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Should we maximise QALYs?

A debate with respect to peak-end evaluation

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In summary, there exists empirical evidence suggesting that the remembered utility of an event is driven by peak-end evaluation rather than by the total utility actually experienced. It is plausible that this observation will translate to (individual and/or social) decisions on the distribution of QALYs over the life course, although empirical evidence needs to be gathered to confirm whether or not this conjecture holds. If it does hold, should it matter? This question is open to debate. There is an enormously topical but far from resolved issue with respect to UK health policy.[28,29] Are patients and/or the general public to be given greater choice in healthcare? One thing is clear. If they are, then we have to accept that their considered choices may justifiably conflict with some of the entrenched (but insufficiently tested) decision rules in the social and clinical sciences.

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  1. 1.

    1Willingness to pay, most notably contingent valuation, has also been criticised for its perhaps more fundamental methodological flaws (e.g. Cookson[10]). These include, for example, ‘scope effects’, where the values that people offer may be insufficiently sensitive to differential ‘risks’, and ‘embedding effects’, where the value that people offer for a particular ‘good’ is not sufficiently ‘picked up’ when they are asked to value a bundle that includes that good. However, it ought to be acknowledged that the flaws in the QALY methodology are equally onerous, not least with respect to the conceptual and empirical problems that have been observed in the health state value elicitation techniques,[11] and the assumption that the values given to health states are independent of the length of time spent in those states.[12]

  2. 2.

    2Strictly speaking, only QALYs elicited with the use of the standard gamble can be thought of as health state ‘utilities’, because, alone among the commonly used health state value elicitation instruments, the standard gamble is implied by the axioms of von Neumann and Morgenstern[13] expected utility theory (EU). Thus, the standard gamble is the only instrument that is grounded in cardinal utility theory. However, neither the distinctions between the different instruments, nor indeed the frequently observed violations of the EU axioms (e.g. Camerer[14]), are of central importance to this article. single individual) over the timeframe of the study.3 The question addressed in this article is whether this maximisation principle really reflects people’s preferences for how they would wish their own health — and/or the health of others — to be ordered?

  3. 3.

    3The values that underlie QALYs are often elicited from random samples of the population and are therefore ‘hypothetical’ in the sense that they are elicited from people who are not actually experiencing the health states under study. However, as is the case in much of the applied QALY literature, we will assume that hypothetical values are an accurate measure of experienced values. Nonetheless, the strength of this assumption lends support to those who might argue that experienced health state utility maximisation really requires a more direct measure of experienced health state utility than the QALY. We will briefly return to this point towards the end of this article, in the section titled Implications for QALY Maximisation.

  4. 4.

    4The arguments and empirical studies that are outlined in this, and the next, section are discussed extensively in Kahneman et al.,[15] where they are related to ‘broad’ concepts of utility. However, the arguments are also applicable to the narrower concept of health state utility.

  5. 5.

    5It is not easy to defend violations of temporal monotonicity, but, if remembered utility drives decisions over future events, there may be some circumstances where knowledge of the phenomenon can be used to beneficial effect. For example, if a patient’s willingness to undertake a repeat procedure can be influenced by ‘extending’ — and reducing the disutility of — the end of an initial procedure (and we know that undertaking the repeat procedure would be genuinely beneficial to the patient), then it is possible that knowledge of the ‘end’ effect could be usefully employed in clinical medicine.[15] Moreover, it is perhaps worth noting that there is also evidence that adding a poor moment to the beginning of a period can improve the overall value of an experience, as experiences that improve over time can attract a higher remembered utility.[21]

  6. 6.

    6Assume that the values of all health states referred to in this example have been elicited with one of the standard instruments for health state value elicitation.

  7. 7.

    7The studies outlined in the previous sections of this article adopted an individual perspective: i.e. respondents were asked questions relating to their own utility. It could be interesting to test whether similar results arise when respondents answer with respect to other people’s utility. Social decision making vis-à-vis QALY maximisation is well suited to this task.

  8. 8.

    8If such an experiment were carried out, measures would need to be taken to ensure that a preference for B over A is not simply due to error. For example, qualitative evidence for the respondents’ choices could be gathered in order to analyse the underlying reasons for their answers. Moreover, after making their choices, all respondents could be informed that B involves fewer lifetime QALYs than A, and then asked if they would like to alter their choices.

  9. 9.

    9Respondents’ attitudes towards discounting future years of life are also likely to have some impact on their assessments of profiles. However, empirical and normative considerations of discounting are a separate issue and do not negate the possible influence of peak-end evaluation.


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The author is grateful to the Editors for comments on a previous draft. No sources of funding were used to assist in the preparation of this manuscript, and the author has no conflicts of interest.

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Correspondence to Dr Adam Oliver.

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Oliver, A. Should we maximise QALYs?. Appl Health Econ Health Policy 3, 61–66 (2004). https://doi.org/10.2165/00148365-200403020-00001

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  • Future Event
  • Standard Gamble
  • Health State Utility
  • Economic Appraisal
  • Experienced Utility