The IEEE defines the UHF radar band as frequencies between 300 MHz and 1 GHz.[1] Two other IEEE radar bands overlap the ITU UHF band: the L band between 1 and 2 GHz and the S band between 2 and 4 GHz.
Radio waves in the UHF band travel almost entirely by line-of-sight propagation (LOS) and ground reflection; unlike in the HF band there is little to no reflection from the ionosphere (skywave propagation), or ground wave.
UHF radio waves are blocked by hills and cannot travel beyond the
horizon, but can penetrate foliage and buildings for indoor reception.
Since the wavelengths of UHF waves are comparable to the size of buildings, trees, vehicles and other common objects, reflection and diffraction from these objects can cause fading due to multipath propagation, especially in built-up urban areas. Atmospheric moisture reduces, or attenuates,
the strength of UHF signals over long distances, and the attenuation
increases with frequency. UHF TV signals are generally more degraded by
moisture than lower bands, such as VHF TV signals.
Since UHF transmission is limited by the visual horizon to
30–40 miles (48–64 km) and usually to shorter distances by local
terrain, it allows the same frequency channels to be reused by other
users in neighboring geographic areas (frequency reuse). Radio repeaters are used to retransmit UHF signals when a distance greater than the line of sight is required.
Occasionally when conditions are right, UHF radio waves can travel long distances by tropospheric ducting as the atmosphere warms and cools throughout the day.
The short wavelengths also allow high gain antennas to be conveniently small. High gain antennas for point-to-point communication links and UHF television reception are usually Yagi, log periodic, corner reflectors, or reflective array antennas. At the top end of the band, slot antennas and parabolic dishes become practical. For satellite communication, helical and turnstile antennas are used since satellites typically employ circular polarization
which is not sensitive to the relative orientation of the transmitting
and receiving antennas. For television broadcasting specialized vertical
radiators that are mostly modifications of the slot antenna or
reflective array antenna are used: the slotted cylinder, zig-zag, and
panel antennas.
Since at UHF frequencies transmitting antennas are small enough
to install on portable devices, the UHF spectrum is used worldwide for
land mobile radio systems, two-way radios used for voice communication for commercial, industrial, public safety, and military purposes. Examples of personal radio services are GMRS, PMR446, and UHF CB. Some wireless computer networks use UHF frequencies. The widely adopted GSM and UMTS cellular networks use UHF cellular frequencies.
Currently channels 21–37 and 39–48 are used for Freeview digital TV.
Channels 55–56 were previously used by temporary muxes COM7 and COM8,
channel 38 was used for radio astronomy but has been cleared to allow PMSE users access on a licensed, shared basis.
694–790 MHz: i.e. Channels 49–60 have been cleared, to allow these channels to be allocated for 5G cellular communication.
791–862 MHz,
i.e. channels 61–69 inclusive were previously used for licensed and
shared wireless microphones (channel 69 only), has since been allocated
to 4G cellular communications.
863–865 MHz: Used for licence-exempt wireless systems.
UHF channels are used for digital television broadcasting on both over the air channels and cable television channels. Since 1962, UHF channel tuners (at the time, channels 14–83) have been required in television receivers by the All-Channel Receiver Act.
However, because of their more limited range, and because few sets
could receive them until older sets were replaced, UHF channels were
less desirable to broadcasters than VHF channels (and licenses sold for lower prices).
There is a considerable amount of lawful unlicensed activity
(cordless phones, wireless networking) clustered around 900 MHz and
2.4 GHz, regulated under Title 47 CFR Part 15. These ISM bands
– frequencies with a higher unlicensed power permitted for use
originally by Industrial, Scientific, Medical apparatus – are now some
of the most crowded in the spectrum because they are open to everyone.
The 2.45 GHz frequency is the standard for use by microwave ovens, adjacent to the frequencies allocated for Bluetooth network devices.
The spectrum from 806 MHz to 890 MHz (UHF channels 70–83) was taken away from TV broadcast services in 1983, primarily for analog mobile telephony.
In 2009, as part of the transition from analog to digital over-the-air broadcast of television,
the spectrum from 698 MHz to 806 MHz (UHF channels 52–69) was removed
from TV broadcasting, making it available for other uses. Channel 55,
for instance, was sold to Qualcomm for their MediaFLO
service, which was later sold to AT&T, and discontinued in 2011.
Some US broadcasters had been offered incentives to vacate this channel
early, permitting its immediate mobile use. The FCC's scheduled auction for this newly available spectrum was completed in March 2008.
225–420 MHz: Government use, including meteorology, military aviation, and federal two-way use
470–512 MHz: Low-band TV channels 14–20 (shared with public safety land mobile 2-way radio in 12 major metropolitan areas scheduled to relocate to 700 MHz band by 2023)
698–806 MHz: Was auctioned in March 2008; bidders got full use after the transition to digital TV
was completed on June 12, 2009 (formerly high-band UHF TV channels
52–69) and recently modified in 2021 for Next Generation 5G UHF
transmission bandwidth for 'over the air' channels 2 thru 69 (virtual 1
thru 36).
806–816 MHz: Public safety and commercial 2-way (formerly TV channels 70–72)
817–824 MHz: ESMR band for wideband mobile services (mobile phone) (formerly public safety and commercial 2-way)
824–849 MHz: Cellular A & B franchises, terminal (mobile phone) (formerly TV channels 73–77)
849–851 MHz: Commercial aviation air-ground systems (Gogo)
851–861 MHz: Public safety and commercial 2-way (formerly TV channels 77–80)
862–869 MHz: ESMR band for wideband mobile services (base station) (formerly public safety and commercial 2-way)
869–894 MHz: Cellular A & B franchises, base station (formerly TV channels 80–83)
894–896 MHz: Commercial aviation air-ground systems (Gogo)
896–901 MHz: Commercial 2-way radio
901–902 MHz: Narrowband PCS: commercial narrowband mobile services
There are no egalitarians in a pandemic. The scale of the
challenge for health systems and public policy means that there is an
ineluctable need to prioritize the needs of the many. It is impossible
to treat all citizens equally, and a failure to carefully consider the
consequences of actions could lead to massive preventable loss of life.
In a pandemic there is a strong ethical need to consider how to do most
good overall. Utilitarianism is an influential moral theory that states
that the right action is the action that is expected to produce the
greatest good. It offers clear operationalizable principles. In this
paper we provide a summary of how utilitarianism could inform two
challenging questions that have been important in the early phase of the
pandemic: (a) Triage: which patients should receive access to a
ventilator if there is overwhelming demand outstripping supply? (b)
Lockdown: how should countries decide when to implement stringent social
restrictions, balancing preventing deaths from COVID-19 with causing
deaths and reductions in well-being from other causes? Our aim is not to
argue that utilitarianism is the only relevant ethical theory, or in
favour of a purely utilitarian approach. However, clearly considering
which options will do the most good overall will help societies identify
and consider the necessary cost of other values. Societies may choose
either to embrace or not to embrace the utilitarian course, but with a
clear understanding of the values involved and the price they are
willing to pay.
1 INTRODUCTION
The COVID-19 pandemic has posed a formidable and virtually
unprecedented challenge to health professionals, health systems and to
national governments. The potential threat to large numbers of patients
has led to restrictions on movement, employment, and everyday life that
have impacted the lives of billions and come at massive economic cost.
Health systems, facing existing or predicted demand overwhelming
capacity, have generated guidelines indicating which patients should
receive treatment.
One ethical theory has been both cited and criticized in public debate about pandemic response.
