Open access peer-reviewed chapter

# Ethical Issues Which Have Prevented the U.S. from Maximizing Quality of Life Years

Written By

Sage Arbor

Submitted: December 18th, 2020Reviewed: April 2nd, 2021Published: May 3rd, 2021

DOI: 10.5772/intechopen.97561

From the Edited Volume

## Health-Related Quality of Life

Edited by Jasneth Mullings, Sage Arbor and Medhane Cumbay

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## Abstract

The cost of healthcare interventions varies greatly with age, with a significant fraction of cost being spent in the last two years of life. Treating a child can save orders of magnitude more life-years than an octogenarian treated for the same disease, such as cancer. While Quality-Adjusted Life Years (QALYs) can be used to plan a roadmap for how resources should be expended to maximize quality of life the execution of those plans often fail due to societal norms which trump the carefully measured QALYs, resulting in lowered average number and/or quality of years lived. The ethical issues concerning age, sex, lifestyle (smoking, drinking, obesity), cost transparency, and extreme examples (war, population explosion vs. collapse) will be discussed.

### Keywords

• Quality Adjusted Life Years (QALY)
• generation
• elder care
• fair innings
• rule of rescue
• standard gamble
• cost transparency
• organ donation
• smoking
• alcoholism
• diabetes

## 1. Introduction

Quality Adjusted Life Years (QALYs) provide a quantified mechanism to alot limited healthcare resources to maximize desired years and quality of life. Both the numbers of years we live and the quality of health has increased more in the last 150 years than in any prior time in human history. It is interesting that QALYs were invented at the same time the variables that go into defining QALYs are changing so rapidly. The U.S. National Council on Disability (NCD) has found sufficient evidence that QALYs are discriminatory by design, and suggested Congress should pass legislation prohibiting the use of QALYs by Medicaid and Medicare [1]. What constitutes a disability and how much should it decrease QALYs? There have been deaf families that argue deafness is not a disability, it heightens other senses, and have chosen not to have cochlear implants. What QALY hit do paraplegics receive compared to quadriplegics? The very nature of QALYs cause users to assign some agreed upon weights to life abilities.

The average human lifespan has increased 80% over the last 120 years, with a clear increase in longevity starting at the end of the 19th century (around 1890). Those living in the United Kingdom, increased average lifespan from 45.2 to 81 years from 1890 to 2015. The United States had a similar increase, doing slightly less well recently with an average lifespan of 79 in 2015. The global average lifespan started from a lower level with its significant increase delayed a decade (1900) but has paralleled the gains each year achieving even more impressive results, starting at 32 years in 1900 and rising to 71.7 years in 2015 [2] (Figure 1). Starting in the 20th Century infant mortality plummeted from 10% to under 1% currently, which significantly contributed to the average lifespan. However, if you look at mortality rates at later ages it is apparent that lifespan has increased after keeping infants alive [3]. There is significant scientific data now that, across the animal kingdom, caloric restriction extends life [4, 5, 6, 7, 8, 9] which provided hope we could continue the trend increasing human longevity. In mice a 60% reduction in calories has been shown to increase lifespan by about a third, however in humans and primates it appears we may only be able to extend our lives 1–5 years [10, 11] though research is ongoing [12].

It has been estimated that while clinical care accounts for 15% of the quality of one’s health, clinical care data only represents 0.1% of the data (0.4 terabytes) applicable to health outcomes over their lifetime (1,106 terabytes) [13]. Most of the data that affects one’s health (1,100 terabytes) concerns one’s social determinants of health and health behaviors which account for 40% and 20% of one’s quality of health respectively. The last 25% of one’s health is determined by “Nonmodifiable factors” such as genetics, but this data (6 terabytes) is still very actionable in that different actions (e.g. pharmaceuticals, diet, lifestyle interventions) can be taken based on one’s genetics. While it is likely most easy to modify healthcare’s actions in clinical care, because it only represents 15% of our health outcomes, in order to maximize QALYs we must invest in analyzing and modifying the other data realms that affect our lifetime biomedical health (social determinants of health, health behaviors, and nonmodifiable factors).

