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June 6, 1990, Vol 263, No. 21 >
ARTICLE | June 6, 1990

Quality-Adjusted Life-Years: Title and subTitle BreakEthical Implications for Physicians and Policymakers FREE

John La Puma, MD; Edward F. Lawlor, PhD
[+] Author Affiliations

The opinions expressed are those of the authors and do not necessarily reflect those of the supporting institutions.

Reprint requests to Center for Clinical Ethics, Lutheran General Hospital, 1775 Dempster St, Park Ridge, IL 60068 (Dr La Puma).


JAMA. 1990;263(21):2917-2921. doi:10.1001/jama.1990.03440210067034
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Article
References

Quality-adjusted life-years have been used in economic analyses as a measure of health outcomes, one that reflects both lives saved and patients' valuations of quality of life in alternative health states. The concept of "cost per qualityadjusted life year" as a guideline for resource allocation is founded on six ethical assumptions: quality of life can be accurately measured and used, utilitarianism is acceptable, equity and efficiency are compatible, projections of community preferences can substitute for individual preferences, the old have less "capacity to benefit" than the young, and physicians will not use quality-adjusted life-years as clinical maxims. Quality-adjusted life-years signal two shifts in the locus of control and the nature of the clinical encounter: first, formal expressions of community preferences and societal usefulness would counterbalance patient autonomy, and second, formal tools of resource allocation and applied decision analysis would counterbalance the use of clinical judgment. These shifts reflect and reinforce a new financial ethos in medical decision making. Presently using quality-adjusted life-years for health policy decisions is problematic and speculative; using quality-adjusted life-years at the bedside is dangerous.

(JAMA. 1990;263:2917-2921)

REFERENCES

1 +
Williams A.  The importance of quality of life in policy decisions . In: Walker SR, Rosser RM, eds. Quality of Life: Assessment and Application . Lancaster, England: MTP Press Ltd; 1988;:279-290.
2 +
Avorn J.  Benefit and cost analysis in geriatric care . NEngl JMed. 1984;;310:310-322.
3 +
Menzel PT. Medical Costs, Moral Choices . New Haven, Conn: Yale University Press; 1983;:185-195.
4 +
Maynard A, Devlin JB.  Economists v clinicians: the crucial debate . Health Soc Service J . (July 18) , 1985;:7-8.
5 +
Jarret RJ.  Economics or coronary artery bypass grafting . Br Med J. 1985;;291:600.
6 +
Smith A.  Qualms about QALYs . Lancet . 1987;;1:1134-1136.
7 +
Harris J.  QALYfying the value of life . J Med Ethics. 1987;;13:117-123.
8 +
The Ian Ramsey Centre Working Party Report on Decision-Making and Quality of Life . Oxford, England: The Ian Ramsey Centre; 1989;.
9 +
Rawles J.  Castigating QALYs . J Med Ethics . 1989;;15:143-147.
10 +
Smith GT, ed. Measuring Health: A Practical Approach . New York, NY: John Wiley & Sons Inc; 1988;.
11 +
Mulley AG.  Assessing patient utilities: can the ends justify the means? Med Care . 1989;;27( (suppl) ): S269-S281.
12 +
Eisenberg JM.  Clinical economics: a guide to the economic analysis of clinical practices . JAMA. 1989;;262:2879-2886.
13 +
Guyatt GH.  Measuring quality of life in clinical trials . Can Med Assoc J. 1989;;140:1441-1448.
14 +
Emery DD, Schneiderman LJ.  Cost-effectiveness analysis in health care . Hastings Cent Rep. 1989;;19( (4) ):8-13.
15 +
Jennings B.  A grassroots movement in bioethics . Hastings Cent Rep. 1988;;18(suppl to No. (3) ):1-16.
16 +
Garland MJ, Crawshaw R.  Oregon's decision to curtail funding for organ transplantation . N Engl J Med. 1988;;319:1420.
