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EDITORIAL 685 Nice and not so nice otherwise. One obvious lesson is that J Med Ethics: first published as 10.1136/jme.2005.014134 on 30 November 2005. Downloaded from ....................................................................................... such exercises are fraught with diffi- culty. However, procedural justice does not solve this problem, rather it seeks to Nice and not so nice make the process of failing to solve the problem transparent, and to demon- John Harris strate the reasonableness of the process and only via the reasonableness of the ................................................................................... process the reasonableness of the pro- duct of that process, inter alia, so that those who make decisions (such as NICE) can be easily held to account. ichael Rawlins and Andrew editorial I provided arguments for all ‘‘When we lack consensus on principles Dillon start their defence of claims made, none of which are engaged that tell us what is fair, or even when we MNice in fine polemical style, by Rawlins and Dillon. Let’s get down to have general principles but are bur- unfortunately polemics is all they have cases. dened by reasonable disagreements to offer. They totally fail to justify the Rawlins and Dillon seem to think that about how they apply, we may never- Nice proposals on dementia treatments unless I (or anyone) is prepared to offer theless find a process or procedure that nor do they make any more plausible solutions to the problem of distributing most can accept as fair to those who are than formerly their use of the notorious health resources under conditions of affected by such decisions. That fair QALY. They say: scarcity we are not entitled to criticise process the determines for us what the work of those, like NICE, who do. counts as a fair outcome…Our approach Harris’s recent editorial, It’s not Rawlins and Dillon claim: ‘‘He offers in this book is to recast the problem of limit setting as a question about how NICE to discriminate, is long on nothing to illuminate the debate about allocating healthcare in circumstances decisions about limits should be made. both polemic and invective – but of finite resources;… Harris, himself, Specifically under what conditions should short on scholarship. He offers whilst accepting that resources should society grant authority to individuals or nothing to illuminate the debate not be wasted, has offered nothing that institutions to set limits to health care?’’16 about allocating healthcare in cir- approaches a workable solution…. The Daniels/Sabin approach thus makes cumstances of finite resources; he Some constructive suggestions, rather the reasonableness of the process cru- has no understanding of the quality than sniping from the sidelines, would cial. This exchange is centred on the adjusted life year (QALY) and its use be appreciated.’’ As it happens I have question of whether QALYs are or are in health economic evaluation; and had quite a lot to say about these issues1- not an unreasonable part of that process he makes ill-researched, unsubstan- 15 but supposing I hadn’t or that these and hence as to whether or not they tiated and offensive charges against solutions are wrong or unworkable, still vitiate the reasonableness claimed for the Institute and its advisory bodies. what Rawlins and Dillon claim is the process. Rawlins and Dillon fail to absurd. They suggest that no-one can see the irony of complaining when they Accusations are easy to make, diffi- criticise a proposed solution to a pro- are in fact held to account. cult to substantiate. There are a number blem unless they have a better one to of claims here, only one of which is true. offer! That would be like saying that it is QALYS, AGEISM, AND LIFE It is true that my editorial was robust, somehow illegitimate to criticise a pro- EXPECTANCY http://jme.bmj.com/ polemical if you like, but editorials are posed treatment for cancer on the grounds that a) it didn’t cure or palliate not the same as research papers and NICE’s preferred approach, to eco- these are important issues which deeply cancer and b) it actually made cancer nomic evaluation, is cost utility affect real lives. Although Rawlins and patients worse off, unless those critics analysis; and the Institute uses esti- Dillon affect to take the high ground had themselves a better cure for cancer mates of the quality-adjusted life their own article contains even more to offer! The point is that NICE’s year (QALY) as its principal (though vigorous and much more personal recommendations on Alzheimer’s drugs not only) measure of health gain. on October 4, 2021 by guest. Protected copyright. invective than my editorial, I make no will deny people palpable benefits and complaints. But as to the rest of what offer no better (or comparable