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QALYs and ethics: A health economist's perspective


  • Williams, Alan


Objectors on ethical grounds to the use of QALYs in priority-setting in public health care systems are here categorised as (1) those who reject all collective priority-setting as unethical; (2) those who accept the need for collective priority-setting but believe that it is contrary to medical ethics; (3) those who accept the need for collective priority-setting and do not believe that it is contrary to medical ethics, but reject the role of QALYs in it on other ethical grounds; and (4) those who accept the need for collective priority-setting in principle, but are unwilling to specify how it should be done in practice. It is argued that the first two groups of objectors are simply wrong, if distributive justice is a proper ethical concern in this context. The third group is of more interest, as this group appears to believe that QALYs are unethical because it is unethical to regard QALY maximisation as the sole objective of the health care system. This paper argues that QALYs are relevant to a much wider range of objectives than QALY maximisation, and that they can accommodate a wide variety of health dimensions and sources of valuation. They can also accommodate the differential weighting of benefits according to who gets them, so they do not commit their users to any particular notion of distributive justice. What they do commit their users to is the notion that the health of people is a central concept in priority-setting, and that it is desirable, for reasons of accountability, to have the bases for such priority-setting made as precise and explicit as possible. The fourth group of objectors needs to acknowledge that there is no perfect system on offer, and since priority-setting does and will proceed willy-nilly we cannot wait until there is. It would be more constructive to set up the desiderata that a priority-setting system should ideally fulfil, and then appraise all feasible alternatives (including the status quo) even-handedly by those criteria. None will be perfect, but this author predicts that QALYs would emerge from such an appraisal with a significant role to play.

Suggested Citation

  • Williams, Alan, 1996. "QALYs and ethics: A health economist's perspective," Social Science & Medicine, Elsevier, vol. 43(12), pages 1795-1804, December.
  • Handle: RePEc:eee:socmed:v:43:y:1996:i:12:p:1795-1804

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    1. repec:cup:judgdm:v:16:y:2021:i:1:p:1-19 is not listed on IDEAS
    2. Martine AUDIBERT, 2009. "Issues and Challenges of Measurement of Health:Implications for Economic Research," Working Papers 200922, CERDI.
    3. Cappelen, Alexander W. & Norheim, Ole Frithjof, 2006. "Responsibility, fairness and rationing in health care," Health Policy, Elsevier, vol. 76(3), pages 312-319, May.
    4. Richard Norman & Gisselle Gallego, 2008. "Equity weights for economic evaluation: An Australian Discrete Choice Experiment, CHERE Working Paper 2008/5," Working Papers 2008/5, CHERE, University of Technology, Sydney.
    5. Mark Blaug, 1998. "Where are we now in British health economics?," Health Economics, John Wiley & Sons, Ltd., vol. 7(S1), pages 63-78, August.
    6. Patrick Hofstetter & James K. Hammitt, 2002. "Selecting Human Health Metrics for Environmental Decision‐Support Tools," Risk Analysis, John Wiley & Sons, vol. 22(5), pages 965-983, October.
    7. Richardson, Jeff & McKie, John, 2007. "Economic evaluation of services for a National Health Scheme: The case for a fairness-based framework," Journal of Health Economics, Elsevier, vol. 26(4), pages 785-799, July.
    8. Odejar, Maria & Baker, Rachel & Ryan, Mandy & Donalson, Cam & Bateman, Ian J. & Jones-Lee, M & Lancsar, Emily & Mason, Helen & Pinto Paredes, JL & Robinson, A & Shackley, P & Smith, R & Sugdem, R & Wi, 2010. "Weighting and valuing quality-adjusted life-years using stated preference methods: preliminary results from the Social Value of a QALY Project," MPRA Paper 108869, University Library of Munich, Germany.
    9. Ariel Beresniak & Antonieta Medina-Lara & Jean Auray & Alain Wever & Jean-Claude Praet & Rosanna Tarricone & Aleksandra Torbica & Danielle Dupont & Michel Lamure & Gerard Duru, 2015. "Validation of the Underlying Assumptions of the Quality-Adjusted Life-Years Outcome: Results from the ECHOUTCOME European Project," PharmacoEconomics, Springer, vol. 33(1), pages 61-69, January.
    10. Karen Huang & Regan M. Bernhard & Netta Barak-Corren & Max Bazerman & Joshua D. Greene, 2021. "Veil-of-ignorance reasoning mitigates self-serving bias in resource allocation during the COVID-19 crisis," Judgment and Decision Making, Society for Judgment and Decision Making, vol. 16(1), pages 1-19, January.
    11. Denburg, Avram E. & Ungar, Wendy J. & Chen, Shiyi & Hurley, Jeremiah & Abelson, Julia, 2020. "Does moral reasoning influence public values for health care priority setting?: A population-based randomized stated preference survey," Health Policy, Elsevier, vol. 124(6), pages 647-658.
    12. Martine Audibert, 2011. "Issues and Challenges of Measurement of Health:Implications for Economic Research," CERDI Working papers halshs-00554267, HAL.
    13. James D. Chambers & Teja Thorat & Colby L. Wilkinson & Mark Salem & Prasun Subedi & Sachin J. Kamal-Bahl & Peter J. Neumann, 2017. "Estimating Population Health Benefits Associated with Specialty and Traditional Drugs in the Year Following Product Approval," Applied Health Economics and Health Policy, Springer, vol. 15(2), pages 227-235, April.
    14. Lidia Engel & Stirling Bryan & David G. T. Whitehurst, 2021. "Conceptualising ‘Benefits Beyond Health’ in the Context of the Quality-Adjusted Life-Year: A Critical Interpretive Synthesis," PharmacoEconomics, Springer, vol. 39(12), pages 1383-1395, December.
    15. Lancsar, Emily & Wildman, John & Donaldson, Cam & Ryan, Mandy & Baker, Rachel, 2011. "Deriving distributional weights for QALYs through discrete choice experiments," Journal of Health Economics, Elsevier, vol. 30(2), pages 466-478, March.


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