I am a big fan of QALYs, and not just because you get to play exciting games of Things That Suck Worse Than Depression Scavenger Hunt. (So far the list includes literally being born without a brain.) I think they’re a great first attempt at actually quantifying utilitarianism and solving the interpersonal utility comparison problem.
A lot of my disabled friends really hate QALYs. They say: “QALYs are literally saying that my life is worth less than an abled person’s. This isn’t theoretical: people have advocated distributing organs on the basis of QALY maximization. Sure, I’d like a cure for my chronic pain issues, but I don’t want to die.”
Worse, some of my utilitarian friends have agreed with them.
(Side note: talking about organ allocation is fairly ridiculous, given that about four-fifths of people on the organ transplant waiting list are waiting for kidneys, and it is possible for living people to donate kidneys. Instead of encouraging people to donate kidneys to strangers, the US medical system inexplicably makes it difficult. Also, if you’re in good health, you should donate a kidney.)
QALYs take two things into account: first, the number of additional years you will live if you have a treatment; second, how much better your life will be if you have that treatment. That is perfectly sensible if you are trying to figure out whether it’s cost-effective to cover my mental health care, because the effects of my mental health care are that I live longer and have a better life. However, this is only a good method of figuring out who should get an organ if you believe that disability is the most important factor in someone’s happiness, to the point that it completely swamps every other consideration.
Ideally, we’d look at people’s happiness setpoints. Unfortunately, we don’t have a way to measure happiness setpoint objectively, and if saying they are extremely happy is what it takes to get an organ most people will say so. However, there are demographic factors correlated with happiness: we should not only favor abled people, but married people, people who attend religious services regularly, Republicans, and rich people. Furthermore, people who are well-rested after only six hours a night have an extra eighth of a life-year per year compared to those who require ten; how much you sleep is just as important as, say, mild intellectual disability.
I notice that no one has invented Sleep-And-Political-Party-Adjusted-Life-Years, much less advocated their use in organ allocation. I feel like this is probably because disability feels very mediciney, the sort of thing doctors should be concerned about, whereas religiosity is clearly out of their sphere.
I suspect my utilitarian readers are half going “okay, you’re right, sleep-and-political-party-adjusted-life-years are kind of absurd”, and half going “actually, that sounds GREAT, exactly how we should allocate kidneys.” However, QALYs do not pass the enemy control ray test.
Non-utilitarians mostly are interested in allocating organs “fairly”, so a proper analogy will involve some people acting quite out of character. So imagine that the Catholic Church, in a sudden fit of consequentialism, invented the Telos-Adjusted Life Year: in the future, you will be far less likely to get an organ from a Catholic hospital if you’re in a gay relationship, you’ve gotten divorced, or your medical history includes contraception use. Both utilitarians and AU Catholics are using the same rule: we’re giving organs to people whose lives more closely fit our idea of the good life. It’s just that utilitarians think the good life is being happy or having your preferences satisfied, whereas AU Catholics think that the good life involves using your passions in a way compatible with their final end. If we want a leg to stand on when condemning the use of Telos-Adjusted Life Years to distribute organs, we shouldn’t use QALYs to distribute them either.
I would like to propose the radical idea that philosophers should figure out the definition of the good life, and the medical system should cure sick people. We wouldn’t give Derek Parfit a scalpel and shove him into the operating theater, and we shouldn’t ask the medical bureaucracy to solve all of normative ethics for us.