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The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Friday, April 29, 2016

Quality adjusted life years is not even argued about any more-

We don't debate  the merits of quality adjust life year determinations any longer, we just do them.

 But, there was a time a few years ago when there was thoughtful criticism of the concept of quality adjusted life years (QALY) but the dogs barked and the caravan moved on.

One  such  analysis  appeared in 1990.I (JAMA 199:263(21):2917-2921), John LaPuma et al  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.

Now it seems that the notion of QALY is firmly established 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, which is what QALY is all about, 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] ( utilitariansim )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.

 Woody Allen tells the following joke. A guy walks into a psychiatrist' office and say  "doc, my brother is crazy, he thinks he is a chicken." The doc replies you should get him in a mental hospital.The guy say I should but we really need the eggs.

The third party payers and their fellow travelers need the eggs.

note: Minor editorial tweeks made on 8/16/12 and joke and other addtions made on 4/8/16

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