–294.Google Scholar

19 See, for instance, Williams, Alan, ‘Economics of Coronary Artery Bypass Grafting’, British Medical Journal 291 (1985), 326–329.CrossRefGoogle Scholar

20 Op. cit. Part IV.

21 Ibid.

22 I have had some very useful discussion with Michael Lockwood on the subject of this paper.