17 +
Welch HG, Larson EB.  Dealing with limited resources: the Oregon decision to curtail funding for organ transplantation . N Engl J Med. 1988;; 319:171-173.
18 +
Todd J.  It is time for universal access, not universal insurance . N Engl J Med. 1989;;321:46-47.
19 +
Aaron HJ, Schwartz WB. The Painful Prescription: Rationing Health Care . Washington, DC: The Brookings Institute; 1984;.
20 +
Lund DS.  Health care rationing plan OK'd in Oregon, stymied in California . Am Med News . (July 21) , 1989;:1.
21 +
Churchill LR. Rationing Health Care in America: Perceptions and Principles of Justice . University of Notre Dame (Ind) Press; 1987;.
22 +
Meyer H.  Oregon Medicaid plan gets boost from health care executives' poll . Am Med News . (March 16) , 1990;:2.
23 +
Patrick DL, Bush HW, Chen MM.  Toward an operational definition of health . J Health Soc Behav. 1973;;14:6-23.
24 +
Torrance GW, Sackett DL, Thomas WH.  Utility maximization model for program evaluation: a demonstration application, Health Status Indexes . In: Berg RL, ed. Proceedings of a Conference Conducted by Health Services Research Tucson, Arizona, 1972 . Chicago, Ill: Hospital Research and Educational Trust; 1973;.
25 +
Weinstein MC, Stason WB.  Foundations of cost-effectiveness analysis for health and medical practices . N Engl J Med. 1977;;296:716-721.
26 +
Rosser R, Kind P.  A scale of valuations of states of illness: is there a social consensus? Int J Epidemiol. 1978;;7:347-358.
27 +
Deyo R, Patrick DL.  Barriers to the use of health status measures in clinical investigation, patient care and policy research . Med Care . 1989;; 27( (suppl) ):S254-S268.
28 +
Jennett B, Buxton M.  Economics and the management of cancer: placing a value on human life . In: Stoll B, ed. Social Impact of Cancer . London, England: Macmillan Publishers Ltd; 1989;.
29 +
Cassell EJ. Talking With Patients: Clinical Technique . Cambridge, Mass: MIT Press; 1985;:2.
30 +
Williams A.  The cost-effectiveness approach to the treatment of angina . In: Patterson DLH, ed. The Management of Angina Pectoris . Dobbs Ferry, NY: Castle House Publications; 1987;:131-146.
31 +
Weinstein MC.  Estrogen use in postmenopausal women . N Engl J Med. 1980;;303:308-316.
32 +
Boyle MS, Torrance GW, Sinclair JC, Horwood SP.  Economic evaluation of neonatal intensive care of very-low-birth-weight infants . N Engl J Med. 1983;;308:1330-1337.
33 +
Churchill DN, Lemon BC, Torrance GW.  A cost-effectiveness analysis of continuous ambulatory peritoneal dialysis and hospital hemodialysis . Med Decis Making. 1984;;4:489-500.
34 +
Weinstein MC, Stason WB.  Cost-effectiveness of coronary artery bypass surgery . Circulation . 1982;;66( (suppl III) ):III-56-III-66.
35 +
Barry MJ, Mulley AG, Fowler FJ, Wennberg JW.  Watchful waiting vs immediate transurethral resection for symptomatic prostatism . JAMA. 1988;;259:3010-3017.
36 +
Williams A.  Economics of coronary artery bypass grafting . Br Med J. 1985;;291:326-329.
37 +
Gudex C. QALYs and Their Use by the Health Service . University of York (England) Centre for Health Economics; 1986;. Discussion Paper 20.
38 +
Gudex C.  QALYs: an explicit outcome measure for today's NHS . Public Finance Accountancy . (November 13) , 1987;:13-15.
39 +
Kind P, Rosser R, Williams A.  Valuation of quality of life: some psychometric evidence . In: Jones-Lee MW, ed. The Value of Life and Safety . Amsterdam, the Netherlands: Elsevier/North Holland; 1982;.
