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| Cost utility analysis (cua) and moral justification | Liviu Oprea
Medic Primar Medicina de Familie, Master in Bioetica, Case Western Reserve University, Cleveland, Ohio
E-mail: liviu_oprea2001@yahoo.com
| Abstract
Background: Health care resources are limited. Consequently Health economists developed in late 1960s Cost-Utility Analysis employing Quality Adjusted Life Years (QALYS) as a method for the rationing of health care resources. The ethical underpinnings of Cost Utility Analysis lie in classical utilitarianism, of providing the maximum health gain for the greatest number of people. The objective of this essay is to analyze how morally justifiable is a policy employing CUA as a rationing method in health care resource allocation.
Methods: MEDLINE database was searched using terms as patients autonomy, human rights, policy analysis, justice, and cost-utility-analysis for 1996-2005.
Findings: Utilization of CUA for resource allocation and rationing of health care services for cost containment reasons aroused a debate about moral infringements of such a policy. While the pro arguments emphasize the maximization of health gains in the society as a goal of health care sectors, the con arguments underscore that this method is unfair, discriminating people based on their life expectancy and quality of life with serious consequences on distributive justice.
Conclusion: In this paper I built an argument against QALYS as systematic policy. I argued that an alternative for rationing care is to promote reforms based in consumer preferences which will move competition in the healthcare system to the level of diseases and treatments that might fuel better care and lower costs. My arguments against a systematic employment of CUA were: (a) that it provides a negative incentive for health care providers in distributing what already exists and not in creating a new value which on the long run might add new costs; (b) CUA employing QALYS is a serious infringement of autonomy rights, promoting discrimination on morally irrelevant features like age and quality of life. I argued that CUA is an unfair policy, likely to produce health inequities and stigmatization of vulnerable groups of population, which is not based on a clear support from a societal standpoint. However, my arguments were limited to rationing scarce resources that result from inefficiency or monopoly not "intrinsic scarce resources" like organ for transplantation or very expensive services.
Key words: QALYS, Cost Utility Analysis, Rationing Care, Policy Analysis, Patient Autonomy, Human Rights
Introduction
Health care resources are limited. Consequently, a process of rationing care should be an intrinsic part of any health care system. Health economists developed in late 1960s Cost-Utility Analysis employing Quality Adjusted Life Years as a method for the rationing of health care resources. The ethical underpinnings of Cost Utility Analysis lie in classical utilitarianism, of providing the maximum health gain for the greatest number of people. However the argument against QALYS emphasizes its discriminatory powers against persons with limited capacity to benefit either because they are old or severely ill. This essay aims to analyze how morally justifiable is a policy employing Cost-Utility Analysis, as a rationing method in health care resource allocation. In the first part of this paper I will briefly describe the technical features and ethical underpinnings of QALYS method, as well as its relationship with the general moral principles. In the second part I will critique, from ethical viewpoint, a policy employing cost utility analysis for rationing health care resources, by assessing its necessity, efficiency, proportionality, and fairness.
Cost Utility Analysis
Under conditions of scarcity, both private and public health care organizations either in USA or internationally, set priorities regarding which health care services will and will not be funded. In the late 1960s, health economists, operation researchers and psychologists developed Quality Adjusted Life Years (QALYS) for use in Cost Effectiveness Analysis. It has two components: health related quality of life and life expectancy. (1) (2) (22) Health related quality of life is described on a scale from 0, representing death, to 1, considered to be full health. The health related quality of life associated with different conditions of health or disease is multiplied by life expectancy and finally produces an estimate of quality adjusted life years (QALYS) associated with different levels of health. Health Adjusted Life Expectancy estimates the average time in years that a person of a specific age is expected to live in equivalent of full health. They conceptualized in this way the health outcome, which is the denominator of the Cost-Effectiveness Ratio. Consequently this ratio describes the incremental price of obtaining a unit of health gain from a specific health intervention when compared with an alternative procedure. When a cost-effectiveness ratio uses as a denominator QALYS, it is called cost-utility analysis (CUA). It is considered useful when quality of life is an important outcome of an intervention and for having a common unit of measurement for comparing different types of procedures and programs. Given a healthcare budget, CUA can maximize the quality adjusted life years, measured as individual utility and aggregates of individuals. QALYS originate in the theoretical underpinnings of welfare economics and utility theory. Accordingly, a social utility function is the aggregate of individual utilities and economists hold that maximization of the social utility is the primary goal of resource allocation. It is often associated with utilitarianism, which states that policies designated to improve social welfare should do the greatest good for greatest number of persons.
Calculation of QALYS
Calculation of QALY involves three steps: (a) description of health as a health state, (b) development of values or weights for health states which are health related quality of life weights, and
(c) combination of values for different health states with estimates of life expectancy. (1)(10)(22)
(a) Description of Health Status
Health Status is built using health related quality of life weights that are attached to individual experiences of health. HRQL is not related to any particular disease or disability, being based on the value individuals attached to their own health state or others attached to their own state. Health state is conceived based on different attributes which are considered to be central to the concept of health. (1) There were developed different standardized instruments (EuroQol, Quality of Well-Being Scale, etc) (1) (10) (22) which incorporate values like physical, psychological status, social role function, health perception and symptoms. These are values considered to be shared across different cultures, ages or genders.
