The Backward QALY

There’s an intriguing paper in May’s JME by Christopher Cowley in which he proposes a “retrospective QALY”.

The paper begins by pointing out a problem with QALY-based assessments of rescource allocation, which is that there are certain disciplines that seem to be institutionally weakened by them.  Terminal care, for example, is always going to appear to perform badly in a QALY scale, because, while

analgesics and antibiotics are often cheap enough, they only go so far in improving quality and generating new life years.  [slightly altered]

In fact, things might be worse than this.  After all, if we interpret “terminal care” reasonably widely, it could well cover palliative care – and palliative care is simply not interested in adding life years at all.  While it may improve a person’s quality of life (or death), that’s never intended to last more than a few weeks; moreover, a patient may be fairly heavily sedated, and so not experiencing all that much of anything.  So a course of palliation will be fairly likely to attract a QALY score that hovers around the zero mark.

Cowley’s suggestion is that the notion of a QALY could be altered.  A good quality of life, he claims, is associated with a life that’s meaningful.  But meaning is time-blind: it “draws the subject not only toward the future but to the past as well”.  And, importantly,

[u]nderstanding the past significance of the important events that comprise my life reaches a climax on my death bed.  We spend so much of our time leaning forward into the future that it becomes the first moment when we can fully take stock of what our life is and has been about.

What I want to argue is that this business of re-examination of one’s life is not merely an organisational exercise, but a creative one.  It is not merely recollection but re-configuration.  Inevitably, during the days and nights of thought and discussion with others there will be new perspectives on the old events, new attitudes taken in place of previously hardened ones, and above all new understandings of the patterns and relationships between the events.  All this novelty, I suggest, constitutes new life-years, and life-years of very high quality in terms of deepening the meaning of a particular life.

I am not saying that the process of end-of-life reflection is valuable and that this value should be introduced into QALY calculations; rather, I am saying that the patient’s life as discovered and constructed during reflection is what is valuable. [slightly altered; emphasis mine]

It’s clearly quite a radical suggestion, and I can see that there’s an attraction to it, inasmuch as it seems to provide a mechanism for putting theoretical bones into an intuition.  But this is actually one of the major problems with the idea, as far as I can tell: inasmuch as it’s a mechanism designed specifically to prop up intuitions, it seems to be a bit dodgy – to adopt a Popperian term, it seems a bit ad hoc.

Moreover, the idea that reflection constitutes new life-years is a bit odd: one would perhaps want to hear more about their metaphysical status; one would also like to hear a bit more about why anyone would want to reflect in this way, especially given the slightly moralistic tone at the end of the paper.

Finally, it strikes me that there’re internal weaknesses with the paper.  If these new life-years aren’t comparable to QALY-standard years after all, it’s hard to see what they add; and when Cowley comments that he doesn’t “think that the death-bed achievements could be compared between people”, that just seems to highlight the problem.  It looks like there’s no external and no internal way to evaluate these extra life-years.  What, then, remains?  Why should they bother us at all?

Having said all this, the difficulty of accounting for terminal care in conventional efficiency terms isn’t going to go away.  For some, that’s a problem with the QALY system; for others, it’s a problem for it.  I think Cowley’s “backward QALY” has things… well, backwards.  But the concerns that motivate the paper are well taken.

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