40 +
Ellwood PM.  Shattuck Lecture: outcomes management: a technology of patient experience . N Engl J Med. 1988;;318:1549-1556.
41 +
Drummond MF.  Resource allocation decisions in health care: a role for quality of life assessments? J Chronic Dis. 1987;;40:605-616.
42 +
Sisk JE.  Discussion: Drummond's 'Resource Allocation Decisions in Health Care: A Role for Quality of Life Assessments?' J Chronic Dis. 1987;;40:617-619.
43 +
Callahan D. Setting Limits . New York, NY: Simon & Schuster Inc Publishers; 1987;.
44 +
Blendon RJ.  The public's view of the future of health care . JAMA. 1988;;259:3587-3593.
45 +
McNeil BJ, Pauker SG, Sox HC, Tversky A.  On the elicitation of preferences for alternative therapies . N Engl J Med. 1982;;306:1259-1262.
46 +
Lipscomb J.  Time preference for health in costeffectiveness analysis . Med Care . 1989;;27( (suppl) ): S233-S248.
47 +
Piliskin JS, Shepard DS, Weinstein MC.  Utility functions for life years and health status . Operations Res. 1980;;28:206-224.
48 +
Caplan AL.  How should values count in the allocation of new technologies in health care?  In: Bayer R, Caplan AL, Daniels N, eds. In Search of Equity: Health Care Needs and the Health Care System . New York, NY: Plenum Press; 1983;:95-124.
49 +
Siegler M.  The progression of medicine: from physician paternalism to patient autonomy to bureaucratic parsimony . Arch Intern Med. 1985;;145: 713-715.
50 +
Mendeloff J.  Measuring elusive benefits: on the value of health . J Health Politics Policy Law . 1983;;8:554-580.
51 +
Abrams FR.  Patient advocate or secret agent . JAMA. 1986;;256:1784-1785.
52 +
Pearlman RA, Uhlmann RF, Cain KC.  Quality of life in chronic diseases: perceptions of elderly patients . J Gerontol. 1988;;43( (2) ):M25-M30.
53 +
Danis M, Patrick DL, Southerland LI, Green ML.  Patients' and families' preferences for medical intensive care . JAMA. 1988;;260:797-802.
54 +
Uhlmann RF, Pearlman RA, Cain KC.  Physicians' and spouses' predictions of elderly patients' resuscitation preferences . J Gerontol . 1988;;43( (5) ): M115-M121.
55 +
Zweibel NR, Cassel CK.  Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies . Gerontologist. 1989;;29:615-621.
56 +
La Puma J, Schiedermayer DL, Gulyas AE, Siegler M.  Talking to comatose patients . Arch Neurol . 1988;;45:20-22.
57 +
Wolf SM.  The persistent problem of PVS . Hastings Cent Rep. 1988;;18( (1) ):26.
58 +
Shaw A.  QL revisited . Hastings Cent Rep. 1988;;18( (2) ):10-12.
59 +
Vladeck BC.  Medicare hospital payment by diagnosis-related groups . Ann Intern Med. 1984;; 100:576-591.
60 +
Hsiao WC, Dunn DL.  The impact of DRG payment on New Jersey hospitals . Inquiry . 1987;; 24:2120.
61 +
Greer EG, Kronenfeld JJ, Baker SL, Amidon RL.  An appraisal of organizational response to fiscally constraining regulation: the case of hospitals and DRGs . J Health Soc Behav. 1989;;30:41-55.
62 +
Kruse JA, Thill-Baharozian MC, Carlson RW.  Comparison of clinical assessment with APACHE II for predicting mortality risk in patients admitted to a medical intensive care unit . JAMA. 1988;;260: 1739-1742.
63 +
Levinson DF.  Toward full disclosure of referral restrictions and financial incentives by prepaid health plans . N Engl J Med. 1987;;317:1729-1731.
64 +
Reagan MD.  Physicians as gatekeepers: a complex challenge . N Engl J Med. 1987;;317:1731-1734.