(b) Generation of Values for Health
Once an illness or disability is described its desirability must be valued in such a way that allows it to be combined with life expectancy. Technically each measure is anchored on a 0 to 1 scale as mentioned above, where 0 is death and 1 full health, concordant with the concept that QALYS is measuring the health expectance, a good that must be maximized. The scale is designed with intervals, for allowing comparisons between changes from a health state to another, between different groups. This is technically necessary because years of life and HRQL must be combined in a single metric. (1) (10) (22)
Health Related Quality of Life is generated through surveys using a series of techniques among which standard gamble (SG) and time trade-off (TTO) are the most common. (1) (10) (22) In TTO respondents are asked how many years of their life in a specific health condition they would sacrifice to live the other years in full health. In SG respondents are asked what risk of death they would accept to be cured for a specific condition. The economists hold that these techniques are reliable, because eliciting preferences in this manner is consistent with utility theory, about how people make decisions under conditions of uncertainty. They used rating scales for this purpose.
(c) Combination of HRQL with Life Expectancy
QALYS are created by multiplying values for health related states or conditions by life expectancy. The proponents of QALYS underscore the consistency of this method with clinical tradition, where efficiency of an intervention is appreciated by life extension and quality of life improvement or symptom relief. Life expectancy information is drawn from observational studies, clinical trials or standard population life tables. (1) (22)
Ethical underpinnings of QALYS
QALYS is designed to support resource allocation framework and is largely utilitarian in its interventions. The goal of Cost-Utility Analysis employing QALYS is to accurately represent outcomes that can be generated most efficiently per monetary unit spent, so that the total good for a population or community is maximized. The proponents of QALYS provide four arguments for supporting it. First, regarding utilization of age as a criterion for priority setting in health care, Allan Williams (8) (10) claims that the solution for the conflict between the principle of justice and effectiveness, when it comes to make priorities in health care, is the argument of intergenerational equity. Based on this account, young should have priority for life extending care because the old had already the opportunity to live more years, and it would be fair to give the young the chance to live those additional years. The fair-innings argument is based on the intuition that everybody is entitled to some normal life span. Therefore those who fall short under this are somehow cheated while the others who are beyond are living on "borrowed time". QALYS is not directly using age as criterion for priority. However utilization of life expectancy in calculating QALYS is using indirectly age as a criterion.
Secondly the benefits are outcome oriented, and defined in terms of life extension and improvement of quality of life. (10) This seems to be in concordance with the role of healthcare providers, because enhancing health is indisputably in concordance with the healing role of medical profession. In the same time the method follows the consequentialist tradition of relying on outcomes and not on means or processes. Moreover the value of benefits is determined by people's preferences, which is important from the utilitarian viewpoint of maximizing the utility, but also from the perspective of public justification of a policy if implemented.
Thirdly the benefits can be quantified, based on QALY method, which is an empirical measurement of the life extension and associated quality of life, produced by any specific program.
Finally it is egalitarian in the sense that preferences does not take into account the social status, race, wealth, IQ, which are morally irrelevant factors. The method is egalitarian in the health domain in the sense that each individual's health is counted equally. Resource allocations based on QALYS, is also egalitarian, ranking programs from lowest to highest cost per QALYS. Therefore every one's QALYS are counted equally, and nobody stands in favored position. (6)
QALY and General Moral Principles
While at first sight the arguments provided by proponents of QALYS are attractive from a distributional point of view, this method can be problematic for some subgroups that cannot benefit so much, as calculated with QALYS method, from medical care. Consequently the QALYS approach gives low priority to patients with limited capacity to benefit in terms of quality of life or life extension, and fails to favor persons which are worst-off. Certain groups of individuals, like the elderly who inexorably have fewer years to live as well as disabled persons who lack capacity for significant improvement are considered under this method as bad healthcare investments. When CUA is applied for specific interventions in elderly people or devoted for people with limited capacity to benefit, QALYS will always rate low these ones. Both limitations either in term of life extension or quality improvement yield fewer QALYS. This is an infringement of the principle of justice. Although CUA is egalitarian and as Amartya Sen (27) claims a justice theory could not have any plausibility in the contemporary world, if it did not value equality in some space, I will argue that this approach does not apply equality principle at the right place. The equality principle is an abstract idea, (27) and does not have much cutting power. The central step is the specification of the space in which equality is to be sought. For instance an income egalitarian would appreciate an equal distribution of incomes, and a committed democrat must insist on equal political rights, while CUA counts each person's health equally and is promoting an egalitarian distribution of healthcare resources employing the cost per QALY. Undertaking a relativist approach, Allan Williams argues in the same context, (0) that in defining, what is just or what is fair, no one expects unanimity, since justice is an essentially contested concept. Consequently there are competing concepts of justice, all having respectable arguments in their favor. Therefore any justice concept might label different positions, as wrong or good in connection with their own conceptions. However he tends to omit that human rights which are part of numerous international declarations and conventions, might be seen as a common universal morality, and subsequently CUA should comply with this framework. From this standpoint all persons have equal rights and as I will show later in this paper, CUA is not respecting the equal rights for life and health, being discriminatory.
