The principle that people's lives and fundamental interests are of equal value and that they must therefore be given equal weight has immense intellectual appeal and intuitive force. It is often enough to discredit a theory or proposal simply to show that it violates this principle. When measures are said to be discriminatory or unfair it is this principle which is in play. Recent philosophers of widely differing schools and outlooks give versions of this principle a central role in their (...) theories. (shrink)

The ethical problem of how to apportion limited resources amongst the needy has been forced on us by arbitrary limitation of health expenditure. Its solution would not be required if health expenditure were higher. Distribution of resources according to best value for money, assessed as Quality Adjusted Life Years (QALYs) per unit cost, has been suggested as a possible solution, but leads to absurd anomalies. In the calculation of QALYs the implied value of life is no more than the absence (...) of suffering. The use of QALYs for the comparison of treatments that are symptomatic or life-saving therefore leads to serious undervaluation of life and treatments that prolong it. Moreover, distribution of resources by best value for money, however assessed, is inequitable since for a given degree of suffering those whose illnesses happen to be cheaper to treat will be treated in preference to those whose treatments are more expensive. (shrink)

A new word has recently entered the British medical vocabulary. What it stands for is neither a disease nor a cure. At least, it is not a cure for a disease in the medical sense. But it could, perhaps, be thought of as an intended cure for a medicosociological disease: namely that of haphazard or otherwise ethically inappropriate allocation of scarce medical resources. What I have in mind is the term ‘QALY’, which is an acronym standing for quality adjusted life (...) year. Just what this means and what it is intended to do I shall explain in due course. Let me first, however, set the scene. (shrink)

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). (shrink)