I think it’s generally fine to use terminology any way you like as long as you’re clear about what you mean.
In this piece I was summarising debates in health economics, and my framing reflects that literature.
The main objective of these posts is to highlight particular issues that may deserve further attention from researchers, and sometimes that has to come at the expense of conceptual rigour (or at least I couldn’t think of a way to avoid that tradeoff). Like you, my natural inclination is to put everything in mutually exclusive and collectively exhaustive categories, but that doesn’t always result in the most action-relevant information being front and centre.
To address your specific points:
I try to make it very clear what I mean by “welfarism” and its alternatives:
The QALY originally emerged from welfare economics, grounded in expected utility theory (EUT), which defined welfare in terms of the satisfaction of individual preferences. QALYs were intended to reflect, at least approximately, the preferences of a rational individual decision-maker (as described by the von Neumann-Morgenstern [vNM] axioms) concerning their own health, and could therefore properly be called utilities.
Others have argued that QALYs should not represent utility in this sense. These “non-welfarists” or “extra-welfarists” typically believe things like equity, capability, or health itself are of intrinsic value (Brouwer et al., 2008; Coast, Smith, & Lorgelly, 2008; Birch & Donaldson, 2003; Buchanan & Wordsworth, 2015). If such considerations are included in the QALY, the (welfarist) utility of patients may not change proportionally with the size of QALY gains.
Most criticism of HALYs has come from three broad camps: welfare economics (which aims to maximise the satisfaction of individual preferences), extra-welfarism (which has other objectives), and wellbeing (often but not always from a classical utilitarian perspective).
In a nutshell, welfarists complain that QALYs, and CEAs based on them, do not reflect the preferences of rational, self-interested utility-maximizers.
Extra-welfarists, on the other hand, generally think the QALY (and CEA more broadly) is currently too welfarist. Though extra-welfarism is ill-defined and encompasses a broad range of views, the uniting belief is that there is inherent value in things other than the satisfaction of individuals’ preferences (Brouwer et al., 2008).
For the welfarist, there are broader efficiency-related issues with using cost-per-HALY CEAs for resource allocation […] Therefore, counting everyone’s health the same does not maximise utility in the welfarist sense, even within the health sector.
So it should be clear that welfarism, as the term is used in modern (health) economics, offers a very specific theory of value (satisfaction of rational, self-regarding preferences that adhere to the axioms of expected utility theory) that is much more narrow than most desire theories. That said, I agree welfarism, extra-welfarism, and wellbeing-oriented ideas are not entirely distinct categories, and note overlaps between them:
Hedonism: … This is associated with the classical utilitarianism of Jeremy Bentham and John Stuart Mill, classical economics (mid-18th to late 19th century)…
Desire theories: Wellbeing consists in the satisfaction of preferences or desires. This is linked with neoclassical (welfare) economics, which began defining utility/welfare in terms of preferences around 1900 (largely because they were easier to measure than hedonic states), preference utilitarianism, …
Objective list theories: Wellbeing consists in the attainment of goods that do not consist in merely pleasurable experience nor in desire-satisfaction (though those can be on the list). … These have influenced some conceptions of psychological wellbeing,[46] and many extra-welfarist ideas. The capabilities approach also falls under this heading…
I mention distributional issues in the context of extra-welfarism:
These “non-welfarists” or “extra-welfarists” typically believe things like equity, capability, or health itself are of intrinsic value (Brouwer et al., 2008; Coast, Smith, & Lorgelly, 2008; Birch & Donaldson, 2003; Buchanan & Wordsworth, 2015). If such considerations are included in the QALY, the (welfarist) utility of patients may not change proportionally with the size of QALY gains.
Descriptively, it seems the extra-welfarists are winning. Although QALYs, and CEA as a whole, do not generally include overt consideration of distributional factors, they do depart from traditional welfare economics in a number of ways …
This “QALY egalitarianism” is often challenged by welfarists on the grounds that WTP varies among individuals, but many extra-welfarists reject it for other reasons. For example, some have argued that more value should be attached to health gained by the young—those who have not yet had their “fair innings”—than by the elderly (Williams, 1997); by those in a worse initial state of health, or for larger individual health gains[43] (e.g., Nord, 2005); by those who were not responsible for their illness (e.g., Dworkin, 1981a, 1981b); by those at the end of life, as currently implemented by NICE; or by people of low socioeconomic status.[44]
They are addressed further in Part 2 when I discussed how HALYs should be aggregated.
