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Precision QALYs, Precisely Unjust

  • LEONARD M. FLECK

Abstract:

Warwick Heale has recently defended the notion of individualized and personalized Quality-Adjusted Life Years (QALYs) in connection with health care resource allocation decisions. Ordinarily, QALYs are used to make allocation decisions at the population level. If a health care intervention costs £100,000 and generally yields only two years of survival, the cost per QALY gained will be £50,000, far in excess of the £30,000 limit per QALY judged an acceptable use of resources within the National Health Service in the United Kingdom. However, if we know with medical certainty that a patient will gain four extra years of life from that intervention, the cost per QALY will be £25,000. Heale argues fairness and social utility require such a patient to receive that treatment, even though all others in the cohort of that patient might be denied that treatment (and lose two years of potential life). Likewise, Heale argues that personal commitments of an individual (religious or otherwise), that determine how they value a life-year with some medical intervention, ought to be used to determine the value of a QALY for them. I argue that if Heale’s proposals were put into practice, the result would often be greater injustice. In brief, requirements for the just allocation of health care resources are more complex than pure cost-effectiveness analysis would allow.

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Notes

1. Heale, W. Individualised and personalised QALYs in exceptional treatment decisions. Journal of Medical Ethics 2016;42:665–71.

2. Soares MO. Is the QALY deaf, dumb and blind to equity? NICE’s considerations over equity. British Medical Bulletin 2012;101:17–31.

3. In the United States, that QALY figure is often put at $50,000. Some researchers believe that figure is too low and should be set at $100,000. In either case, neither of these numbers has any “official” standing. One reference point that might reasonably be used is the $88,000 per patient per year we now (2017) spend to support a patient on dialysis through the Medicare End-Stage Renal Dialysis program. In essence, the implied argument is that if we are willing to fund through taxes this level of support for dialysis patients, then we ought (for justice reasons) to be willing to fund effective life-prolonging efforts for other disease processes at this same level.

4. Lakdawalla, DN, Romley, JA, Sanchez, Y, Maclean, JR, Penrod, JR, Philipson, T. How cancer patients value hope and the implications for cost-effectiveness assessments of high-cost cancer therapies. Health Affairs 2012;31(4):676–82.

5. See note 1, Heale 2016, at 665.

6. Advocates for a QALY methodology generally imagine that QALYs would be imputed on the basis of some set of objectively-measurable criteria. This is the focal point of a very large literature within which much is disputed. We need to put aside those disputes, given our objectives in this essay. See Schwartz S, Richardson J, Glasziou PP. Quality-adjusted life years: Origins, measurements, applications, objections. Australian Journal of Public Health 1993;17(3):272–8.

7. See note 2, Soares 2012, at 27.

8. Wilhelm, MJ. Long-term outcome following heart transplantation: Current perspective. Journal of Thoracic Disease 2015;7:549–51.

9. Kilic, A. Younger patients more likely to live at least ten years after heart transplant. Annals of Thoracic Surgery 2012;93:699704.

10. One notable exception to this last statement would be John Harris, a strict egalitarian. See Harris J. The Value of Life: An Introduction to Medical Ethics. London: Routledge & Kegan Paul; 1985:87–111.

11. Ubel, PA. Pricing Life: Why It’s Time for Health Care Rationing. Cambridge, MA: MIT Press; 2000:6795.

12. See Harris J. QALYfying the value of life. Journal of Medical Ethics 1987;13:117–23. More recently, see Campbell SM, Stromondo JA. The complicated relationship of disability and well-being. Kennedy Institute of Ethics Journal 2017;27:151–84.

13. Peppercorn J. Financial toxicity and societal costs of cancer care: Distinct problems require distinct solutions. The Oncologist 2017;22:123–5. The phrase “targeted cancer therapies” refers to drugs that target specific “driver” mutations of a cancer, such as BRAF (colon cancer or melanoma) or EGFR mutations (lung cancer), with the intent of disabling that cancer by disabling its driver.

14. See note 2, Soares 2012.

15. Cookson contends that this end-of-life premium cannot be given a coherent ethical justification. He considers and refutes ten possible justifications that various writers have offered. See Cookson R. Can the NICE “end-of-life premium” be given a coherent ethical justification? Journal of Health Politics, Policy and Law 2013;38:1131–50.

16. Prasad V, Vandross A. Characteristics of exceptional or super responders to cancer drugs. Mayo Clinic Proceedings 2015;90:1639–49.

17. See note 1, Heale 2016, at 670.

18. Heale may not have noted that 59% of adults in the UK are overweight or obese. See Yang YC, McPherson K, Marsh T, Gortmaker SL, Brown M. Health and economic burden of the projected obesity trends in the USA and the UK. Lancet 2011;378:815–25.

19. See note 1, Heale 2016, at 666.

20. Dworkin, R. Sovereign Virtue: The Theory and Practice of Equality. Cambridge, MA: Harvard University Press; 2000:1164.

21. Daniels, N. Just Health Care. Cambridge, UK: Cambridge University Press; 1985.

22. Fleck, LM. Case study: My conscience, your money. Hastings Center Report, 1995;25(3):28–9.

23. Henig RM. At war with their bodies, they seek to sever limbs. New York Times (22 Mar 2005); available at https://www.nytimes.com/2005/03/22/health/psychology/at-war-with-their-bodies-they-seek-to-sever-limbs.html (last accessed 1 Sept 2018).

24. Kamm, F M. Morality, Mortality: Death and Whom to Save From It . New York, NY: Oxford University Press; 1993:144–64.

25. See note 1, Heale 2016, at 671.

26. No doubt, bedside rationing decisions (at the level of individual patients) must be made and made fairly. However, my own view is that multiple justice-relevant considerations should be used to justify such decisions, not just cost-effectiveness in relation to QALYs. See Fleck LM. Controlling health care costs: Just cost effectiveness or “just” cost effectiveness? Cambridge Quarterly of Healthcare Ethics 2018; 27(2):271–83.

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