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Wednesday, August 15, 2012

Basis of Quality Adjusted life years is a fiction Ask Jeremy Bentham

There was a time a few years ago when there was sincere honest thoughtful criticism of he concept of quality adjusted life years (QALY) , not so much now.In 1990 (JAMA 199:263(21):2917-2921), John LaPuma and Edward Lawlor published thoughtful critique of QALY. They said that the QALY concept was :

founded on six ethical assumptions: quality of life can be accurately measured and used, utilitarianism is acceptable, equity and efficiency are compatible, projections of community preferences can substitute for individual preferences, the old have less "capacity to benefit" than the young, and physicians will not use quality-adjusted life-years as clinical maxims.

In their article they offer valid critiques of each of those assumptions.

But the dogs bark and the caravan moves on. Pick up almost any issue of JAMA and the Annals of Internal Medicine and you will find articles on the cost effectiveness of some or other medical procedure or treatment.

Now it seems that the notion of QALY is well ensconced in the practice of " determining" the cost effectiveness of medical procedures and treatments. Why is the word determining placed in scare quotes? Because my argument is that the idea of determining QALY is, in the words of the founder of utilitarianism, a fiction.

Jeremy Bentham did not discuss QALYs since the term was not invented in his day but he did consider the idea of adding up individuals happiness or utility as it was essential to his philosophy.

Bentham's famous principle is "the greatest happiness of the greatest number is the foundation of morals and legislation". To him happiness was the balance of pleasure over pain and this would be summed up somehow for everyone affected by the policy proposal and was known as the principle of utility and is the essence of utilitarianism.

Those who favor a utilitarian approach to public policy issue will not be pleased to learn than Bentham himself admitted that summing happiness or utilities or some measure of quality of life did not make sense. Bentham wrote:

"Tis vain to talk of adding quantities which after the addition will continue distinct as they were before,one man's happiness will never be another man's happiness:a gain to one man is no gain to another;you might as well pretend to add 20 apples to 20 pears,which after you had done that could not be 40 of any one thing but 20 of each as there were before. This addibility of the happiness of different subjects , however, when considered rigorously it may appear fictitious, is a postulatum without the allowance of which all political reasoning is at a stand.."

So Bentham realized that adding up everyone's happiness did not make sense (when considered rigorously) but we need to do it to make policy.

The economist, Anthony de Jasay ,said that scientifically speaking aggregating the utilities of different persons, e.g. to subtract from the gains of some the losses of others,is just as nonsensical as taking four apples out of seven oranges.So nonsense that is "useful" for some analysis is still nonsense.

Cost effectiveness analysis as applied to medical procedures does not exactly sum happiness over many individuals but sums instead quality adjusted life years. The QALY ( or the simpler concept of life years) is foundational in the current efforts to determine cost effectiveness.

John Rawls' A Theory of Justice proposes a redistribution scheme different from utilitarianism about which he said "[it]does not take seriously the distinction between persons".Thomas Nagel,a critic of utilitarianism said of it that it treats the needs and satisfactions of multiple individual beings as if they were the features of some hypothetical mass person.

Nonsense or not it is a handy tool for the elites who would make their value judgments determinative of what the rest of us are allowed to have in terms of medical care.

note: minor editorial changes made 8/16/2012 in the final paragraph to clarify meaning.


Andrew_M_Garland said...

Our politicians have maintained themselves in power by making promises, essentially buying votes. The promises had to be dramatic and simple. The medical care promise has been "pay into the system, and we will do everything possible to keep you alive and functioning as you become old and sick".

"Everything possible" used to be quite limited for almost everyone. Now, expensive treatments produce some extension of an enjoyable life. More of a problem, some very expensive treatments cure a few percent of people who would have died, but we can't tell in advance who will benefit. The politicians can't keep their promise, yet that promise is essential to remaining in power.

Politicians can't keep their promise because they did not collect and save enough money (resources) to provide the promised future medical care, either at past or current costs. They didn't save anything; they immediately spent all available cash on their own incomes and on other vote buying. Any care now for the old must be pay-as-you-go by the current working population. The government told the now-old that the government was saving for their future care, but it actually saved nothing. The old were robbed when they were young, and they will be quite angry if they ever figure this out.

The political solution must be complicated, sly, and involve middlemen to take the blame instead of the politicians.

The first principle of government is to continue buying votes. Quality Adjusted Life Years (QALY) is better understood as Quality Adjusted Voting Years (QAVY). There is just so much money available to be spent on people who can supply votes. If the money runs out at $10,000 per QAVY, then $30,000 is too expensive and will be denied.

When "everything possible" was limited, the collectivist (Marxist) nature of government healthcare was tolerable to most people. The program was costly and complicated, but everything possible would be done in the end. Now, it is clear that most people will die sooner for lack of funds, sooner than "everything possible". People may complain that this was not the deal they made. If they are going to be sick or die anyway, maybe they could have enjoyed their money rather than contribute it to this scheme. Maybe they could have done better. Maybe they could have saved their money and apply it now to options that the government does not see as QAVY effective.

A bad part of ObamaCare is its control of all insurance contracts, other than those for elite politicians and union members. All health insurance must provide a list of services specified by government. Strangely, coverage limits for these may vary according to the cost of the insurance. These broad requirements make the insurance expensive. Government subsidies are supposed to make the insurance less expensive. Where are the subsidies supposed to come from?

Richard Epstein:
=== ===
[edited] Extensive federal regulations specify the kinds of coverage that any health insurance carrier has to supply: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services, chronic disease management, and pediatric services.
=== ===

There is a strong bias toward supplying insured services that a person might use in their young life, and away from providing a cheaper coverage only for catastrophic care. People will pay a large amount each year and will want a large amount of almost-free services in response. They may regard this as a good deal while they are young, as they collect a stream of moderate-cost services. They will see QAVY restrictions when they become old and expensive.

Andrew_M_Garland said...

(continued from above)

Another bad part of ObamaCare is to limit the choices of people both inside and outside of the system. A free market in health care is likely to provide some less expensive options, including catastrophic care plans for much less money. Government needs to keep everyone in a standard and expensive insurance contract so it can extract artificially large insurance payments from the young to provide cash for delivering health care to the old. This is a stealth tax administered by the insurance companies, applied to the young. This is how the young will be robbed. Maybe they will figure this out when they become old.

Our Democrat politicians have found a durable principle to cement a bond between the generations. Current producers will pay taxes to support the old. In return, they will gain the right to tax their children to support them. The enduring principle is inter-generational theft under the color of law.

Obamacare Bails Out Medicare