Health Improvement vs. Treatment

Appeals to quality-adjusted life-years (QALYs) in medical resource allocation decisions are naturally supported by a broadly utilitarian view of the role of health institutions, i.e. as having the purpose of improving social welfare (via health improvement) as much as possible.  But is that the right view to have? My colleague Mary recently pressed me on an intuitive alternative conception of healthcare as aiming at treating localized health problems rather than yielding global health benefits to patients.  Might that be a better view?


When contrasting the views, two major points of difference seem noteworthy. The first is that the "Treatment" view depends upon (and reinforces) the commonsense distinction between treatment (restoring you to "normal" health) and enhancement (as going beyond "normal" health), whereas on the "Improvement" view, we simply consider the benefit to be gained from a given health intervention, with no need to compare it against any assumed baseline of normalcy.

The second point is that the Treatment view will be less "discriminatory" than assessing QALY benefits, in that it will tend to treat other aspects of the patient's health status (including disability status, age / life expectancy, etc.) as irrelevant to allocation decisions.  After all, if the aim is just to treat local conditions of ill-health that arise (this disease, those infections, that cancer, etc.), this goal is just as well achieved by curing the disease of a 90 year old patient with Alzheimer's as it is by curing that same disease in an otherwise healthy 20 year old.  Either can be restored to a health state without the disease in question, and no further comparisons need or should be made (according to the Treatment view) about the respective values of those health states, or how much better off each patient is made by receiving the treatment in question.

One immediate challenge that arises for the Treatment view is how to make sensible allocation / prioritization decisions.  Presumably nobody wants to treat curing a cold as just as important as curing cancer, for example.  But what is the basis for considering the latter more important, if not that the treatment does more good (or prevents a greater harm) for the patient?  I guess if the aim is to make allocation decisions in a way that disregards individual factors other than the condition being treated, one natural solution would be to opt for allocation by generic QALYs, where this is understood to mean the QALY gain that could be expected from treatment for a "generic individual" with the condition in question. (The "generic individual" might in turn be understood as an otherwise healthy 40 year old, say. Though I'm not really sure what the basis would be for choosing that particular age over any other.  Perhaps a better view would be to use the age of the actual patient, thus allowing for age-based "discrimination", and simply using the generic-QALY construct to avoid differential treatment based on disability (etc.) status.)

While that seems a possible view, it's a little unclear to me what principled motivation could be offered in its support (i.e. besides simply wanting to avoid the implications of the standard QALY approach).  Deliberately ignoring pertinent information (namely, how much individuals stand to gain from proposed treatments) strikes me as rather perverse.  It is like how "common sense" bioethicists typically seem to prefer indiscriminate/coarse-grained allocation methods over more fine-grained ones -- throwing away information in a way that seemingly only harms our attempts to make our allocation practices more closely approximate the normative facts.

When different interests are at stake, why would you want to treat the cases indiscriminately?  Given that health is a mere means to what really matters in life (our "interests", broadly construed), why would we want our health institutions to narrowly focus on providing "treatments", independently of how much the individual patients in question can actually be expected to benefit from them?  It seems incomprehensible.

The only sense I can make of it is a broadly "rule consequentialist" justification -- if you do not trust our institutions to make decisions that are even on the right track -- if their attempts at fine-grained allocation could be expected to actually do more harm than good -- then that would be a practical reason to favour a more coarse-grained, indiscriminate approach.  But of course such merely pragmatic reasons are no reason to think that the QALY approach is in any way unjust in the way that most of its critics seem to believe.  It is, on the contrary, to recognize that while QALYs would be ideally just, the dangers posed by our flawed institutions mean that justice must take a back seat to more prosaic considerations of institutional competency.