INTRODUCTION

As the volume of research on quality-adjusted life years (QALYs) has increased, concerns have begun to be expressed about the equity implications of this research. Lockwood (1988), for example, has argued that the QALY approach ‘is in principle liable to result in forms of allocation that are unjust or unfair’ (Lockwood, 1988, p. 45), emphasis in original. Similar concerns have been expressed by inter alia Broome (1988), Harris (1988) and Smith (1987).

That these concerns continue to be expressed despite attempts by advocates of the QALY approach to reassure critics suggests that there has been a misunder-standing either on the part of the critics of the QALY approach or on the part of its advocates. One of the aims of this chapter is to find out the nature of any misunderstanding. More generally the aim of the chapter is to explore the nature of the tradeoff between equity and efficiency in the context of resource allocation via QALYs. To do so clearly requires consideration of the concepts of equity and efficiency. What do advocates of the QALY approach mean by efficiency? What is the concept of equity underlying the QALY approach? Is it at variance with that proposed by the critics of the QALY approach? What is the nature of the tradeoff between efficiency and equity (if any)? How could such a tradeoff be taken into account in resource allocation decisions?

EFFICIENCY AS HEALTH MAXIMIZATION

The policy objective underlying the QALY literature is the maximization of the community's health.