QALYS also imply an infringement of the principle of beneficence. It is true that clinical tradition look to beneficence in terms of life extension and improvement of quality of life. However the notion of benefit as incorporated in the QALYS concept do not rely on individual life extension but on life expectancy, and not on quality of life as perceived by individuals but as generated by general public. Consequently there is little difference between the impacts of treatment of elderly people as compared with younger persons. (17) A treatment can extend the life of an older person or improve its quality, but application of the QALYS method will result in opposite outcomes. This is endorsed by the American Medical Association (25) which states that programs which utilize age as a criterion for health care rationing fail to recognize that chronological age is not necessarily an indicator of severity of illness or recuperative ability of individual patients, nor is it an absolute predictor of the efficiency of the treatment. Therefore employing this approach might be equal with denying a treatment that a particular person might medically benefit, for social reasons. This would be equal with harming that person.
Moreover, as mentioned above, the method relies on general public preferences regarding the quality of life. On the other hand, quality of life is a personal value based concept, with large variance from individual to individual. From this standpoint this method can be seen as imposing others' values on individuals, with consequences on autonomy rights.
Policy Analysis
CUA analysis is already employed in many health care systems for cost containment reasons both in developed and developing countries. In the UK it is already practiced through their National Health System. (24) (26) Consequently age of 55 is utilized as the cut-off for certain health care services, among the most common mentioned is access to dialysis services. Therefore their per-capita health care expenditures are one-third of that of USA. (24)
However a prospective payment system, employing Diagnose Related Groups (DRG) introduced by Medicare in 1982, for increasing efficacy of the healthcare system, succeeded in being a rationing tool for the care of hospitalized elderly. (24) Medicare system's of reimbursing through DRGs caused rationing to be instituted because hospitals are no longer reimbursed on costs, but rather on a fixed amount for the particular diagnosis. Therefore an incentive of doing as little as possible eliminated any extraordinary or expensive procedures on Medicare patients. The DRGs system currently applies only in hospitals but Medicare is expected to develop a similar tool for prospective payment for outpatient services. (24) Moreover the US is the only industrialized country that does not guarantee access to healthcare for all its citizens, and currently millions of Americans have no insurance, while its healthcare system is the most expansive system in the world. Therefore for increasing access to care, implementation of a rationing program is likely in the future for the US health care system. (25)
In the developing countries, (23) (29) healthcare system reform is a high priority subject for local governments as well as for international institutions including the World Bank. One of the (23) (29) goals of health care system reformation in developing countries, stated in World Development Report, is the improvement of the aggregate health status. Advocates argue (23) that states can achieve the largest improvement in population health status by allocating limited resources to the provision of treatments for those diseases which have the highest health impact per dollar spent, implying a cost utility analysis for priority setting.
While rationing of care, is intended to increase the access of care, and decrease the health risks of uninsured persons, and subsequently to promote people's health, one might legitimately question to what extent human rights should be limited to promote a common good. Human rights instruments often express a norm, and then go to specify conditions under which they might be limited usually for attainment of common good. (18) They are prima facie norms, and consequently a legitimate question regarding the infringements implied by using QALYS is whether they are justified. Lawrence Gostin offers a framework for the exercise of public policy powers, (18) stating that a policy should be necessary, effective, proportional with human rights, and fair. Because cost-utility analysis is acting in the public space, being promoted by governments and international agencies, I will analyze it employing these criteria.
Necessity
Rationing health care resources, using CUA might be considered a good policy whenever its proponents or health care decision makers can demonstrate its necessity for averting an important risk. There is no doubt that the costs of healthcare are rising at a rate which is not comparable with any other industry. Health care costs continue to rise both in absolute value as well as percentage from Gross Domestic Product in USA. (13) In 1960 the per-capita health care expenditure in USA, was $ 146, in 1980 increased to $ 1,067, and in 1998 reached the value of $ 3,760. It is estimated that in 2010 the health care expenditures will double as compared with year 2001. (13) A recent survey (11) of employer-based insurance showed that in the last four years the inflation of health care costs was double digit each year. Between 2001 and 2004 the costs insurance premiums raised 59%. Consequently the percentage of the employees covered by their own employer health plan dropped from 65% in 2001 to 61% in 2004. This survey identified that five million fewer jobs provided health insurance in 2004 as compared with 2001. Looking to this statistics we might say that rationing care would be a solution for cost containment.
While the literature refers to what kind of costs should be included in cost utility analysis, when is about the sources of costs, the recommendation is to include existing market prices in health care system. (23) While World Development Report suggests utilization of disability adjusted life years (DALYS), instead of QALYS in reformation of health care systems in developing countries, is worth mentioning that the costs that were included in cost-effectiveness analysis were assessed at market prices and considered to be the same across all countries. Although they recognize that costs in developing world might be lower, (29) the proponents argue that it is not possible to rely on them because of markets failure. While this might be true, the underlying assumption is that health care systems in countries with established market economies are highly efficient. From this standpoint when one discusses rationing as a potential solution for cost containment the underlying assumption is that the health care systems are highly efficient at the level of supply services. Consequently there is a need to explore further the main forces that drive up the costs, in order to see whether the main causes of increasing costs in healthcare stem in the irrational use of resources by healthcare consumers.
