Health Care Analysis

, Volume 9, Issue 1, pp 65–76 | Cite as

Utilitarianism and the Measurement and Aggregation of Quality – Adjusted Life Years

  • Paul Dolan


It is widely accepted that one of the main objectives ofgovernment expenditure on health care is to generate health. Sincehealth is a function of both length of life and quality of life, thequality-adjusted life-year (QALY) has been developed in an attempt tocombine the value of these attributes into a single index number. TheQALY approach – and particularly the decision rule that healthcare resources should be allocated so as to maximise the number of QALYsgenerated – has often been equated with the utilitarian philosophyof maximising `the greatest happiness of the greatest number'. Thispaper considers the extent to which the measurement and aggregation ofQALYs really is utilitarian by developing a new taxonomy in order toclassify utilitarianism and the different aspects of the QALY approach.It is shown that the measurement of QALYs is consistent with a number ofdifferent moral positions and that QALYs do not have to be aggregatedaccording to the maximisation rule. Therefore it is inappropriate tonecessarily equate QALYs with utilitarianism. It is shown thatmuch turns on what in principle the QALY represents and howin practice it can be operationalised. The paper highlights thecategory confusion that is often present here and suggests possibleavenues for future theoretical and empirical research.

health policy moral philosophy priority-setting quality-adjusted life-year utilitarianism 


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  1. Anand, P. (1999) Procedural fairness in economic and social choice: evidence from a survey of voters, paper presented to the Royal Economic Society, University of Nottingham.Google Scholar
  2. Bentham, J. (1789) An introduction to the principles of morals and legislation, W. Harrison (Ed.), Oxford: Blackwell, 1967.Google Scholar
  3. Bleichrodt, H. and Quiggin, J. (1999) Life-cycle preferences over consumption and health: when is cost-effectiveness analysis equivalent to cost-benefit analysis? Journal of Health Economics 18(6), 681-708.Google Scholar
  4. Boadway, R.W. and Bruce, N. (1984) Welfare Economics, Ch. 6, Oxford: Blackwell.Google Scholar
  5. Broome, J. (1991) Weighing goods, Oxford: Blackwell.Google Scholar
  6. Broome, J. (1993) Qalys, Journal of Public Economics 50, 149-167.Google Scholar
  7. Broome, J. (1994) Fairness versus doing the most good, Hastings Center Report, July-August, pp. 36-39.Google Scholar
  8. Culyer, A.J. (1991) The normative economics of health care financing and provision, in A. McGuire, P. Fenn and K. Mayhew (Eds.), Providing health care, Oxford: Oxford University Press.Google Scholar
  9. Culyer, A.J. (1997) The principal objective of the NHS should be to maximise health: the case for, in B. New (Ed.), Rationing: Talk and Action in Health Care, London: King's Fund and British Medical Journal Publishing.Google Scholar
  10. Culyer, A.J. and Wagstaff, A. (1993) Equity and equality in health and health care. Journal of Health Economics 12, 431-457.Google Scholar
  11. Hahn, F. (1982) On the difficulties of the utilitarian economist, in Sen, A. and Williams, B. (Eds.), Utilitarianism and beyond, Cambridge: Cambridge University Press, pp. 187-199.Google Scholar
  12. Hammond, P. (1982) Utilitaranism, uncertainty and information, in Sen A and Williams B (Eds.), Utilitarianism and beyond, Cambridge: Cambridge University Press, pp. 85-102.Google Scholar
  13. Harris, J. (1996) What is the good of health care? Bioethics 10(4), 269-291.Google Scholar
  14. Harsanyi, J. (1982) Morality and the theory of rational behaviour, in A. Sen and B. Williams (Eds.), Utilitarianism and beyond, Cambridge: Cambridge University Press, pp. 39-62.Google Scholar
  15. Hausman, D. and McPherson, M. (1993) Taking ethics seriously: economics and contemporary moral philosophy, Journal of Economic Literature 31: 671-731.Google Scholar
  16. Hughes, T. and Larson, L. (1991) Patient involvement in health care: a procedural justice viewpoint, Medical Care 29, 3.Google Scholar
  17. Kant, I. (1785) Groundwork of the metaphysics of morals, translated by H. Paton, London: Harper and Row, 1948.Google Scholar
  18. Menzel, P. (1990) Strong medicine: The ethical rationing of health care, Oxford: Oxford University Press.Google Scholar
  19. Mill, J.S. (1859) On liberty, C.V. Shields (Ed.), London: Macmillan, 1985.Google Scholar
  20. Mooney, G. (1994) Key issues in health economics, New York: Harvester Wheatsheaf.Google Scholar
  21. Mooney, G. and Jan, S. (1997) Vertical equity: weighing outcomes? or establishing procedures?, Health Policy 39, 79-87.Google Scholar
  22. Nelson, J. (1994) Publicity and pricelessness: grassroots decision-making and justice in rationing, Journal of Medicine and Philosophy 19, 333-342.Google Scholar
  23. Nozick, R. (1974) Anarchy, state and utopia, New York: Basic Books.Google Scholar
  24. Rawls, J. (1971) A Theory of Justice.Google Scholar
  25. Rawls, J. (1982) Social unity and primary goods, in A. Sen and B. Williams (Eds.), Utilitarianism and beyond, Cambridge: Cambridge University Press, pp. 159-185.Google Scholar
  26. Scanlon, T.M, (1975) Preference and urgency, Journal of Philosophy 77, 655-69.Google Scholar
  27. Sen, A. (1987) On ethics and economics, Oxford: Blackwell.Google Scholar
  28. Sen, A. (1987) Justice, in J. Eatwell, M. Milgate and P. Newman (Eds.), The new polgrave: a dictionary of economics, London: Macmillan.Google Scholar
  29. Sen, A. and Williams, B. (1982) Introduction, in A. Sen and B. Williams (Eds.), Utilitarianism and beyond, Cambridge: Cambridge University Press, pp. 1-21.Google Scholar

Copyright information

© Kluwer Academic Publishers 2001

Authors and Affiliations

  • Paul Dolan
    • 1
  1. 1.Sheffield Health Economics Group and Department of EconomicsUniversity of SheffieldSheffield

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