Well, for all you NICE and HIP people, this is the book for you. The Ethical QALY is the fruition of a research project into the allocation of healthcare resources, funded by the European Commission.
It considers the technical feasibility of using quality of life measures, and the broader issues of the justice or moral legitimacy of such use. Not only does it examine whether such measures could be used for planning and reforming healthcare, but also whether they should be used at all.
This book is packed with definitions and explanations, and the appendices offer an insight into the approaches to healthcare rationing and provision throughout Europe.
The Ethical QALY group which produced this report brought together public health physicians, health economists, psychometricians and philosophers. This blend of professions and disciplines has produced not only a breadth of opinion, but a depth of knowledge difficult to match in any other publication.
But what about the detail? The first chapter sets the context, justifying the need for explicit prioritisation of resources. The second looks at the construction of quality of life measures and various instruments in common use.
The third examines the issue from the perspective of the health economist and highlights how moral criticism could be avoided in the use of QALYs. The fourth gives a philosophical interpretation, attempting to give a moral defence of QALYs that has implications for their design and use. The fifth chapter summarises the findings of the research group.
What does the team recommend?
Some points are obvious: the need for explicit mechanisms for resource allocation and clarification of the overall objectives of any healthcare system; the derivation of such mechanisms through the application of a discourse ethics approach - we all have the ability to debate issues and revise our preferences - and the need for regular review.
More complex and inconclusive recommendations cover moral and ethical issues, societal preferences, the application of weightings and the economic variability of time and change.
The authors draw no conclusions other than the need for a European institution to accredit cost-perQALY data before inclusion in league tables. They add that applying a humanist model to the process would allow the recognition of the complexity of the individual's perception of their own health.
In this World Cup, with so many of us rushing through the Channel tunnel to see the games, I leave you with a quote from J Griffin (1986) on where quantity and quality of life may be compared:
'The French government knows that each year several drivers lose their lives because of the beautiful roadside avenues of trees, yet they do not cut them down. Even aesthetic pleasure is allowed to outrank a certain number of human lives.'
Peter Buckley Service development and contracting director, St Andrew's Hospital, Northampton.
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