Rilke's remark conjures up an officious array of well-meaning persons bent on completing our orderly passage from cradle to grave. They tidy our files cosily about us, inject us with extreme unction and slide us into the warm embrace of the undertaker. At the forefront of the array stands the doctor, part mechanic and part priest. His main task is to repair the living with resources whose effective and impartial allocation is a chief topic of medical ethics. But his role is not that of an impartial allocator: his patients want his partisan support. This builds a moral tension into a role played out where system meets patient, and one made instructively plain in the care of the dying. The system no doubt prefers death to be cheap and orderly but this thought may not move someone like Rilke wanting a death of his own. The doctor is then caught between his general duty to patients at large and his particular duty to the patient in front of him, a tension tautened for a Hippocratic promoter of health and life by a patient in search of an exit.

The precise application of the term ‘heroic measures’ in the discourse of medicine and medical ethics is somewhat uncertain. What counts and what does not is, at the margins, a perpetually contentious issue. Basically, though, we can say that the term refers to the deployment of unusual (rare, experimental, expensive, non-standard) technologies or treatment regimes, or of ordinary technologies or treatment regimes beyond their usual limits.

A new word has recently entered the British medical vocabulary. What it stands for is neither a disease nor a cure. At least, it is not a cure for a disease in the medical sense. But it could, perhaps, be thought of as an intended cure for a medicosociological disease: namely that of haphazard or otherwise ethically inappropriate allocation of scarce medical resources. What I have in mind is the term ‘QALY’, which is an acronym standing for quality adjusted life year. Just what this means and what it is intended to do I shall explain in due course. Let me first, however, set the scene.

Counting QALYs (quality adjusted life years) has been proposed as a way of deciding how resources should be distributed in the health service: put resources where they will produce the most QALYs. This proposal has encountered strong opposition. There has been a disagreement between some economists favouring QALYs and some philosophers opposing them. But the argument has, I think, mostly been at cross-purposes. Those in favour of QALYs point out what they can do, and those against point out what they can't. There need be no disagreement about this. What is needed is to sort out what is the proper domain of QALYs, and it may be possible to do this amicably. Then we may be able to get on with the more useful job of deciding how well QALYs perform within their domain. In this paper I shall try to accomplish the first task (sections II–IV), and make a start on the second (sections V–VIII).

The principle that people's lives and fundamental interests are of equal value and that they must therefore be given equal weight has immense intellectual appeal and intuitive force. It is often enough to discredit a theory or proposal simply to show that it violates this principle. When measures are said to be discriminatory or unfair it is this principle which is in play. Recent philosophers of widely differing schools and outlooks give versions of this principle a central role in their theories.

How much by way of economic reward is due to health care providers?

Although this problem usually presents itself as a practical matter of policy, it has buried within it a number of philosophical issues, for it can be regarded as a question in the theory of economic justice. The formal principle of justice is that we should render persons what is due to them. But on what consideration in the case of health care providers can we make an assessment of what is due?

The answer we give to this question has significant implications for the ethical appraisal of the allocation of resources in the health care system. Some of the most difficult issues of ethical appraisal emerge when we consider the problems of allocating potentially life-saving resources between different groups of patients. Many of the most significant current issues in medical ethics—the role of QALYs, the meaning of equality and the economic evaluation of life—find their point of reference in the ‘tragic choices’ that are created when there are insufficient resources to meet apparently legitimate medical need. Yet, as Robert Evans has pointed out, it is a simple matter of accounting identity that health care expenditures must equal health providers' incomes. So, in asking how we limit or allocate costly health care resources, we are implicitly offering an answer to the question of how much we should pay providers. I hope by seeking an answer explicitly to that question to throw light on the problems that are raised when considering ethically the allocation of health care resources.

1.1. A major purpose in nationalizing the provision of health care in the UK was to affect its distribution between people, and, in particular, to minimize the impact of willingness and ability to pay upon that distribution. It has never been clear, however, what alternative distribution rule is to apply. There is no shortage of rhetoric about ‘equality’ and ‘need’, but most of it is vacuous, by which I mean it does not lead to any clear operational guidelines about who should get priority and at whose expense. The closest we have got so far to such explicit guidelines has been the formulae which determine the geographical distribution of NHS funds, the driving force behind which is a notion of need based on relative mortality rates and on the demographic structure. The avowed objective is to bring about equal access for equal need irrespective of where in the UK you happen to be.