Yesterday’s New York Times Magazine had an article by the eminent utilitarian philosopher Peter Singer with the provocative title, “Why We Must Ration Health Care”:
It is partly a defense of the idea of a national health insurance program, but it also discusses the idea of ‘rationing’ health care. Singer is brave enough to endorse this, so long as it is carried out according to utilitarian principles. He carefully explains what these are, and the sense in which they put a price on a human life (and on states of affairs like being cured of quadriplegia). Singer is not only a brilliant and powerful thinker, he is one of our discipline’s most effective writers. I highly recommend his article.
The only point I’d add is this. Singer explains nicely how economists have developed a way to quantify the badness of having a certain condition (like quadriplegia)–which, of course, also measures the goodness of avoiding it or curing it.
Health care does more than save lives: it also reduces pain and suffering. How can we compare saving a person’s life with, say, making it possible for someone who was confined to bed to return to an active life? We can elicit people’s values on that…One common method is to describe medical conditions to people—let’s say being a quadriplegic—and tell them that they can choose between 10 years in that condition or some smaller number of years without it. If most would prefer, say, 10 years as a quadriplegic to 4 years of nondisabled life, but would choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life or 10 years with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life. (These are hypothetical figures, chosen to keep the math simple, and not based on any actual surveys.) If that judgment represents a rough average across the population, we might conclude that restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.
This is the basis of the quality-adjusted life-year, or QALY, a unit designed to enable us to compare the benefits achieved by different forms of health care. The QALY has been used by economists working in health care for more than 30 years to compare the cost-effectiveness of a wide variety of medical procedures and, in some countries, as part of the process of deciding which medical treatments will be paid for with public money.
I have read one psychologist (Daniel Gilbert, in Stumbling on Happiness)) who mentions something that might give us some pause in utilizing this method. He refers to some research which shows that when people who do not have a certain condition (like quadriplegia) are asked to say how unhappy they would be if they did have it, they tend to give more negative answers than do the people who actually have it. In other words, non-quadriplegics tend to think that quadriplegia is worse than quadriplegics themselves do. (Gilbert uses this finding to support his general claim that people are not good in imagining how happy they will be in the future.) Perhaps if what Singer is proposing to do takes account of both perspectives then the values we arrive at will not be biased in the way that Gilbert warns us about. But, in any case, I find Singer to be very convincing when he argues that some such calculation needs to be a part of any morally defensible public health insurance program.