1. Valuing Health Daniel M. Hausman University of Wisconsin-Madison October 19, 2009

2. Outline 1.Purposes of generic health measurement 2.What is health? 3.How can health be measured? 4.How should health be valued? 5.Against preference-based evaluation 6.Against evaluation in terms of well-being 7.Health-state evaluation: A new view Overall purpose: to present the philosophical questions and to provoke others to join me in working on them

3. 1. Purposes of generic health measurement 1.Assessment of treatments 2.Epidemiological research 3.Guide health policy via cost- effectiveness information –Fairness is also critical –Non-health consequences matter, too –Non-health interventions can have health consequences

4. 2. What is health? Health is the absence of pathology Pathology is subnormal part functioning –“Normal” = statistically normal –Health is multidimensional –Health is “objective” The value of a health state depends on –Functional limitation –Adaptation –Physical and technological environment –Social environment –Social norms –Individual objectives and preferences

5. 3. How can health be measured? If one health state “dominates” another, then the first has “more” health Without dominance, there is no way to compare health states with respect to the “quantity of health”

6. 4. How should health be valued? Value of health as the time-integral of the value of health states Implies that the value of a health state is independent of how long it lasts Need to classify and to value health states

7. Health-state classification Define “dimensions” Define levels along the dimensions Limiting the number of health states Examples: HALex: 2 dimensions: subjective assessment activity limitation 5 levels and 25 states EQ5D: 5 dimensions 1 mobility, 2 self-care, 3 usual activity, 4 pain/discomfort, and 5 anxiety/depression 3 levels: 243 states HUI (3) 8 dimensions 5-6 levels 974,000 states

8. Assigning “quality weights” There are many possible ways Economists focus on prefer- ences and well-being and conflate the two "Measures of health-related quality of life that incorporate explicit values in the ordering of health states are referred to as utility-weighted or preference- weighted measures.” (Patrick and Erickson 1993) “Utilities and values are different types of preferences” (Drummond et al. 1987) Philosophers weigh in: Evaluation aims "to measure how good a person's health is for the person, or how bad her ill-health).... That is to say, it aims to measure the contribution of health to well- being." (Broome 2002) "When people make these [evaluative] judgments,... they must be making judgments about the goodness of health, the degree to which different functional limita- tions reduce overall well-being.” (Brock 2002)

9. Preference-based evaluation Three main issues: 1.Whose preferences? The public or those familiar with the health states? 2.How should they be elicited and inferred? Questionnaires vs. deliberative groups Estimating multiattribute utility functions 3.How should they be quantified on a 0-1 scale? Visual analog scales Standard gamble Time trade-offs Person trade-offs

10. 5. Against preference-based evaluation Preferences among health states depend on factors that are not obviously relevant to their value. –The case of the draftee who prefers not to be healthy –Effects on the well-being of others Preference-based evaluation presupposes the existence of some other unmodeled method of evaluating health states. Preferences among health states are unreliable. –Disagreements among preferences concerning disabilities

11. 6. Against evaluation by well-being What is well-being? The case of the well-off disabled Some kinds of adaptation increase well- being without improving health What is bad about a health state if it does not make its possessor worse off?

12. 7. Health-state evaluation: a new view Health has two important aspects –How you feel –What you can do Limits on activities Limits on opportunities Resolution to the puzzle of disabilities Sketch of a new health-state classification Problem of evaluation remains

13. Constraints on evaluation Should be deliberative Should reflect the values of the target population Should be democratically determined Should be normatively acceptable, but questions of fairness should be kept separate Should be emotionally acceptable Should depend only on factors that are relevant to the value of health states Should be revisable

14. Implications of the constraints Rely on deliberative groups and public discussion The evaluative question needs to be widely understood –Contrasts with preference rankings –Contrast with normative assessment of resting policy exclusively on maximizing population health The evaluators need an accurate imaginative picture of what sorts of states constitute the different activity-limitation and feeling pairs

15. Conclusions Rational health policy requires a quantitative measure of the net health benefits of alternatives, even though it should not aim exclusive to maximize these. Current preference-based measures of health benefits are indefensible. Defining a defensible generic health measure is a complex task to which philosophers have a good deal to contribute.