McCornell describes (13) the most acknowledged causes for inflation in health care sector as being increased cost of hospitalization, prescription drugs, professional fees, use of related services as well as of advancing medical technology, increasing number of medical procedures, duplication of services and facilities, malpractice litigations and associated defensive medicine, increased regulatory costs and overuse and abuse of medical services. Furthermore he mentions as additional causes personal life-style issues and aging population. A special focus is paid to increased costs which are not translated into better care. Consequently the price of drugs is increasing at twelve percents per year, and only in part is this due to increased number of prescription. This increased cost of pharmaceutical products is also reflected in the hospital costs. Diffusion of new technology is especially mentioned as a leading cause for driving up costs. The cost of early detection of medical conditions usually associated with positive findings is increased many times because most of procedures conducted result in negative findings but who add costs. Some hospitals are still over dimensioned and the cost of underused beds increase the fixed cost of hospitals. Moreover McCornell mentions regions where there are hospitals that offer same services to same populations, leading to underused services resulting in expensive administration. Analyzing the impact of regulatory costs on health care system, he states that every inspection and audit conducted by third parties adds new costs which are not translated into a better care. Moving his attention to consumers and their life styles he shows that a quarter of the health care expenditures in 2000 was spent on medical care for unhealthy habits and other modifiable risks such as smoking, alcohol and drug abuse as well as obesity. Regarding the ageing population, McCornell states that age correlates positively with costs in health care. However research conducted in different OECD countries (14) (15) shows that caring for aged per se is not likely to lead to increased costs spiraling out of control. The already-mentioned factors like new technology diffusion hospitals inefficiency are likely to be the cause.
Porter and Teisberg (12) argue that while in a state controlled system it is expectable to have an unsatisfactory performance of costs and quality of care, this might not happen in the US, a country where health care is largely private and subject to competition. However costs are high and rising, and not explained by increasing quality of care. (12) Moreover medical services are restricted or rationed, diffusion of best practices is slow, and high rates of preventable medical errors persist. For instance they mention that it takes approximately seventeen years for an intervention, demonstrated to be efficient through a clinical trial, to enter in medical practice. They further explore why competition did not succeed to bring adequate value and to decrease costs like in any other industry.
Porter and Teisberg (12) claim that the actual situation is the result of a zero-sum competition. Consequently the competition in health care is at wrong level, being placed at the level of health plans, networks and hospital groups, instead to be at the level of disease and medical conditions where the real healthcare value might be created. Moreover it is fueled by a wrong objective, namely to reduce the costs, instead to increase the health care value, which really matters. They state that competing only on cost makes sense in commodity business where all the sellers are more or less the same, and obviously this is not the case in health care. They further show that the forms of competition existing in the health care system are responsible for increasing prices. Consequently instead of competing at the level of medical care, providers compete for being admitted in health plans and networks by giving huge discounts to payers and employers that have large patient populations.
However there is no difference in treating a patient belonging to a large group, with a random distribution of diseases, compared with persons from small groups or self-employed persons, because every patient is treated individually and at once. This creates benefits for large employers and shift the costs to small groups, unaffiliated individuals or self-employed, or people seeking care out of networks, or to uninsured persons. This shift in cost ultimately drives up the overall costs by increasing the number of uninsured persons, who subsequently are treated free in expensive medical settings like emergency rooms, which subsequently is reflected in future increased cost of health insurance. Another form of wrong competition is the focus on bargaining power instead of competing for a better care. This happens when hospitals merge in their competition for forming powerful groups able to provide a large array of services, resulting finally in duplication of services and facilities as mentioned before and subsequent increase in costs without a better added health care value.
Moreover the relationship between competition and diffusion of new technology is very important. Rare disease, or complicated medical conditions which are usually expensive to treat, are better managed in institutions with high level of specialization acting at a regional or national level. This allows those providers to manage enough patients, allowing them to maintain their expertise and also to decrease costs. This is not actually the case when the care is provided in local networks, focused on providing large array of services, and not on specific expertise.
Finally they reveal that while information is vital in any well-functioning market, in health care information is largely absent. They rightly point out that there is plenty of information regarding health plans coverage, and subscriber satisfaction surveys, but the real information that matter for health consumers, namely providers' experiences and outcomes in treating medical conditions is lacking.
This is not a plea for a national health system and a unique payer. A similar critique is coming from United Kingdom, a country with a National Health System. Bosanquet (16) shows that a monopoly system is not a solution for increasing the supply of services. Referring to NHS in the United Kingdom, he claims that in a centralized monopoly there will always be problems in acquiring relevant local information for developing health care services, creating a gap between the central aspirations and day-to-day local needs. Moreover in a monopoly the system will not generate the pressure to innovate that arises when there are a cluster of competing providers. Monopoly will be more likely in producing capture, namely the most informed in the system will yield more power, unfortunately not associated with increasing the supply of services. Finally a unique payer system is more likely to fail due to increased capacity for diffusion of mistakes.
