Hostname: page-component-78c5997874-8bhkd Total loading time: 0 Render date: 2024-11-19T07:22:36.295Z Has data issue: false hasContentIssue false
  • English
  • Français

Allocating Healthcare By QALYs: The Relevance of Age

Published online by Cambridge University Press:  29 July 2009

John McKie ,
Helga Kuhse ,
Jeff Richardson  and
Peter Singer
John McKie
Affiliation:
Resources Development Officer in the Centre for Human Bioethics, Monash University, Melbourne, Australia.
Helga Kuhse
Affiliation:
Director of the Centre for Human Bioethics at Monash University, Melbourne, Australia. and Editor of Bioethics News and with Peter Singer, of Bioethics.
Jeff Richardson
Affiliation:
A Professor of Health Economics at Monash University, and the Director of the Health Economics Unit at the Centre for Health Program Evaluation at Monash University, Melbourne, Australia.
Peter Singer
Affiliation:
Deputy Director of the Centre for Human Bioethics, Monash University, Melbourne, Australia.
Get access Rights & Permissions [Opens in a new window]

Extract

What proportion of available healthcare funds should be allocated to hip replacement operations and what proportion to psychiatric care? What proportion should go to cardiac patients and what to newborns in intensive care? What proportion should go to preventative medicine and what to treating existing conditions? In general, how should limited healthcare resources (people, facilities, equipment, drugs…) be distributed If not all demands can be met?

Type
Articles
Information
Cambridge Quarterly of Healthcare Ethics , Volume 5 , Issue 4 , Fall 1996 , pp. 534 - 545
Copyright
Copyright © Cambridge University Press 1996

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Notes

1. See, Torrance, GW. Measurement of health state utilities for economic appraisal. Journal of Health Economics 1986;5:3.CrossRefGoogle ScholarPubMed

2. Harris, J. QALYfying the value of life. Journal of Medical Ethics 1987;13:117–23.CrossRefGoogle ScholarPubMed

3. Rawles, J. Castigating QALYs. Journal of Medical Ethics 1989;15:143–7.CrossRefGoogle ScholarPubMed

4. Hope, T, Sprigings, D, Crisp, R. 'Not clinically indicated': Patient's interests or resource allocation? British Medical Journal 1993;306:379–81.CrossRefGoogle ScholarPubMed

5. See note 2. Extending this criticism, Harris argues that the cost-per-QALY approach dictates providing aid to a country whose citizens have a normal average age in preference to a country whose citizens have a high average age, even if the high average age of the latter country is a result of its young people being killed in a war, or lost to famine or some other natural disaster, because the lower the average age of a country the higher the potential QALY gain from healthcare.

6. See, Bentham, J. An Introduction to the Principles of Morals and Legislation. New York: Anchor/Doubleday, 1973.Google Scholar

7. Mill, JS. Utilitarianism and On Liberty. New York: Anchor/Doubleday, 1973.Google Scholar

8. See notes 6,7. Bentham, . 1973.Google ScholarMill, . 1973.Google Scholar

9. Hare, RM. Moral Thinking: Its Levels, Method and Point. Oxford: The Clarendon Press, 1981.CrossRefGoogle Scholar

10. See, Wagstaff, A. QALYs and the equity-efficiency trade-off. Journal of Health Economics 1991; 10(1):23.CrossRefGoogle ScholarPubMed

11. In this connection it is worth correcting a misleading statement by Wagstaff, to the effect that QALYs are a measure of a person's health rather than the utility he or she derives from it. Note 10. Wagstaff. 1991:23. This is not quite accurate. The QALY incorporates information about preferences for health states rather than health states themselves. It tells us nothing about such medical conditions as arthritis, cancer, or diabetes, but rather about the undesirability (or “disutility”) of the consequences of such medical conditions: needing to use a wheel chair or walking stick, being in pain, having trouble dressing or bathing, and so on. In this sense, the QALY is a measure of utility rather than health, Wagstaff to the contrary notwithstanding. However, it incapsulates only one component of utility: namely, health-related quality of life.

12. See note 1. Torrance, . 1986:17.Google Scholar

13. Daniels, N. Equity of access to healthcare: Some conceptual and ethical issues. Milbank Memorial Fund Quarterly 1982;60(1):53.Google ScholarPubMed

14. Lockwood, M. Quality of life and resource allocation. In: Bell, JM, Mendus, S, Eds. Philosophy and Medical Welfare. Cambridge: Cambridge University Press, 1988.Google Scholar

15. Kappel, K, Sandoe, P. QALYs, Age and Fairness. Bioethics 1992;6(4):297–316.CrossRefGoogle ScholarPubMed

16. Support for the second version of the “fair innings argument” might be sought in the views of Callahan on the goals of medicine. (Callahan, D. Setting Limits: Medical Goals in an Aging Society. New York: Simon and Schuster, 1987.Google ScholarCallahan, D. What Kind of Life—The Limits of Medical Progress. New York: Touchstone, 1991.) Callahan argues that healthcare resources, even if they are relatively ample, should not be allocated with the aim of indefinitely extending the life of the elderly but only for the full achievement of a fitting life span. Callahan maintains that there is a natural life span, which it is not desirable to strive to exceed.Google Scholar

17. See note 14. Lockwood, . 1988:50.Google Scholar Kappel and Sandoe (note 15) have expressed the same view: “If we give the liver to the older person, he will get another ten years on top of those 60 that he has already got. And he will end up with 70 life years. Whereas if we give the liver to the young person he will only end up with a total of thirty life years. To give the liver to the older person is like giving money to the rich rather than to the poor.” (See note 11. Kappel, and Sandoe, . 1992:314.)Google Scholar

18. See note 7. Mill, . 1973.Google Scholar

19. Daniels, N. Am I My Parents' Keeper?: An Essay on Justice Between The Young And The Old. New York: Oxford University Press, 1988:18.Google Scholar

20. It should be noted, however, that the prudential life span approach depends on a certain view of personal identity that might be questioned; namely, that we should think of the elderly as the same persons as the young at a later stage of their lives. Underlying this view is the assumption that personal identity is an all-or-nothing affair and survives marked changes in character, beliefs, life-style, and so on. An alternative view has it that personal identity comes in degrees, corresponding to the degree of bodily and psychological connection between our earlier and later selves. If we take this view, the moral problem of distributing resources among different groups of people, characterized by stage of life, becomes a much more complex problem. (For more on the connec- tion between ethics and different views about personal identity see, Parfit, D. Later selves and moral principles. In: Montefiore, A, Ed. Philosophy and Personal Relations: An Anglo-French Study. London: Routledge and Kegan Paul, 1973:137–69.)Google Scholar

21. Battin, MP. Age rationing and the just distribution of health care: Is there a duty to die? Ethics 1987;97:326.CrossRefGoogle Scholar