Quality Adjusted Life Years: An Essentially Utilitarian Metric

Utilitarianism is a philosophy described by Jeremy Bentham, the 18th-century philosopher from whom it originated, as a strategy for maximizing the availability of happiness to the greatest number of people. Historically, societies have proscribed rules which are rooted in both pragmatism and a sense of innate morality. Utilitarianism offers a unique perspective from which to judge the meaning of health, happiness, and time. With universal access to healthcare becoming the defining issue of contemporary American politics, it is essential to examine the metrics which measure the outcomes and consequences of furnishing healthcare to the citizenry. The quality-adjusted life year or QALY is a measurement of time which tries to account for both length and quality of life; measurements which are arguably objective and subjective respectively.

Bentham himself did not include health as part of happiness, but it is difficult to discuss happiness in the absence of good health. This problem is raised by Dolan when stating that health and happiness may not necessarily be reduced to comparable measures of utility. The subjectivity of happiness has plagued utilitarians since Bentham first proposed it as the main goal of both the individual and society as a whole. Nevertheless, the "pursuit of happiness" is enshrined in the Declaration of Independence, ironically disparaged by Bentham himself at the time of its publishing, and similar aspirations can be found across a broad swath of societal charters.

In many ways, healthcare is the pursuit of happiness as health: increasing quality of life through medical interventions and allocating funding in order to satisfy the healthcare needs of as many persons as possible. Healthcare eases suffering, or if it increases it, it is a consequence of the future goal of good health and happiness: e.g. chemotherapy and other radical cancer treatments. There is an ongoing debate in the medical community which refers to the utilitarian goal of maximizing positive patient outcomes regarding such painful cancer screenings and treatments and whether or not they are effective in increasing QALYs. Such risk-benefit analysis is a hallmark of Bentham's felicific calculus, which looks for maxima and minima representing the equilibrium between pleasure and pain.

If routinely recommended prostate screening results in reduced pleasure and increased pain, with no guarantee of the future benefit of health, what Bentham would call certainty, then a utilitarian might consider reducing screening which provides no or questionable benefits by altering these policies from the top down.

Dolan states that QALYs are an effective way of using utility to guide healthcare theory and policy, with some caveats; "if QALYs represent health benefits and if the objective of health policy is to maximize health, then it follows that resources should be allocated so as to maximize the number of QALYs generated." (Dolan, 2005) Dolan creates a taxonomy of utilitarianism that consists of five dimensions: consequentialism, monism, welfare, preference-satisfaction, and advantage which is aggregated according to sum ranking. The paper questions how fully QALYs express utilitarianism and does so by developing this new taxonomy to classify utilitarianism and the dimensions of the QALY construct.

Consequentialists believe that the underlying morality of an action is less important or does not matter at all compared to the consequences of that action. One of the more infamous proponents of a consequentialist view, Machiavelli, would suppose that morality can be defined solely in terms of consequences. An example of this is how Bentham argues that legalizing homosexuality might prevent even more egregious actions by the state which increase pain and decrease pleasure on a greater scale both individually and as a group compared to the behaviors homosexuality entails themselves. Following the range of discourse from Bentham through Foucault, punishment by torture or imprisonment of homosexual acts inflicts more pain and deprives more pleasure than the alternative, which is simply allowing the behaviors to occur. By acting to reduce the quality of life, the state takes an anti-utilitarian role. This is a consequentialist belief because the rightness or wrongness of an action is not derived from opinion, norm, religious or social more, but rather the overall consequences of taking or not taking that action. Non-consequentialists, on the other hand, value ideas such as individual liberty and weighing consequences by considering the intention behind action. (Dolan, 2005)