Medical spending has increased by an order of magnitude in the last 200 year as a proportion of GDP. The share of GDP used on healthcare in 1800, 1850, 1900, 1950, 200o was 2%, 2.1%, 2.5%, 4.5%, 13.5% respectively (Figure 1) [14]. There is a clear and historically long trend of healthcare accounting for larger percentages of GDP in the developing world. Despite concern that this increased expenditure is just going to fatten the profits of big pharma, the reality is more nuanced with significantly more people and services being funded. Concomitantly and unsurprisingly, in the U.S. rapid growth is projected in both health and STEM occupations while office support, food service, and manufacturing production jobs will decline [1]. In order to maintain or lower the cost of healthcare, country’s must either lower costs per treatment (increased efficiency) or reduce treatment provided (decreased expenditure). While everyone would like the former solution of getting the same treatment for cheaper, the continual rise in healthcare expenditures despite plateauing lifespan suggests cuts will be needed. There are large economic differences in healthcare expenditures between countries which do not translate to better care. Common examples are the United States spending 10-fold more per citizen than Cuba despite similar life expectancies. The counties of the E.U. also spend less than the United States while having the same or better life spans. The successes and failures of using QALYs to reduce healthcare costs will be discussed. Most of the QALY issues discussed apply globally. However, this chapter will focus on data and issues in the United States, which is unusual among industrialized countries because it does not have a single payer system, and therefore has uniquely heightened QALY misallocations.

### 1.1 QALYs vs. DALYs

In 1976 Zeckhauser and Shepard first used the term Quality-Adjusted Life Years (QALYs) to describe measurements of health outcomes which were defined by both duration and quality of life measurements [15]. Pliskin detailed the three assumptions QALYs required to act as valid metrics to assign health resources [16], namely:

1. Independence between health status and life years

3. Risk neutrality of life years

While these foundational assumptions of QALYs have been questioned [17], they have been globally accepted and used by most countries for making economic decisions [18, 19, 20, 21].

Two decades after the description of a QALY, the Disability-Adjusted Life Years (DALYs) were developed in the 1990s measuring both duration as well as quality. DALYs by definition measure disease burden but are also often used like QALYs to maximize cost-effectiveness. QALYs have a health-related quality of life weighting (Q) that ranges from 0 to 1, with 1 representing a year of perfect health and 0 representing death. A Q measure of 0.5 has been expressed as bed ridden, and it should be noted that a state considered “worse” than death can have a negative Q rating. The quality of life each year can be added up to calculate one’s quality-adjusted life expectancy (QALE). On the other hand DALYs are measured from 0 to 1 where 0 represents no disability. Therefore in QALYs the higher the weighting the better, but in DALYs the lower the weighting the better. Usually expert valuations are assigned to a universal set of weightings for DALYs, whereas QALYs use preference-based health-related measures gathered from groups of patients or the general population [22]. DALYs have an age-weighting function, and can therefore preferentially favor spending money on the young versus the old compared to QALYs.

• QALYs lived in one year = 1*Q (where Q ≤ 1)

QALEt=tt+RLEQt

Qt = Health related quality of life weighting at year t.

QALE = quality-adjusted life expectancy at a given age.

RLE = Residual Life Expectancy at given age.

t = individual years within residual life expectancy range.

## 2. Equity - is each year of perfect life equal?

As QALYS are used to determine the allotment of financial resources, the age of the citizens receiving these resources can be a significant issue. The most common causes of death in the U.S. (stroke, cancer, Chronic Lower Respiratory Diseases (CLRD), Alzheimers, heart disease, and diabetes) debilitate patients for a broad duration, ranging from immediate death to 20 years (Table 1, Figure 2). Death can occur suddenly with almost no recourse for intervention or financial expenditure by society aimed to improve life, such as in an unforeseen and lethal suicide or stroke. However, disease care is becoming more often a case of extended managed care, such as with diabetes.

DiseaseTotal Deaths (million, U.S. 2017)Deaths/100,000 (U.S. 2017)Deaths/100,000 (U.S. 2007)Change 2007–2017
(% change)
Average duration of disease
Heart disease647165190.9−13.67.3 yrs
Cancer599152.5178.4−14.52 yrs
Chronic lower respiratory diseases (CLRD)16040.940.804 yrs
Stroke14637.643.5−13.61 yr
Alzheimer disease1213122.736.66 yrs
Diabetes8421.522.5−4.430 yrs
Influenza and pneumonia561415.7−10.81.5 weeks
Kidney disease511315.7−17.27 yrs
Suicide471411.323.91 day

### Table 1.

Duration of Disease vs. Population Effect.

