I Spend Therefore I Am by Philip Roscoe

Author:Philip Roscoe [Roscoe, Philip]
Language: eng
Format: epub
ISBN: 978-0-345-81269-8
Publisher: Random House of Canada
Published: 2014-02-25T00:00:00+00:00

Cost-effectiveness and the allocation of care

Thaler and Rosen begin their analysis from the position that our behaviour, in aggregate, can reveal an objective, scientific price for risk and that, in their words, ‘the value of a life is the amount members of society are willing to pay to save one’. But – as their forty-odd pages of dense economic prose, not to mention three decades of subsequent modelling, testing and debate show – the VSL is itself an artefact embedded in an intellectual and technical milieu. It is manufactured according to a particular ideological agenda, and in that sense it is just like the $200,000 figure, and like another, equally curious, set of calculations developed in Great Britain in the 1970s to arbitrate the best – the most useful – use of medicine.

Every day, doctors and health-care administrators face terrible questions. They must decide who receives treatment and who does not, a question that at its worst becomes a decision over who should live and who should die. If resources are always scarce we should, the argument runs, focus on what is most useful for the money available, understood according to some standard metric or other. Thanks to the growing discipline of health-care economics, a barrage of measures has grown up to help practitioners decide on the most useful allocation of treatments. Pre-eminent among them is the Quality Adjusted Life Year (QALY).15

In outline, a patient’s QALY is calculated by the number of years of life they are expected to have left, multiplied by the expected ‘quality’ of those years, with 1 being perfectly healthy, 0 being dead, or even −1, worse than dead. As always, calculation rests on more calculation: the measure of ‘quality’ is itself a hybrid of distress and disability scales, carefully quantified and developed through survey work, which then vanishes into the background as the measure becomes ever more widely accepted.16 To give some examples, ‘severe distress’ with full mobility makes little impact on the quality of life (0.967), while being confined to a chair and bed without distress score 0.875 and 0.677, respectively. The combination is much more damaging: confinement to a chair with severe distress, and to bed with moderate distress both score 0, equivalent to being dead, while being confined to bed with severe distress, or being unconscious both score −1, much worse than being dead. These figures develop unhelpful equivalences from the outset. For example someone in the later stages of terminal cancer scores the same as someone in a coma; someone with a migraine also scores worse than dead. Though clearly quite different, all three of these conditions become commensurate through the quality measure.

The next step in the QALY’s logic is for doctors or administrators to compare the change in the QALY brought about by a given treatment to the cost of the treatment to derive a cost-utility score. Using the QALY, administrators can see which treatments represent better value for money understood in terms of quality-adjusted life years per pound. When

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