1. The ‘QALY Trap’: Can Maximizing Health Benefit Be Reconciled with Principles of Non-Discrimination? Paul T. Menzel, Ph.D. * December, 2004, for the Workshop “Healing with Dollars and Sense: The Ethics of C.E.A. in Health Care Decision Making,” Defining the Medicare Basket Research Project, Faculty of Law, University of Toronto * Department of Philosophy, Pacific Lutheran University. Significant parts of Sections I, II, and III of this paper are taken from P. Ubel et al. 2000.

2. The ‘QALY Trap’ and Discrimination A Problem Right at the Heart of the Conceptual Structure of the QALY A Problem Right at the Heart of the Conceptual Structure of the QALY One Plausible Escape from the Trap: Societal Value Measurement One Plausible Escape from the Trap: Societal Value Measurement Interventions that Simultaneously Save Lives and Cure Disability Interventions that Simultaneously Save Lives and Cure Disability Could the Equal Value of Lifesaving Still Be a Judgment of Individual Utility? Could the Equal Value of Lifesaving Still Be a Judgment of Individual Utility? Another Escape from the Trap: Simply Accept ‘Discrimination’ in Lifesaving Another Escape from the Trap: Simply Accept ‘Discrimination’ in Lifesaving

3. Full health Paraplegia Death– 0 Full health– 1.0 Paraplegia– 0.8 F IGURE 1 Saving the lives of patients with pre-existing disabilities brings fewer QALYs than saving patients without chronic disabilities  = 1 QALY  =.8 QALY

4. What Have the Disabled Said about the Value of Their Very Life ? In responding to TTO and SG questions, they are saying that a cure for their paraplegia has a certain proportion of the value of saving their very life. But have they thereby said that their very life itself (with paraplegia, e.g.) has less value than the life of another person in full health? LIKELY NOT. Isn’t it likely that they have said that their life with paraplegia, compared to death, is just as valuable to them as anyone else’s “better” life is to him or her? And won’t a moment’s thought likely convince most people that their very life itself, even if they were disabled, would be just as valuable to them as another person’s very life in full health was to that other person?

6. F IGURE 3 Non-discrimination in lifesaving, but where the sum of QALYs obtained for patients B & C still equals the QALYs obtained for patient A HRQoL of health conditions 1 0.8 0.5 0.2 0 Full health Paraplegia Paraplegia A B C Patients or Programs 1 QALY 0.0 QALYs 1.0 QALYs

7. HRQoL of health conditions 0 0.2 0.5 0.8 1 1.0 SV 1.0 SV 0.16 SV ABC Programs Full health Paraplegia Full health Paraplegia F IGURE 4 How societal value measurement avoids the QALY trap: The societal value brought by Programs B and C is greater than the SV brought by Program A

8. F IGURE 5 Escaping the QALY Trap: Abandon Assumption that B + C = A (A– B = C) Societal Value 1 0.8 0.6 0.4 0.2 0 A B C A = saving a life to full health B = saving the life of a person with paraplegia C = curing paraplegia to full health