THE PROBLEMS

Let me bring together the main points of the two previous chapters. The QALY approach, in its initial form, equates the societal value of a health-care intervention with the sum of individual utility gains produced by the activity. This has the following implications:

1. A. The societal value of an outcome in one individual is proportional to the size of the utility gain in that individual.

2. B. The societal value of utility gains of a given size are the same, irrespective of the severity of the patient's initial condition.

3. C. The societal value of an outcome in one individual is close to proportional to the duration of the utility gain.

4. D. From B it follows that the societal value of an outcome with lifelong duration is inversely proportional to the patient's age.

5. E. Societal value is proportional to the number of people who get to enjoy a particular benefit.

Unfortunately, each of these propositions is contradicted by evidence. The assumption of utility maximization is simply not tenable, in neither the caring-for-others nor the self-interest perspective.

Some will argue that this could be remedied by constructing an alternative valuation model in which the functional relationship between individual utility gains and societal value is specified differently. For instance, one could add weights for severity of initial condition and for age, and discount factors for the duration of gains and for the number of people helped. Such a modified model could still be called a QALY model, inasmuch as individual utility gains would still be the basic source of societal value, only at a transformation rate different from that presumed in the conventional QALY model.