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Bursting Bubbles? QALYs and Discrimination

  • BEN DAVIES (a1)


The use of Quality-Adjusted Life Years (QALYs) in healthcare allocation has been criticized as discriminatory against people with disabilities. This article considers a response to this criticism from Nick Beckstead and Toby Ord. They say that even if QALYs are discriminatory, attempting to avoid discrimination – when coupled with other central principles that an allocation system should favour – sometimes leads to irrationality in the form of cyclic preferences. I suggest that while Beckstead and Ord have identified a problem, it is a misdiagnosis to lay it at the feet of an anti-discrimination principle. The problem in fact comes from a basic tension between respecting reasonable patient preferences and other ways of ranking treatment options. As such, adopting a QALY system does not solve the problem they identify.



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1 Franklin, D., ‘Calibrating QALYs to Respect Equality of Persons’, Utilitas 29 (2017), pp. 6587, at 66.

2 Harris, J., ‘QALYfying the Value of Life’, Journal of Medical Ethics 13 (1987), pp. 117–23; Menzel, P., Dolan, P. and Richardson, J., ‘The Role of Adaptation to Disability and Disease in Health State Valuation: A Preliminary Normative Analysis’, Social Science and Medicine 55 (2002), pp. 21492588; Kamm, F., ‘Deciding Whom to Help, Health-Adjusted Life Years and Disability’, Public Health, Ethics, and Equity, ed. Anand, S., Peter, F. and Sen, A. (Oxford, 2004), pp. 225–42; Brock, D., ‘Cost-effectiveness and Disability Discrimination’, Economics and Philosophy 25 (2009), pp. 2747.

3 Persad, G., Wertheimer, A. and Emanuel, E. J., ‘Principles for Allocation of Scarce Medical Interventions’, The Lancet 373 (2009) pp. 423–31, at 427.

4 Harris, ‘QALYfying’, pp. 119–20.

5 Barnes, E., The Minority Body: A Theory of Disability (Oxford, 2016).

6 Cubbon, J., ‘The Principle of QALY Maximisation as the Basis for Allocating Health Care Resources’, Journal of Medical Ethics 17 (1991), pp. 181–4; Singer, P., McKie, J., Kuhse, H. and Richardson, J., ‘Double Jeopardy and the Use of QALYs in Healthcare Allocation’, Journal of Medical Ethics 21 (1995), pp. 144–50; Rawlins, M. and Dillon, A., ‘NICE Discrimination’, Journal of Medical Ethics 31 (2005), pp. 683–4.

7 Beckstead, N. and Ord, T., ‘Bubbles under the Wallpaper: Healthcare Rationing and Discrimination’, Bioethics: An Anthology, 3rd edn., ed. Kuhse, H., Schüklenk, U. and Singer, P. (Oxford, 2016), pp. 406–12. See also Beckstead, N. and Ord, T., ‘Rationing and Rationality: The Cost of Avoiding Discrimination’, Inequalities in Health: Concepts, Measures, and Ethics, ed. Eyal, N., Hurst, S., Norheim, O. and Wikler, D. (Oxford, 2013), pp. 232–9.

8 Beckstead and Ord, ‘Bubbles’, p. 407.

9 Beckstead and Ord, ‘Bubbles’, p. 407.

10 Beckstead and Ord, ‘Bubbles’, p. 407.

11 Beckstead and Ord, ‘Bubbles’, p. 410.

12 For instance, there may be egalitarian reasons to prioritize worse-off patients. See John, T.., Millum, J. and Wasserman, D., ‘How to Allocate Scarce Health Resources without Discriminating against People with Disabilities’, Economics and Philosophy 33 (2016), pp. 161–86, at 167–8.

13 Beckstead and Ord, ‘Bubbles’, p. 407.

14 Beckstead and Ord, ‘Bubbles’, p. 407.

15 This aligns to some extent with public views on parents’ rights to choose substandard treatments for children, with a recent survey of public attitudes showing a majority tolerating substandard treatments that increased the risk of death by up to 5 per cent. See Nair, T., Savulescu, J., Everett, J., Tonkens, R. and Wilkinson, D.Settling for Second Best: When Should Doctors Agree to Parental Demands for Suboptimal Medical Treatment?’, Journal of Medical Ethics 43 (2017), pp. 831–40.

16 Beckstead and Ord, ‘Bubbles’, pp. 408–9.

17 Thanks to participants in the King's College London summer seminar (2017), Dale Miller, and to two anonymous referees for feedback on this article.

Bursting Bubbles? QALYs and Discrimination

  • BEN DAVIES (a1)


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