Discrimination and Fairness in QALY-Based Healthcare Allocation

This thesis addresses the question of what criteria we should apply in healthcare allocation. I accept that benefit maximisation is an important pro tanto aim, but I also argue that other pro tanto aims and constraints are important too.

I argue that we should base our assessment of benefit on deliberative assessments of how much a health outcome constrains the possibilities of living well, usually done by patients in the state unless there are reasons to doubt the reliability of their preferences. However, we should confine our attention to the effects of the disease we are treating or its treatment and ignore symptoms of conditions unrelated to the condition we are treating.

Once this is established, each chapter then defends a different principle that must be weighed against benefit maximisation. First, I argue that we should not allow healthcare allocation policies to be influenced by false or unwarranted judgments regarding groups who lose out by such policies. We should also avoid reinforcing any sense that people with historically disadvantaged traits are excluded. I argue that we should relax our normal criteria in the case of rare diseases, when deciding whether to licence and fund treatments for them on the basis of a principle of inclusiveness. I suggest that perhaps egalitarian considerations give us reason to avoid a sharp cost-effectiveness threshold that discriminates sharply between patients just above and just below the threshold (this could be by instituting a lottery for patients whose cost-effectiveness is near the threshold). I argue that we should give extra weight to QALYs for patients whose quality-adjusted life expectancy, without treatment, is less than society's average. I also argue that we should prioritise patients who have had very little notice of their expected death for life-extending treatment.