Intended for healthcare professionals

Education And Debate Measuring quality of life

Is there such a thing as a life not worth living?

BMJ 2001; 322 doi: (Published 16 June 2001) Cite this as: BMJ 2001;322:1481
  1. Bobbie Farsides, senior lecturer, medical ethics (,
  2. Robert J Dunlop, honorary senior lecturerb
  1. a Centre of Medical Law and Ethics, King's College London, London WC2R 2LS
  2. b Guy's, King's College, and St Thomas's Hospitals School of Medicine and Dentistry, London SE5 9PJ
  1. Correspondence to: B Farsides

    This is the last in a series of five articles

    Measuring quality of life has an important place in health care, but what about when life has no quality? Or worse? From an ethical perspective there are two areas in which these issues have been extensively explored: termination of pregnancy and end of life decision making for competent and non-competent adults. One way in which quality of life is sometimes introduced to decision making is through the concept of “a life not worth living.” The seemingly logical conclusion is that lives not worth living may not be worth creating or saving. This final paper in the series debates the problems—both the practical difficulties of measurement and ethical issues—associated with measuring quality of life in situations in which lives have been judged to have no quality.

    Summary points

    There are no quality of life measures that reliably identify patients who feel that life is not worth living

    Basing management decisions on such measures requires extreme caution because of the fluctuating nature of patients' valuations of life and their desire for death

    Patients who are dying may find some quality in life, even when their quality of life as assessed by current measures is abysmal

    The use of proxies to determine whether a life is worth living is problematic because of the possible disparity between an observer's assessment and the patient's own valuation

    Both patients and their proxies have identified health states that they consider to be worse than death

    The beginning and the end

    If a pregnancy is terminated because the fetus has an abnormality we will never know for sure whether the life in question would have been worth living. However, we allow lives to be terminated if they are predicted to be of low (or maybe only slightly diminished) quality. We base these decisions not only, …

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