Appendix - Devising a methodology for open rationing

            B. Prioritizing health services - The Quality Problem

Most of the substantive difficulties that critics (including the federal government) have had with the Oregon rationing scheme can be categorized under the general heading of the Quality Problem.

The Quality Problem, in essence, is a restatement of the conundrum we have seen many times already.  If quality measures are used to assess the cost-effectiveness of a therapy, the results will systematically discriminate against patients with disabilities.  However, if quality measures are not used, there is no way in most circumstances to calculate cost-effectiveness, and therefore no way to assess the most beneficial distribution of resources.  In other words, we need to take quality into account to maximize public good, but using quality measures tends to be inherently discriminatory.

The inherent discriminatory effects of quality measures can best be illustrated by examining the Quality Adjusted Life Year (QALY) measurement, an index of quality that is becoming increasingly popular.  QALYs measure a combination of the life-prolonging characteristics of a therapy (or the duration of benefit of a therapy), plus the therapy’s effect on the quality of life.

Thus, consider a treatment that prolongs the life of a person by one year.  If the treated individual would lead a “normal” life for that extra year, the QALY provided by that treatment would be 1.0.  But if the treated individual would have to spend that extra year in a wheelchair, and if some quality measure (such as the QWB scale) indicates that life in a wheelchair is only half as worthwhile as life without a wheelchair, for that individual the therapy would provide a QALY of only 0.5.

It should be noted that QALYs can also be applied to therapies that do not affect the length of life.  Consider, for instance, a therapy that did not affect longevity but allowed a patient previously confined to a wheelchair to begin walking.  For every year of expected survival after that therapy, the therapy would provide an increase in QALY from 0.5 to 1.0.

Thus, the QALY measure provides an index of the “total good” produced by a therapy, so that the benefits of very different therapies for very different diseases can be compared to each other and ranked numerically. In this way QALYs offer an attractive methodology for deciding how to spend the health care dollar in order to maximize the total good provided.

But (even leaving methodological problems aside), using QALYs in this way implies a fundamental violation of the principle of “fairness.” By strictly ranking patients’ therapies according to QALYs, we are assigning a numeric value to an individual’s life, depending on that person’s diseases or disabilities (i.e., depending on his quality of life).  In essence, QALYs allow two human lives to be compared numerically to see which one is worth more, and patients whose quality of life is diminished for any reason will be valued lower.

This, in a nutshell, is the Quality Problem.  It defines the crux of the ethical dilemma inherently raised by rationing – the dilemma between fairness and goodness, distributive justice and beneficence, individual rights and societal rights.

How can we maximize quality without discriminating?

I submit that the FCEO standard can provide us with guidance as we attempt to maximize beneficence without discriminating against patients on the basis of their diseases or disabilities.  That principle, to review, is:

All individuals should have a fair chance for an equal opportunity to enjoy the fruits of life, within the constraints imposed on them by nature.

Consider two patients who have cancer.  One is confined to a wheelchair, and one is not. Which one gets priority for expensive chemotherapy?  

The FCEO standard indicates that, within the constraints imposed by nature (i.e., within the constraints of being confined to a wheelchair), both individuals should have reasonably equal opportunities to enjoy their lives.  Thus, according to the FCEO principle, they should receive equal priority for receiving the chemotherapy.

As we have seen, however, the traditional use of quality of life measures (such as QALYs) would give priority to the patient who is not in the wheelchair. This “traditional” methodology clearly discriminates against people in wheelchairs.  In fact, using QALYs in the traditional way systematically discriminates against every patient with any disease or disability, because such disabilities will always reduce their priority score.

Does this mean we can never use quality measures to help us distribute resources in the most beneficial way possible?

No, it does not.  For it is not the QALY itself that is discriminatory, it is the traditional use of the QALY.

Next: Three rules for applying quality measures

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