Utilitarian monists see decisions as having impacts that are comparable. Monism includes all actions and their consequences under the umbrella of their effect on utility. Monism does not focus on the potential unrealized benefits which could be derived from individual considerations. According to Dolan, proponents of the QALY as a metric adopt a monist view that collapses "the benefits of healthcare into a homogenous magnitude." Monism is preferable because it offers "consistency" when examining various facets of health services. (Dolan, 2005) Conceptually, disparate healthcare products and services can be compared by translating their benefits into the number of QALYs furnished to society per dollar. For example, elder care can be contrasted with prenatal care simply in terms of QALYs provided. A caveat to this monistic view is that "individual behavior may be shot through," by societal actions that ignore personal considerations in favor of consistency. (Dolan, 2005) On a case-by-case basis healthcare choices may be difficult to compare (Nord, 1994); however, on a societal scale, monism ensures consistency despite "incommensurable values" which arise from pluralistic considerations. All choices are difficult choices because they involve unique trade-offs, and in order to compare them, a monistic view is useful. However, policymakers desire some "discretion" as to which trade-offs society chooses. (Dolan, 2005) For example, healthcare services that add a specific number of QALYs to an individual's life may have different levels of utility based on who that individual is. A president or Nobel prize winner may be seen as more deserving of a QALY than an average person due to pluralistic concerns.

Welfarists view goodness as a purely measured individual utility, as opposed to viewing goodness as separate from the amounts of pain and pleasure attained by a person, e.g. "goodness" which entails extreme suffering with no pleasure payoff, such as martyrdom. Welfarism is a consequentialist position because the only morally significant factors are the consequences that result in an increase in the sum of individual utilities or welfare. Utility, however, encompasses more than just a measurement of health. Therefore, when studied empirically, individuals must assign a quantitive value of utility based on their health states. QALYs are generally welfarist because good health is necessary for attaining increased utility. (Dolan, 2005) Nevertheless, judging the wellbeing of a person exclusively on the basis of happiness is limiting. Sen, as paraphrased by Dolan, states that a non-welfarist approach that emphasizes equality of access to healthcare is reasonable because some people will choose to be unhealthy.

This is further complicated by the final two attributes of preference satisfaction and aggregation according to sum ranking. Preference satisfaction proposes that stated preferences are true preferences, rather than dividing human desires into "needs" and "wants." (Dolan, 2005) A preference-based approach emphasizes the utility of an individual's ability to make his or her own choices. This is especially important in the realm of healthcare, where patient needs and wants may even be in direct opposition due to lack of knowledge, fear, or subjectivity. QALYs do not account for happiness, but they do factor into utility for the aforementioned reasons of the ability to enjoy happiness and minimize pain. (Blackorby, 2002) A non-preference approach allows for societal interventions that frustrate individual preference and liberty to obtain a greater utility overall, e.g. a total ban on smoking. Dolan laments the inability to reconcile individual status and freedoms with societal outcomes, which is related to the problem of aggregation according to sum ranking. (2005)

Aggregation of QALYs according to sum ranking can be viewed as just in light of the goal of maximizing total utility. Choosing how to prioritize healthcare allocation is based on more than the size of need alone. (Dolan, 2005) Broome (1991), as quoted in Dolan, urges policymakers to look for "a class of reasons, referred to as claims," to administer benefits according to the various strengths of those claims. Harris (1996) further states that each individual should have an equal opportunity to have his or her health claims honored. While it is typical to aggregate QALYs using sum ranking it is not necessary. Based on a large body of prior research, according to Dolan, clearly, weighing benefits equally seems appropriate; however, he strongly urges further "empirical investigation" in this area. (2005) When considering the broader topic of utilitarianism, researchers and the general public have much to offer in terms of identifying the weight and legitimacy of claims.

Dolan's new taxonomy of utilitarianism is useful because it helps delineate different moral philosophies and, most importantly, "distinguish utilitarianism from other theories." (Dolan, 2005) "In principle," the QALY metric adheres to all five facets of Dolan's evaluation of utilitarianism and very strictly embodies both consequentialism and monism. (2005) QALYs are consequentialist because benefits are delivered based on outcomes regardless of intention or the unique status of each individual. Monism is wholly compatible with QALYs due to the equalizing nature of the metric across different individuals and contexts and the conflation of health and length of life into one quantitative measurement. While Dolan asserts the consequentialist nature of the measurements encompassed by QALYs, the aggregation of benefits can be applied by the utilitarian concept of sum ranking or other novel methods. Strategically, QALYs provide an understandable and quantifiable guide for dispensing healthcare to a large population of individuals.

Works Cited

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Nord, Erik. "The QALY—A Measure of Social Value Rather than Individual utility?" Health Economics 3.2 (1994): 89-93. Print.

Tsuchiya, A. "The QALY Model and Individual Preferences for Health States and Health Profiles over Time: A Systematic Review of the Literature." Medical Decision Making 25.4 (2005): 460-467. Print.