I do think I could perhaps have been clearer about the distinction between HALYs and economic evaluation (the latter is typically HALY-maximising, but doesn’t have to be), and analogously between the unit of value (e.g. wellbeing, health) and moral theory (utilitarianism, egalitarianism, etc). I may edit the post later if I have time.
What you call problem 2 I’d reframe as expectations =/= reality.
“Preferences =/= value” was intended as shorthand for something like “the preferences on which current HALY weights are based do not accurately reflect the value of the states to people experiencing them”. Or as I put it elsewhere: “They are based on ill-informed judgements of the general public”. It wasn’t a philosophical comment on desire theories. Still, I can see how it might be misleading (plus it doesn’t strictly apply to DALYs, which arguably aren’t preference-based), so I may change it to your suggestion...though “expectations” doesn’t really fit DALYs either, so I’d welcome alternative ideas.
I agree problem 3 (suffering/happiness) is about inadequate scaling and doesn’t presuppose hedonism, but I don’t think I imply otherwise. I decided to include it as a separate problem, even though it’s applicable to more than one type of scale/theory, because it’s an issue that is very neglected—in health economics and elsewhere. As noted above, the aim of this series is to draw attention to issues that I think more people should be working on, not make a conceptually/philosophically rigorous analysis.
That’s also why I didn’t have distributional issues as a separate “problem”. I note at the the start of the list that “The criticisms assume the objective is to maximize aggregate SWB” (while also noting that they “should also hold some force from a welfarist, extra-welfarist, or simply ‘common sense’ perspective”) and from that standpoint the current default (in most HALY-based analyses/guidelines) of HALY maximisation is not a “problem,” so long as they better reflect SWB. That said, as noted above, I do mention distributional issues earlier in the post and in Part 2, in case someone does want to work on those.
Problem 4 is not that HALYs don’t include spillovers; it’s that “They are difficult to interpret, capturing some but not all spillover effects.” (When I say “Neglect of spillover effects,” I mean that the issue of spillovers is problematically neglected in the literature, not that HALYs don’t measure them at all.) This should be clear from the text:
there is some evidence that people valuing health states take into account other factors, especially impact on relatives … On the other hand, it seems reasonable to assume health state values do not fully reflect the consequences for the rest of society—something that would be impossible for most respondents to predict, even if they were wholly altruistic.
I agree this is likely to be an issue with other metrics too (Part 6 is all about this, and it’s mentioned in Part 2), and I suspect it will mostly have to be dealt with at the aggregation stage, but it’s not the case that the content of the metrics is irrelevant. For example, the questionnaires (and therefore the descriptive system) could include items like “To what extent do you feel you’re a burden on others?” (a very common concern expressed in qualitative studies); and/or the valuation exercise could ask people to take into account the impact of their (e.g.) health condition on others (or alternatively to consider only their own health/wellbeing). If this makes a difference to the values produced, it would make HALYs/WELBYs easier to interpret, which would also inform broader evaluation methodology, like whether to administer health/wellbeing measures to relatives separately and add them to the total.
Problem 5 is not merely a restatement Problem 1, though of course they’re closely connected. Problem 1 focuses on why HALYs aren’t that good at prioritising within healthcare (i.e. achieving technical efficiency, from a fixed budget). Problem 5 is that are useless at cross-sector prioritisation (i.e. allocative efficiency). The cause is similar (health focus), and I think I combined them in an early draft; but as with states worse than dead, I wanted to have 5 as a separate issue in order to draw particular attention to it. The difference becomes especially relevant when comparing, for example, the sHALY (which assigns weight to health states based on SWB, thereby addressing Problem 1 but not 5) and the WELBY (which potentially addresses both, but probably at the expense of validity within specific domains such as healthcare, in which case it may be useful for high-level cross-sector prioritisation, e.g., setting budgets for different government departments [Problem 5], but not for priority-setting within, say, the NHS [Problem 1]). Following similar feedback from others, I did change 5 to “They are consequently of limited use in prioritising across sectors or cause areas” in my main list in order to highlight the relationship.