The civil rights office of the US Department of Health and Human Services stated that:
persons
with disabilities, with limited English skills, or needing religious
accommodations should not be put at the end of the line for health
services during emergencies. Our civil rights laws protect the equal
dignity of every human life from ruthless utilitarianism.
After the New York Times reported that some state
pandemic plans instructed hospitals not to offer mechanical ventilation
to people above a certain age or with particular health conditions (e.g.
‘severe or profound mental retardation’ as well as ‘moderate to severe
dementia’), the Office for Civil Rights (OCR) responded: ‘… persons with
disabilities should not be denied medical care on the basis of
stereotypes, assessments of quality of life, or judgments about a
person’s relative “worth” based on the presence or absence of
disabilities or age’.
Utilitarianism is now often used as a pejorative term,
meaning something like ‘using a person as a means to an end’, or even
worse, akin to some kind of ethical dystopia.
Yet utilitarianism was originally conceived as a progressive liberating
theory where everyone’s well-being counted equally. This was a powerful
and radical political theory in the 19th century, when large sections
of the population were completely disenfranchised and suffered from
institutional discrimination. The theory played a role in antislavery,
women’s liberation and animal rights movements. Yet utilitarianism
remains relevant in the 21st century. As we will discuss, it may be
particularly salient and important to consider in the face of global
threats to health and well-being.
In this paper, we will summarize what utilitarianism is and
how it would apply to the COVID-19 pandemic. Our aim is not to argue
that utilitarianism is the only relevant ethical theory, or that a purely
utilitarian approach must be adopted. However, it is important to note
that whenever a utilitarian solution to a dilemma is adopted, there will
be more well-being or happiness in the world. Typically, some people
will be better off. Of course, there may be good ethical reasons to
deviate from a pure utilitarian approach, for example in order to
protect rights or promote equality. However, considering the alternative
will help societies to identify and consider the necessary cost of
these other ethical values. Utilitarianism is not the end of ethical
reflection, but it is a good place to start.
1.1 What is utilitarianism?
Most moral theories imply that there is a (moral) reason
to do what is expected to maximize what is good for all, or more
precisely, the net surplus of what is good for all over what is bad for
them. This might be called a principle of beneficence.
Utilitarians hold that maximizing what is good for all is all there is
to morality. It makes moral decisions simple by supplying a single
measure of rightness: maximization of utility. In many situations this
may be enough, along with rules of thumb with the help of which it could
be determined what maximizes utility.
According to most moral theories there are, however,
other moral reasons. For instance, utilitarianism has often been
criticized for ignoring the question of what is a just or fair distribution
of what is good for all. The outcome that generates the greatest good
overall may be different from the outcome whose distribution of goodness
comes closest to being just or fair. Then the principle of beneficence
will have to be balanced against the principle of justice. This will
most likely have to be done in an intuitive way. It is very
controversial what a just or fair distribution consists in, e.g. whether
it consists in getting what is deserved or in more equal shares. This
is far too controversial to be settled here. It follows that the issue
of balancing justice and beneficence against each other must also be
left aside.
Another moral principle is a principle of autonomy,
which gives weight to an individual’s freedom to choose and to
determine, for themselves, how to live their own life. Individual
freedoms may conflict with overall good, for example, when individuals
choose to flout social distancing laws, or when individuals demand a
scarce resource for themselves or their family members. This also brings
us to the issue of whether the principle of beneficence should be
impartial and accord the same moral weight to the good of all other
individuals or whether it should allow greater weight to the good of
those who are close to us (and to human over non-human beings). For the
purpose of discussing what policies societies should adopt to deal with
pandemics, it is reasonable to assume impartiality.
A further issue is what constitutes goodness and badness for individuals. According to the most familiar theory, hedonism,
what is intrinsically good consists in various positive experiences, of
pleasure and happiness. What is intrinsically bad consists in negative
experiences of pain and unhappiness. Hedonism is, however, frequently
criticized for being too narrow in not recognizing that what we are not
aware of can be good or bad for us, e.g. that our partners deceive us,
or that the state surveys our behaviour, so cleverly that we never
notice it. For such reasons a wider conception of what is intrinsically
good or bad for us than hedonism will be assumed here, though to
determine its precise import would take us too far afield.
Some moral theories imply that there is a stronger or more stringent moral reason to omit doing harm than to benefit.
Thus, they imply that there is a stronger reason to avoid making things
worse for somebody by killing them, causing them injury or pain, than
to benefit them by preventing them from being killed, injured, etc. With
respect to pandemics, considerable moral weight has been attached to
harms such as death and disease that can be prevented by various
constraints. Therefore, for the present discussion it is better to
proceed on the assumption that there is no significant moral difference
between harming and omitting to benefit.
Utilitarianism typically accepts that instances of goodness and badness can be aggregated in a quantitative fashion.
Thus, consider a very mild pain that is caused by a physical stimulus
of one unit and that lasts for 10 min. Now compare 100 instances of such
a pain either spread out over 100 lives or over one life lasting many
decades with a single instance of excruciating pain caused by 75 units
of the physical stimulus lasting for 10 min. According to a standard
utilitarian calculus the former outcome is worse than the latter, but
this seems implausible. Most of us would prefer 100 instances of mild
pain dispersed over our lives than 10 min of excruciating pain. It might
be thought that this issue is crucial in the present context, since we
will have to balance the deaths of a lower number of people against
smaller burdens for a much higher number of people. We will, however,
see that what is morally relevant from a utilitarian perspective isn’t
death in itself but rather the length and quality of life the deceased
would have had if they hadn’t died.
It might be said that what matters in the end is what action actually maximizes what is good for all rather than what action is expected
to maximize what is good for all. But our best guide to what will
actually happen is what is expected to happen on the best available
evidence. So, when we decide what to do, we have to go by what is
predicted to be best. This is true in most situations (although in some
special cases we know that what is expected to be best is not what will
actually be best).
The expected utility of an action is the sum of the products of the
probability and value of each of the possible outcomes of that action.
1.2 Act and rule utilitarianism
There are two broad schools of utilitarianism. According
to act utilitarianism, the right act is the act that produces the best
consequences. According to rule utilitarianism, the right rule is the
rule that produces the best consequences. The law is often an
instantiation of rule utilitarianism: laws are chosen because they bring
about the best consequences.
These versions of utilitarianism can come apart.
Sometimes an act will clearly have better consequences, or no adverse
consequences but a rule proscribes that act.
Principles or laws around non-discrimination are examples
of this. Not considering a person’s advanced age or severe disability
(e.g. severe dementia) in the allocation of resources, including
ventilators, might mean that another person is unable to access those
resources who would have gained greater benefit from it, against act
utilitarianism. Yet the rule might still overall have better
consequences if the non-discrimination rule has over-riding benefits.
1.3 Two level utilitarianism
The two different schools of utilitarianism can be
combined. The father of modern utilitarianism, Richard Hare, argued that
moral thinking occurs at two levels: intuitive and critical, and that
we should move between these depending on the circumstances.
At the intuitive level, we have many rough rules of thumb that can be
rapidly deployed without protracted and demanding reflection: don't
kill, don't steal, be honest, etc. These enable us to act efficiently in
everyday life. During a pandemic, doctors and other decision-makers
require rules of thumb. For example, when faced with multiple
simultaneous patients in the emergency department it is important to
have a way of reaching a decision quickly about which patient to attend
to first. Triage rules are potentially justified by a form of rule
utilitarianism that enables rapid intuitive decisions.
