Because you are not worth it.

by reestheskin on 21/08/2020

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I read about the QALY (quality adjusted life year) during my intercalated degree in 1980-81, when we were exposed to some health economics. It was considered new and interesting at the time. It took me about 10 minutes to sense that it was nonsense, even if I couldn’t quite put my feelings into words that quickly1. The goal was fine, but the methodology was metaphysical in nature, rather than grounded in the world that you could touch with your fingers. At least not if you look at the world through the prism of the natural sciences.

Economists have a disturbing habit of confusing how the world works with their own (strange) ideas of rationality. If only the world could be said to work in a way that was amenable to their methods. When physicists wanted to estimate the speed of light they recognised that they had to create some theory and some technology in order to obtain the correct answer. Embarrassingly — at least from the economists point of view — they had to do some experiments and see if their answer made sense when applied to new observations in the external world. Until they had done this, they stayed shtum.

Not so, for our economists. Their solution is effectively to agree some conventions, and then define what the speed of light should be. Whether their theory explains the way the world really works is neither here-nor-there. So QUALYs became a make-believe that suited both economists and the technocrats in government. The former, because the need for QUALYs became a job creation scheme for health economists (just as evidence based medicine (EBM) became a lifeline for all those epidemiologists who belatedly realised that much of their subject was methodologically deeply flawed). The technocratic governments liked what the economists brought them because it exiled judgement (and hence blame), allowing human suffering to be traded in arbitrage markets from which they could metaphorically wash their hands — ‘just following the science’, ‘just following the science’ (ring any bells?). Many politicians don’t want to do politics, but they do want to stay in power. As do economists2, who appear pathologically obsessed with rank and status3. The Economist had a nice line earlier this year germane to my doubts:

But unlike poets, economists prefer to quantify their analogies—to measure whether thou art 15% or 20% more lovely and more temperate.

But if you think that artificial models that cannot predict the world are still useful — useful in the way the philosophers trolley problems are — then the quote below should indeed make you sit up and stare.

If we’re willing to pay $150,000 for each quality-adjusted extra year of life (a commonly used estimate), then we ought to view a 10% increase in spending per capita as a good investment if it extended average life expectancy by 2.5 days. That number may give readers pause — hence the importance of clarifying our spending priorities and focusing on care that produces real value for patients. With such a focus, we could feel more confident that higher health care spending was worth it.

Do We Spend Too Much on Health Care? | NEJM


  1. A nice critical (and perhaps dated) introduction from a once QUALY-enthusiast who returned from the dark side is Erik Nord’s, Cost-Value analysis in Health Care: Making Sense out of QALYs, CUP, 1999. The rearguard action is still ongoing (advance proceeds one funeral at a time …(Max Planck)).
  2. Here is a revealing quote from Alan Maynard, a health economist: “… unless we tackle the doctors, health reforms will fail to deliver … processes of health care are dominated by clinicians, who merely represent their own vested interests, we must therefore strengthen the role of health managers and economists, who would speak for society at large.” Quoted in Julian Tudor-Hart, Lancet 2004. Well good luck with that!
  3. A strange quirk of economists is that they appear obsessed with proxies for their own self-doubts. US economists cannot help but focus on why you have to graduate from the top five schools with a PhD in order to obtain a faculty position at the same school, and how critical math scores are to being academically successful(‘I could have been a physicist — honest!’) It is quite a contrast with the lives of some of the greatest natural scientists. Natural science is much more open. 

(Image of NotGeld (emergency money) at top of page from here)