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An Existential Model for Valuing Health States
- Tim Benson (10 May 1998)
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Diminishing marginal utility of health effects
- Werner Brouwer, Ben van Hout (14 May 1998)
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Questionnaires for the general public are needed to resolve the "duration of life left effect"
- Wai-Ching Leung (21 May 1998)
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Tim Benson, Chairman Electronic Point of Care Ltd
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Problems with the valuation of life expectancy and quality adjusted life years (QALY) (1), can be traced to the underlying philosophical paradigm. The QALY paradigm is based on nineteenth century classical utilitarianism. The greatest good is perfect health, valued at one; being dead (and the event of death) has value of zero. Other states are given values less than one; states judged worse than death may be given negative values (2). This century, philosophers such as Martin Heidegger and Sir Karl Popper have put forward ideas that differ from those of the utilitarians and suggest an alternative model of how to value health. Heidegger’s premise is that we are unaware of things when they are normal. Our conscious concern is with the abnormal. For example, we are not aware of using a door handle when we enter a room, unless it is broken (3). We are not consciously aware that our body is healthy, only when we are ill, injured or dying. This existential approach directs attention to aspects of health that we are aware of, such as distress, disability and impending death. Popper exhorts us to minimise misery and misfortune, not seek to maximise good. These are not symmetrical. One man’s suffering cannot be traded for another man’s happiness. There is an analogy here with Popper’s premise that the task of science is to eliminate of false theories, not to attain ultimate truth (4). Deaths at different ages and circumstances have different consequences and should be valued differently. Once one is dead, one has ceased to exist (at least for direct healthcare). This distinction, between the event of death and the state of being dead, is ignored in the QALY literature. The table below compares the valuations using the QALY Scale and the approach based on Heidegger and Popper, which we call an Existential Model. It shows the fundamental asymmetry: QALY Scale Existential Model Healthy for one year 1 0 Illness for one year Less than 1 More than 0 Event of death 0 More than 0 Dead for one year 0 0 The task of commissioners of health care is to allocate resources in order to minimise the overall consequences of morbidity and mortality for their population. An Existential Model provides a direct indicator of these consequences. Unfortunately, the QALY Scale creates a utilitarian distortion. (1) Waugh N, Scott D. How should different life expectancies be valued? BMJ 1998:316:1316. (25 April.) (2) Rosser R. From Health Indicators to Quality Adjusted Life Years: Technical and Ethical Issues. In: Hopkins A, Costain D, eds. Measuring the Outcomes of Medical Care. London: Royal College of Physicians of London, 1990:1-17. (3) Dreyfus H. Husserl, Heidegger and Modern Existentialism. In: Magee B, The Great Philosophers: An Introduction to Western Philosophy. London: BBC Books, 1987:252-277. (4) Popper K. The Open Society and Its Enemies: Volume I, The Spell of Plato. London: Routledge & Kegan Paul, Fifth Edition 1966:284-285. Funding: None. Conflict of Interest: None |
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Werner Brouwer, Research Fellow (Brouwer) and Senior Research Fellow (Van Hout) institute for Medical Technology Assessment, Erasmus University Rotterdam, The Netherlands, Ben van Hout
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Diminishing marginal utility of health effects EDITOR - Recently, Waugh and Scott wrote a letter in which they raised some important questions and proposed to triple or double health effects when total life expectancy is below 6, repectively 12 months taking the ‘duration of life time left’ into account in economic evaluations.1 We feel that they raised a number of issues, in which economic theory may be of help. Firstly, the principle of attaching more weight to benefits gained when life expectancy is short, seems familiar. This idea corresponds to the economic principle of diminishing marginal utility, reflecting that giving an additional sandwich to someone having few is to be preferred over giving it to someone having many. Applying this principle here implies that giving an additional QALY to a person with a quality adjusted life-expectancy of 20 years, is less valuable than adding one to a person with an expectancy of only 3 months. That this notion implicitly is already used, may be derived from the fact that life-saving lung-transplantation, with a huge costs per QALY, is considered worthwile, while prevention programmes for cholestorol, with much lower costs per QALY are not considered cost-effective. Additionally, the same notion may explain the acceptance of high costs in last year(s) of life, where potential health gains and life-expectancy are oftentimes low. However, we do feel that Waugh and Scott’s proposal to triple or double health effects is as arbitrary as no adjustment and that more research is needed to find the appropriate weights. Secondly, correcting for diminishing marginal utility may partly solve the problem that persons with a shorter life-expectancy may be more willing to accept a poor quality of life than persons with a longer life-expectancy. However, this also relates to one of the principles underlying QALYs, namely that of constant proportional trade-off, which means that indifference between 10 years in health state A and 5 years in health state B implies indifference between 10 months in A and 5 months in B. Again, more research is needed to indicate how the concept of QALYs should be adapted for situations involving very short life-expectancies. Finally, in relation to the above, Waugh and Scott mention discounting of future effects. It should be noted that discounting and diminishing marginal utility are two different subjects, with similar consequences, but from completely different backgrounds. Therefore, we feel that they should be treated separately. Werner Brouwer, Research fellow Ben van Hout, Senior Research Fellow institute for Medical Technology Assessment Erasmus University Rotterdam PO Box 1738, 3000 DR Rotterdam, The Netherlands phone: + 31 10 408 8584, fax: + 31 10 452 6086 1 Waugh N, Scott D. How should different life-expectancies be valued? BMJ 1998: 316: 1316 (Word count: text including title 399 words) |
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Wai-Ching Leung, Senior Registrar in Public Health Medicine Sunderland Health Authority, Durham Road, Sunderland SR3 4AF
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Waugh and Scott suggested that the benefits of a life year gained may be more if the duration of life left is shorter, and invited BMJ readers to comment on how weightings should be used to guide commissioners of health care.(1) How this problem should be approached must depend on the reasons the authors have in mind for their suggestions, and these reasons should be made explicit. It may be argued that patients, their dependants or the society may potentially derive higher benefits for the time closer to death. For the patients, they can make preparations for the arrangements of their estates and the care of their dependants; to complete their work for which they have unique abilities; to say goodbye to their relatives, friends and acquaintances; and to come to terms with their deaths. Their dependants and family members may benefit from the financial and practical arrangements made and possibly reduce the risks of complicated grief.(2) The society may benefit from any work which the patient may be in a unique position to complete. However, there are several difficult issues. Firstly, these factors apply more to some groups of patients than others. For example, older people may be more likely to have already made suitable arrangements for their estates, less likely to have dependants, and more likely to be psychologically prepared for death. It is difficult to have a policy which takes these factors into consideration without appearing inequitable. Secondly, the suggested higher benefits are entirely attributable to knowing the timing of one’s death earlier. If we endorse this approach, one may argue that it is cost-effective under some circumstances to screen for diseases for which no treatments are available. Thirdly, whilst only the average increase in life expectancy of a treatment and its costs are required for the traditional cost-utility analysis, we must also gather data on the variations for the increase in life expectancy if we wish to take into account the “duration of life left” effect in commissioning. Fourthly, some patients may prefer not to live with a death sentence over their heads for any period of time. Most importantly, health professionals and BMJ readers are not in a better position than anyone else in judging the benefits associated with the “duration of life left” effect, and questionnaires to the general public using time trade-off methods would be more appropriate. (394 words) References 1 Waugh N, Scott D. How should different life expectancies be valued? BMJ 1998; 316: 1316. (25 April) 2 Parkes CM Bereavement in adult life. BMJ 1998; 316: 856-859 |
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