‘Critical level’ utilitarianism requires choosing the
action that will maximize the good when we are thinking in the ‘cool,
calm hour’, with all the facts at hand. Hare imagined a decision-maker
who had perfect knowledge of the outcomes of all available options (he
called them a ‘utilitarian archangel’). In complex situations, where
there is time to do so, we must try to rise to the more reflective and
deliberative critical level and ask what action we should endorse. What
really is the right answer? Hare argues that in such situations we
should employ act utilitarianism (this corresponds to system 1 and 2
thinking in psychology).
We will explore some of the implications of critical
level utilitarianism for the current COVID-19 pandemic. We will also
describe plausible rules of thumb that would tend to maximize utility
and would be useful in emergency and urgent situations. Box 1
illustrates two questions that have been prominent in the early phase of
this pandemic.
Box 1.
Alessandro is a 68-year-old doctor. He has
moderate chronic obstructive airways disease. He contracts COVID-19
while caring for patients with the same disease. He develops respiratory
failure. Jason is a 52-year-old businessman who contracted COVID-19
while travelling for business reasons. He is otherwise well but develops
respiratory failure.
The triage question: There is only one ventilator remaining. Who should receive ventilation?
The UK government received modelling that
predicted that COVID-19 would lead to 500,000 deaths in the absence of
measures to reduce spread. This could be reduced to 20,000 by
implementing major social distancing measures (lockdown). The economic
effects arising from restriction of liberty will predictably result in
large numbers of job losses, mental illness, and increased medical risk
(e.g. unemployment is associated with increased risk of coronary heart
disease). 7Cancellation
of elective operations and interventions will result in prolongation of
suffering and potentially death. Those suffering from non-COVID illness
may not be able to receive treatment in hospital because there are no
beds available.
The lockdown question: How should we balance
preventing deaths from COVID-19 with causing deaths and reductions in
well-being from other causes?
1.4 Utilitarian rules of thumb
There are several rules of thumb that can guide rapid decision-making about these kinds of cases.
1. Number
One utilitarian rule of thumb is to save the greatest
number (other things being equal). This rule could be applied to the
lockdown question by assessing how many lives would be lost if lockdown
is applied, or not applied. It could also be used for the triage
question: in practice, this would mean considering the following
variables:
A. Probability
If Jason has a 90% chance of recovery and Alessandro has a
10% chance, other things being equal, you should use your ventilator
for Jason. Indeed, if you treat people like Jason rather than people
like Alessandro, you will save nine people instead of one for every 10
treated. That is why probability is a relevant consideration.8
B. Duration of treatment
In a setting of scarcity, duration of time on a
ventilator has implications for the numbers of lives saved. The longer
one person will be on a ventilator, the more people who potentially die
because they cannot get access to breathing support. If Alessandro needs
a ventilator for 4 weeks, and four others (including Jason) need it for
1 week, the choice is between saving one person or four people. So
doctors should take duration of use into account.
C. Resources
When resources are limited, resources equate to numbers
of lives. The more resources a treatment or a person uses, the fewer are
available for others. Imagine that Alessandro and Jason had identical
chances of survival, but Alessandro needed a treatment that required
three staff to administer the treatment (e.g. extracorporeal membrane
oxygenation [ECMO]—essentially cardiac bypass) and Jason needed a
treatment that required only one staff member (e.g. mechanical
ventilation). We can potentially save three people with ventilation for
every patient we save with ECMO. ECMO should be a lower priority than
ventilation.
2. Length of life
According to utilitarianism, how long a benefit will be
enjoyed matters—it affects the amount of good produced. Thus for
life-saving treatment, treatment that saves people’s lives for longer is
to be preferred over treatments that save life for shorter periods.
According to this criterion, priority should be given to
the younger Jason rather than the older Alessandro, because Alessandro
is expected to live less long if successfully treated. If it were Jason
who was expected to die sooner, utilitarianism would support treating
Alessandro, even though he is older.
Age is thus a de facto measure of length. Because older
people tend to die sooner than younger people, utilitarianism tends to
favour saving the lives of the younger. However, age itself does not
matter: it is the expected length of the benefit. This is why
utilitarianism is not unfairly discriminatory, and not ‘ageist’ in an
ethically problematic sense (we will discuss discrimination further
below).
Length of life is also relevant for the lockdown
question. It is the length of life extended that matters. This has
implications for evaluation of current policy. In the UK, the decision
to implement national lockdown at the end of March was influenced by
modelling produced by Imperial College (Figure 1).
The UK Government opted to try to reduce deaths to
20,000. But it was not clear from the modelling figure of 500,000 how
many of these people would have died anyway from other causes,9
or relatively soon after not contracting COVID-19. Every year more than
600,000 people die in the UK. For utilitarians, the number of lives
saved is irrelevant—it is how long these lives would be prolonged by the
intervention.
The average age of death of COVID-19 patients in Italy was 78.10
This implies that many of those saved by implementing lockdown would
have short life expectancies. The average life expectancy at age 80 is 9
years, and overall, COVID-19 has been estimated to lead to a loss of 11
life years on average. According to utilitarianism, the value of a year
of full quality life is the same regardless of how old a patient is.
However, if the pandemic largely affects patients with short life
expectancy, the benefit of a lockdown (preventing deaths) would be
smaller than a different illness that affected younger patients. The
cost of lockdown per year of life saved could be astronomical, when one
considers all costs including economic and wider social effects.
At the end of March, economists van den Broek-Altenburg
and Atherly, from the University of Vermont estimated the
cost-effectiveness of implanting large scale protective measures to
reduce the spread of COVID-19. They calculated the cost per Quality
Adjusted Life Year (QALY) of a $US 1 trillion economic stimulus package
against the number of lost life years potentially averted (up to 13
million in the USA). They estimated that such a package would cost
between $75,000–650,000 per QALY.
(The US government subsequently approved a $US 2 trillion stimulus
package.) That suggests that such measures are unlikely to be
cost-effective according to the usual thresholds applied to the costs of
medical interventions to save lives. For example, the upper limit for
cost-effectiveness of an intervention in the USA is often taken to be
about $100,000 per year of life saved.
There are two points to make about such an analysis. The
first is that assessing the utilitarian answer to the lockdown question
is highly dependent on the specific factual answers—the harm averted by acting, the harm caused by
acting. It is exceedingly difficult to determine which course of action
would be best from the point of view of critical level utilitarianism,
partly because of enormous uncertainty about the relevant facts.
Secondly, even if lockdown were cost-effective, it would not be as
cost-effective as different interventions that save babies or young
people. For example, if an intervention saved the life of a younger
person with a different disease for 50 years, you would only have to
save one-fifth as many to bring about as much benefit. It costs a few
dollars to save the life of a child in a developing country.
While interventions to prevent COVID-19 may be cost-effective (though this seems perhaps unlikely), they are unlikely to be the most
cost-effective actions that we could take. There are likely to be
better investments for utilitarians. As an example, The Gates Foundation
has estimated that global eradication of malaria by the year 2040 would
cost up to $120 billion. Such an initiative (costing only 1/15th as much as the US pandemic stimulus package) would potentially save 11 million lives.
3. Quality of life
Utilitarians consider not just how long someone will live
after treatment but how well they will live. They consider quality of
life important.
This could be relevant to the triage question (as
suggested in the quote from the Office for Civil Rights at the start of
this paper).
Consider an extreme example. The end point of dementia is
unconsciousness. Imagine that of our two patients with respiratory
failure Alessandro is still working, in possession of all of his
faculties. Jason, by contrast (in this version of the case) has end
stage dementia. According to utilitarians, we should treat Alessandro if
we cannot treat both. Jason would derive zero benefit from being kept
alive in an unconscious state. Indeed, this would apply potentially even
if Jason (with dementia) had a higher chance of survival, or were going
to survive for longer.
