I remember that when I first heard about the Quality Adjusted Life Year (QALY) I thought it was a good idea. After all, we do want to do as much good as possible with the limited resources available for health care, don't we? And doing good through health care does involve precisely what QALYs purport to encapsulate: reducing symptoms, improving functioning, and prolonging life.

Ten years later I still like to say that the QALY has an intuitive appeal as a measure of benefit. But I must add that economists and others advocating its use in informing decisions have no reason to be proud of the way in which they have raised their baby. At the age of twenty-five, it remains much the same simple construct as it was at birth, in spite of countless suggestions from its surroundings that a fair amount of socialization and sophistication would be needed for the baby to become an accepted and respected member of the community.

In this book I first explain the rationale of economic evaluation in health care and the problem that QALYs purport to resolve in such evaluation. I then address a number of issues related to the value basis of QALYs and the particular way in which the concept of QALYs is operationalized in mainstream health economic analysis. The aim of these sections is to shed critical light on the meaning and validity of the numbers that are presently being produced and used in the field.