Utilitarian Ethical Theory and QALYs

Here is what a recent bioethics textbook (Schuklenk and Chadwick, This is Bioethics) has to say about utilitarian ethical theory and QALYs:

“12.27 When we turn to a utility‐based theory …, we are inevitably being directed towards consideration of consequences and outcome. The question is, how is that outcome to be measured? The extent to which life can be extended is obviously an issue. But what about the quality of that life? Much effort has gone into trying to develop tools to measure outcome successfully. 

12.28 The most well‐known concept of well‐being that has been developed in the context of health care distribution is the QALY (quality‐adjusted life year)… The QALY was one of the earliest tools for evaluating interventions and it measures not only quantity of life achieved but also quality. 

12.29 The essence of a QALY is that it takes a whole year of life expectancy to be worth 1, but regards a year of unhealthy life expectancy as worth less than 1. Its precise value is lower, the worse the quality of life of the unhealthy person (this is the ‘quality adjusted bit’) If being dead is worth zero, it is, in principle, possible for a QALY to be negative, i.e., for the quality of someone’s life to be judged worse than being dead.

12.30 The QALY’s advantage, apart from providing a tool of measurement, is that it can offer a mechanism for making a decision: if intervention X will produce three QALYs, but intervention Y will produce 5, then intervention 5 is the right choice.

12.32 The QALY has had many critics, however, who have pointed out its weaknesses. The main difficulty concerns how the QALY is measured: who decides what a certain state of health is worth? Perceptions of value have to feed into the establishment of QALYs. There are, however, several problems regarding the methodology for assessing the quality element. People who have a particular condition are likely to have a different view of it from those who have not experienced it. There is also a view that different types of features of quality are incommensurable, for example, physical as opposed to mental suffering. If the information is based on the preferences of individual patients, furthermore, there are clearly difficulties in collecting health‐related quality‐of‐life information from some groups of patients, such as children and persons suffering from mental disorder.

12.34 A second serious ethical objection to the use of QALYs relates to concerns about equity. It might be assumed that an additional QALY has the same weight regardless of the other characteristics of the individuals in question. This is a reflection, in QALY terms, of the utilitarian principle that each counts for one and no one for more than one. A QALY counts the same no matter whose life it is. This, however, is not a position with which all members of the public are likely to agree.

12.35 It might appear that applying QALYs to distribution issues is bound to result in a preference for interventions benefitting young people, partly because more life years can in all likelihood be achieved, but also because of perceptions of quality of those years in later life as compared with youth and indeed midlife. …. In addition, health care for the elderly is likely to be high in cost. Nevertheless, when cost per QALY is calculated some interventions benefitting older persons, such as hip replacements, may compare favorably with very expensive interventions on younger people.

12.39 Another objection to the use of the QALY and other such decision tools arises from the view that such a procedure fails to give due weight to the individual. Each person has only one life which is of unique importance to them, and to use QALYs to take health care decisions involves, it is argued, weighing lives against each other. However, the fact of scarce resources suggests that weighing lives is unavoidable. It is true, however, that the use of the QALY is subject to the same objection frequently levelled at utilitarianism in general – namely that it is concerned with aggregation (in order to achieve its maximization aim) rather than with fairness in distribution. Decisions about people’s treatment and lives become a numbers game.”

Q1. What are QALYs? How do they work?

Points 2. Word count 100-150.

Q2. How do you come up with the Quality Adjustment values or numbers used in calculating QALYs? The quote above from says that there are problems here. What would these be?

Points 3. Word count 500-750.

Q3. Are they something a utilitarian should use as a way of measuring the good and bad things produced by our choices? Are there problems with QALYs that are not also problems with utilitarianism?

Points 5. Word count 500-1000.

Grading rubric for each question

-1 if not understandable by someone with no background

-1 if includes something incorrect

-1 if leaves out something that should be included

-1 if includes irrelevant material

-1 if no references or sources.