65 +
Hillman AL.  Financial incentives for physicians in HMOs: is there a conflict of interest? N Engl J Med. 1987;;317:1743-1748.
66 +
La Puma J, Cassel CK, Humphrey H.  Ethics, economics, and endocarditis: the physician's role in resource allocation . Arch Intern Med. 1988;;148: 1809-1811.
67 +
Morreim EH.  Fiscal scarcity and the inevitability of bedside budget balancing . Arch Intern Med. 1989;;149:1012-1015.
68 +
 In the courts . Hastings Cent Rep. 1986;; 16( (6) ):32.
69 +
Wickline v California , 2nd Appellate District, Division 5, No. B010156, (July 30) , 1986;.
70 +
Schiedermayer DL, La Puma J, Miles SH.  Ethics consultations masking economic dilemmas in patient care . Arch Intern Med. 1989;;149:1303-1305.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Williams A.  The importance of quality of life in policy decisions . In: Walker SR, Rosser RM, eds. Quality of Life: Assessment and Application . Lancaster, England: MTP Press Ltd; 1988;:279-290.
2 +
Avorn J.  Benefit and cost analysis in geriatric care . NEngl JMed. 1984;;310:310-322.
3 +
Menzel PT. Medical Costs, Moral Choices . New Haven, Conn: Yale University Press; 1983;:185-195.
4 +
Maynard A, Devlin JB.  Economists v clinicians: the crucial debate . Health Soc Service J . (July 18) , 1985;:7-8.
5 +
Jarret RJ.  Economics or coronary artery bypass grafting . Br Med J. 1985;;291:600.
6 +
Smith A.  Qualms about QALYs . Lancet . 1987;;1:1134-1136.
7 +
Harris J.  QALYfying the value of life . J Med Ethics. 1987;;13:117-123.
8 +
The Ian Ramsey Centre Working Party Report on Decision-Making and Quality of Life . Oxford, England: The Ian Ramsey Centre; 1989;.
9 +
Rawles J.  Castigating QALYs . J Med Ethics . 1989;;15:143-147.
10 +
Smith GT, ed. Measuring Health: A Practical Approach . New York, NY: John Wiley & Sons Inc; 1988;.
11 +
Mulley AG.  Assessing patient utilities: can the ends justify the means? Med Care . 1989;;27( (suppl) ): S269-S281.
12 +
Eisenberg JM.  Clinical economics: a guide to the economic analysis of clinical practices . JAMA. 1989;;262:2879-2886.
13 +
Guyatt GH.  Measuring quality of life in clinical trials . Can Med Assoc J. 1989;;140:1441-1448.
14 +
Emery DD, Schneiderman LJ.  Cost-effectiveness analysis in health care . Hastings Cent Rep. 1989;;19( (4) ):8-13.
15 +
Jennings B.  A grassroots movement in bioethics . Hastings Cent Rep. 1988;;18(suppl to No. (3) ):1-16.
16 +
Garland MJ, Crawshaw R.  Oregon's decision to curtail funding for organ transplantation . N Engl J Med. 1988;;319:1420.
17 +
Welch HG, Larson EB.  Dealing with limited resources: the Oregon decision to curtail funding for organ transplantation . N Engl J Med. 1988;; 319:171-173.
18 +
Todd J.  It is time for universal access, not universal insurance . N Engl J Med. 1989;;321:46-47.
19 +
Aaron HJ, Schwartz WB. The Painful Prescription: Rationing Health Care . Washington, DC: The Brookings Institute; 1984;.
20 +
Lund DS.  Health care rationing plan OK'd in Oregon, stymied in California . Am Med News . (July 21) , 1989;:1.
21 +
Churchill LR. Rationing Health Care in America: Perceptions and Principles of Justice . University of Notre Dame (Ind) Press; 1987;.
22 +
Meyer H.  Oregon Medicaid plan gets boost from health care executives' poll . Am Med News . (March 16) , 1990;:2.