What about lesser degrees of cognitive impairment or
other disabilities? According to utilitarians, these would also be
considered in making allocation decisions if they affect the person’s
well-being.
However, comparisons of overall well-being between
individuals are not straightforward. It is not necessarily the case that
someone with a disability would have lower well-being than someone
without a disability. Probably the most profound question in ethics is
what makes a person’s life good, or constitutes well-being. Philosophers
have debated this question for thousands of years. Answers include
happiness, desire fulfilment or flourishing as human animals (which
includes having deep relationships with others and being autonomous,
amongst other things).
As a heuristic for triage, it may be that in developed
countries a threshold is set at a level where overall well-being is
certain to be low.
One practical cut off would be unconsciousness or severe disorders of
consciousness, such as being in a minimally conscious state. It is
highly unlikely to be cost-effective to provide intensive care for a
patient who is permanently minimally conscious.
Lines could be drawn where there is more uncertainty, and may need to
be in countries with more limited resources, or if the demand were much
greater. For example, the threshold might be set at the ability to
recognize and respond meaningfully with other people. So, on this
approach, cognitive impairments that reduced the capacity to have
minimal human relationships would reduce priority for treatment as a
proxy for believed reduced well-being.
Quality of life may also be relevant to the lockdown
question. If the life years saved by lockdown were likely to be of
reduced quality that would influence how much benefit overall is gained,
and therefore what economic cost would be worth incurring.
4. Equivalence of acts and omissions, withdrawing and withholding
For utilitarians, how an outcome arises is morally
irrelevant. It makes no difference if it is the result of an act, or an
omission.
Doctors, patients and families, however, hold that there
is a moral difference between acts and omissions. Many people hold a
causal account of responsibility: they tend to think that we are
responsible for the consequences of our acts but not for our omissions.
Thus people tend to believe that withdrawal of life-sustaining treatment
is morally worse than withholding life-sustaining treatment.
This folk commitment to a causal sense of responsibility and the acts/omission distinction has a number of bad consequences.
It means that there is considerable attention in pandemic
guidelines to decisions about initiation of treatment. The ‘triage
question’ is largely or entirely focused on whether to start treatment.
Withholding of treatment from patients with poorer prognosis is often
thought to be ethically acceptable. However, some apparently poor
prognosis patients will do well and a trial of treatment might provide
more accurate prognostic information. Thus, under conditions of
uncertainty, a trial of treatment with the possibility of withdrawal
would be preferable to withholding treatment.
Utilitarianism would reject the idea of employing any
form of ‘first come, first served’ to decide about treatment. The timing
of when a patient arrives needing treatment is morally irrelevant to
whether or not they should receive treatment. This is a principle that
we have elsewhere labelled the principle of temporal neutrality.
According to utilitarianism, doctors should be prepared to withdraw
treatment from poor prognosis patients in order to enable the treatment
of better prognosis patients if they arrive later.
Consideration of acts and omissions is also relevant to
wider social questions raised by the pandemic. Failing to implement a
good policy is equivalent to actively implementing a bad policy, when
the outcome of the two decisions is the same. So utilitarians hold
policy makers responsible not only for what they do, but for what they
fail to do. Failing to implement other policies, with the result of
avoidable, foreseeable deaths is equivalent to killing for utilitarians.
(This means that policy makers are just as blameworthy for failing to
eradicate malaria as they would have been if they had failed to act in
response to coronavirus.)
5. Social benefit
According to utilitarianism, all the consequences of
actions, both short and long term, direct and indirect are relevant to
decisions. Thus it may be relevant to consider not only the benefit to
the person directly affected by an action (for example, by being placed
on a ventilator), but also others. This can be called ‘social benefit’
or social worth.
In pandemics, one rule of thumb likely to maximize
utility would be to give priority to health care workers, those
providing key services and others who are necessary to provide essential
benefits to others. This has been applied in many countries, including
the UK, to testing for coronavirus. However, it might also apply to
access to ventilators or other medical treatments. A reason given for
this is that it will potentially mean that they can also return to work
sooner.
What about the social worth of others? Should criminals
have a lower priority in accessing limited resources? What about
scientists working on a vaccine? Related to social benefits is the issue
of dependents. Should pregnant women and parents of dependent children
be given greater priority for health care? Developing rules of thumb for
assessing social worth is ethically and epistemically complex, liable
to abuse and difficult to enforce fairly. Critical level utilitarianism
would likely not endorse such priority rules, perhaps beyond
prioritizing critical essential services workers (which is relatively
clear cut and easy to enforce and has wide social acceptance).
Utilitarianism is sensitive to the potential for abuse of
its operationalized principles. If there is a risk that a principle
will be abused, this should be taken into account in deciding whether to
operationalize it or not. For example, social worth is easily abused by
the powerful to claim privilege and priority.
6. Responsibility
For utilitarians, we are morally responsible to the
extent that the effects of our acts or omissions are foreseeable and we
have control over them. Intentions are irrelevant for utilitarians. It
is not what we want to happen that matters: it is what we can foresee,
and what actually happens. So even if consequences are unintended, we
are still responsible if they are foreseeable and avoidable.
This implies that failing to take a course of action that would bring about more good, or avert more harm, is equivalent to intentionally causing
that harm. The moral responsibility for choosing an inferior policy is
high for utilitarians and actions that result from this are subsequently
blameworthy.
Utilitarianism is a very demanding theory in several
ways. Whenever we foreseeably and avoidably bring about a less good
state of affairs, we are morally responsible and blameworthy. If
bringing about the best policy requires more research, we are
responsible for the deaths that occur because that research was not
done.
Another issue in resource allocation is responsibility
for illness. Many people have the intuition that responsibility for
illness should be taken into account in the allocation of limited
resources. Smokers should receive lower priority for lung transplants,
drinkers for liver transplants. The UK government has also encouraged
the public to take responsibility for their health.
In the case of COVID-19, people with various comorbidities have worse
prognoses. For example, type II diabetes is one such comorbidity, and
its risk factors include so-called 'lifestyle' factors such as diet and
exercise.
There are numerous problems with trying to use responsibility for illness in the allocation of resources.22
Utilitarians eschew all direct consideration of causal contribution to
illness and, indeed, any ‘backward looking’ considerations like desert.
They are only concerned with bringing about the best outcome. If, for
example, diabetes reduces the chance of survival, it is relevant insofar
as it reduces the chance of survival, not because it was the result of
any voluntary behaviour.
Responsibility (or the disposition to behaviour that led
to ill health) is only relevant for utilitarians insofar as it affects
probability, length or quality of survival. This is in line with how
responsibility is generally used in the NHS.
7. Avoid psychological biases, intuitions and heuristics
Utilitarianism seeks to avoid biases, emotions, intuitions or heuristics that prevent the most good being realized.
For example, humans are insensitive or numb to large numbers.
They are also more moved by a single identifiable individual suffering
than by large numbers of anonymous individuals suffering each to the
same extent (this is the so-called ‘rule of rescue’).
Thus they will be motivated to alleviate the suffering of a single
highly publicized individual, rather than taking action that prevents
suffering of a larger amount of unknown or unidentifiable individuals.
To some extent, national responses to COVID-19 might represent a massive
form of the ‘rule of rescue’.
Probably most relevant to political decision-making is
bias towards the near future. The desire to avoid deaths now is stronger
than the desire to avoid deaths in the future. It is psychologically
easier to impose severe lockdown now in the name of saving lives
threatened now, even if the toll of loss of life would be greater in the
future. There is some evidence that the lockdown and related factors
such as reduced access to medical care are leading to additional deaths
from causes other than coronavirus.
