Distinction with a difference

And now, an important clarification: the QALY concept as applied considers only the net effects of treatments. It does not generally consider the baseline status of any particular individual who may receive the treatment, except perhaps insofar as this is relevant to the effectiveness of the treatment under particular circumstances. (For example, you would want to avoid adverse drug interactions, or people who are at higher risk for adverse outcomes of a treatment.)

In other words, NICE does not view medical care for Stephen Hawking less favorably because he has crippling ALS. Whatever people in surveys may have said about how much they don't want to be paralyzed, the issue is not Prof. Hawking's current disability but how much people in general can be expected to benefit from the medical care he receives. His life is not worth less. Indeed, if an effective treatment could be found for ALS, it would score very highly on any health utility scale and the National Health Service would be willing to pay a lot for it.

That is also why former governor WinkyWinky Starburst is wrong about baby Trig (whoever's son he may be). That he has Down Syndrome is irrelevant to the valuation of any medical care he may receive. And indeed, were the baby a subject of Her Majesty Elizabeth II, WinkyWinky would never have to worry about his medical care, unlike the situation here in which people with income-limiting disabilities are at the mercy of state Medicaid programs which are often not very good.

However, NICE does take into account people's age because that has a strong influence on their current life expectancy. It is not true that older people cannot get joint replacements, for example, but it requires special analysis. Indeed, it is unfortunate that my father had his knees replaced as he was entering the middle stages of dementia, because he never did the rehabilitation work he needed to benefit from it, and in fact he suffered post-surgical delirium which probably hastened his deterioration. Under a more judicious system, the surgery would have been discouraged, to everyone's benefit.

Nevertheless, the recognition that expensive interventions yield progressively less benefit as people grow older seems to be very difficult for Americans. It is sometimes unsettling for the Brits as well and there are occasional controversies over specific cases. That is inevitable, and in my view a good thing. These problems ought to be processed publicly and openly and where people come to conflicting ethical conclusions they should debate. Without, however, hurling invective.