In healthcare policy, striking a balance between equality and cost-effectiveness is an ongoing task. A common tool in this task is the Quality-Adjusted Life Year (QALY), a widely used measure in health economics for assessing the value of medical interventions. It merges both the length of life and quality of life (QoL) into a single number, enabling policymakers to compare treatments across varied health conditions. While the QALYs have been significant in informing healthcare resource utilization (HCRU) decisions, their application is becoming increasingly controversial due to the potential bias they cause against the elderly and individuals with disabilities.[1-3]
Essentially, QALY considers a year of perfect health to be worth 1, and lesser health states are counted between 0 and 1 as per the perceived QoL. However, this approach can burden those who start at a lower baseline of health, for e.g. people with disabilities, the elderly, or those receiving palliative care; because their possible health gains may happen to be smaller or less “valuable” within this framework. The QALY is under scrutiny because such valuation unfairly treats some lives as worth less than others, a drawback reinforcing the concept of “states worse than death,” (SWTD), where negative QALY scores signify reduced overall utility with prolonged life.[3] In reality, this leads to underestimating life-extending therapies for already sidelined populations. These issues have triggered debates among researchers. For instance, in 2024, the introduction of the Protecting Health Care for All Patients Act (H.R.485) stirred a controversy by restricting the use of QALYs in federal healthcare decisions.[4] While both proponents and opponents continue to argue about the issue largely on theoretical basis, the ethical impact of assigning lower value to lives lived with disability or growing age continue to be an intense challenge to the metric’s equality.[1-3]
A treatment that prolongs life is often ranked higher in QALYs for younger patients than for older ones, even though both benefit, because of the younger person’s longer life expectancy. Even if the treatment largely improves the older patient’s well-being, it may be deprioritized under strict QALY-based evaluations, efficiently assigning lower value to the lives of older individuals. This causes an ethical dilemma for researchers for whether they should account for age or remaining lifespan into decisions about whose care is “worth” more.[1, 2, 5]
Moreover, the methods used to derive the QoL weights often fail to understand and depict the perspectives of individuals living with disabilities. These weights usually depend on a general public opinion about a life with certain weaknesses, rather than on self-assessments from people actually living with those impairments. This misrepresents those individuals, lowering valuations of disabled lives, emphasizing ableist assumptions about worth and happiness.[3]
Therefore, the use of QALYs in healthcare decision-making poses a risk of causing age and disability biases, necessitating careful implementation. Health critics debate about how strongly supporting QALYs could result in unfair practices, where society inadvertently prefers the health demands of younger, able-bodied individuals. Although QALYs have been a helpful metric of health outcomes and maximum efficiency, they must be implemented with ethical consciousness, cultural sensitivity, and a motivation to select alternative or harmonizing guidelines that impartially represent the diverse human experience.
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References
- Xie F, Zhou T, Humphries B, et al. Do Quality-Adjusted Life Years Discriminate Against the Elderly? An Empirical Analysis of Published Cost-Effectiveness Analyses. Value Health. 2024; 27(6):706-712.
- Kocot E, Kotarba P, Dubas-Jakóbczyk K. The application of the QALY measure in the assessment of the effects of health interventions on an older population: a systematic scoping review. Arch Public Health. 2021 Nov 18;79(1):201.
- Schneider P. The QALY is ableist: on the unethical implications of health states worse than dead. Qual Life Res. 2022 May;31(5):1545-1552.
- US Congress. H.R.485 — 118th Congress (2023-2024): H.R.485 – Protecting Health Care for All Patients Act of 2023. Available online at: https://www.congress.gov/bill/118th-congress/house-bill/485
- Braithwaite RS. A Parsimonious Approach to Remediate Concerns about QALY-Based Discrimination. Medical Decision Making. 2024;45(2):214-219.