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I was recently thinking about adaptive preferences in the context of health resource allocation. As you and many others know, one of the motivations behind the capabilities approach is that if our metric of advantage is well-being or happiness, then some people who have adapted to unjust circumstances may report experiencing the same level of well-being or happiness than others who have not been unjustly treated (or even the same level as they themselves would have reported in the counterfactual situation in which they are not the recipient of unjust treatment).

But now consider two individuals, both of whom can be (let us say) expected to die at 70 (apologies to those approaching 70; I don't mean anything by it). First consider a person who has lived with a disability her entire life (she is now 60). That disability places her at .7 on some quality of life scale (from 0 to 1), but she has long since adapted to it. Now imagine a 30 year old who has always been in full health and will continue to be in full health right up until her quite elderly dying day, but who will experience a sudden drop from 1.0 to .4, unless treated. If he is treated, he will remain at 1.0 indefinitely. If he is not treated, he will live at .4 for two years, but then be returned naturally to 1.0 (it is a condition that usually resolves itself in two years, e.g.).

If we think that people should not be discriminated against because they have adapted to an unfortunate decision, and if we think that people are owed some sort of QALY-related fair innings (Alan Williams's view), then we ought to say that the 60 year-old deserves priority over the 30 year old. After all, if nothing is done for either person, the currently older person will experience 49 total QALYs in her life, and the currently younger person will experience 68.8 QALYs. That seems completely unfair. Still, the fact that the currently older person has adapted to her lower health-related quality of life seems relevant, and combined with the *lack* of adaptivity we might expect of the 30 year old when he drops from 1.0 to .4 for two years, I am tempted to say that the 30 year old should get priority.

These are new thoughts, and I offer them here because, you know, where else? :)

Bill Gardner

Am I missing something? How much benefit would the person at 0.7 get from treatment? Is the question at hand something like, should we give A two years of 0.3 additional QALYs in light of her history of many years of 0.7, instead of giving B two years of 0.6 additional QALYs? That is, should a history of deprivation over ride the greater expected benefit?

Your question gets at the issue of what medical care is for. I used to think that the point was to improve quality of life, raise well-being, etc. But one could argue that people make their own well-being, and medical care just maintains the technology that a person uses to produce it. So, one might say that people have a right to health care because they have a right to a working body. But they do not have a right to a good life.


Sorry, yes, I wrote that too quickly. Here, then, is a better scenario. You have to choose between two interventions:

1. Extend life of 80 y.o., who has adapted to .7 health-related quality of life, for 10 years. Total potential lifetime QALYs: 90x.7= 63

2. Prevent sudden drop for 30 y.o. from 1.0 to .4. There is every reason to expect 30 y.o. to live to 90 in any case, and for diminution of quality of life to resolve itself after 2 years. Total potential lifetime QALYs= [(90x1.0)-(.6x2)] = 88.8

Thus, on any fair innings view that takes health-related quality of life into account, it seems as if we should extend the life of the 80 y.o. This remains true even if we imagine the sudden drop for the 30 y.o. to last decades before it resolves itself.

Again, I'm not sure I know yet what, exactly, this shows.

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