Data was retrieved from the National Vital Statistics Reports Final Death Reports. The color coding represents better values in green (low deaths, low disease duration, and decreased deaths over time) adn worse values in red.

https://pubmed.ncbi.nlm.nih.gov/25075874/

https://pubmed.ncbi.nlm.nih.gov/32501199/

### 2.1 Old vs. Young

#### 2.1.1 Fair innings

The philosophical framework termed “fair innings” posits that each human has an equal right to experience each phase (age) of life. Therefore if the same intervention could extend for one year the life of a 60-year-old or a 26-year-old, then the younger patient should preferentially get the intervention so they have their “fair-inning” at living the age of 27. Human lifespan has roughly doubled in the last century, from roughly 40 to 80 years of life in the developed world. Does a child that is born into the world that now lives 10% longer than their parents have the scaled protection to get to the world’s future average lifespan (10% older than their parents), or do fair innings apply as a static set of years based on the oldest generations having care rationed? If nations had been rationing care based on the “fair innings” philosophy they would have possibly undervalued young years of life if they were not taking into account the projected increase in lifespan for younger generations. Recently the lifespan in the United States decreased for the first time in decades due to a combination of macro health issues (obesity, opiod overdose, and suicide epidemics). While the current U.S. healthcare system does not ration care based on fair innings principles, if it had done so and taken into account the longstanding historical increases in lifespan younger generations would have received more resources than deemed fair in hindsight since their projected lifespan has dropped from historical trends. One of the most important aspects for implementing allotment of healthcare resources based on QALYs is for the electorate to have supreme confidence in its fairness. The use of fair innings is very transparent in taking from one group (older) to give to another group (younger), and any projection based on moving average lifespans could increase the publics distrust in QALY use for policy decisions.

## 3. Organ Donor Waitlist

The transplant of organs could theoretically have extremely positive QALY returns per dollar spent, depending on the age. There are a plethora of ethical issues that arise from organ donations however, such as how important is the patient’s age, their relation to the organ donor, the duration of organ viability after transplantation, or the degree to which their personal actions resulted in their need for an organ transplant.

If a young child in need of an organ could live a full life time with one transplant the QALY calculations would likely result in societies funding these transplants without any second guessing. Indeed curably treating young patients with a lethal disease is the best scenario to maximize QALYs gained, if comparing similarly priced interventions. However, organ transplants often do not alleviate a patient’s disease for a normal lifespan. For example, cystic fibrosis (CF) patients most often die from lung failure due to thick mucus and biofilm accumulation leading to necrosis of the tissue. Lung transplants are done for CF patients but transplants usually only perform sufficiently for 5 years. CF patients can now live over 40 years, double the 20 year lifespan they had half a century ago. Therefore, contrary to other QALY based interventions, transplants are not recommended for the younger CF patients.

While most donated organs come from donors after they have died, there are also living organ donations. Directed living organ donation, the most common type as opposed to non-directed organ donation, allows the donor to choose the recipient (often a family member) [30]. Even the most rigorous ordering of donor recipients using rankings to maximize QALYs can suddenly be shortcut by directed living organ donors. This is an example where there is a limited supply (of organs) and the calculations to maximize QALYs changes because a family member is willing to increase that limited supply but only if used in the manner they want. Therefore there are times when a healthcare system can increase QALYs at the sacrifice of absolute ethical parity of all patients based on their need.

Smokers receiving lung transplants is another case example highlighting societies’ concern about funding healthcare solutions for ailments which has been self-inflicted. More than a third of lung transplants in the U.S. are for former smokers (40%), but they often only qualify once they have proven they have quit smoking. This achieves two outcomes. Most quantifiably it increases QALYs in that a lung transplant given to someone who will never smoke again, will on average produce more QALYs than if the lung transplant were given to someone that immediately starts smoking multiple packs a day after surgery. It also addresses the moral issue, allowing the donor and society to feel like the gift of the organ is being valued by the recipient. However one study showed after smokers receive lung transplants 11% admitted they resumed smoking, with another 6% showing high levels of urinary cotinine (a metabolite of nicotine). These values are similar to heart and renal transplant recipients, who reported smoking after transplantation at a frequency of 21% and 25% respectively [31].

## 4. Self-inflicted medical issues

### 4.1 Smokers

There are many health issues for which the individual is primarily responsible. Smoking and alcoholism may be the best examples. A recent study showed that cessation of smoking alone could save up to 12 years of life [32]. Should the population that lives a healthier lifestyle pay for the less healthy lifestyle chosen by other individuals? Even cases that seem extremely clear, such as smoking, are often more complicated. For example, those living in Beijing, China have the exposure equivalent to smoking 25 cigarettes per day, just from breathing in the high particulate air [33, 34]. It seems unfair to not cover the respiratory issues of a child born in Bejing, just because those same respiratory issues are self-induced by a heavy smoker in the countryside.