There is no doubt that maintaining costs at a reasonable level is vital for many aforementioned reasons. However if Porter and Teisberg as well as Bosanquet (12) (16) are correct in their analysis, one may legitimately question the necessity of a policy employing rationing care with QALYS is the real solution for cost containment. Equally they would argue (12) that a profound reform which would move the competition at the level of diseases and treatments will act as an engine of progress. In a positive-sum competition providers will compete for developing their distinctiveness for specific services, which will create new value in healthcare and will drive down prices. Moreover all restriction for choices at the level of treatment and disease should be removed, and prices should be the same inside and outside networks, and for any patient regardless of their insurance company or type of employer.
Consequently the system of multiple prices for same service, which impose huge administrative costs, will disappear. This will eliminate the actual situation of shifting the costs, when patients covered by public funds are subsidized by patients covered by private insurance, and the latter are subsidized by patients belonging to small groups or self insured. Under a positive-sum competition patients would find enough information for making appropriate health care decisions for them, which will allow them to avoid medical care of marginal value which does not improve their longevity of quality of care. Consequently they will forego medical services of small value, without the help of the QALYS method. Society should identify solutions for people which do not belong to large employer groups to facilitate their access to health insurance. In the same time standards for malpractice litigation should be changed, to avoid the huge costs of defensive medicine. Lawsuits are appropriate only for cases of real negligence or medical mistakes, not in situations when bad medical outcomes occur despite correct medical treatments. Finally solutions for decreasing the number of uninsured persons will decrease the costs of health care, avoiding expensive treatments in emergency rooms, and on the other hand will enable appropriate treatments in earlier and cheaper stages of diseases.
Finally there is a need to limit the argument against rationing of care. Even in a health care system operating in a highly efficient way there would be some rationing as a result of high costs or scarcity of several services like organ transplantation. (16) However it is important to differentiate between this "intrinsic" rationing (16) from rationing which is caused by supply limitations, imposed by monopoly or inefficiency. Taking into account this limitation, one might argue that cost-containment is a need, for averting significant risks, like increasing number of uninsured persons. On the other hand the solution resides in creating health care value, and not in denying people's access to care, based on their life expectancy or capacity to benefit as the QALYS approach is suggesting.
Effective Means
QALYS are designed for resource allocation under a pre-established health care budget. Consequently one might say that it is useful for cost-containment into the health care systems. However Bosanquet (16) argues that a long experience with QALYS in United Kingdom shows that it contributed little to either management task of using limited resources or to the social policy challenge of reducing social costs. However there is no research done to evaluate for instance potential losses produced by QALYS due to limitation of consumer choices in health care services, which might also contribute to cost containment. On the other hand QALYS is a positive incentive for preserving inefficiency in health care systems, being oriented on what already exists, and not on creating a new value.
Consequently the social loses arising from rationing will be increased by supply limitations, attracting new loses if there is little room for consumer preferences in deciding on the pattern of services to be provided. A relevant example given by Bosanquet refers to hemodialysis, where there is much literature in United Kingdom, about how to ration dialysis services, but very few about how to improve the programs for providing more services.
On the other hand a health care system should be responsive to people's needs. It is important to mention health care is only one determinant, and probably not the most important of the health status. Consequently whether one accepts that twenty five percent of health care funds are spend on medical conditions produced by life styles, (13) a more efficient approach comparing with rationing would be to develop health promotion programs or other relevant public health programs. This might decrease on long run the costs of health care.
Finally I would say that rationing of care using QALYS might contribute on cost-containment, but on long run, will limit the efficiency of health care system through a negative incentive in developing its services. Moreover whether one of the goals of health care systems is to provide an equitable access to care, this might be profoundly affected by rationing of care.
Proportionality
To justify ethically a policy it is not enough to demonstrate its utility and effectiveness; it must also be acceptable from human rights perspective. (18) Consequently a policy should not unduly interfere with individual rights and freedoms. For analyzing to what extent the QALYS method is interfering with individual human rights I will use the framework of human rights. (17) (19) Central and indispensable in analyzing the acceptability of a policy under human rights framework are, the principles of equality, and indivisibility of human rights. Virtually all declarations and conventions on human rights, including Universal Declaration on Human Rights, stress the fundamental value of equality.
Therefore right to life and health should be applied equally to all members of the human family. All international declarations and conventions emphasize the equal respect for human rights such as dignity, life and integrity. (9) In these declarations, equality is understood mainly in terms of non-discrimination based on sex, race, age, color, ethnic or social origin, as well as on religious, and political opinions. (19) (20) Indivisibility refers to the fact that all human rights are considered interrelated and inseparable. (19) Subsequently the right to health and health care cannot be separated from other rights including right to life, as well as the freedom to non-discrimination.
Simona Giordano (9) referring to principle of equality, as it should be applied in the context of human rights, including the right to health and right to life, claims that equality means equal respect for each person's preference to live the longest and best quality of life attainable. It follows that health care systems should treat each of these preferences equally, according them equal moral value regardless morally irrelevant factors as age, sex, race, ethnicity, IQ, etc. The underlying ethical value implied by this statement is that each person has an equal moral value. In other words because each person counts equal, each person preference to continue to live should be equally considered, even if his or her quality of life or life expectancy appear to be lower compared with other persons, or even if other health professionals or general public believe that his or her life is not worth living. Therefore respect for equality is respect for this preference, for the value of life each person attaches to their own personal life, and each person's wish to continue to live should count equally. This is correlative with equal consideration for each person's needs, and not as a matter of degree with capacity to benefit from medical care. As Harris (4) shows there is a strong presumption in most societies that a person's moral claims derive from his or her dignity and standing as human being and are not dependent on any particular features. This presumption cut across all human rights declarations.
