ArticleQuality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation2022
The QALY is ableist: on the unethical implications of health states worse than dead.
Article in Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. An erratum has been issued. Cited by 8 papers.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
8 citing papers in PubMed.
- The 3D Value Framework for Sustainable Access to Effective Antibiotics.Health care analysis : HCA : journal of health philosophy and policy · 2026Article
- Empowering Older Patients in Advance Care Planning: Evaluating MyCare™ as a Decision Support Tool.Health expectations : an international journal of public participation in health care and health policy · 2026Article
- Developing a utility value set for the Gambling Quality of Life Scale-Brief (GQoLS-Brief) using a discrete choice experiment.Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation · 2025Article
- Economic evaluation of NALIRIFOX vs. nab-paclitaxel and gemcitabine regimens for first-line treatment of metastatic pancreatic ductal adenocarcinoma from U.S. perspective.Cost effectiveness and resource allocation : C/E · 2024Article
- Measuring Quality-weighted Hospital-Free Days in Acute Respiratory Failure: A Modified Delphi Study.Annals of the American Thoracic Society · 2024Article
- Examining the economic impacts of caregiving among families of children of medical complexity: A qualitative study to inform inclusive economic models.Journal of participatory medicine · 2024Article
- What if 0 is not equal to 0? Inter-personal health utilities anchoring using the largest health gains.The European journal of health economics : HEPAC : health economics in prevention and care · 2023Article
- Worth their weight in gray matter? A narrative review of cost-effectiveness analyses of monoclonal antibodies for Alzheimer's disease.Alzheimer's & dementia (New York, N. Y.)Review
Corrections and comments
- Erratum issued
Authors and funding
1 author.
Funding
Abstract
introductionA long-standing criticism of the QALY has been that it would discriminate against people in poor health: extending the lives of individuals with underlying health conditions gains fewer QALYs than extending the lives of 'more healthy' individuals. Proponents of the QALY counter that this only reflects the general public's preferences and constitutes an efficient allocation of resources. A pivotal issue that has thus far been overlooked is that there can also be negative QALYs. METHODS AND
resultsNegative QALYs are assigned to the times spent in any health state that is considered to be worse than dead. In a health economic evaluation, extending the lives of people who live in such states reduces the overall population health; it counts as a loss. The problem with this assessment is that the QALY is not based on the perspectives of individual patients-who usually consider their lives to be well worth living-but it reflects the preferences of the general public. While it may be generally legitimate to use those preferences to inform decisions about the allocation of health care resources, when it comes to states worse than dead, the implications are deeply problematic. In this paper, I discuss the (un)ethical aspects of states worse than dead and demonstrate how their use in economic evaluation leads to a systematic underestimation of the value of life-extending treatments.
conclusionStates worse than dead should thus no longer be used, and a non-negative value should be placed on all human lives.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.