One model of how resources are allocated and delivered to the health sector is the QALY (quality adjusted life year).
This is an objective measure of the quantity of years of life gained combined with the quality of life of those years.
If a person was given a medical treatment which extended their life and also maintained the quality of that life to the full, it would have a greater value than when the years of life are similarly extended but there is a poorer quality of life.
When the cost of a QALY is measured it can give information about the "value for money" of that medical treatment. An area with a cheap QALY benefit is seen as a good investment. A cheap QALY could be the immunisation of children or the new Gardasil vaccination.
An expensive QALY could be anything from palliative care after a stroke to costly medications used in fighting HIV infection.
According to the new stance of the Royal Australian College of Surgeons (RACS) patients are being refused operations due to poor surgical outcomes linked to smoking and obesity.
Director of RACS, John Quinn has stated: "Surgeons should not have to operate on people who are not willing to quit smoking. There has to be some community responsibility with this, especially in terms of today's limited health dollar."
If you add the poor outcomes of operating on smokers with the limited resources, such as the time of surgeons and hospital staff, this would be an expensive QALY. That is, a poor benefit for the individual while using up valuable resources.
The QALY model influences decisions of who should obtain life saving operations or even what drugs are put on the Pharmaceutical Benefits Scheme. Why should we spend large amounts of time and community resources on operations for elderly people who continue to damage their bodies?
Or on the other hand, how can we deny people medications and operations just because they have made bad choices, or are old? Doesn't everyone deserve equal rights?
The QALY approach could be seen as a utilitarian perspective on health. That is, attempting to maximise the good on a population level. This may seem to make the individual subordinate to the common good.
The egalitarian perspective would be that all people deserve equal treatment despite individual differences – in this case smoking. Tobacco sellers' spokesman Shane Smith said smokers should not get second-class health care: "Everyone should get equal treatment under the health system."
Which approach is correct? What should we use in our health system? Neither approach is wrong, both are correct. Both are useful principles when considering such issues. This deficiency of the utilitarian QALY model has given rise to the rank-dependent QALY's prototype.
The use of the QALY measure is commonly associated with the assumption that health care resources should be allocated so as to achieve the maximal health gain as measured by additional QALYs.
Many experts have raised concerns about the equity implications of this allocation rule. Is it equitable to give an increase of say one QALY to people who are already "rich" in years or to someone whose life without treatment would be short and miserable?
This new approach suggests that the increment of QALY's should be given by ranking individuals according to their relative differences in society – or their individual characteristics. An advantage of the rank-dependent QALY model is that it offers a procedure to estimate equity weights for QALYs. In other words, who is worse-off or most deserving of the treatment.
Does anybody have the authority to draw the line or make decisions about who does and who doesn't receive operations and other healthcare? Where does the onus of decision making lie? Is it with patient or doctor or society? Has the onus changed, or will it ever?
There are people who say that smokers should not be punished for their addiction, and that denying treatment is discriminatory.
A feature of a free society is that there is a certain degree of individual rights and the ability to choose, which will always exist to some extent. If the surgeon deems the best treatment for the patient is to stop smoking, is that considered unfair?
People should be justly treated in the healthcare system, but just treatment should take into account what is in the interest of the society as a whole, and also the individual circumstances of the person.
In any case, there should be modification to the purely utilitarian approach of the QALY model, one that takes into account the individual circumstances of the person. This may not directly apply to the case of smokers; however, it does raise the issue of a refined approach to delivering healthcare.
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