In the field of health care distribution however, QALYS, while committed to an egalitarian view, does not rely on the principle of equality. For Allan Williams (3) (18) or McKie and his collaborators (6) equality is not correlative with treating persons' equally. They argue that in the field of health care, persons, who are already old or disabled, and who cannot benefit from medical care, in terms of life expectancy or improvement in quality of life, should not be treated equally with younger and healthier persons, and should have lower priority in assigning medical care. Because people differ in these respects treating them differently is not treating them unequally. Their underlying value is that the goal of health care systems is to distribute the greatest amount of quantity and quality of life to the greatest number of people. Consequently equal respect for each person's wish to continue his or her own life, regardless his or her life expectancy or quality of life, would be unfair, because this will reduce the total amount of health gains in the population as a whole. Subsequently health care resources should be allocated with priority to those with positive capacity to benefit from medical care in terms of life extension or quality of life improvement. Accordingly their commitment for equality in health care implies giving everybody a similar positive amount of quantity and quality of life.
At first sight their ethical approach seems to be concordant with medical ethics and clinical tradition. Of course every patient is interested in obtaining the maximum life extension and quality improvement from medical care. This is concordant with the beneficence principle as seen from medical profession perspective. Physicians believe that their duty is to maximize the length and quality of life of each patient. However this is not correlative with QALYS' ethical underpinnings. While is true that everybody wants from himself or herself the maximum quality and quantity of life, when comes about medical care, it not follows that every body would like that physicians or health care systems distribute their services first to those with better capacity to benefit, according to general public or professionals' preferences for quality of life, or tables revealing their life expectancy. (9) Subsequently nobody would agree to delegate to others the right to judge the value of their life, neither professionals nor society at large. What really matters for people here is the quality and quantity of their own lives, and not the total amount of quality adjusted life years in the world. (9)
A legitimate question regarding QALYS is in what extent the right for an equal life span is consistent with the right for life as mentioned in most declarations. The fair innings argument either in its original or relative form as incorporated in QALYS (2) implies that life is divisible like a commodity and can be appreciated in this way, assigning it different values at different points in time according with the prospect and quality of life. However for most of us life is strongly associated with an integrity view. Ronald Dworkin (21) argues that an autonomous life is structured around projects people assign priority and the critical interests at which they aim. Consequently a good life has a structure and coherence that binds what people's value and result in a narrative of the kind of person each of them are. For many people this coherence comes from the fact that commitments to their goals and interests are in various ways identity-conferring. Subsequently it is difficult to make a value judgment about a person's life at certain points in time. Moreover it is even more difficult to make comparisons between values of different persons' lives, which are different points of their lives. Additionally it is hard to understand why people are entitled to an equal life span. I would say that the length of life is the result of multiple factors beyond our control (e.g. genetic, environment in some extent), but also by our contributions and personal efforts (e.g. education, wealth, life style). Therefore the number of years already lived is not only the opportunity old persons had, but also the efforts they did. Taking into account all these arguments and having in mind an integrity view of people's lives, one might argue that people have an equal right in having their lives protected. Employing an analogy, Harris (4) argues that murder is seen equally wrong, despite victim's prospect or quality of life. He provides a very well constructed anti-ageist argument, claiming that nobody regardless age, knows when death will come. Consequently for all of us, who are committed to continue to live, the rest of our lives are indefinite, and of equal value.
Finally one might say that QALYS is interfering strongly with human rights, in two ways. First it implies a discrimination of persons based on their prospect and quality of life, and secondly by imposing societal values on individuals. If practiced in a systematical way QALYS, would equal with a dictatorship of health professionals or policy decision-maker over individuals, narrowing their autonomy in a large extent. This is very well articulated by Williams (3) (8) when he claims that societal values should prevail over individual autonomy, when is to deny treatment to individuals who cannot benefit as measured by QALYS. Finally health professionals and others will decide what lives are worth to be lived, based on societal preferences and norms, irrespective of people's individual values and commitments.
As a corollary one might say that QALYS is a systematic infringement of people's autonomy rights, and an imposition of discriminations on a significant segment of vulnerable populations like the elderly and disabled persons.
Fairness
Fairness is essential for a good policy. Fairness (18) refers to three characteristics: equity, procedural justice and transparency. Equitable allocations mandate that policies are not designed or applied in a discriminatory manner.
