ABSTRACT
Leaving aside the technical problems, the most common criticism of the QALY approach to health care allocation claims that it unfairly discriminates against some groups, such as the aged and the dis abled. Although QALYs might be useful for deciding between different treatment options for individual patients, since what each patient wants from medical care is to maximize his or her own quality and quantity of life, QALY maximization fails as a way of dealing with the problem of distributive justice that arises when there is competi tion for resources.1 We have already noted that QALYs are egalitarian in the sense that they incorporate no preferences based on race, gender, intelligence, and so on. And allocation on the basis of QALYs is egalitarian in the sense that, if the cost/QALY ratio of programme A is lower than the cost/QALY ratio of programme B, programme A should have priority (in the absence of compelling reasons for doing otherwise), irrespective of the way those QALYs are distributed throughout the population. It is irrelevant how the QALYs are dis tributed because everyone is considered equally; the aim is simply to maximize QALYs. But a number of critics have argued that QALYbased allocation is unfair, and results in distributions that are unjust, despite this egalitarianism. These critics argue that comparing the worth of various health care programmes in terms of QALYs, to the neglect of considering to whom they accrue, has implications that are incompatible with our considered moral judgments about fairness and justice.2
