Evaluating Consequences

Consequences and Value

To evaluate something is most basically to determine its value or to determine its effect on that which has value. The positive value of health may be taken as a given in medical decision making. Sometimes, however, it is not clear what concrete outcomes contain more health. Will a patient in chronic pain be more healthy taking opiates that reduce her mental abilities and may create dependency, or will she be more healthy without opiates but with more pain? Will an elderly patient with myeloma enjoy better health after treatment with cytostatics that pacify the disease but weaken the immune system, or will his health be better without the treatment? Depending on the details of the case, the answers to these questions are far from obvious, showing that the concept of health is complex and will sometimes stand in need of specification.

Health may be defined biomedically as the absence of disease and infirmity. This is the common definition in medical practice, though seldom explicitly stated. Alternatively, health may be defined biopsychosocially, which is common in theoretical contexts. The 1946 constitution of the World Health Organization (WHO) states that health is “a state of complete physical, mental and social well-being.” Several recent definitions aim to avoid the somewhat utopian character of the WHO definition and to shift focus from outcome to opportunity, by defining health in terms of potential or ability rather than well-being.

Quantitative measurements of health have increasingly been made in terms of quality-adjusted life years (QALYs), that is, the number of person life years adjusted by a factor representing the quality of the person's life. Like health, quality of life may be defined biomedically or biopsychosocially, and more or less broadly. What will be said in the following about values in general and health in particular holds equally for quality of life. Regardless of how exactly quality is defined, evaluating consequences in terms of QALYs incorporates a richer understanding of why we value life, as opposed to measuring only years of life of whatever quality or only death or survival. A strategy of QALY maximization has the further advantage of allowing quantitative comparisons of different alternatives, such as treatment programs, but has the disadvantage that other values may be disregarded, such as equity and autonomy.

Like any value, the value of health may be final and/or instrumental. Health is obviously instrumental to other values such as happiness and achievement. In other words, we need health to promote or protect these other values. In addition, however, health may also be of final value—of value in itself, independently of its impact on other values. Whether or not health has final value becomes important in conflict cases, where it must be balanced against other values. If, for example, health, defined biomedically, is important only because of its instrumental contribution to the higher value of happiness, a healthy life without happiness has no value. This conclusion may have direct relevance for important medical decisions concerning life and death, including the issue of euthanasia.

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