Consequently characteristics as race, sex, age, ethnicity, religion or other beliefs, are not relevant for the exercise of power. Public policies should always demonstrate respect for persons and toleration of the group differences. (18) Procedural justice is an important means of preventing or correcting errors, by providing a timely and meaningful opportunity to correct mistakes. (18) Procedural due process reduces risk of errors, by requiring an evaluation of evidence by an impartial independent body. Moreover this provides a sense of justice allowing a grievance to be manifested and providing the potential of remedy which should be proportional with the harm produced. This might lead to prevention of stigmatization and stereotyping associated with a public policy. Transparency implies that a policy should be formulated and implemented in a manner allowing public scrutiny and oversight. Citizens should have the opportunity to contribute, and critique the policy decisions. (18)
Equity
For a comprehensive argumentation we should look to the difference between inequalities and inequities. According to World Health Organization equity in health implies that every body is entitled to a fair opportunity to attain their full health potential, and nobody should be disadvantaged from achieving this potential. There are two types of equity. Horizontal equity assumes that people with equal needs use equal amounts of care and vertical equity which implies that people with different needs, consume proportionately different amounts of care. Inequity means an unjust inequality. Therefore inequalities between persons with different needs are not inequitable, while inequalities at horizontal level are.
For understanding this concept we should look to the meaning of health need, and the concept of capacity to benefit as implied by QALYS. An acceptable definition (16) is that a need for health care exists when an individual has an illness and or disability for which there is an effective and acceptable cure or treatment. Consequently this implies that there is a gap between the actual health status of an individual person and a desirable standard of the health of that person after the medical care is provided. However capacity to benefit has a different meaning when it comes about QALYS (8) (10), because it refers to life expectancy as indicator and health status as an aggregate social value. Regarding the constraint on access to care of those with limited capacity to benefit, Allan Williams (8) argues that wouldn't be fair to divert health care resources from people who might benefit from medical services, and to devote them to those with limited capacity to benefit, just to reinforce their sense of security about care being available to them when they need it. According to him "need" means "capacity to benefit" as calculated by QALYS, and what is available will benefit people on equal basis for everybody. Consequently all these conditions are fulfilled by QALYS maximization system. However one might discover that persons with similar needs are treated differently because of their age for instance, because they yield fewer quality adjusted life years. Therefore a systematic employment for QALYS in resource allocation can lead to health disparities. Moreover any conception of social justice (27) that accepts the need for a fair distribution and efficient formation of human capabilities cannot ignore the role of health in human life and the opportunities that persons have to achieve good health. Consequently Amartya Sen argues that lack of opportunities to achieve good health because of social arrangements, as opposed to personal decisions, is an injustice. Moreover there is evidence (28) that among developed countries it is not the richest societies which have the best health, but those that have the smallest income differences between rich and poor. Taking into account that the burden of diseases fall disproportionately on vulnerable groups as poor or elderly persons, one might say that QALYS approach is promoting health disparities and social injustice.
Procedural Justice
Systematic employment of QALYS approach for resource allocation in health care can lead to stigmatization and stereotyping of vulnerable groups as elderly and disabled persons. Old age might be perceived as a period of frailty, dependence and small contributions to the society. (9) Studies conducted by WHO (15) show that elderly persons beside their previous contributions to society, are actually contributing to social and economic development. Many people continue to work in formal or informal labor sector. There are many situations when elderly take household or childcare responsibilities, empowering younger persons to continue their work. Therefore the idea of complete dependency of elderly people is simply false.
Another myth which might lead to stigma and which is simply false is that old persons are not able to benefit from the healthcare resources they use. This assumption is often mistaken, because the results of most medical procedures vary little between persons aged over 65 and those under this age. (15) (25) Only benefits in terms of QALY might show real differences. There is no age per se which creates frailty, but poor health and disability, which is sometimes associated with old age. But the capacity to benefit is varying from person to person.
Finally I will say that physician patient relationship might be profoundly affected, because in some instances they will be obliged to deny treatment to some patients, based on reasons external to medical practice. This is correlative with abandonment of a vulnerable group of patients. Although QALYS approach acts in public space, there is no mechanism put in place for preventing or mitigating these adverse effects.
Transparency
As its proponents argue the underlying ethical underpinnings of QALYS is preference utilitarianism. However public opinion surveys conducted in last period of time reveal contradictory data and only limited support for fair innings argument. When age-specific services are ranked or choices between hypothetical patients should be made, a moderate tendency to favor young persons has been observed. However the same studies do not show a correlation of the general public preference for negative discrimination of old persons. (7) When it comes to capacity to benefit, based on QALYS concept, it might be expected that there would be indifference in people's judgments about equally sized improvements from different health states. However there is strong empirical evidence that general public would like to favor the worst-off. (7)
Conclusion
Utilization of cost utility analysis for resource allocation and rationing of health care services for cost containment reasons aroused a debate about moral infringements of such a policy. While the pro arguments emphasize the maximization of health gains in the society as a goal of health care sectors, the con arguments underscore that this method is unfair, discriminating people based on their life expectancy and quality of life with serious consequences on distributive justice. In this paper I built an argument against QALYS as systematic policy, employing a framework suggested by Lawrence Gostin for policy analysis.
