Choosing who shall not be treated in the NHS

doi:10.1016/0277-9536(89)90352-3

Social Science & Medicine

Volume 28, Issue 12, 1989, Pages 1331-1338

https://doi.org/10.1016/0277-9536(89)90352-3 Get rights and content

Abstract

In the face of severe resource constraints, health care systems are seeking both to control costs and to ensure maximum benefits for the resources consumed. The use of Quality Adjusted Life Years (QALYs) is becoming more widely advocated as a decision aid in the solution of resource allocation problems. The QALY combines two dimensions of health outcome—the quantity of life and its quality—in such a way that choices between different services with different purposes can be made using comparisons based on common units of measurement. The combination of these two dimensions allows comparisons between services with different objectives, such as curing and caring services. The QALY, however, lacks a third dimension which is vital to the decision-making process to which it is intended to contribute: the worth of a specific life relative to others. This paper presents results based on interviews of 719 residents of Cardiff drawn at random from the electoral register. The results suggest that further development of the novel methodology used to establish the relative value placed on various human lives is worthwhile. Evidence is given which indicates that the public consider lives to be of unequal worth. The results also show that these values are consistent for different types of choices phrased in different ways on a large number of control variables, implying the existence of a cultural stable value system which is a necessary prerequisite if consensus values of human life are to be used to assist decision-making in non-private health care systems. The paper suggests that it is right that the value system of those who pay for a group-funded health care system (such as the NHS) should guide choices between services. It is suggested that these choices are not the prerogative of professionals, whose view should carry no more weight than that of any other citizen. It is recognised that the suggestion that lives are not intrinsically of equal worth poses serious ethical problems for society, but the exploration of the value system of society, as advocated in this paper, may highlight issues which need further consideration.

References (18)

N.J. Vetter et al.
The Cardiff Health Survey. The relationship between smoking habits and beliefs in the elderly
Publ. Hlth
(1988)
M. Charny
Risk-targetting: the application of epidemiological data to problems of resource allocation in insurance based health care systems
National Health Service Act 1977
(1981)
C.B. Rodning
Disaster preparedness
South. med. J.
(1983)
H.R. Champion
Assessment of injury severity: the Triage Index
Crit. Care Med.
(1980)
E.G. Butchart
Low risk of thrombosis and serious embolic events despite low-intensity anticoagulation
Circulation
(1988)
S. Lemeshow et al.
A comparison of methods to predict mortality of intensive care unit patients
Crit. Care Med.
(1987)
R.W.S. Chang
Predicting deaths among intensive care unit patients
Crit. Care Med.
(1988)
J.F. Zimmerman
Patient selection for intensive care: a comparison of New Zealand and United States hospitals
Crit. Care Med.
(1988)

There are more references available in the full text version of this article.

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^∗: Present address: Bath District Health Authority, New-bridge Hill, Bath BA1 3QE, England.

View full text

Choosing who shall not be treated in the NHS

Abstract

Publ. Hlth

Risk-targetting: the application of epidemiological data to problems of resource allocation in insurance based health care systems

National Health Service Act 1977

Disaster preparedness

South. med. J.

Assessment of injury severity: the Triage Index

Crit. Care Med.

Low risk of thrombosis and serious embolic events despite low-intensity anticoagulation

Circulation

A comparison of methods to predict mortality of intensive care unit patients

Crit. Care Med.

Predicting deaths among intensive care unit patients

Crit. Care Med.

Patient selection for intensive care: a comparison of New Zealand and United States hospitals

Crit. Care Med.