(Really, all of these problems are due to (a) the descriptive system, (b) the valuation method, and possibly (c) the aggregation method, so any further breakdown risks overlap and confusion—but those categories don’t really tell you why you should care about them, or what elements you should focus on, so it didn’t seem like a helpful typology for the “Problems” section.)
Still, I am not entirely happy with this way of dividing things up or framing things (e.g., some problems focus more “causes” and some on “effects”) and would welcome suggestions of alternatives that are both conceptually rigorous/consistent and draw attention to the practical implications.
I’ve made a few edits to address some of these issues, e.g.:
Clearly, there are many possible “wellbeing approaches” to economic evaluation and population health summary, defined both by the unit of value (hedonic states, preferences, objective lists, SWB) and by how they aggregate those units when calculating total value. Indeed, welfarism can be understood as a specific form of desire theory combined with a maximising principle (i.e., simple additive aggregation); and extra-welfarism, in some forms, is just an objective list theory plus equity (i.e., non-additive aggregation).
However, it seems that most advocates for the use of wellbeing in healthcare reject the narrow welfarist conception of utility, while retaining fairly standard, utility-maximising CEA methods—perhaps with some post-hoc adjustments to address particularly pressing distributional issues. So it seems reasonable to consider it a distinct (albeit heterogenous) perspective.
For the purpose of exposition, I will assume that the objective is to maximise total SWB (remaining agnostic between affect, evaluations, or some combination). This is not because I am confident it’s the right goal; in fact, I think healthcare decision-making should probably, at least in public institutions, give some weight to other conceptions of wellbeing, and perhaps to distributional concerns such as fairness. One reason to do so is normative uncertainty—we can’t be sure that the quasi-utilitarianism implied by that approach is correct—but it’s also a pragmatic response to the diversity of opinions among stakeholders and the challenges of obtaining good SWB measurements, as discussed in later posts.
However, I am fairly confident that SWB-maximization—or indeed any sensible wellbeing-focused strategy—would be an improvement over current practice, so it seems like a reasonable foundation on which to build. Moreover, most of these criticisms should hold considerable force from a welfarist, extra-welfarist, or simply “common sense” perspective. One certainly does not have to be a die-hard utilitarian to appreciate that reform is needed.
Changed the first two problem headings to avoid ambiguity and, in the first case, to focus on the result of the problem rather than the cause, which helps distinguish it from 5.
Hi Michael. Thanks for the feedback.
A few general points to begin with:
I think it’s generally fine to use terminology any way you like as long as you’re clear about what you mean.
In this piece I was summarising debates in health economics, and my framing reflects that literature.
The main objective of these posts is to highlight particular issues that may deserve further attention from researchers, and sometimes that has to come at the expense of conceptual rigour (or at least I couldn’t think of a way to avoid that tradeoff). Like you, my natural inclination is to put everything in mutually exclusive and collectively exhaustive categories, but that doesn’t always result in the most action-relevant information being front and centre.
To address your specific points:
I try to make it very clear what I mean by “welfarism” and its alternatives:
So it should be clear that welfarism, as the term is used in modern (health) economics, offers a very specific theory of value (satisfaction of rational, self-regarding preferences that adhere to the axioms of expected utility theory) that is much more narrow than most desire theories. That said, I agree welfarism, extra-welfarism, and wellbeing-oriented ideas are not entirely distinct categories, and note overlaps between them:
I mention distributional issues in the context of extra-welfarism:
They are addressed further in Part 2 when I discussed how HALYs should be aggregated.
I do think I could perhaps have been clearer about the distinction between HALYs and economic evaluation (the latter is typically HALY-maximising, but doesn’t have to be), and analogously between the unit of value (e.g. wellbeing, health) and moral theory (utilitarianism, egalitarianism, etc). I may edit the post later if I have time.
