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Quality of Life and Value Assessment in Health Care

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Abstract

Proposals for health care cost containment emphasize high-value care as a way to control spending without compromising quality. When used in this context, ‘value’ refers to outcomes in relation to cost. To determine where health spending yields the most value, it is necessary to compare the benefits provided by different treatments. While many studies focus narrowly on health gains in assessing value, the notion of benefit is sometimes broadened to include overall quality of life. This paper explores the implications of using subjective quality of life measures for value assessment. This approach is claimed to be more respectful of patients and better capture the perspectival nature of quality of life. Even if this is correct, though, subjective measurement also raises challenging issues of interpersonal comparability when used to study health outcomes. Because such measures do not readily distinguish benefits due to medical interventions from benefits due to personal or other factors, they are not easily applied to the assessment of treatment value. I argue that when the outcome of interest in value assessment is broadened to include quality of life, the cost side of these measures should also be broadened. I show how one philosophical theory of well-being, Jason Raibley’s “agential flourishing” theory, can be adapted for use in quality of life research to better fit the needs and aims of value assessment in health care. Finally, I briefly note some implications of this argument for debates about fairness in health care allocations.

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Notes

  1. As of 2017, for instance, OECD nations have spent on average approximately 70% more on health care than they do on education for each citizen [56].

  2. The word ‘subjective’ can be used in different senses when describing quality of life research. In one sense, quality of life measures are subjective when they rely on self-report rather than direct measures of some state or condition—for instance, a subjective measure may ask a respondent to answer questions about some aspect of their current health (such as difficulty breathing) rather than using standard medical exams. However, ‘subjective’ can also refer to the theoretical underpinnings of the measure. In this sense, subjective measures are those that assume a subjective account of well-being or quality of life—one in which quality of life is in some way inherently perspectival. In this paper, I use ‘subjective’ in this latter sense.

  3. Sidgwick [83], Rawls [67], Brandt [10], and Heathwood [38] have all developed desire accounts of well-being.

  4. See Sumner [87] and Tiberius and Plakias [88] for examples of life satisfaction accounts.

  5. Other examples of eudaimonistic theories of well-being can be found in Kraut [43], Haybron [36], Annas [4], Russell [70], LeBar [45], and Besser-Jones [5].

  6. Sen’s account, though influenced by Aristotle, emphasizes the freedom to exercise fundamental human capacities rather than the actual exercise and achievement of these goods. Accordingly, Sen conceives of his account more as a framework for thinking about justice and policies for human development rather than a full theory of well-being [81]. Because he believes this approach needs to remain flexible for application in different countries, he does not provide a definitive list of fundamental human capabilities [82]. Nussbaum, on the other hand, does develop this account with a list of capabilities, including bodily integrity, practical reason, affiliation, and control over one’s environment. The quality of different people’s lives can then be compared by the extent to which they possess and are able to pursue these capabilities [54].

  7. See, for instance, Frisch et al. [29] and Strine et al. [85]. Although I focus primarily on life satisfaction in this paper, much of what I say here also applies to the use of other subjective measures for value assessment.

  8. For an overview of these issues and a defense of desire theories, see Heathwood [38].

  9. See, for instance, Schwarz and Strack [79]; Lucas and Baird [46]; and Ogden and Lo [57] for empirical research on factors affecting assessments of life satisfaction. See Haybron [35] for a philosophical discussion of why judgments of life satisfaction do not consistently track the circumstances of people’s lives.

  10. For a good discussion of adaptive preferences and other objections to subjective measures in well-being research and policy, see Nussbaum [55].

  11. For detailed discussions of the challenges of interpersonal comparability, see, for instance, Elster and Roemer [25], Hausman [33], Boot [9], Chang [17] and Broome [12].

  12. For an overview of QALYs, see, for instance, Weinstein [95] and MacKillop and Sheard [48].

  13. In this way, Raibley’s account is consistent with Daniels’ [21] argument regarding the role of health in protecting opportunities (see also Hausman [34]).

  14. Such a list could also be informed by Sen [82] and Nussbaum’s [54] capabilities accounts. Instead of being justified by an objective theory of well-being, though, the items on this list would be justified by their contributions to dispositional well-being.

  15. Discussions of open and closed systems in economics may be relevant to these debates about quality of life assessment. Open systems are those that have a variety of external interactions, and this additional complexity makes modeling and assessing such systems more difficult. See, for instance, Bigo [6]. Thanks to an anonymous reviewer for making this point.

  16. See Emanuel [26], Pratt and Hyder [63], and Walker [94] for detailed discussion of these issues.

  17. Although I have suggested adapting Raibley’s account of agential flourishing—and thus measuring the dispositional well-being goods people possess—this is just one example of how a subjective account of well-being could be adapted to fit the needs of value assessment in health care.

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Acknowledgments

The opinions expressed in this publication are those of the author and do not necessarily reflect the views of the John Templeton Foundation. I would like to thank the members of the Department of Philosophy and Religion Work in Progress group at Mississippi State University for their helpful feedback on earlier versions of this work. I am also grateful to comments received from attendees of the Midpoint and Capstone meetings for the “Happiness and Well-Being: Integrating Research Across the Disciplines” project, held in St. Louis in June 2017 and May 2018.

Funding

This project was made possible by a grant from the John Templeton Foundation, with additional support from Saint Louis University (Grant No. 38900).

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    Alicia Hall

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Hall, A. Quality of Life and Value Assessment in Health Care. Health Care Anal 28, 45–61 (2020). https://doi.org/10.1007/s10728-019-00382-w

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