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Quality Adjusted Life Year

March 12, 2012

The Quality Adjusted Life Year is a technique for evaluating the effectiveness of health care policies and innovations. More life is better than less; higher quality lives are prefered to lower quality, but there are some several methodological problems with this approach. First, it conflates a measurement for a maximand. Second, it creates false certainty surrounding a subject full of subtle tradeoffs. Last, and most importantly, it imposes one fixed set of values on life in a world where people value different things.

“The changes that are ahead of us will change the lives of the elderly, disabled, chronically sick, terminally ill, and those people with serious health problems such as cancer and a multitude of other conditions. What do these populations share in common? They are expensive and their lives are not valued.”
Peter Singer (emphasis added)

Valued by whom? If human life is not valued at all, why even bother with a health care system at all? But that’s clearly not what Singer meant. Perhaps he meant that the lives are not valued by those living them. Dan Gilbert explored this topic and found that people tend to return to a hedonic baseline. Basically, no matter what happens, eventually people return to the level of happiness they were before. Both crippling disabilities and winning the lottery lose their impact after a few months. People overestimate the amount life events will change the amount of meaning and happiness in their lives.

I am worried by how policy based on this line of reasoning will play out in practice. Because people will usually rate their own lives as highly valuable, Singer’s position is only enforcable if other people rate how valuable your life is. Such a system would allow those who make the definition to punish groups they don’t like. If you don’t like smokers, simply say their lives are not “quality” enough. Don’t like gays? Count their lives as half as valuable. Furthermore, such a system is in violation of the 14th Amendment’s equal protection clause.

When people are left to their own devices, they place rather strange values on various policies. For example, the availability heuristic can influence people to overreact to highly salient disasters, such as terrorism, and underreact to more boring dangers, such as aging, unsafe driving or kitchen accidents, which kill far more people. Utilitarianism was quite radical when it was first developed, because it argued that all people’s welfare should be weighted equally, including the low status. It can be a powerful way to clarify thinking on societal problems, by forcing one to think about how many people will be affected, and by about how much, but it can be abused.

Further Reading:
A good example

2 Comments leave one →
  1. March 13, 2012 8:15 am

    Good post, food for thought. It always struck me that while Jack Kevorkian was out killing a few hundred people (and I agree with that right, btw), there were literally millions in that state alone who decided to not die, despite life affecting diseases, accidents, disorders.

  2. March 13, 2012 10:26 am

    As a society, the US is still a long way from meaningful right-to-die discourse in the mainstream. -_-

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