Why the Coming Debate Over the QALY and Disability Will be Different

The QALY has served for over 30 years as the gold standard within health economics for measuring the impact of treatments on patients' health. Created with the explicit goal of capturing the impact of treatment on both length of life and quality of life, the QALY is a summary measure that can be used in a consistent fashion across all types of conditions, and therefore is uniquely able to help decision-makers compare “apples to apples” as part of cost-effectiveness analyses (CEA) in health and medicine. A staple of health technology assessments in Europe, Canada, Australia, and elsewhere, CEA using the QALY is also at the heart of the methods used by my research group in the United States, the Institute for Clinical and Economic Review (ICER).Persad1 contributes valuable new insights and ideas that take their place in debates over the ethical implications of using CEA to help inform decisions about funding, insurance coverage, and appropriate pricing of health interventions. Around many points there is strong consensus. Does the QALY capture all the potential factors of benefit to patients, families, and society that can be gained from successful treatment? No. Does it tell us how to compare equal QALY gains that arise from small health gains for many individuals versus large health gains for a few? No. Does it automatically reflect our individual or social values that might ascribe more weight to health gains for children, for people with more serious conditions, for socially or historically disadvantaged communities? No, no, and no. To address these limitations, ethicists and health economists have always called for deliberative processes to integrate the findings of CEA with social values and other considerations so that the “cost per QALY” is not used as a single dispositive factor in any decision.Persad contributes valuable new insights and ideas that take their place in debates over the ethical implications of using CEA to help inform decisions about funding, insurance coverage, and appropriate pricing of health interventions.But what about the QALY and its measurement of health gains among disabled populations? Is the QALY inherently discriminatory? If so, is it beyond redemption by deliberative process, requiring some form of quantitative “fix” or even outright rejection as a tool to aid decision-making? Since the early days of CEA experts recognized that any extension of life for patients with a persistent disability would be “weighted” in the QAL