Choosing who shall not be treated in the NHS

Abstract

In the face of severe resource constraints, health care systems are seeking both to control costs and to ensure maximum benefits for the resources consumed. The use of Quality Adjusted Life Years (QALYs) is becoming more widely advocated as a decision aid in the solution of resource allocation problems. The QALY combines two dimensions of health outcome—the quantity of life and its quality—in such a way that choices between different services with different purposes can be made using comparisons based on common units of measurement. The combination of these two dimensions allows comparisons between services with different objectives, such as curing and caring services. The QALY, however, lacks a third dimension which is vital to the decision-making process to which it is intended to contribute: the worth of a specific life relative to others. This paper presents results based on interviews of 719 residents of Cardiff drawn at random from the electoral register. The results suggest that further development of the novel methodology used to establish the relative value placed on various human lives is worthwhile. Evidence is given which indicates that the public consider lives to be of unequal worth. The results also show that these values are consistent for different types of choices phrased in different ways on a large number of control variables, implying the existence of a cultural stable value system which is a necessary prerequisite if consensus values of human life are to be used to assist decision-making in non-private health care systems. The paper suggests that it is right that the value system of those who pay for a group-funded health care system (such as the NHS) should guide choices between services. It is suggested that these choices are not the prerogative of professionals, whose view should carry no more weight than that of any other citizen. It is recognised that the suggestion that lives are not intrinsically of equal worth poses serious ethical problems for society, but the exploration of the value system of society, as advocated in this paper, may highlight issues which need further consideration.