23 +
Patrick DL, Bush HW, Chen MM.  Toward an operational definition of health . J Health Soc Behav. 1973;;14:6-23.
24 +
Torrance GW, Sackett DL, Thomas WH.  Utility maximization model for program evaluation: a demonstration application, Health Status Indexes . In: Berg RL, ed. Proceedings of a Conference Conducted by Health Services Research Tucson, Arizona, 1972 . Chicago, Ill: Hospital Research and Educational Trust; 1973;.
25 +
Weinstein MC, Stason WB.  Foundations of cost-effectiveness analysis for health and medical practices . N Engl J Med. 1977;;296:716-721.
26 +
Rosser R, Kind P.  A scale of valuations of states of illness: is there a social consensus? Int J Epidemiol. 1978;;7:347-358.
27 +
Deyo R, Patrick DL.  Barriers to the use of health status measures in clinical investigation, patient care and policy research . Med Care . 1989;; 27( (suppl) ):S254-S268.
28 +
Jennett B, Buxton M.  Economics and the management of cancer: placing a value on human life . In: Stoll B, ed. Social Impact of Cancer . London, England: Macmillan Publishers Ltd; 1989;.
29 +
Cassell EJ. Talking With Patients: Clinical Technique . Cambridge, Mass: MIT Press; 1985;:2.
30 +
Williams A.  The cost-effectiveness approach to the treatment of angina . In: Patterson DLH, ed. The Management of Angina Pectoris . Dobbs Ferry, NY: Castle House Publications; 1987;:131-146.
31 +
Weinstein MC.  Estrogen use in postmenopausal women . N Engl J Med. 1980;;303:308-316.
32 +
Boyle MS, Torrance GW, Sinclair JC, Horwood SP.  Economic evaluation of neonatal intensive care of very-low-birth-weight infants . N Engl J Med. 1983;;308:1330-1337.
33 +
Churchill DN, Lemon BC, Torrance GW.  A cost-effectiveness analysis of continuous ambulatory peritoneal dialysis and hospital hemodialysis . Med Decis Making. 1984;;4:489-500.
34 +
Weinstein MC, Stason WB.  Cost-effectiveness of coronary artery bypass surgery . Circulation . 1982;;66( (suppl III) ):III-56-III-66.
35 +
Barry MJ, Mulley AG, Fowler FJ, Wennberg JW.  Watchful waiting vs immediate transurethral resection for symptomatic prostatism . JAMA. 1988;;259:3010-3017.
36 +
Williams A.  Economics of coronary artery bypass grafting . Br Med J. 1985;;291:326-329.
37 +
Gudex C. QALYs and Their Use by the Health Service . University of York (England) Centre for Health Economics; 1986;. Discussion Paper 20.
38 +
Gudex C.  QALYs: an explicit outcome measure for today's NHS . Public Finance Accountancy . (November 13) , 1987;:13-15.
39 +
Kind P, Rosser R, Williams A.  Valuation of quality of life: some psychometric evidence . In: Jones-Lee MW, ed. The Value of Life and Safety . Amsterdam, the Netherlands: Elsevier/North Holland; 1982;.
40 +
Ellwood PM.  Shattuck Lecture: outcomes management: a technology of patient experience . N Engl J Med. 1988;;318:1549-1556.
41 +
Drummond MF.  Resource allocation decisions in health care: a role for quality of life assessments? J Chronic Dis. 1987;;40:605-616.
42 +
Sisk JE.  Discussion: Drummond's 'Resource Allocation Decisions in Health Care: A Role for Quality of Life Assessments?' J Chronic Dis. 1987;;40:617-619.
43 +
Callahan D. Setting Limits . New York, NY: Simon & Schuster Inc Publishers; 1987;.
44 +
Blendon RJ.  The public's view of the future of health care . JAMA. 1988;;259:3587-3593.
45 +
McNeil BJ, Pauker SG, Sox HC, Tversky A.  On the elicitation of preferences for alternative therapies . N Engl J Med. 1982;;306:1259-1262.
