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The ‘QALY Trap’ and Discrimination

The ‘QALY Trap’: Can Maximizing Health Benefit Be Reconciled with Principles of Non-Discrimination? Paul T. Menzel, Ph.D. *

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The ‘QALY Trap’ and Discrimination

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  1. The ‘QALY Trap’: Can Maximizing Health BenefitBe Reconciled with Principles of Non-Discrimination? Paul T. Menzel, Ph.D. * December, 2004, for the Workshop “Healing with Dollars andSense: The Ethics of C.E.A. in Health Care Decision Making,”Defining the Medicare Basket Research Project,Faculty of Law, University of Toronto * Department of Philosophy, Pacific Lutheran University. Significant parts of Sections I, II, and III of this paper are taken from P. Ubel et al. 2000.

  2. The ‘QALY Trap’ and Discrimination • A Problem Right at the Heart of the Conceptual Structure of the QALY • One Plausible Escape from the Trap: Societal Value Measurement • Interventions that Simultaneously Save Lives and Cure Disability • Could the Equal Value of Lifesaving Still Be a Judgment of Individual Utility? • Another Escape from the Trap: Simply Accept ‘Discrimination’ in Lifesaving

  3. F 1 IGURE Saving the lives of patients with pre-existing disabilities brings fewer QALYs than saving patients without chronic disabilities Full health – 1.0 Paraplegia – 0.8  = .8  = 1 QALY QALY Death – 0 Paraplegia Full health

  4. What Have the Disabled Said about the Value of Their Very Life ? In responding to TTO and SG questions, they are saying that a cure for their paraplegia has a certain proportion of the value of saving their very life. But have they thereby said that their very life itself (with paraplegia, e.g.) has less value than the life of another person in full health? LIKELY NOT. Isn’t it likely that they have said that their life with paraplegia, compared to death, is just as valuable to them as anyone else’s “better” life is to him or her? And won’t a moment’s thought likely convince most people that their very life itself, even if they were disabled, would be just as valuable to them as another person’s very life in full health was to that other person?

  5. F 2 IGURE Traditional QALY example in which the sum of QALYs obtained for patients B & C equals the QALYs obtained for patient A Full health 1 0.2 QALYs Paraplegia 1 0.8 Paraplegia QALY HRQoL of health 0.8 0.5 conditions QALYs 0.2 0 A B C Patients or Programs

  6. F 3 IGURE Non - discrimination in lifesaving, but where the sum of QALYs obtained for patients B & C still equals the QALYs obtained for patient A Full health Full health 1 0.0 QALYs Paraplegia 1 0.8 HRQoL of Pa raplegia QALY health 0.5 conditions 1.0 QALYs 0.2 0 A B C Patients or Programs

  7. FIGURE 4 How societal value measurement avoids the QALY trap: The societal value brought by Programs B and C is greater than the SV brought by Program A Full health Full health 1 0.16 SV Paraplegia 1.0 HRQoL of 0.8 SV Paraplegia health conditions 1.0 0.5 SV 0.2 0 A B C Programs

  8. F 5 IGURE Escaping the QALY Trap: Abandon Assumption that B + C = A (A – B = C) 1 0.8 Societal 0.6 Value 0.4 0.2 0 A B C A = saving a life to full health B = saving the life of a person with paraplegia C = curing paraplegia to f ull health

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