It might be anticipated that there will be large numbers of future
deaths caused by the economic downturn induced by the pandemic. After
the 2008 financial crash it is estimated that there were 250,000 excess
cancer deaths just in Organisation for Economic Co-operation and
Development countries.
These future and non-identifiable deaths might be greater
than or less than those prevented by lockdown. They are hard to predict
and even to confidently assign, which is one reason that they are
difficult to take into account. However, they are just as ethically
relevant as the deaths caused by COVID-19. We should not ignore them
because they are less psychologically real and motivating.
Utilitarianism aims to the maximize the good, impartially conceived. Statistical lives matter as much as identifiable lives.
Another bias is to one’s family and friends. According to
utilitarianism, we should give equal weight to the lives of strangers,
even those in other countries. The effects on the pandemic in Africa are
yet to be documented or manifest. Given that there are fewer advanced
life support systems, the mortality is likely to be greater.
Utilitarianism would favour diverting resources there if the effects
would be greater.
Much of ordinary decision-making is driven by emotion,
biases and heuristics. Thus, much of utilitarianism will strike ordinary
people as counterintuitive.
1.5 The triage question
The above rules of thumb could be assembled into an algorithm for allocation of ventilators (Figure 2).
Such an algorithm could be used to inform rapid decisions if there were
overwhelming numbers of patients presenting in future surges relating
to COVID-19. Alternatively, it might be used to inform decisions about
highly scarce and expensive treatments such as ECMO. Because of the need
for rapid decisions, based on limited information, this represents an
attempt to guide ‘intuitive level’ decisions in a way that would
generate most benefit overall. It is thus different from what act
utilitarianism (or the critical level approach) would recommend.
FIGURE 2
An ethical algorithm for rationing life sustaining treatment
The algorithm divides decision-making into stages, and
prioritizes on the basis of different criteria, depending on the
availability of resources. For example, it starts by giving highest
priority to those with the highest chance of surviving and needing the
lowest duration of treatment. This would maximize the number of lives
saved. If there are sufficient ventilators to treat all patients with at
least a moderate chance of surviving, there would be no need to invoke
other criteria. Thus, for example, health care systems with ample
pre-existing intensive care capacity, or who have been able to expand
their capacity acutely, might have no need to ration on the basis of
life expectancy or quality of life.
If there are insufficient ventilators, additional
principles might be invoked. As noted, utilitarianism does not
necessarily seek to save most lives, but would aim to achieve the most
well-being overall, including elements of both length of life and
quality of life. At a second level, triage might assess both of these
factors for patients in need of treatment. In practice, however,
estimation of predicted quality adjusted life years for individual
patients is highly complex (and may be uncertain). It would be quicker
to set a threshold of length and quality of life worth saving. As an
example, we have suggested that a health system under severe pressure
might elect to only provide mechanical ventilation to patients predicted
to survive for at least 5 years with normal quality of life, but the
specific threshold used will depend on the level of resource
availability and on the level of demand.
1.6 The lockdown question
While the triage question lends itself to heuristics, and
the development of a rule that might generate the best outcome overall,
it is difficult to know what intuitive-level response would be best for
the lockdown question. Because of the scale of the impact of the
pandemic, there is a danger that rapid rule-based responses might go
badly wrong and lead to a much worse outcome overall. Instead, this is a
question that would be better answered by drawing on critical level
utilitarianism. In large part because of uncertainty, there are
different views about which strategy for entering or leaving lockdown
would generate the best outcome overall. For example, there remains
debate about whether the approach in Sweden (avoiding a national
lockdown) is better or worse than the approach of Sweden’s Scandinavian
neighbour Norway, which implemented a lockdown in early March. At the
time of writing, Sweden has reported 2,769 deaths, (274 deaths/million
population), compared with 214 deaths in Norway (39/million population).
The important issue for utilitarians is not the number of
deaths, but the QALYs lost. Because a large proportion of the deaths in
Sweden are in care homes, there may be fewer QALYs lost than a policy
that caused a smaller number of avoidable deaths of younger, healthier
people. What is important is whether the QALYs lost in Sweden are
greater or less than Norway, overall, as a result of the policy. It is
far from clear at this point the answer to that question.
Moreover, there can be difficulties in comparing
countries, since they differ in more than just the policy applied. They
may also differ in other characteristics. The mortality of Stockholm
stands out in Sweden: half of Sweden's deaths were in Stockholm, yet its
population is roughly 1/5th of Sweden’s: specifically, 1,428
out of 2,854 deaths (May 5, 2020). The mortality rate of a region in
the south of Sweden with a population of 1.4 million was half that of
Oslo, the capital region of Norway (April 21, 2020), in spite of not
having had a lockdown policy for 5 or 6 weeks. The number of deaths in
this southern region is 78 compared to 1,428 in Stockholm whose
population is only a couple of hundred thousand greater (May 5, 2020).
One potential explanation for differences in mortality relates to
differences in population density. Another relates to the amount of
circulating coronavirus prior to any change in community behaviour
(which may or may not have been imposed formally as a lockdown). A
further factor may be whether the virus has had access to vulnerable
groups. The virus may have been more effectively kept out of aged care
in the south of Sweden. That it isn’t simply due to a national lockdown
is confirmed by the fact that this mortality figure is lower both than
that of the neighbouring Danish capital, Copenhagen, 293, and the county
surrounding it, 93 (May 5, 2020), despite that fact that shops, etc.
have been locked down in Copenhagen since mid-March.
It might be that conditions all over Sweden will soon be
worse than in Norway and Denmark because of the absence of a national
lockdown. However, it is possible that Norway and Denmark’s approach
might lead to more deaths at a later stage because of further surges of
the virus when lockdown is relaxed. More importantly, as we have argued,
the number of deaths from COVID-19 at a given point in time is not
decisive. The question is which strategy will prevent the most deaths
from any cause (and more importantly preserve the most years of
life in full heath). We must keep in mind the prospect of wider harms to
the community as a result of lockdown and the economic consequences.
It is difficult to know what overall strategy would be
best. There are several clear points, though about how utilitarianism
would inform a policy response to the lockdown question.
1.7 Evidence sensitivity
Utilitarianism is highly dependent on accurate
information about the world. It requires good evidence. Without good
evidence, it is less likely that we would choose means that will bring
about the most good.
Utilitarianism is thus complementary to science—it
requires science. Thus utilitarianism will urge more research to get
better estimates of consequences and probabilities from a wide range of
possible courses of action. Utilitarianism invites scientific inquiry.
The Swedish approach to lockdown has been informed by epidemiological
models of the impact of coronavirus that were lower and less dramatic
than some of the models used elsewhere (for example in the UK).28
Any modelling or data that is used to inform decision-making should be
openly available and subject to peer review. If the evidence changes, or
the modelling needs to be revised, policy should also change. This
means that countries might need to change their policy. That could mean
relaxing lockdown, or implementing stricter lockdown. The UK government
changed tack in its response to coronavirus in late March in response to
revised modelling.
That does necessarily mean that the previous policy was mistaken. As
noted, utilitarianism directs decisions on the basis of expected
utility. Where our expectations change, decisions should change too.
For example, in order to get better estimates of true
mortality, utilitarianism would support random population testing to see
the incidence of COVID-19 in asymptomatic or minimally symptomatic
community members.
Sometimes the opportunity costs of gathering more
information or evidence will be prohibitive when urgent action is
needed. In these cases, it is important that beliefs are as rational as
possible. They should result from wide expert dialogue, embracing the
possibility of dissensus.
