Problemas detectados

Before we take a closer look at this possibility, let us first look at the preference-based health index approach. (This approach can be regarded as something between the health approach and the quality of life approach.) By letting individuals themselves rank possible health

states with regard to ‘value’, we can (for example, by calculating the average) create a

preference-based‘health value index’ in which a utility number is assigned to each possible

health state. Here, it is possible to make use of the Rosser classification (Rosser and Kind, 1978), a two-dimensional system where health states are ranked with regard to disability

(8 levels ranging from 1¼ normal functioning to 8 ¼ unconsciousness) and suffering

(4 levels ranging from A¼ no suffering to D ¼ severe suffering). We can assign the utility

number 1 to health state 1A, and then make use of the individual preference rankings to

calculate a utility number for the other 28 possible health states (8 B–D are not possible).

This utility number may well be negative, for example, in the case of 7D, bedridden with

severe suffering (Levinet al., 1991).

The individual rankings can be generated in several different ways, for example, by using Standard Gamble (SG), Time Trade-Off (TTO), Rating Scale or Magnitude Estimation (Karlsson, 1991). Let us call the health state we want to evaluate H. In SG, the individual is supposed to choose between H (with certainty) and a lottery (or gamble)

with full health and death as‘prices’. The utility of H (for the individual) is calculated by

18 _{It should be noted that all pluralistic approaches make it rather tricky to measure health. For}

example, how should one’s position in the functioning dimension be combined with one’s position in the subjective well-being dimension to yield a single measure? Maybe we should let each individual attach a weight to each dimension, assume that the dimensions are independent, let each individual place a value on the different levels in each dimension, and then use the average value to calculate the health level?

19 _{The question of to what extent it is acceptable to promote health by paternalistic means falls outside}

finding at what odds the individual is indifferent between H and the lottery. In TTO, the choice is between being in H during a certain time and being fully healthy during a

shorter time, for example, between 5 years in full health andx years in H. By finding the

x-value where the individual is indifferent between the alternatives, we can assign a utility value to H. This method provides us with a way to balance health gains against life years gained, since this is exactly the kind of balancing the individuals are asked to make. This may well be the best solution to the calibration problem formulated above.

Utility values of different health states (or severity weights for different disabilities) can also be generated by the Person Trade-Off (PTO) method. Here, people are asked how many outcomes of one kind they consider equivalent in social value (for example,

measured in terms of claims on resources) to x outcomes of another kind, where the

outcomes are for different groups or individuals with different conditions (Brock, 2004). That is, people are asked to adopt the perspective of a policy maker. There are several versions of PTO. Let us assume that we want to determine the preference weight for a health state H, for example, a state of severe disability. One way to do this is to make trade-offs between life extensions for people in H and equal life extensions for healthy people, for example, by asking how many one year life extensions for people in H are equivalent in value to 1000 one year life extensions for healthy people (Murray and Acharya, 1997). Suppose we regard 8000 life extensions for people in H as equivalent in value to 1000 life extensions for the healthy. In this case, the value of H is 0.125. Another way to determine the value of H is to make trade-offs between raising those in H to perfect health for one year and extending life for healthy individuals for one year, for example, by asking how many improvements for people in H that are equivalent in value to 1000 one-year life extensions for healthy people (Murray and Acharya, 1997). Suppose we regard 5000 one-year long improvements for people in H (to full health) as equivalent in value to 1000 one-year life extensions for the healthy. In this case, the value of H is 0.2. It is worth noting that the PTO approach is designed to permit people to incorporate concerns for equity or distributive justice into their judgements about the social value of alternative health programmes (Brock, 2004: 221). The values generated by this approach are (most probably) strongly affected by distributive concerns, and they are thus unsuit- able for assigning utility values to individual health states. It is better to use some other method to determine the relevant utility values, and then use the PTO method as a purely distributive device (Brock, 2004; and below).

There are several general objections to the preference-based health approach. First, we can ask how informed people’s preferences are in this area. The value of a certain health state is mainly instrumental (it is good as a means rather than as an end), and it can be quite difficult to determine the consequences of different health states. One might try to avoid this problem by disregarding the preferences of non-disabled ordinary citizens, and instead appeal to the preferences of people who are well acquainted with the relevant health state, for example, the disabled. A problem with this approach is that the disabled tend to adapt rather

well to their condition, which may result in evaluations that are‘too positive’. Another option

is to rely on the preferences of independent health experts, but this suggestion is also problematic (Brock, 2004). It seems quite hard to determine whose preferences should be used to determine the values of different health states, and since different evaluative standpoints tend to give rise to different evaluations, this is rather problematic.

Second, we may ask what kind of value is assigned to the different health states. With the exception of the PTO approach, it seems quite clear that it is value for the

individual rather than value from a public health perspective (the kind of value public

health is supposed to promote or maximize). This suggests that the‘health-related utility

values’ that are generated by for example, SG or TTO have a diminishing marginal value in a public health perspective (see above). A third objection is that the restriction to health states is somewhat arbitrary. If we decide to appeal to people’s preferences when we construct the relevant quality measure (the y-axis), why should we restrict ourselves to

how people evaluate theirhealth states? Why not start from how people evaluate their lives

as wholes? This suggestion is very closely related to the idea that the most relevant ‘qualitative’ individual measure is quality of life.