Abstract
BackgroundPatients with a permanent impairment may be unable to reach full health. Consequently health services which cure illnesses which are unrelated to the impairment may increase health less than services for patients with no impairment. While it has been argued that this should not lead to discrimination against impaired patients there is little evidence to determine whether this equity-efficiency trade-off is consistent with social values.ObjectivesTo measure the effect of permanent impairment upon the social valuation of services for unrelated illnesses.MethodsSocial valuations of services for illnesses associated with mobility, depression or pain were assessed and compared for patients with and without a permanent impairment using the Relative Social Willingness to Pay (RS-WTP) instrument. The maximum valuation of services for impaired patients was also compared with the maximum utility which could be gained when utility was measured using three multi attribute utility instruments.ResultsCuring the illness of impaired patients was valued 8–11 percent less than the cure of patients with no impairment. Discrimination decreased as the severity of the illness increased. Valuation of health states using the utility instruments implied significantly greater discrimination than the social valuations using the RS-WTP instrument.ConclusionsHealth services are valued less highly when a patient’s health potential is impaired. However discrimination is significantly less than would occur if the value of the services were limited to the value of the health state causing the impairment. The argument for disregarding a patient’s limited health potential when resources are allocated therefore receives some support from social valuations but the case for completely equal treatment depends upon additional ethical arguments.
Highlights
Discrimination is significantly less than would occur if the value of the services were limited to the value of the health state causing the impairment
Cost Utility Analyses (CUA) assists the prioritisation of resources by comparing the cost per additional quality adjusted life year (QALY) of different health services where QALYs are calculated as life years times the utility of the relevant health state
The present study is concerned with the empirical question of whether social values and preferences are consistent with this view and would result in the equal valuation of health services when they are given to patients who do and do not have an impairment when the services are for illnesses which are unrelated to the impairment and improve the quality, not length of life
Summary
Cost Utility Analyses (CUA) assists the prioritisation of resources by comparing the cost per additional quality adjusted life year (QALY) of different health services where QALYs are calculated as life years times the utility of the relevant health state. An issue which has received relatively little attention is the potential discrimination against patients with a permanent impairment which reduces their health potential–the best health they can achieve–and the number of QALYs which may be obtained from health services. In the most widely discussed case, a patient with an impaired potential for full health would gain fewer QALYs from an unrelated, life extending treatment than a patient whose additional life years were in full health: life extension times a utility of 1.00 exceeds life extension times a utility less than 1.00. A similar problem may arise if a permanent impairment prevents a patient from obtaining the same increase in the quality of life from a service as other patients [8,9,10]. While it has been argued that this should not lead to discrimination against impaired patients there is little evidence to determine whether this equity-efficiency trade-off is consistent with social values
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