In the specific instance that someone challenges you over using QALYs/DALYs at all, what would you say in response?
It seems to me that you do at some point have to bite the bullet and believe that ‘some disabilities are more life limiting than others’; and ‘there are many disabilities that I would choose to avoid’. But then I feel like I’m implicitly saying something about valuing some people’s lives less than others, or saying that I would ultimately choose to divert resources from one person’s suffering to another’s.
This actually came up in a corporate talk that I did and I fudged the answer, incidentally.
This is a conversation I have a fair amount when I talk to non-EA + non-medical friends about work, some quick thoughts:
If someone asks me Qs around DALYs at all (i.e. “why measure”), I would point to general cases where this happens fairly uncontroversially, e.g.:
-If you were in charge of the health system, how would you choose to distribute the resources you get?
-If you were building a hospital, how would you go about choosing how to allocate your wards to different specialties?
-If you were in an emergency waiting room and you had 10 people in the waiting room, how would you choose who to see first?
These kinds of questions entail some kind of “diverting resources from one person to another” in a way that is pretty understandable (though they also point to reasonable considerations for why you might not only use DALYs in those contexts)
If someone is challenging me over using DALYs in context of it being a measurement system that is potentially ableist, then I generally just agree—it is indeed ableist by some framings![1]
Though, often in these conversations the underlying theme isn’t necessarily a “I have a problem with healthcare prioritisation” but a general sense that disabled folk aren’t receiving enough resources for their needs—so when having these conversations it’s important to acknowledge that disabled folk do just face a lot more challenges navigating the healthcare system (and society generally) through no fault of their own, and that we haven’t worked out the answers to prioritising accordingly or for solving the barriers that disabled folk face.
If the claim goes further and is explicitly saying interventions for disabilities are more cost effective than current DALYs approach give them credit for, then that’s also worth considering—though the standard would correspondingly increase if they are suggesting a new approach to resource allocation—as Larks’ comment illustrates, it is difficult to find an singular approach / measure that doesn’t push against intuitions or have something problematic at the policy level.[2]
On how you’re feeling when talking about prioritising:
But then I feel like I’m implicitly saying something about valuing some people’s lives less than others, or saying that I would ultimately choose to divert resources from one person’s suffering to another’s.
This makes sense, though I do think there is a decent difference between the claim of “some people’s lives are worth more than others” and the claim of “some healthcare resources go further in one context than others (and thus justify the diversion)”. For example, I think if you never actively deprioritised anyone you would end up implicitly/passively prioritising based on things like [who can afford to go to the hospital / who lives closer / other access constraints]. But these are going to be much less correlated to what people care about when they say “all lives are equal”.
But if we have data on what the status quo is, then “not prioritising” / “letting the status quo happen” is still a choice we are making! And so we try to improve on the status quo and save more lives, precisely because we don’t think the 1000 patients on diabetes medication is worth less than the one cancer patient on a third-line immunotherapy.
E.g., for DALYs, the disability weight of 1 person with (condition A+B) is mathematically forced to be lower than the combined disability weight of two separate individuals with condition A and condition B respectively. That means for any cure of condition A, those who have only condition A would theoretically be prioritised under the DALY framework than those who have other health issues (e.g. have a disability). While I don’t have a good sense of when/if this specific part of the DALY framework has impacted resource allocation in practice, it is important to acknowledge the (many!) limitations the measures we use have.
Also, different folks within the disability community also have a wide range of views around what it means to live with a disability / be a disabled person (e.g. functional VS social models of disability), so it’s not actually clear that e.g., WELLBYs would necessarily lead to more healthcare resources in that direction, depending on which groups you were talking to.
Thanks so much for writing this.
In the specific instance that someone challenges you over using QALYs/DALYs at all, what would you say in response?
It seems to me that you do at some point have to bite the bullet and believe that ‘some disabilities are more life limiting than others’; and ‘there are many disabilities that I would choose to avoid’. But then I feel like I’m implicitly saying something about valuing some people’s lives less than others, or saying that I would ultimately choose to divert resources from one person’s suffering to another’s.
This actually came up in a corporate talk that I did and I fudged the answer, incidentally.
This is a conversation I have a fair amount when I talk to non-EA + non-medical friends about work, some quick thoughts:
If someone asks me Qs around DALYs at all (i.e. “why measure”), I would point to general cases where this happens fairly uncontroversially, e.g.:
These kinds of questions entail some kind of “diverting resources from one person to another” in a way that is pretty understandable (though they also point to reasonable considerations for why you might not only use DALYs in those contexts)
If someone is challenging me over using DALYs in context of it being a measurement system that is potentially ableist, then I generally just agree—it is indeed ableist by some framings![1]
Though, often in these conversations the underlying theme isn’t necessarily a “I have a problem with healthcare prioritisation” but a general sense that disabled folk aren’t receiving enough resources for their needs—so when having these conversations it’s important to acknowledge that disabled folk do just face a lot more challenges navigating the healthcare system (and society generally) through no fault of their own, and that we haven’t worked out the answers to prioritising accordingly or for solving the barriers that disabled folk face.
If the claim goes further and is explicitly saying interventions for disabilities are more cost effective than current DALYs approach give them credit for, then that’s also worth considering—though the standard would correspondingly increase if they are suggesting a new approach to resource allocation—as Larks’ comment illustrates, it is difficult to find an singular approach / measure that doesn’t push against intuitions or have something problematic at the policy level.[2]
On how you’re feeling when talking about prioritising:
This makes sense, though I do think there is a decent difference between the claim of “some people’s lives are worth more than others” and the claim of “some healthcare resources go further in one context than others (and thus justify the diversion)”. For example, I think if you never actively deprioritised anyone you would end up implicitly/passively prioritising based on things like [who can afford to go to the hospital / who lives closer / other access constraints]. But these are going to be much less correlated to what people care about when they say “all lives are equal”.
But if we have data on what the status quo is, then “not prioritising” / “letting the status quo happen” is still a choice we are making! And so we try to improve on the status quo and save more lives, precisely because we don’t think the 1000 patients on diabetes medication is worth less than the one cancer patient on a third-line immunotherapy.
E.g., for DALYs, the disability weight of 1 person with (condition A+B) is mathematically forced to be lower than the combined disability weight of two separate individuals with condition A and condition B respectively. That means for any cure of condition A, those who have only condition A would theoretically be prioritised under the DALY framework than those who have other health issues (e.g. have a disability). While I don’t have a good sense of when/if this specific part of the DALY framework has impacted resource allocation in practice, it is important to acknowledge the (many!) limitations the measures we use have.
Also, different folks within the disability community also have a wide range of views around what it means to live with a disability / be a disabled person (e.g. functional VS social models of disability), so it’s not actually clear that e.g., WELLBYs would necessarily lead to more healthcare resources in that direction, depending on which groups you were talking to.
Thank you, this is helpful