46 +
Lipscomb J.  Time preference for health in costeffectiveness analysis . Med Care . 1989;;27( (suppl) ): S233-S248.
47 +
Piliskin JS, Shepard DS, Weinstein MC.  Utility functions for life years and health status . Operations Res. 1980;;28:206-224.
48 +
Caplan AL.  How should values count in the allocation of new technologies in health care?  In: Bayer R, Caplan AL, Daniels N, eds. In Search of Equity: Health Care Needs and the Health Care System . New York, NY: Plenum Press; 1983;:95-124.
49 +
Siegler M.  The progression of medicine: from physician paternalism to patient autonomy to bureaucratic parsimony . Arch Intern Med. 1985;;145: 713-715.
50 +
Mendeloff J.  Measuring elusive benefits: on the value of health . J Health Politics Policy Law . 1983;;8:554-580.
51 +
Abrams FR.  Patient advocate or secret agent . JAMA. 1986;;256:1784-1785.
52 +
Pearlman RA, Uhlmann RF, Cain KC.  Quality of life in chronic diseases: perceptions of elderly patients . J Gerontol. 1988;;43( (2) ):M25-M30.
53 +
Danis M, Patrick DL, Southerland LI, Green ML.  Patients' and families' preferences for medical intensive care . JAMA. 1988;;260:797-802.
54 +
Uhlmann RF, Pearlman RA, Cain KC.  Physicians' and spouses' predictions of elderly patients' resuscitation preferences . J Gerontol . 1988;;43( (5) ): M115-M121.
55 +
Zweibel NR, Cassel CK.  Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies . Gerontologist. 1989;;29:615-621.
56 +
La Puma J, Schiedermayer DL, Gulyas AE, Siegler M.  Talking to comatose patients . Arch Neurol . 1988;;45:20-22.
57 +
Wolf SM.  The persistent problem of PVS . Hastings Cent Rep. 1988;;18( (1) ):26.
58 +
Shaw A.  QL revisited . Hastings Cent Rep. 1988;;18( (2) ):10-12.
59 +
Vladeck BC.  Medicare hospital payment by diagnosis-related groups . Ann Intern Med. 1984;; 100:576-591.
60 +
Hsiao WC, Dunn DL.  The impact of DRG payment on New Jersey hospitals . Inquiry . 1987;; 24:2120.
61 +
Greer EG, Kronenfeld JJ, Baker SL, Amidon RL.  An appraisal of organizational response to fiscally constraining regulation: the case of hospitals and DRGs . J Health Soc Behav. 1989;;30:41-55.
62 +
Kruse JA, Thill-Baharozian MC, Carlson RW.  Comparison of clinical assessment with APACHE II for predicting mortality risk in patients admitted to a medical intensive care unit . JAMA. 1988;;260: 1739-1742.
63 +
Levinson DF.  Toward full disclosure of referral restrictions and financial incentives by prepaid health plans . N Engl J Med. 1987;;317:1729-1731.
64 +
Reagan MD.  Physicians as gatekeepers: a complex challenge . N Engl J Med. 1987;;317:1731-1734.
65 +
Hillman AL.  Financial incentives for physicians in HMOs: is there a conflict of interest? N Engl J Med. 1987;;317:1743-1748.
66 +
La Puma J, Cassel CK, Humphrey H.  Ethics, economics, and endocarditis: the physician's role in resource allocation . Arch Intern Med. 1988;;148: 1809-1811.
67 +
Morreim EH.  Fiscal scarcity and the inevitability of bedside budget balancing . Arch Intern Med. 1989;;149:1012-1015.
68 +
 In the courts . Hastings Cent Rep. 1986;; 16( (6) ):32.
69 +
Wickline v California , 2nd Appellate District, Division 5, No. B010156, (July 30) , 1986;.
70 +
Schiedermayer DL, La Puma J, Miles SH.  Ethics consultations masking economic dilemmas in patient care . Arch Intern Med. 1989;;149:1303-1305.

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