1.8 Global, impartial equality
Critical level utilitarianism requires impartial and
equal consideration of the well-being of all sentient creatures. In this
case, it requires consideration of people now and in the future, as
well as people without coronavirus who might be affected by lockdown. It
includes the well-being of all people, old and young, sick and well, in
one’s own country and internationally.
This means that it is critical to assess both the
well-being costs of COVID-19, and the well-being costs of lockdown.
There is currently huge attention to quantifying the numbers of cases of
COVID-19 infection and the number of consequent deaths. However, there
is much less attention to the possible consequences of lockdown measures
for people without coronavirus. Recent figures (at the end of April)
suggest that the UK has had a large increase in all-cause mortality—the
highest in Europe, and that this rate has not been decreasing even as
reported deaths from COVID-19 have fallen.
There is an urgent need to identify and quantify deaths (and more
importantly loss of years of well-being) from all causes in order to
inform decisions. Deaths or illness from COVID-19 might be greater in
number than other causes (or they might not), but they are not ethically
more important than those from other causes.
Lockdown measures themselves will have direct morbidity
and mortality (through denial or delay of medical treatment), as well as
indirect effects through economic recession. One estimate is that 25
million jobs will be lost worldwide32 with associated loss of well-being and death.
According to utilitarianism, the right policy is the one
that maximizes well-being overall, across all people across all
countries. Utilitarianism embraces radical impartial equality—all
well-being and deaths are equal (other things being equal). The cause of
loss of well-being does not matter. Thus, a utilitarian policy will
only invest in preventing loss of life from COVID-19 provided it is the
most efficient way of saving all lives.
We have noted already that other global health priorities
might be considerably more cost-effective than the financial costs of
responding to coronavirus. However, there are other important global
considerations. The UK has banned the sale of 80 drugs to other
countries in a bid to prevent NHS shortages.
From a utilitarian perspective, this may be the wrong course of action
if the sale of the drugs would save more lives globally if exported.
There may be a moral obligation to help others that overrides the
obligation to one’s own citizens. Many countries have sourced large
numbers of ventilators in order to be able to meet anticipated demand in
their own country. However, the consequences of the pandemic may be
much more severe in low and middle income countries (LMIC). Some of the
investment that countries have made into their own (already
well-resourced) health care systems would yield much greater benefit for
LMIC. That might include making ventilators available (poor countries
have been outbid by wealthy countries in the scramble to purchase
ventilators).
It might include support for LMIC policies that are less costly but
potentially effective ways of averting the crisis (for example, Vietnam
employed mass testing and contact tracing to prevent the spread of
COVID-19, and as a result, reported zero COVID-19 deaths at the end of
April).
Policy makers in LMIC may benefit from some of the modelling and
scientific expertise available in other countries to support their
decision-making. It has been questioned whether isolation will work in
Africa or whether it will kill more young people through its economic
effects and subsequent malnutrition.
For utilitarians, policy will need to be sensitive to
context and facts about individuals and local communities. The policy
that is best for one country may be worst for another.
Utilitarianism is a theory with no national boundaries.
1.9 Well-being matters more than rights and liberty
For utilitarianism, well-being is all that matters.
Liberty and rights are only important insofar as they secure well-being.
Thus a utilitarian approach to the lockdown question may be prepared to
override the right to privacy or liberty to protect well-being.
Vietnam, Singapore, Taiwan and China have used methods
such as tracing contacts and enforcing self-isolation using mobile phone
data, with severe penalties for failure to comply (in Singapore, it is
up to 6 months gaol).
These countries have been highly effective at containing COVID-19, more
so than liberal Western countries with greater emphasis on rights and
liberties. Utilitarians support the East Asian approach of constraining
liberty and privacy to promote security and well-being. This approach
also appears cost-effective while delayed response may not be.
One recent suggestion has been an app that facilitates contract tracing.
However, participation in the programme is meant to be voluntary:
people would need to agree to share information about their whereabouts
and health status. Utilitarianism would favour a more coercive approach
if this is more effective. Those who favour such voluntary programmes
give greater weight to consent and privacy than to well-being and life.
This is a value choice: it chooses individual rights over overall
reduction in the spread of disease. Of course, countries are free to
pursue individual freedom, but if the liberty based approach is less
effective, it will necessarily come at the cost of additional cases of
COVID-19 and additional deaths.
Importantly, the extent of the liberty restriction or
rights violation should be commensurate with the effect on well-being.
Utilitarianism would support isolating certain groups if the benefit to
them was greater or the benefit to others was greater. Thus a
utilitarian approach to lockdown might favour selective isolation of the
elderly and other vulnerable groups if that was the most cost-effective
way to secure overall well-being.
Likewise, the restriction of liberty of low risk groups
may also be necessary to secure large collective benefits. This
justifies, for example, in the case of influenza, vaccinating children,
who are at low risk of flu complications, in order to protect the
elderly, who have less effective immune responses to vaccination and are
at greater risk of flu complications.
Although children have little expectation of benefit themselves from
vaccination, vaccinating children is necessary to secure benefits to
overall well-being that cannot otherwise be achieved. (It would also
support challenge studies being performed [voluntarily] on low risk
populations for a COVID-19 vaccine, e.g. young people.)
It is often objected that utilitarianism leads to discrimination against those in ‘protected’ categories, such as the elderly, disabled, women, ethnic minority groups, etc.
For example, in COVID-19, it appears that elderly, male, obese, and
BAME patients have a worse prognosis than other groups (to varying
degrees). Utilitarians, it is argued, will give lower priority to some
or all of these groups for access to limited resources and/ or a higher
priority to isolating these groups, which is discrimination.
The first issue at hand is the accuracy of the
information. For example, apparent differences in mortality between
groups may be mere proxy correlations, that arise from unrelated factors
such as faster spread amongst different groups in the community meaning
there is uneven distribution of cases in the first place (we still do
not know the true number of cases due to testing shortages in nearly all
countries), the presence or absence of different groups in high-risk
occupations (in addition to uneven distribution of cases, there may be a
‘dose-dependent’ effect of the viral load on the severity of illness
making some workers more vulnerable), existing comorbidities that are
correlated with different groups, but unrelated to them and should be
considered separately, or poorer care due to bias or lack of access.
Moreover, identification and analysis of these factors may lead to the
ability to apply effective focussed measures such as equipping care
homes with better testing and protective equipment, or focussed testing
measures. Utilitarianism fails if it is applied unscientifically,
without fine-grained information, or if it fails to consider the best
policy responses.
If the evidence associating a group of people with higher
mortality is indeed both accurate and predictive of a higher mortality,
and the association is of sufficient strength, and the proposed policy
is both necessary and effective, then assigning resources or burdens
such as lockdown selectively is no more discriminatory than other
policies, such as the selective isolation of people on the basis of a
proxy risk factor for infection, such as travel history or contact with
someone who has COVID-19 (this was the early strategy).
Nevertheless, there would still be utilitarian reasons to
reject policies that give lower priorities to these groups. In
particular, these groups (with the exception of males) have already been
disadvantaged, and indeed this disadvantage may even be the direct
cause of vulnerability to COVID-19. Justice requires that they not be
further disadvantaged. Accepting the validity of justice need not mean
rejecting utilitarianism. Utilitarians must consider all the effects of
their policies and actions. If some policy will perpetuate or exacerbate
discrimination or injustice with concomitant effects on well-being,
these must be considered. Loss of short-term utility is justified by the
larger long-term gains of a more just society.
