Qalys and ageism: Philosophical theories and age weighting

Health Economics

Volumn 9, Issue 1, 2000, Pages 57-68

  Tsuchiya, Aki ^a  

^a UNIVERSITY OF YORK   (United Kingdom)

Author keywords

Age weights; Ageism; Fair innings; QALYs

Indexed keywords

ADULT; AGED; ARTICLE; ELDERLY CARE; HEALTH CARE DELIVERY; HEALTH CARE ORGANIZATION; HEALTH ECONOMICS; HUMAN; LIFE EXPECTANCY; LIFESPAN; PRIORITY JOURNAL; QUALITY ADJUSTED LIFE YEAR;

AGE FACTORS; AGED; FEMALE; HEALTH CARE RATIONING; HEALTH SERVICES FOR THE AGED; HEALTH STATUS; HUMANS; MALE; MODELS, THEORETICAL; PREJUDICE; QUALITY-ADJUSTED LIFE YEARS; SOCIAL JUSTICE;

EID: 0033976824     PISSN: 10579230     EISSN: None     Source Type: Journal    
DOI: 10.1002/(SICI)1099-1050(200001)9:1<57::AID-HEC484>3.0.CO;2-N     Document Type: Article

References (49)

1. Harris, J. QALYfying the value of life. Journal of Medical Ethics 1987; 13: 117-123.
2. Harris, J. More and better justice. In: Bell, J.M. and Mendus, S. (eds.), Philosophy and medical welfare. Royal Institute of Philosophy Lecture Series 23, Cambridge University Press, Cambridge, 1988, pp. 75-96.
3. Evans, J.G. Rationing health care by age: the case against. British Medical Journal 1997; 314: 822-825.
4. Note that the criticism should be addressed to QALY maximization and not to the health outcome measure QALY. Some authors do not distinguish between these two, which is confusing, especially when cost is not explicitly mentioned.
5. Nord, E., Richardson, J., Street, A., Kuhse, H. and Singer, P. The significance of age and duration of effect in social evaluation of health care. Health Care Analysis 1996; 4: 103-111.
6. Throughout this paper, the term 'ageism' is used to mean disadvantageous treatment of the old, without any implication with regard to either its moral or its political acceptability.
7. Harris, J. The value of life: an introduction to medical ethics. Routledge, London, 1985, p. 87f.
8. McKie, J., Richardson, J., Singer, P. and Kuhse, H. The allocation of health care resources: an ethical evaluation of the 'QALY' approach. Ashgate Publishing, Hampshire, 1998.
9. Williams, A. Intergenerational equity: an exploration of the 'fair innings' argument. Health Economics 1997; 6: 117-132.
10. Nevertheless, because different population subgroups have different overall life expectancies, it should be noted that a person from an advantaged subgroup is given less weight than a person of the same age from a disadvantaged subgroup.
11. There are several studies that explored this possibility on the empirical front, and some studies quantify the extent of age-related preferences.
12. Busschbach, J.J.V., Hessing, D.J. and de Charro, F.T. The utility of health at different stages in life: a quantitative approach. Social Science & Medicine 1993; 37: 153-158.
13. Cropper, M.L., Aydede, S.K. and Portney, P.R. Preferences for life saving programs: how the public discounts time and age. Journal of Risk and Uncertainty 1994; 8: 243-265.
14. Johannesson, M. and Johansson, P.-O. Is the valuation of a QALY gained independent of age? Some empirical evidence. Journal of Health Economics 1997; 16: 585-599.
15. Nord, E., Richardson, J., Street, A., Kuhse, H. and Singer, P. The significance of age and duration of effect in social evaluation of health care. Health Care Analysis 1996; 4: 103-111.
16. Tsuchiya, A. The value of health at different ages. Journal of Health Care and Society 1996; 6: 123-136 (in Japanese).
17. Also see Tsuchiya, A. Age-related preferences and age weighting health benefits. Social Science and Medicine 1999; 48: 267-276 for a review of the empirical findings.
18. The assumption of two individuals is equivalent to the assumption of homogeneous groups, and is partly for simplicity and partly because of the way the issue has been treated in the existing literature. There is no doubt that these, and the remaining assumptions, are extreme abstractions compared with the real world.
19. Needless to say, the particular distribution of the genders between the two patients is entirely immaterial to the substance of the argument.
20. Literally, the version of OFIA advocated by Harris (1985) does not refer to an explicit age as a fixed cut-off point, but a more vague idea of whether people have 'already lived full lives' or not, as judged by 'reasonable people' (ibid., p. 94). Nevertheless, what is relevant here is that OFIA requires one to have reached some specific point in life to be considered to have had a fair innings. Throughout this present paper, OFIA is to have a specific threshold defined in terms of age, and those above (below) this are assumed to have (are not to have) achieved a full life. Also see note 46 below.
21. Also see Menzel, P.T. Medical choices, moral choices: a philosophy of health care economics in America. Yale University Press, New Haven, 1983, chapter 5, where the notion of a 'prima facie right to a minimum number of life years' is briefly discussed.
22. Harris, J. The value of life: an introduction to medical ethics. Routledge, London, 1985, pp. 94, 101.
23. Callahan, D. What kind of life: the limits of medical progress. Georgetown University Press, Washington, DC, 1990.
24. See also Callahan, D. Setting limits: medical goals in an aging society. Simon and Schuster, New Jersey, 1987, where he refers to the same concept as the Natural Life Span.
25. Daniels, N. Am I my parents' keeper? An essay on justice between the young and the old. London: Oxford University Press, 1988.
26. Also see Daniels, N, Just health care, Cambridge University Press, Cambridge, 1985.
27. Murray, C.J.L. Quantifying the burden of disease: the technical bases for disability-adjusted life years. In: Murray, C.J.L. and Lopez, A.D. (eds.), Global comparative assessments in the health sector. World Health Organization, Geneva, 1994.