Consequently I argued that an alternative for rationing care is to promote reforms based in consumer preferences which will move competition in the healthcare system to the level of diseases and treatments that might fuel better care and lower costs. I showed that the QALYS method is not efficient in cost containment, that it provides a negative incentive for health care providers in distributing what already exists and not in creating a new value which on long run might add new costs. Shifting the attention to proportionality, I tried to demonstrate that cost utility analysis employing QALYS (1) is a serious infringement of autonomy rights, (2) promotes discrimination on morally irrelevant features like age and quality of life, (3) can systematically lead to a dictatorship of the health care system, where health care professionals and other decision-makers will judge what lives are worth living. I argued that cost utility analysis is an unfair policy, likely to produce health inequities and stigmatization of vulnerable groups of population, which is not based on a clear support from a societal standpoint. However, my arguments were limited to rationing scarce resources that result from inefficiency or monopoly not "intrinsic scarce resources" like organ for transplantation or very expensive services.
References
[1] Benatar, RS, Daar, AS, Singer, PS, Global Health Ethics: The Rationale for Mutual Caring. International Affaires 2003; 79(1): 107-138
[2] Bosanquet N. A ?Fair Innings' for Efficiency in Health Services? J Med Ethics. 2001 Aug; 27(4): 228-33
[3] Braveman P, Gruskin S. Defining Equity in Health. J Epidemiology Community Health. 2003 Apr; 57(4): 254-8
[4] Dixon, J, Welch HG. Priority Setting: Lessons from Oregon. Apr. 1991; 337(8746): 891-94
[5] Dworkin, R (1993). Life's Dominion. An Argument about Abortion, Euthanasia, and Individual Freedom. Vintage Books, A Division of Random House Inc. New York, pp. 205-206
[6] Floyd EJ. Healthcare Reform Through Rationing. Journal of Healthcare Management. Jul/Aug 2003; 48(4): 233-41
[7] Gabel, J, Claxton, G, Isadora, G, Pickreign J, Withmore, H, Holve, E, Finder, B, Hawkins, S, Rowland, D. Health Benefits in 2004: Four Years of Double Digit Premium Increases Take Their Toll on Coverage. Health Tracking 2004; September/October: 200-209
[8] Giordano S. Respect for Equality and the Treatment of the Elderly: Declarations of Human Rights and Age-Based Rationing. Camb Q Healthc Ethics. 2005 Winter; 14(1): 83-92
[9] Gold MR, Stevenson D, Fryback DG. HALYS and QALYS and DALYS, Oh My: Similarities and Differences in Summary Measures of Population Health. Annu Rev Public Health. 2002; 23: 115-34
[10] Gostin, LO. When Terrorism Threatens Health: How Far Are Limitations on Human Rights Justified? Journal of Law Medicine and Ethics. 2003; 31: 524-528
[11] Hammer, JS, Berman, P. Ends and Means in Public Health Policy in Developing Countries. Health Policy. 1995; 32: 29-45
[12] Harris J. The Age-Indifference Principle and Equality. Camb Q Healthc Ethics. 2005 winter; 14(1): 93-9
[13] Leidl, R, Stratmann, D. Economic Evaluation is Essential in Healthcare for Elderly: A viewpoint. Drugs and Ageing 1998 Oct; 13 (4): 255-262
[14] McConell CR. Health Care Costs Containment: A Contradiction in Terms? The Health Care Manager 2001; 20 (2): 68-79
[15] McKie J, Kuhse, H, Richardson J, Singer, P. Allocating Healthcare by QALYs: the Relevance of Age. Camb Q Healthc Ethics 1996 fall; 5(4): 534-545
[16] Nord, E (1999). Cost Value Analysis in Health Care. Making Sense out of QALYS. Cambridge University Press, pp. 18-21 and 23-30
[17] Paalman, R, Bekedam, H, Hawken, L, Nyheim, D. A Critical Review of Priority Setting in the Health Sector: the Methodology of the 1993 World Development Report. Health Policy and Planning 1998; 13(1): 13-31
[18] Porter, EM, Teisberg, EO. Redefining Competition in Health Care. Harvard Business Review. 2004; June: 65-76
[19] Schwappach DL. Resource Allocation, Social Values and the QALY: a Review of the Debate and Empirical Evidence. Health Expect. 2002 Sep; 5(3): 210-22
[20] Sen, A. Why Health Equity? Health Economics 2002; 11: 659-666
[21] Small R. The Ethics of Life Expectancy. Bioethics. 2002 Aug; 16(4): 307-34
[22] Tsuchiya A. QALYs and Ageism: Philosophical Theories and Age Weighting. Health Econ. 2000 Jan; 9(1):57-68
[23] United Nations. United Nations on Human Rights. Vienna. GA resolution number 48/121, 1993
[24] Universal Declaration of Human Rights. Available at: http://www.un.org/Overview/rights.html
[25] Wayland G, Kleiner, BH. Medical Rationing as a Health Care Strategy. Health Manpower Management 1997; 23(6): 223-228
[26] WHO. Active Ageing. A policy Framework. WHO/NMH/NPH/02.8. Geneva: WHO; 2002
[27] Williams A. Intergenerational Equity: an Exploration of the ?Fair Innings' Argument. Health Econ. 1997 Mar-Apr; 6(2):117-32
[28] Williams A. QALYS and Ethics: a Health Economist's Perspective. Soc Sci Med. 1996 Dec; 43(12): 1795-804
[29] Williams A. The ?Fair Innings Argument' Deserves a Fairer Hearing! Comments by Alan Williams on Nord and Johannesson. Health Econ. 2001 Oct; 10(7): 583-5
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