This paper argues that the Quality Adjusted Life Year or QALY is fatally flawed as a way of priority setting in health care and of dealing with the problem of scarce resources. In addition to showing why this is so the paper sets out a view of the moral constraints that govern the allocation of health resources and suggests reasons for a new attitude to the health budget.

In this article, I first compare positions I have taken in the past and those taken by Peter Singer on how the allocation of life-saving resources should be affected by the aggregation of expected quality of life, quantity of life, and need, both within the life of a person and across persons . I then reexamine the specific issue of whether and why differences in expected years of life and quality of life that a scarce resource can provide a disabled (...) and a nondisabled person should affect our allocation decisions. I attend to how the use of the veil of ignorance bears on this issue and also how the conclusions I reach differ in certain ways from my past positions. (shrink)

The authors refute Harris’s criticism of the work of NICE and in turn criticise his description of the institute’s positionHarris’s recent editorial,1It’s not NICE to discriminate, is long on both polemic and invective but short on scholarship. He offers nothing to illuminate the debate about allocating health care in circumstances of finite resources; he has no understanding of the quality adjusted life year and its use in health economic evaluation; and he makes ill researched, unsubstantiated charges against the institute and (...) its advisory bodies.ALLOCATING HEALTHCARE RESOURCESThe British National Health Service , like every other healthcare system in the world, has finite resources. How the NHS’s budget should be most appropriately allocated is a very specific example of the more general problem of distributive justice.2The NHS, with its requirement3 to provide all care that is “necessary and appropriate”, was founded with an egalitarian purpose. Yet despite its laudable emphasis on fairness, the implementation of the NHS’s egalitarian approach remains uncertain. What is necessary? What is appropriate? How should the tensions between the service’s egalitarian aspirations, and the need to provide health care from finite resources, be resolved? On what principles should these allocative decisions be made?Utilitarianism, with its goal to maximise overall good, is another approach. Yet experience with the original Oregon plan demonstrated that, when rigidly applied, it can yield solutions that most find unacceptable—for example, tooth capping taking precedence over emergency appendectomy.4 Moreover, some versions of utilitarianism can allow the interests of minorities to be overridden by the majority; and it has next to nothing to offer in eradicating health inequalities.There is no single, broadly accepted, theory of distributive justice …. (shrink)

The so-called Disability Paradox arises from the apparent tension between the popular view that disability leads to low well-being and the relatively high life-satisfaction reports of disabled people. Our aim in this essay is to make some progress toward dissolving this alleged paradox by exploring the relationship between disability and various “goods of life”—that is, components of a life that typically make a person’s life go better for her. We focus on four widely recognized goods of life (happiness, rewarding relationships, (...) knowledge, achievement) and four common types of disability (sensory, mobility, intellectual, and social) and systematically examine the extent to which the four disability types are in principle compatible with obtaining the four goods of life. Our findings suggest that that there is a high degree of compatibility. This undermines the widespread view that disabilities, by their very nature, substantially limit a person’s ability to access the goods of life, and it provides some guidance on how to dissolve the Disability Paradox. (shrink)

Utilitarianism is more convincing than resource egalitarianism or welfare egalitarianism as a theory of how resources should be distributed between disabled people and nondisabled people. Unlike resource egalitarianism, utilitarianism can redistribute resources to the disabled when they would benefit more from those resources than nondisabled people. Unlike welfare egalitarianism, utilitarianism can halt redistribution when the disabled would no longer benefit more than the nondisabled from additional resources. -/- The author considers one objection to this view: it has been argued, by (...) Sen and others, that there are circumstances under which utilitarianism would unfairly distribute fewer resources to the physically disabled than to nondisabled people, on the ground that the disabled would derive less benefit from those resources. In response, the author claims that critics of utilitarianism have fallaciously exaggerated the circumstances under which the disabled would benefit less than the nondisabled from additional resources. In those limited circumstances in which the disabled really would benefit less from resources, the author argues, it does not seem unfair to distribute fewer resources to them. (shrink)

Two principles form the basis for much priority setting in health. According to the greater benefit principle, resources should be directed toward the intervention with the greater health benefit. According to the worse off principle, resources should be directed toward the intervention benefiting those initially worse off. Jointly, these principles accord with so-called prioritarianism. Crucial for its operationalisation is the specification of the worse off. In this paper, we examine how the worse off can be defined as those with the (...) fewer lifetime Quality-Adjusted Life Years (QALYs). We contrast this proposal with several alternative specifications. (shrink)

It is widely recognized that prioritizing health care resources by their relative cost-effectiveness can result in lower priority for the treatment of disabled persons than otherwise similar non-disabled persons. I distinguish six different ways in which this discrimination against the disabled can occur. I then spell out and evaluate the following moral objections to this discrimination, most of which capture an aspect of its unethical character: it implies that disabled persons' lives are of lesser value than those of non-disabled persons; (...) it constitutes “double jeopardy” or violates Frances Kamm's non-linkage principle; it conflicts with equality of opportunity; it conflicts with fairness, which requires ignoring (some/most) differential impacts of treatment; it wrongly gives lower priority to disabled persons for equally effective treatment; it conflicts with giving all persons an equal chance to reach their full potential; and, it is in conflict with giving priority to the worse off. (shrink)

In the Paraplegia Case, we must choose either to preserve the life of a paraplegic for 10 years or that of someone in full health for the same duration. Non-consequentialists reject a benefit-maximising view, which holds that since the person in full health will have a higher quality of life, we ought to save him straightaway. In the Unequal Lifespan Case, we face a choice between saving one person for 5 years in full health and another for 25 years in (...) full health. Frances Kamm has recently unfurled an Equal Respect Argument in an effort to support the position that while we ought to give each person a 50% chance of being saved in the Paraplegia Case, we are morally permitted to save straightaway the person who would live longer in the Unequal Lifespan case. The article tries to show that a Kant-inspired account of the dignity of persons is far more successful than Kamm's argument in supporting this position. The Kant-inspired account owes this success to its conceiving of respect for persons not primarily as respect for their pursuit of what is of value for them, but rather as respect for the value in them. (shrink)

In using quality of life as a guide to rationing health services, Oregon laid itself open to charges of bias against the disabled—charges that cannot be dismissed out of hand.

In using quality of life as a guide to rationing health services, Oregon laid itself open to charges of bias against the disabled—charges that cannot be dismissed out of hand.

One generally considered plausible way to allocate resources in health care is according to people’s needs. In this paper I focus on a somewhat overlooked issue, that is the conceptual structure of health care needs. It is argued that what conceptual understanding of needs one has is decisive in the assessment of what qualifies as a health care need and what does not. The aim for this paper is a clarification of the concept of health care need with a starting (...) point in the general philosophical discussion about needs. I outline three approaches to the concept of need and argue that they all share the same conceptual underpinnings. The concept of need is then analyzed in terms of a subject x needing some object y in order to achieve some goal z. I then discuss the relevant features of the object y and the goal z which make a given need qualify as a health care need and not just a need for anything. (shrink)

Cost effectiveness analysis is a tool for evaluating the aggregate benefits of medical treatments, health care services, and public health programs. Its opponents often claim that its use leads to unfair discrimination against people with disabilities. My aim in this paper is to clarify the conditions under which this might be so. I present some ways in which the use of cost effectiveness analysis can lead to discrimination and suggest why these forms of discrimination may be unfair. I also discuss (...) some proposals for avoiding discrimination without rejecting cost effectiveness analysis altogether. I argue that none of these proposals is ultimately convincing. I describe a different approach to the problem and conclude by answering the question in the title. (shrink)