“Preferences =/= value” was intended as shorthand for something like “the preferences on which current HALY weights are based do not accurately reflect the value of the states to people experiencing them”. Or as I put it elsewhere: “They are based on ill-informed judgements of the general public”. It wasn’t a philosophical comment on desire theories. Still, I can see how it might be misleading (plus it doesn’t strictly apply to DALYs, which arguably aren’t preference-based), so I may change it to your suggestion...though “expectations” doesn’t really fit DALYs either, so I’d welcome alternative ideas.
I agree problem 3 (suffering/happiness) is about inadequate scaling and doesn’t presuppose hedonism, but I don’t think I imply otherwise. I decided to include it as a separate problem, even though it’s applicable to more than one type of scale/theory, because it’s an issue that is very neglected—in health economics and elsewhere. As noted above, the aim of this series is to draw attention to issues that I think more people should be working on, not make a conceptually/philosophically rigorous analysis.
That’s also why I didn’t have distributional issues as a separate “problem”. I note at the the start of the list that “The criticisms assume the objective is to maximize aggregate SWB” (while also noting that they “should also hold some force from a welfarist, extra-welfarist, or simply ‘common sense’ perspective”) and from that standpoint the current default (in most HALY-based analyses/guidelines) of HALY maximisation is not a “problem,” so long as they better reflect SWB. That said, as noted above, I do mention distributional issues earlier in the post and in Part 2, in case someone does want to work on those.
Problem 4 is not that HALYs don’t include spillovers; it’s that “They are difficult to interpret, capturing some but not all spillover effects.” (When I say “Neglect of spillover effects,” I mean that the issue of spillovers is problematically neglected in the literature, not that HALYs don’t measure them at all.) This should be clear from the text:
I agree this is likely to be an issue with other metrics too (Part 6 is all about this, and it’s mentioned in Part 2), and I suspect it will mostly have to be dealt with at the aggregation stage, but it’s not the case that the content of the metrics is irrelevant. For example, the questionnaires (and therefore the descriptive system) could include items like “To what extent do you feel you’re a burden on others?” (a very common concern expressed in qualitative studies); and/or the valuation exercise could ask people to take into account the impact of their (e.g.) health condition on others (or alternatively to consider only their own health/wellbeing). If this makes a difference to the values produced, it would make HALYs/WELBYs easier to interpret, which would also inform broader evaluation methodology, like whether to administer health/wellbeing measures to relatives separately and add them to the total.
Problem 5 is not merely a restatement Problem 1, though of course they’re closely connected. Problem 1 focuses on why HALYs aren’t that good at prioritising within healthcare (i.e. achieving technical efficiency, from a fixed budget). Problem 5 is that are useless at cross-sector prioritisation (i.e. allocative efficiency). The cause is similar (health focus), and I think I combined them in an early draft; but as with states worse than dead, I wanted to have 5 as a separate issue in order to draw particular attention to it. The difference becomes especially relevant when comparing, for example, the sHALY (which assigns weight to health states based on SWB, thereby addressing Problem 1 but not 5) and the WELBY (which potentially addresses both, but probably at the expense of validity within specific domains such as healthcare, in which case it may be useful for high-level cross-sector prioritisation, e.g., setting budgets for different government departments [Problem 5], but not for priority-setting within, say, the NHS [Problem 1]). Following similar feedback from others, I did change 5 to “They are consequently of limited use in prioritising across sectors or cause areas” in my main list in order to highlight the relationship.
(Really, all of these problems are due to (a) the descriptive system, (b) the valuation method, and possibly (c) the aggregation method, so any further breakdown risks overlap and confusion—but those categories don’t really tell you why you should care about them, or what elements you should focus on, so it didn’t seem like a helpful typology for the “Problems” section.)
Still, I am not entirely happy with this way of dividing things up or framing things (e.g., some problems focus more “causes” and some on “effects”) and would welcome suggestions of alternatives that are both conceptually rigorous/consistent and draw attention to the practical implications.
I’ve made a few edits to address some of these issues, e.g.:
Changed the first two problem headings to avoid ambiguity and, in the first case, to focus on the result of the problem rather than the cause, which helps distinguish it from 5.