In any case, as we outlined at the beginning of this
paper, utilitarianism is not necessarily a complete answer: one can
sacrifice utility for other values. Thus, there might be
straightforwardly utilitarian reasons for treating different groups in
the same way: the resulting fractures in society arising from a policy
that did not do so would ultimately cause a greater loss of well-being.
Or there might be pure justice reasons: upholding central values such as
justice is more important than the net difference in expected health
outcomes.
A key aspect of the law on discrimination is
proportionality. In a pandemic, very large numbers of lives are at
stake. Equality, even for those opposed to utilitarianism, is only one
value amongst others. Discrimination may be proportionate if the stakes
are high enough and alternative measures are not available.
1.10 Separateness of persons
One prominent objection to utilitarianism is that it fails to respect the separateness of persons.44
One instantiation of this problem that is relevant to pandemic
management is that utilitarianism can favour very small risk reductions
spread over very large numbers of persons rather than the saving of one
long life. Small goods can be summed to outweigh one large good.
Insofar as this is a problem, it can be avoided in
practice by only comparing and summing comparable goods, for example
lives. For example, one could count only the saving of lives or the
saving of a life for a sufficiently long period of time (say 1 year) as a
minimum good to be counted.
This vice can also be a virtue. The significant misery
that a large number of people experience during lockdown (unemployment,
depression, being victims of domestic violence, etc.) should not be
ignored and must be recognized as an ethical cost. If that well-being
loss is great enough for a large enough number of people it could
outweigh even the loss of some years of life for a relative few.
1.11 Conclusion
Utilitarianism is a demanding and counterintuitive
theory. Why should we consider it? If the utilitarian course of action
is not adopted, someone (often many) people will suffer or die
avoidably. There may be good reasons (such as the preservation of
liberty) to sacrifice well-being or lives. But such choices need to be
made transparently and in full awareness of their ethical cost. One must
have good reasons to deliberately choose a course of action that will
be worst overall.
Policy is often driven by politics or popular opinion,
not ethics. This is morally wrong. Much of ethics in the public sphere
involves social signalling, moralism and sometimes wishful thinking (for
example, trying to wish away difficult ethical dilemmas). Careful
consideration of the consequences of our actions requires us to face the
facts and our values. A utilitarian approach is not simple, or easy. It
requires that we choose the course of action that will benefit most
people to the greatest degree, however difficult or counterintuitive
that is.
There is some support for utilitarianism. In one survey
investigating the public’s views on how to allocate intensive care beds
amongst critically ill infants, we found the general public widely
supported utilitarian allocations.
They supported allocating the intensive care bed to save the infant
with a greater chance of survival, who would have a longer life or less
disability. They also supported saving the greater number. This suggests
that there may be public support for the algorithm that we have
proposed for the triage question. When people understand that there is
an unavoidable need to choose between patients, they appear to recognize
that securing the most benefit overall is both logical and ethical.
One of the psychological biases that dominates
decision-making is loss aversion. Losses loom larger than gains. And
when we evaluate a policy we are liable to focus on the negatives,
rather than the positives. Thus governments, such as East Asian
governments, who radically curtail liberty and protect health and
security are criticized for being overly authoritarian. Liberal
governments that protect liberty and incur greater infection risks (such
as the UK and Australia) are criticized for failing to protect the
vulnerable and secure public health. There is no win the in the court of
public opinion.
That is why we need, in the cool, calm hour, to set our
policy objectives and priorities. Utilitarianism gives a clear framework
for that. And it gives criteria to judge success.
The universal common ethical currency is well-being. What
matters to each of us is how well our lives go. This is the very heart
and basis of utilitarianism: it takes an impartial approach to
everyone’s well-being. While people may argue other things matter
(autonomy, privacy, dignity), everyone can agree that well-being
matters.
It is doubtful that any of the policies currently being
adopted by any governments worldwide are purely or simply utilitarian.
However, some are potentially reflecting more clearly and carefully
about the costs and benefits of different courses of action and policy.
The fundamental difficulty facing all of us during this pandemic is that
we cannot know for certain which action will be best overall. We do not
know what a utilitarian ‘archangel’ would choose: it would require a
detailed understanding of the science and facts, the nature of
well-being and an exhaustive understanding of the consequences of our
choices. But that is what we should be aspiring to. We must strive to
get the facts straight on all the consequences of our choices. Our
societies may then choose to embrace or choose not to embrace the
utilitarian course. But at least we will then do so with a clear
understanding of our values and the price we are willing to pay for
them.
Acknowledgements
JS and DW were supported by the Wellcome Trust (WT203132).
JS through his involvement with the Murdoch Children's Research
Institute was supported by the Victorian Government's Operational
Infrastructure Support Program.
Demonstration
of quality-adjusted life years (QALYs) for two individuals. Individual A
(who did not receive an intervention) has fewer QALYs than individual B
(who received an intervention). The letters A and B designate the
boundary lines, with the QALY for A being only the blue area, the QALY
for B being the blue area plus the additional tan area. NB It is
possible to experience an improvement in health-related quality of life with age, for example through healthier life choices.
The quality-adjusted life year (QALY) is a generic measure of disease burden, including both the quality and the quantity of life lived. It is used in economic evaluation to assess the value of medical interventions. One QALY equates to one year in perfect health. QALY scores range from 1 (perfect health) to 0 (dead).QALYs can be used to inform health insurance coverage determinations,
treatment decisions, to evaluate programs, and to set priorities for
future programs.
Critics argue that the QALY oversimplifies how actual patients
would assess risks and outcomes, and that its use may restrict patients
with disabilities from accessing treatment. Proponents of the measure
acknowledge that the QALY has some shortcomings, but that its ability to
quantify tradeoffs and opportunity costs from the patient and societal
perspective make it a critical tool for equitably allocating resources.
Calculation
The
QALY is a measure of the value of health outcomes to the people who
experience them. It combines two different benefits of treatment—length
of life and quality of life—into a single number that can be compared
across different types of treatments.
Calculating a QALY requires two inputs. One is the utility
value (or utility weight) associated with a given state of health by
the years lived in that state. The underlying measure of utility is
derived from clinical trials and studies that measure how people feel in
these specific states of health. The way they feel in a state of
perfect health equates to a value of 1 (or 100%). Death is assigned a
utility of 0 (or 0%), and in some circumstances it is possible to accrue
negative QALYs to reflect health states deemed "worse than dead." The value people perceive in less than perfect states of health are expressed as a fraction between 0 and 1.
The second input is the amount of time people live in various
states of health. This information usually comes from clinical trials.
To calculate the QALY, the two measures are multiplied. For
example, one year lived in perfect health equates to 1 QALY. This can be
interpreted as a person getting 100% of the value for that year. A year
lived in a less than perfect state of health can also be expressed as
the amount of value accrued to the person living it. For example, 1 year
of life lived in a situation with utility 0.5 yields 0.5 QALYs—a person
experiencing this state is getting only 50% of the possible value of
that year. In other words, they value the experience of being in less
than perfect health for a full year as much as they value living for
half a year in perfect health (0.5 years × 1 Utility). This
characteristic is what makes the QALY useful for evaluating tradeoffs.
Weighting
The
utility values used in QALY calculations are generally determined by
methods that measure people's willingness to trade time in different
health states, such as those proposed in the Journal of Health Economics:
Time-trade-off
(TTO): Respondents are asked to choose between remaining in a state of
ill health for a period of time, or being restored to perfect health but
having a shorter life expectancy.
Standard gamble (SG): Respondents are asked to choose between
remaining in a state of ill health for a period of time, or choosing a
medical intervention which has a chance of either restoring them to
perfect health or killing them.
