ORIGINAL PAPERS Ethics and resource allocation: can health care outcomes be QALYfied? Femi Oyebode This paper discusses the theoretical foundation of QALY and examines the assumptions which underlie these theories. It argues that there are methodological flaws in the construction of QALY and that there are inherent risks in its possible application to psychiatry. It also draws attention to fundamental ethical problems with the concept of QALY as a tool for valuing the quality of life or well-being of persons. Quality adjusted life years (QALY) incorporates both life expectancy and quality of life in the measurement and valuation of the benefits of health care (Williams, 1985). It is a concept which has arisen in the context of growing con cern about the finitude of health care resources, and it is meant to provide a rational basis for the allocation of scarce resources. This paper will discuss the theoretical foundation of QALY and then proceed to a critical appraisal of its under lying assumptions and methodology. It will argue that there are a number of methodological flaws in the construction of QALYs, especially in its possible application to psychiatry. Furthermore, it will hope to show that even without these flaws, there are fundamental ethical difficulties with the concept of QALYs as a tool for valuing the quality of life or well being of persons. The theory of QALY The proponents of QALY argue that in a climate of limited resources, decisions need to be made to determine health care priorities, and, that these decisions should at least be based on both the costs of resource inputs and on the health care outcome for the patients involved. The impact of medical intervention upon quality of life must also be a component of any measure of outcome. The QALY measure, it is argued, fulfils such a role (Williams, 1985). The assessment of quality of life used in QALY is based upon a classification of illness states (Rosser & Watts, 1972). This classification Is a general classification of morbidity which is said to be applicable to all diseases and therefore will permit comparisons of the impact of diseases across disease classes and across medical specialities. It is constructed from a summation of disability and distress questionnaires respec tively. There are eight degrees of disability and four degrees of distress which are combined into a valuation matrix, consisting of 32 possible cells, each representing a particular illness state. For example, cell IA represents having no dis ability and no distress, cell IIB represents slight social disability and mild distress, and cell VC represents inability to undertake any paid employment or inability to continue education or old people confined to home except for outings and short walks and unable to do shopping or housewives able only to perform a few simple tasks and who are moderately distressed. The weighting for each cell in the valuation matrix was calculated from the responses of 70 individuals comprising ten doctors who were members of a royal college, ten experienced psychiatric nurses, ten experienced general hospital nurses, 20 healthy volunteers, ten patients from medical wards and ten patients from psychiatric wards. The weighting derived from these interviews is a ratio scale in which being healthy is rated 1 and being dead is rated 0. Thus, an illness state valued at 0.5 is be lieved to be only half the value of being healthy. The assumption here is that two years life expectancy in this state is of equal value to one year of healthy life. In clinical situations, the technique may pro vide the following kind of information: interven tion A which produces perfect health for ten years yields a QALY score of 10, whereas inter vention B which extends life for 20 years but at a quality valued at 0.2 yields a QALY score of 4. Cost per QALYcan also be derived: if intervention A costs £20000 then cost per QALY is 2000, whereas if intervention B costs £1000, then cost per QALYis 250. In this scenario priority must be given to intervention B. Psychiatric Bulletta (1994), 18, 395-398 395