Academic journal article Erasmus Journal for Philosophy and Economics

Valuing Health. Well-Being, Freedom, and Suffering

Academic journal article Erasmus Journal for Philosophy and Economics

Valuing Health. Well-Being, Freedom, and Suffering

Article excerpt

Review of Daniel M. Hausman's Valuing health. Well-being, freedom, and suffering. Oxford: Oxford University Press, 2015, 267 pp.


At least since the 1980s, rising health care expenditures have become a central public policy issue in industrialized countries all over the world. Since then, the debate on resource allocation in health care has been increasingly framed in terms of the economic framework of costs and benefits. Economic evaluations gained pivotal significance in public policy and keep attracting a lot of attention as an area of research today. Given this practical and theoretical relevance, critical, conceptual analyses of economic evaluations of health practices, which open up the discourse for non-economists, are indispensable. Daniel M. Hausman has provided such an analysis. He offers a painstaking investigation of generic health measures, i.e., scalar measures quantifying the overall health in a population. These measures are not only needed when it comes to the allocation of resources, but are also required for epidemiological and demographic purposes (pp. 1-6).


The book can be divided into three parts. In the first part (ch. 2-5), Hausman raises the questions what health is and how it can be measured. Following Boorse, he adopts a naturalistic definition of health in terms of the relative functional efficiency of the body's parts and processes (p. 14). While this notion of health would be tentatively measurable in terms of probabilities of survival in some specified environment, Hausman argues that this is not what those interested in health measures are actually up to (p. 31). What is relevant for constructing generic health measures is how health bears on things people care about, such as activities, relationships, and feelings. Hence, generic health measures are not measuring the amount of health as such, but rather the value of health (p. 42). To approach the question of what kind of value we are dealing with, Hausman asks what the preference elicitation methods currently used are actually measuring. The most common generic health measure used in the context of allocating resources is the quality-adjusted life year (QALY). It combines information on mortality and morbidity by adjusting each life-year with a quality weight which is supposed to mirror the health related quality of life (HrQOL) in the respective health state. While the concept of HrQOL seems intelligible at first glance, a closer investigation reveals that its meaning is unclear and its relevance for generic health measures highly questionable (pp. 47-51). For one thing, there is no consensus in the literature as to how quality of life should be defined. Some authors refer to mental states, others to subjective judgments, just to mention two examples. Yet, if quality of life is taken to be a subjective measure of how good one's life is at a certain point in time, it is doubtable whether it can serve as a measure of the value of health. The reason given by Hausman consists in an argument running like a common thread through the whole book: the badness of ill health cannot be completely captured by its effect on well-being; in fact, one can have a very high subjective quality of life while being in bad health and vice versa (pp. 48, 94-95, 117-16, 144-45). Beyond that, it is also unclear how the predicate "health related" is to be understood. A motorized wheelchair, for instance, certainly has the potential of improving a person's quality of life but the question remains as to whether such external tools should be regarded "as improving HrQOL, in the same way as treatments do", or rather "as improving quality of life while leaving the health-related part unchanged?" (p. 48).

When it comes to the actual measurement of HrQOL, health economists implicitly shift to another measure. Currently, health states are valued by means of preference elicitation methods, an example being the time trade-off, which asks the respondents for the number of life years they would be willing to sacrifice in order to be cured from a certain condition. …

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