#HEJC for 24/10/2014

The next #HEJC discussion will take place Friday 24th October, at 1pm London time on Twitter. To see what this means for your time zone visit Time.is or join the Facebook event. For more information about the Health Economics Journal Club and how to take part, click here.

The paper for discussion is a working paper published by Glasgow Caledonian University’s Yunus Centre. The authors are Neil McHugh and colleagues. The title of the paper is:

Extending life for people with a terminal illness: a moral right or an expensive death? Exploring societal perspectives

Following the meeting, a transcript of the Twitter discussion can be downloaded here.

Links to the article

Direct: http://www.gcu.ac.uk/media/gcalwebv2/ycsbh/yunuscentre/Extending%20Life%20for%20People%20with%20a%20Terminal%20Illness.pdf

RePEc: https://ideas.repec.org/p/yun/hewpse/201403.html

Summary of the paper

A lot of research effort has been spent on whether health economists’ most ingrained normative assumption should hold; is a QALY of equal value regardless of to whom it accrues. In the UK, the National Institute for Health and Care Excellence has given weighting to ‘special cases’; namely, life-extending drugs for patients near the end of their life (mainly for cancer). However, existing empirical research about whether societal values support such a weighting has given conflicting results.

McHugh et al, in their new working paper, present the first major mixed methods study of societal perspectives for QALY-weighting. The authors use Q methodology – which involves the ranking of opinion statements according to agreement – to elicit societal perspectives on the relative value of life extension for people with terminal illness. Opinion statements were collected from 4 sources:

  • newspaper articles
  • a NICE public consultation
  • 16 interviews with key informants
  • 3 focus groups with the general public

The Q sort was conducted with people from academia, the pharmaceutical industry, charities, patient groups, religious groups, clinicians, people with experience of terminal illness and a sample of the general public. The authors’ final sample included 61 Q sorts and factor analysis identified 3 distinguishable perspectives, which can be summarised as:

  1. A population perspective (value for money, no special cases)
  2. An individual perspective (value of life, not cost)
  3. A mixed perspective

Factor 1 individuals are unlikely to support any QALY-weighting, maintaining a utilitarian-type health-maximising perspective. Factor 2 respondents reject the denial of life extending treatments and assert that patients and their families should decided whether or not they wish to receive the treatment; regardless of cost. This group appear to disagree with cost-effectiveness analysis altogether. Factor 3 represents a more nuanced view, asserting that value is broader than health gain alone. However, factor 3 was associated with a focus on quality of life, and so support for expensive life-extending treatment would depend on this. It is unclear whether QALY-weighting would adequately achieve this.

Discussion points

  • Is the question of QALY-weighting a normative one or a positive one?
  • Are the three factors likely to be robust across ethical dilemmas other than terminal illness?
  • To what extent are the opinions associated with the 3 factors likely to be robust to further deliberation?
  • Are factor 2 respondents simply wrong?
  • Should QALY-weighting be based on democratic processes?
  • Is it of concern that current policy appears to reflect the views of health economists better than other groups?
  • Where do you stand?

Can’t join in with the Twitter discussion? Add your thoughts on the paper in the comments below.

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