### 4.2 Alcoholism

For a decade scientific papers appeared to show low levels of alcohol could be beneficial, with people pointing to the resveratrol in wine as an epigenetic antiaging molecule, or the blue zones of the world that consumed red wine such as Italy. In reality their high fish, high vegetable, and low calorie diet are greater life prolonging life styles. It also turns out in many of these studies the alcohol “abstainer” groups had prior alcoholics included in them, who had previously changed their lifestyle to never consume alcohol. While the abstainer group had slightly poorer health than the one drink a day group, it is likely that could be due to prior damage the alcoholics had done to their body before becoming abstainers. Such scientific errors will cause resources to be misallocated if QALYs are used coarsely to allocate every dime of resource. Should alcoholics be required to quit drinking before receiving a liver transplant? Is one drink a day ok for them. One drink a day should be physically ok for the transplanted liver, but could cause the patient to slip and start drinking heavily again. Heavy alcohol consumption clearly causes cirrhosis of the liver, however contrary to the lay public’s view this is the second leading cause of cirrhosis (while hepatitis C is the leading cause) [35]. Not publicly funding healthcare for self-induced ailments clearly could save significant percentages of healthcare expenditures. However, it could lead to patients lying about their health habits and is difficult to implement fairly given the multimodal hazards for multiple diseases.

### 4.3 Diabetes

Diabetes and Alzheimer disease are two of the most serious medical conditions the developed world must grapple with. Both diseases are increasing rapidly in the population, while patients are able to live with the conditions for over a decade. Alzheimer’s will not be discussed as there are excellent reviews of the issues [36, 37, 38], but in short it poses a problem in that there is no treatment on the horizon. Diabetes (type II) on the other hand is extremely targetable, with reduced caloric consumption and exercise literally at the patients finger tips. However, both of these solutions have some socioeconomic interacting factors. Wealthier people can afford the time for leisure exercise, and can buy more expensive but healthier food that is less calorically dense (e.g. fresh vegetables). Some of these caveats are not as pernicious as they sound. While some fresh vegetables can be expensive and perishable, frozen vegetables, potatoes, and legumes are all healthy and cheap with a long shelf life. In addition, while difficult, anyone can choose to “just eat less” which actually has a negative cost. The true social cost to reduced calorie intervention is in building and supporting structures to increase the success rate obese individuals have in transitioning from an unhealthy to healthy lifestyle.

Are genetic predispositions a disability? Generally any inherited disorder is more likely to have healthcare solutions funded for it than self-imposed maladies. Historically these inherited disabilities have been very binary, e.g. an extreme life threatening autosomal recessively inherited disease in which a child had the poor misfortune, 25% chance, of getting both deleterious alleles from their mom and dad. However we are now getting genetic knowledge that a person is only predisposed to ailments, which often have environmental causes as well. For example obese grandparents can pass on epigenetic modifications to their grandchildren that makes them 4-fold more likely to be diabetic. Is that a self-induced ailment? The grandparents might have caused their metabolic disorder by overeating, but the grandchildren clearly started birth with a biological handicap.

## 7. Conclusions

Human lifespan has doubled over the last 150 years, with the quality of those extra years also rising. However, the % of GDP spent on healthcare has more than doubled at a rate that is unsustainable to continue for the next 150 years. The concept of using QALYs to maximize quality with limited resources has gained acceptance in countries throughout the world. The country’s (e.g. in the E.U) with single payer systems are better situated to measure QALYs and use them to maximize quality of care compared to the United States. Societal norms, such as Rule of Rescue, prevent the maximum use of QALYs. The lack of transparency to prices and the ease with which the U.S. can borrow money has both made the use of QALYs difficult. As the costs, outcomes, and options of clinical interventions are made more clear and accessible to society writ large, the cost of healthcare can be lowered and average quality increased at a national level.

## Conflict of interest

The authors declare no conflict of interest.

## Appendices and nomenclature

ACA

Affordable Care Act (also known as Obamacare)

CAR-T

Chimeric Antigen Receptor T-cell therapy

CLRD

Chronic Lower Respiratory Disease

DALY

IVF

In Vitro Fertilization

NCD

National Council on Disability

NICE

UK’s National Institute for Clinical Excellence

GDP

Gross Domestic Product

HF

Heart Failure

PFD

Pelvic Floor Disorder

POP

Pelvic Organ Prolapse

ppm

Parts Per Million

QALE

QALY

RCP

Representative Concentration Pathway

SUI

Stress Urinary Incontinence

USD

United States Dollar

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Written By

Sage Arbor

Submitted: December 18th, 2020Reviewed: April 2nd, 2021Published: May 3rd, 2021