Summarizing Population Health Directions for the Development and Application of Population Metrics (1998) / Chapter Skim
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Appendix E: Ethical Issues in the Development of Summary Measures of Population Health Status
Appendix E: Ethical Issues in the Development of Summary Measures of Population Health Status
Pages 73-86
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From page 73... ...
In a companion paper Norman Daniels will address issues of equity and distributive justice in the use of such measures for pnor~tization of health resources. Typical measures of the health status of a population at a point in time include the Health Utilities Index (HUl)
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From page 74... ...
Since virtually no one disagrees that it is desirable to reduce infant mortality rates, we can evaluate interventions for their effects in doing so without raising the problem of how to assign relative values to different heals outcomes. The usefulness of life expectancy or infant mortality rates is clearly very limited, however, because they give us information about only one of the aims of health interventionsextend~ng life or preventing premature loss of life and they provide only limited information about that aim.
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From page 75... ...
The second step in developing measures like the HU] involves assigning relative values or utilities to the different conditions that reduce people's ~QL.
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From page 76... ...
The disabled should have a more informed understanding of what it is actually like to live with the particular disability in question than a person who has never experienced the disability. Nondisabled persons will often have false beliefs about what it is like to live with particular disabilities, beliefs which should not influence the relative values assigned to the EIRQL of living with Rose disabilities.
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From page 77... ...
These differences will be magnified when summary measures of population health are employed for international comparisons among very disparate countnes. The ethical evaluation of health differences is complicated further when great differences between and among groups or countnes, such as In the level of economic development or the treatment of disadvantaged groups, are themselves unjust.
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From page 78... ...
quality of life would be reduced if he or she suffered the venous impairments of function. This individual perspective is appropriate for a number of uses to which a summary measure of population health status might be put.
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From page 79... ...
The second difficulty is that calculations of aggregate QALYs from different health interventions fail to reflect the ethical importance people place on the fact that health benefits to different individuals or groups are being traded off or prioritized. When summary measures of population health status like the HU]
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From page 80... ...
The most prominent example is Erik Nord's "person trade-off" approach which explicitly asks people how many outcomes of one kind they consider equivalent In social value to "X,' outcomes of another kind, where the outcomes can be for different groups of individuals. For example, people can be asked, for two diseases of equal initial severity, how many patients with the disease whose treatment is fully effective would be equivalent in social value to treating 100 patients with the other disease whose treatment is only partially effective and so results in a lesser health improvement for each patient treated, in this example, Nord found that people tended to give more weight to initial severity of illness than to the degree of health improvement, "saying that they would prefer the 'less effective' program even if it treated only one person more than the 'more effective' program."~° The person trade-off approach is designed to permit people to incorporate concerns for equity or distributive justice into their judgments about the social value of alternative health programs.
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From page 81... ...
The principal justifications offered for this feature of DALYs were the different social roles that individuals typically occupy at different ages and the typical emotional, physical, and financial dependence of the very young and the elderly on individuals in their productive work years. ~ believe this justification of age-based differences in the value of life extension adopts an ethically problematic social (in a different sense of "social" than that used In the preceding section)
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From page 82... ...
Moreover, individuals and their society might choose to give lesser weight to a year of life extension beyond the normal life span than to a year of life extension before one has reached the end of the normal life span. People's plans and central long-term projects will typically be constructed to fit within the normal life span, and so the completion of these central projects will typically require reaching, but not living beyond, the normal life span.l4 FOURTH ISSUE: WHAT LIFE EXPECTANCIES SHOULD BE USED FOR CALCULATING THE BENEFITS OF LIFE SAVING INTERVENTIONS?
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From page 83... ...
They justified their choice in explicitly ethical terms as conforming to a principle of"treat~ng like events as like."~5 I note below even more briefly two other ethical issues which are important in costeffectiveness analyses of health programs and in pnor~tization of health interventions and programs; the first arises directly in constructing a summary measure of increases and decreases In population health. Space limitations preclude any exploration of the details of these two Issues.
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From page 84... ...
Instead, giving lower priority to the second group of patients simply because they are not a means to the indirect benefits produced or indirect costs saved by treating the first group of patients gives the second group of patients and their health care needs lower priority simply because they are not a means to these indirect benefits or cost savings to others. This Kantian reason for ignoring indirect benefits and costs could serve as a moral basis of the idea of "separate spheres," that is, that the purpose of health care and of public health is health and the reduction of disease, and so only these goals and effects should guide health care and public health programs.'" The six ethical issues discussed very briefly above are all issues involved in developing a summary measure of population health, and of changes in population health, that permits equitable evaluation of populations' health or health programs.
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From page 85... ...
al., Multi-Attribute Preference Functions for a Comprehensive Health Status Classification System. Working Paper No.
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