By Jennifer Popik, JD, Robert Powell Center for Medical Ethics
In “Treatment Cost Could Influence Doctors’ Advice,” the New York Times’s Andrew Pollack reports that several major physician groups are poised to begin openly considering cost when seeking to deny life-saving treatment—and that some of them are explicitly calling for factoring in patients’ “quality of life” in judging cost-effectiveness.
Last month the American College of Cardiology and the American Heart Association released a report calling for the use of “Quality Adjusted Life Years” or QALYs in assessing whether the added life associated with a treatment is worth the cost. This is the often criticized assessment process for approving or disapproving particular treatments employed by Great Britain’s National Institute for Health and Care Excellence.
It is essential to understand what is meant by the term “quality of life” to understand why this move is so dangerous.
A QALY would be used (and is used abroad) to deny treatments to patients against their will based on their age, expected length of life, or of the patient’s present or predicted disability or quality of life. Under such a system someone in a wheelchair, for example, is determined to have a lower quality of life compared with an able-bodied person. Thousands of subjective judgments enter mathematical equations – ones that treat those with disabilities of lower value, simply because those making judgments “would not want to live that way.”
Those developing QALY’s combine these value judgments and only those they deem quality lives can get more costly life-saving treatments. This is extremely dangerous territory fraught with dangers.
In one example in the medical literature, an attempt was made to assess different “quality adjusted life year” scores for each of the following:
“no physical disability, limp, walk with crutches, and need a wheelchair.”  In another, the authors wrote, “[I]t may be judged that one year of life with a moderate disability is equivalent to 0.75 years of life at optimal health.”
The American College of Cardiology and the American Heart Association recommend that doctors refuse to provide health care exceeding a target amount per QALY: They write in their report
“The proposed threshold for L and H [low and high quality] are those recommended by the World Health Organization, which labels a care strategy as ‘poor value’ if the cost per life year gained is greater than three times the gross domestic product (GDP) per capita, and a ‘good value’ if the cost per life year gained is less than one times the GDP per capita. In the U.S., treatments that have a cost-effectiveness ratio of $150,000/QALY or more would be considered low value.”
Even Obamacare, riddled though it is with provisions that can lead to the denial of treatment, forbids the use of QALYs in assessing the comparative effectiveness of treatments:
“The Patient-Centered Outcomes Research Institute … shall not develop or employ a dollars-per-quality adjusted life year (or similar measure that discounts the value of a life because of an individual’s disability) as a threshold to establish what type of health care is cost effective or recommended. The Secretary shall not utilize such an adjusted life year (or such a similar measure) as a threshold to determine coverage, reimbursement, or incentive programs…” 42 USCS § 1320e-1
As Pollock noted,
“In practical terms, new guidelines being developed by the medical groups could result in doctors choosing one drug over another for cost reasons or even deciding that a particular treatment — at the end of life, for example — is too expensive. In the extreme, some critics have said that making treatment decisions based on cost is a form of rationing.”
 Duru, G, Auray, J P, Beresniak, A, Lamure, M, Paine, A, & Nicoloyannis, N (2002). Limitations of the methods used for calculating quality-adjusted-life-year values. Pharmacoeconomics, 20, 463-73.
 A. Atherly, S.D. Cutler, E.R. Becker. “The Role of Cost Effectiveness Analysis in Health Care Evaluation,” The Quarterly Journal of Nuclear Medicine 2000 June; 44 (2): 112-120.