28. Murray, C.J.L. Rethinking DALYs. In: Murray, C.J.L. and Lopez, A.D. (eds.), The global burden of disease. Cambridge, MA: Harvard University Press, 1996.
29. World Bank. World Development Report 1993: investing in health. London: Oxford University Press, 1993.
30. Apart from age, welfare interdependency may well be affected by, for example, occupation and income, but weights adjusting for these are not employed in DALYs. This is because people experience different ages on an equal footing as they go on living, and differential treatment by age is not the same as differential treatment by these elements.
31. Note that the difference arises from the difference in the relative value of a healthy year at different ages. The ratio of loss owing to a given disability to full health is assumed to be the same across all ages.
32. Under certain conditions (viz. 3% discount rate and 'standard' life expectancy), the social value of life for her may be smaller than that for him if, for example, she is age 5 and he is age 10, because this function is hump shaped with a peak at around age 10, and the value for age 0 is about the same as the value for age 20. This function is not to be confused with the age weight function. For details, see [27,28].
33. Harris, J. The value of life: an introduction to medical ethics. Routledge, London, 1985, p. 92.
34. Harris maintains that a fair innings is only satisfied when it is achieved, and cannot be satisfied in portions. For example, supposing 70 years was the fair innings, then somebody dying at 40 years cannot be said to have had a 'fairer' innings than another dying at 30 years (ibid., p. 92). Nevertheless, note that this argument is valid only when one presupposes that there is such a thing as a fixed fair innings. Furthermore, OFIA may be subject to the same criticism, namely, that it is also invidious not to save his life simply because he is older than the threshold by some marginal degree (a point made by one of the anonymous referees).
35. Lockwood, M. Quality of life and resource allocation. In: Bell, J.M. and Mendus, S. (eds.). Philosophy and medical welfare. Royal Institute of Philosophy Lecture Series 23, Cambridge University Press, Cambridge, 1988.
36. As such, this perhaps should no longer be referred to as being a variant of the fair innings argument. Nevertheless, both Harris ([2], p. 93) and Lockwood ([35], p. 50) refer to this (i.e. the format without a specific cut off age) as the fair innings argument.
37. ibid., p. 54.
38. Also see Kappel, K. and Sandøe, P. QALYs, age and fairness. Bioethics 1992; 6: 298-316.
39. Also see Kappel, K. and Sandøe. P. Saving the young before the old-A reply to John Harris. Bioethics 1994; 8: 84-92.
40. Lockwood himself does not discuss this case.
41. Harris, J. Does justice require that we be ageist? Bioethics 1994; 8: 297-316.
42. Here, Harris seems to think that if we follow RFIA then we should save her, conditional to her being killed when she reaches his present age: a condition which is absurd and hence, as Harris concludes, RIFA must be unsupportable. If we do not allow this, then RFIA may have to choose to save neither patient (a possibility pointed out by one of the anonymous referees).
43. If people are unconcerned with distribution of health and there is no trade-off, then the contour will be a straight line and the present level of average lifetime QALYs will be the fair innings. In this case, because the contour is a straight line, all weights will be equal to 1.
44. Because those with permanent or long-term disabilities will have a smaller prospect of achieving the fair innings than those without disabilities, other things being equal, the former will be given a larger fair innings weight. Thus, EFIA offers a way to accommodate the so-called double jeopardy argument within QALY maximization.
45. Needless to say, the operationalization of any system will involve efficiency and equity concerns in the sense that waste should be minimized, and irrelevant attributes of individuals should not enter the decision-making process. The discussion here explores the major concerns, or underlying reasons, of each of these proposals.
46. This conclusion does not apply to the literal version of OFIA as advocated by Harris. This is because it sets the fair innings as whether one has had a 'full life' or not, and age itself does not determine whether one has achieved the fair innings in this sense. Note that it is not the chance or opportunity that one has had, but the actual achievement of a full life that is the issue here. Also see note 20 above.
47. In fact, one implication of Harris's position is that there should be no recourses allocated to the treatment of non-fatal conditions while there are people dying from treatable conditions despite their wishes to go on living, and this applies regardless of the magnitude of HRQOL improvements forgone or, in other words, costs.
48. It will nevertheless be difficult to apply the literal version of OFIA advocated by Harris to the policy level, because whether one has reached the fair innings is to be determined individually, not categorically by one's age. Individual versus categorical treatment is an important issue regarding ageism, but is not addressed in this paper. There are arguments throughout Callahan [23] in favour of categorical treatment. For an argument against categorical treatment in the context of ageism, see for example Evans [3].
49. Under the life-saving scenario, the first and third cases do not apply. This is because the assumptions are such that her fair innings weight is larger than 1 and his weight is smaller than 1. They become possible under the health improvement context, because, depending on their lifetime expected QALYs, it is possible for her fair innings weight to be larger than his, despite her present age being less than his.