WHAT IS FAIRNESS?

In both a caring-for-others and a self-interest perspective, members of society generally feel that some categories of patients have stronger moral claims on scarce health-care resources than others. I shall shortly discuss various factors that determine the strength people assign to such claims. I define a fair resource allocation in health care as one that accords with societal feelings about the strength of claims of different patient groups (Broome 1988; Lockwood 1988). A resource allocation that violates such feelings is defined as unfair.

QALYS AND FAIRNESS

The QALY approach rests on the assumption that the health-care system should aim at maximizing health benefits with the resources that are available, irrespective of how these benefits are distributed across people. In the first twenty years of QALYs, this assumption of distributive neutrality was rarely questioned by economists, perhaps because in the field of economics generally it is felt that the role of the economist is to work for efficiency and leave distribution to others. Unfortunately, in the area of health, redistribution is not separable from the achievement of efficiency.

The view of QALYs as ultimate indicators of societal value manifested itself in terms of so called QALY league tables (Williams 1985; O'Kelly and Westaby 1990; Smith 1990). In an often quoted article on “the foundations of cost-effectiveness analysis for health care and medical practices,” Weinstein and Stason (1977) recommend that “alternative programs or services are then ranked, from the lowest value to the highest, and selected from the top until available resources are exhausted.”