QALYs, justice and the capabilities approach

Governments are responsible for ensuring access to healthcare. Unfortunately, due to the scarcity of medical and financial resources, medical rationing must take place. The rational allocation of healthcare resources is significant in any society and directly affects health outcomes. This raises the question of which criteria should be used to decide how medical treatments are allocated. Can age or ability, for example, be appropriate selection criteria? How can ethics inform and shape how healthcare resource allocation decisions are made? This paper studies and critiques quality-adjusted life year (QALY) resource allocation methods and does so through the lens of Martha Nussbaum’s social justice framework. Methodology The study design employed here is normative – it investigates how governing institutions ought to allocate healthcare resources. Those research methods and standards typical of philosophical research will be employed. I use Martha Nussbaum’s capabilities approach framework to ultimately argue that the use of QALY evaluation in healthcare is unjust. Conclusions Cost-effectiveness or cost-utility assessment tools (used in QALY) for allocating health care resources aim to maximise beneficial health outcomes. This raises two ethical concerns. The first is the commodification of human lives. The second is that QALYs fail to implement accurate health preference measurements for patients – especially in relation to patients with disabilities. Nussbaum's capabilities approach places particular value on the significance of human dignity in human development. She also sees human dignity as crucial for social justice, which can be achieved through governing bodies promoting ten central capabilities. But, through their employment of preference utilities, QALYs undermine access to this minimum threshold of capabilities. In this case, people’s capacities – that is their freedoms and opportunities to have the sort of human dignity intrinsic to a good life – are violated
A research report submitted in fulfilment of the requirements for the degree Masters of Science in Medicine (Bioethics and Health Law) to the Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, 2021