Visual analogue scale
(VAS): Respondents are asked to rate a state of ill health on a scale
from 0 to 100, with 0 representing being dead and 100 representing
perfect health. This method has the advantage of being the easiest to
ask, but is the most subjective.
Another way of determining the weight associated with a particular
health state is to use standard descriptive systems such as the EuroQol
Group's EQ-5D
questionnaire, which categorises health states according to five
dimensions: mobility, self-care, usual activities (e.g. work, study,
homework or leisure activities), pain/discomfort and anxiety/depression.
In the Netherlands the use of QALYs is also applied to decision
making on security measures of highways and local roads and railway
crossings.
History
The
first mention of Quality Adjusted Life Years appeared in a doctoral
thesis at Harvard University by Joseph S. Pliskin (1974). The need to
consider quality of life is credited to work by Klarman et al. (1968), Fanshel and Bush (1970) and Torrance et al. (1972) who suggested the idea of length of life adjusted by indices of functionality or health. A 1976 article by Zeckhauser and Shepard was the first appearance in print of the term. QALYs were later promoted through medical technology assessments conducted by the US CongressOffice of Technology Assessment.
In 1980, Pliskin et al. justified the QALY indicator using
multiattribute utility theory: if a set of conditions pertaining to
agent preferences on life years and quality of life are verified, then
it is possible to express the agent's preferences about couples (number
of life years/health state), by an interval (Neumannian) utility
function.
This utility function would be equal to the product of an interval
utility function on "life years", and an interval utility function on
"health state".
Debate
According to Pliskin et al., the QALY model requires utility independent, risk neutral, and constant proportional tradeoff behaviour.
For the more general case of a life time health profile (i.e.,
experiencing more than one health state during the remaining years of
life), the utility of a life time health profile must equal the sum of
single-period utilities. Because of these theoretical assumptions, the meaning and usefulness of the QALY is debated.
Perfect health is difficult, if not impossible, to define. Some argue
that there are health states worse than being dead, and that therefore
there should be negative values possible on the health spectrum (indeed,
some health economists have incorporated negative values into
calculations). Determining the level of health depends on measures that
some argue place disproportionate importance on physical pain or
disability over mental health.
The method of ranking interventions on grounds of their cost per QALY gained ratio (or ICER) is controversial because it implies a quasi-utilitarian calculus to determine who will or will not receive treatment.
However, its supporters argue that since health care resources are
inevitably limited, this method enables them to be allocated in the way
that is approximately optimal for society, including most patients.
Another concern is that it does not take into account equity issues such
as the overall distribution of health states—particularly since
younger, healthier cohorts have many times more QALYs than older or
sicker individuals. As a result, QALY analysis may undervalue treatments
which benefit the elderly or others with a lower life expectancy. Also,
many would argue that all else being equal, patients with more severe
illness should be prioritised over patients with less severe illness if
both would get the same absolute increase in utility.
As early as 1989, Loomes and McKenzie recommended that research be conducted concerning the validity of QALYs. In 2010, with funding from the European Commission, the European Consortium in Healthcare Outcomes and Cost-Benefit Research (ECHOUTCOME) began a major study on QALYs as used in health technology assessment. Ariel Beresniak,
the study's lead author, was quoted as saying that it was the
"largest-ever study specifically dedicated to testing the assumptions of
the QALY."
In January 2013, at its final conference, ECHOUTCOME released
preliminary results of its study which surveyed 1361 people "from
academia" in Belgium, France, Italy and the UK.
The researchers asked the subjects to respond to 14 questions
concerning their preferences for various health states and durations of
those states (e.g., 15 years limping versus 5 years in a wheelchair). They concluded that:
"preferences expressed by the respondents were not consistent with the QALY theoretical assumptions";
quality of life can be measured in consistent intervals;
life-years and quality of life are independent of each other;
people are neutral about risk; and
willingness to gain or lose life-years is constant over time.
ECHOUTCOME also released "European Guidelines for Cost-Effectiveness
Assessments of Health Technologies", which recommended not using QALYs
in healthcare decision making. Instead, the guidelines recommended that cost-effectiveness analyses focus on "costs per relevant clinical outcome."
In response to the ECHOUTCOME study, representatives of the National Institute for Health and Care Excellence, the Scottish Medicines Consortium, and the Organisation for Economic Co-operation and Development made the following points. First, QALYs are better than alternative measures. Second, the study was "limited." Third, problems with QALYs were already widely acknowledged. Fourth, the researchers did not take budgetary constraints into consideration.
Fifth, the UK's National Institute for Health and Care Excellence uses
QALYs that are based on 3395 interviews with residents of the UK, as
opposed to residents of several European countries.
Finally, according to Franco Sassi, a senior health economist at the
Organisation for Economic Co-operation and Development, people who call
for the elimination of QALYs may have "vested interests".
While supporters laud QALY’s efficiency, critics argue that use
of QALY can cause medical inefficiencies because a less-effective,
cheaper drug may be approved based on its QALY calculation.
The use of QALYs has been criticized by disability advocates
because otherwise healthy individuals cannot return to full health or
achieve a high QALY score. Treatments for quadriplegics, patients with
multiple sclerosis, or other disabilities are valued less under a
QALY-based system.
Critics also argue that a QALY-based system would limit research
on treatments for rare disorders because the upfront costs of the
treatments tend to be higher. Officials in the United Kingdom were
forced to create the Cancer Drugs Fund to pay for new drugs regardless
of their QALY rating because innovation had stalled since NICE was
founded. At the time, one in seven drugs were turned down.
Additionally there is a trend where QALY is getting position as a
capital allocation tool although many sources and publications show that
QALY has relatively significant gaps as formula and as organization
management mechanism in healthcare.
The Partnership to Improve Patient Care, a group opposed to the
adoption of QALY-based metrics, argued that a QALY-based system could
exacerbate racial disparities in medicine because there is no
consideration of genetic background, demographics, or comorbidities that
may be elevated in minority racial groups that do not have as much
weight in the consideration of the average year of perfect health.
Critics have also noted that QALY only considers the quality of
life when patients may choose to suffer negative side-effects to live
long enough to attend a milestone event, such as a wedding or
graduation.
The Rule of rescue
and immoral or "inhuman acting" are frequently used arguments to ignore
cost-effectiveness analysis and the use of QALYs. Especially during the
2020/2021 Covid-19 pandemic, national responses represented a massive
form of applying the ‘rule of rescue’ and disregard of
cost-effectiveness analysis (see e.g. Utilitarianism and the pandemic).
Both the Rule of rescue and immoral behaviour are heavily
attacked by Shepley Orr and Jonathan Wolff in their 2014 article
“Reconciling cost-effectiveness with the rule of rescue: the
institutional division of moral labour” (https://link.springer.com/article/10.1007/s11238-014-9434-3).
They argued that the “Rule of rescue” is the result of wrong reasoning.
Cost-effectiveness reasoning with the aid of QALYs always leads to
moral superior outcomes and optimal public health outcome, allthough not
always perfect, given constraints of resources.
Future development
The UK Medical Research Council and others are exploring improvements to or replacements for QALYs.
Among other possibilities are extending the data used to calculate
QALYs (e.g., by using different survey instruments); "using well-being
to value outcomes" (e.g., by developing a "well-being-adjusted
life-year"; and by value outcomes in monetary terms. In 2018 HM Treasury set a discount rate
of 1.5% for QALYs, which is lower than the discount rates for other
costs and benefits, because the QALY is a direct utility measure.
