Quality-adjusted life-years. Ethical implications for physicians and policymakers
J. La Puma and E. F. Lawlor
Center for Clinical Ethics, Lutheran General Hospital, Park Ridge, IL 60068.
Quality-adjusted life-years have been used in economic analyses as a
measure of health outcomes, one that reflects both lives saved and
patients' valuations of quality of life in alternative health states. The
concept of "cost per quality-adjusted life year" as a guideline for
resource allocation is founded on six ethical assumptions: quality of life
can be accurately measured and used, utilitarianism is acceptable, equity
and efficiency are compatible, projections of community preferences can
substitute for individual preferences, the old have less "capacity to
benefit" than the young, and physicians will not use quality-adjusted
life-years as clinical maxims. Quality-adjusted life-years signal two
shifts in the locus of control and the nature of the clinical encounter:
first, formal expressions of community preferences and societal usefulness
would counterbalance patient autonomy, and second, formal tools of resource
allocation and applied decision analysis would counterbalance the use of
clinical judgment. These shifts reflect and reinforce a new financial ethos
in medical decision making. Presently using quality-adjusted life-years for
health policy decisions is problematic and speculative; using
quality-adjusted life-years at the bedside is dangerous.
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