but The QALY is simple in concept. It they say, well, let’s just see! cheaper) alternatives. Indeed if NICE ranks health-related quality of life They claim I offer nothing to illumi- followed the absurd advice of their on a scale of zero (dead) to one (full nate resource allocation and that I have Chair and Chief Executive, they would health), and multiplies this by the no understanding of the QALY. Both of have no basis for rejecting the time (years) during which this these claims may well be true, but Alzheimer’s drugs since they themselves improved state of health is enjoyed. nothing they say goes any way to offer no better alternatives, indeed they If one form of treatment is superior support these claims or even towards do worse than ‘‘snipe from the side- to another, but costs more, the lines’’, they propose, from the sidelines, making them plausible. I have studied incremental cost effectiveness ratio to leave patients untreated. and written about the QALY for almost provides an expression of the addi- 20 years1-15 and Rawlins and Dillon tional money required to achieve an show no evidence of any awareness or In the face of a lack of consensus improvement in health… indeed any understanding of the issues, amongst moral philosophers, NICE whether discussed by me (in 15 papers has adopted the principles of pro- Rawlins and Dillon go on to affirm that: and many more popular pieces) or by cedural justice – ‘‘accountability for ‘‘The QALY is not… inherently ageist’’. others who have found the QALY highly reasonableness’’ Here it is Rawlins and Dillon who problematic. True, these papers have clearly have no understanding of been criticised, but the arguments they I accept that there is no consensus QALYs. One of the chief architects of contain have never been refuted, cer- among philosophers about distributing the QALY described it as ‘‘a simple, tainly not by Rawlins and Dillon. In my scarce resources. I have never suggested versatile, measure of success, which www.jmedethics.com 686 EDITORIAL incorporates both life expectancy and patients but this does not show that don’t believe any numerical ratings of J Med Ethics: first published as 10.1136/jme.2005.014134 on 30 November 2005. Downloaded from quality of life’’.17 It is the fact that they are not inherently ageist, only that this sort can be meaningful) and sup- younger people usually (though not there are some cases where the sums pose it is agreed that Jackie’s quality always), have more life expectancy to come out differently and favour older score before illness or accident was 6 gain from treatment than older people patients. The presence of some black and Jill’s was 10. Then to rescue Jill that makes the QALY ‘‘inherently age- officers is no evidence that a police makes a difference of 10, while saving ist’’. One wants to ask which of the two service is not ‘‘inherently racist’’, the Jackie yields only a score of 6. It is surely words ‘‘life’’ and ‘‘expectancy’’ do existence of some cases where QALYs the treatment and the rescue that makes Rawlins and Dillon not understand? may favour older patients is likewise no this difference because without out True, Rawlins and Dillon give some evidence that they are not inherently them Jackie and Jill would score zero. examples in which QALY’s are neutral, ageist. QALYs are of course likely to They would be dead. This shows that the or might indeed favour the aged in the benefit older patients in a range of QALY scores of the treatment are not distribution of health resources. treatments where there is either 1) no meaningfully separable from the QALY Unfortunately Rawlins and Dillon are effect of the treatment on length of life scores of the individual treated, if what not paying attention. In my editorial and the time in which the treatment matters is the QALY expectations of the and indeed in everything I have written works is so short that natural differ- individual after treatment. Indeed, how on QALYs, I distinguish two ways in ences in length of life do not matter (for could it be otherwise, for the point of which QALYs may be used. As I expli- example, analgesia for acute pain), 2) high QALY scores of treatment is to citly noted in my editorial: where old people are significantly more deliver high QALY scores to individuals. likely to die if not treated than young The same is of course true of life The QALY combines life expectancy people or, 3) where old people are expectancy. after treatment with measures of the significantly more likely to require costly Once grant that part of the justifica- support if not treated than young expected quality of that life. There tion for using QALYs as a prioritising people. are two ways in which QALYS can principle is that we ought to maximise The bottom line is that in QALYs and be used.

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