Done: https://forum.effectivealtruism.org/s/2nMw7ASQNQ35iAz4T

Hi Sam,

Thanks for the comments.

1. Have you done much stakeholder engagement? No. I discuss this a little bit in this section of Part 2, but I basically just suggest that people look into this and come up with a strategy before spending a huge amount of time on the research. I do know of academics who would may be able to advise on this, e.g. people who have developed previous metrics in consultation with NICE etc, but they’re busy and I suspect they wouldn’t want to invest a lot of time into efforts outside academia.

I think they’d reject the assumption that they are “not improving these metrics” and would point to considerable quantities of research in this area. The main issue, I think, is that they want a different kind of metric that what I’m proposing, e.g. they think it’s important that they are based on public preferences and are focused on health rather than wellbeing. A lot of resources are going into what I see (perhaps unfairly) as “tinkering around the edges,” e.g. testing variations of the time tradeoff/DCE and different versions of the EQ-5D, rather than addressing the fundamental problems.

As I say in Part 3 with respect to the sHALY (SWB-based HALY):

In my view, the strongest reason not to do this project is the apparent lack of interest among key stakeholders. Clinicians, patients, and major HALY “consumers” such as NICE and IHME seem strongly opposed to a pure SWB measure, even if focused on dimensions of health, and to the use of patient-reported values more broadly. As discussed in previous posts, this is due to a combination of normative concerns, such as the belief that those who pay for healthcare have the right to determine its distribution or that disability has disvalue beyond its effect on wellbeing, and doubts about the practicality of SWB measures in these domains.

So this project may only be worth considering if the sHALY would be useful for non-governmental purposes (e.g., within effective altruism), or in “supplementary” analyses alongside more standard methods (e.g., to highlight how QALYs neglect mental health). Either that, or changing the minds of large numbers of influential stakeholders will have to be a major part of the project—which may not be entirely unrealistic, given the increasing prominence of wellbeing in the public sector. We should also consider the possibility that projects such as this, which offer a viable alternative to the status quo, would themselves help to shift opinion.

That said, there is increasing increasing interest in hybrid health/wellbeing measures like the E-QALY, and scope for incremental improvement of current HALYs (see Part 2), and in the use of wellbeing for cross-sector prioritisation. In at least the latter case, you are likely to know more than me about how to effect policy change within governments.

2. Problem 4 - neglect of spillover affects – probably cannot be solved by changing the metric.  I discuss spillovers a little in Part 2 and plan to have a separate post on it in Part 6 (but it might be a while before that’s out, and it’s likely to focus on raising questions rather than providing solutions). I’m still unsure what to do about them and would like to see more research on this. I agree changing the metric alone won’t solve the issue, but it may help—knowing the extent to which the metric captures spillovers seems like an important starting point.

3. Who would you recommend to fund if I want to see more work like this? It probably depends what your aims are. If it’s to influence NICE, IHME, etc, it probably has to go via academia or those institutions. If you want to develop a metric for use in EA, funding individual EAs or EA orgs may work—but even then, it’s probably wise to work closely with relevant academics to avoid reinventing the wheel. So I guess if you have a lot of money to throw at this, funding academics or PhD students may be a good bet; there is already some funding available (I’m applying for PhD scholarships in this area at the moment), but it may be hard to get funding for ideas that depart radically from existing approaches. I list some relevant institutions and individuals in Part 2.

4. How is the E-QALY project going? It got very delayed due to COVID-19. I’m not sure what the new timeline is.

Interesting, thanks!

Thanks Bob! I will probably do this after publishing the next post.

I've made a few edits to address some of these issues, e.g.:

Clearly, there are many possible “wellbeing approaches” to economic evaluation and population health summary, defined both by the unit of value (hedonic states, preferences, objective lists, SWB) and by how they aggregate those units when calculating total value. Indeed, welfarism can be understood as a specific form of desire theory combined with a maximising principle (i.e., simple additive aggregation); and extra-welfarism, in some forms, is just an objective list theory plus equity (i.e., non-additive aggregation).

However, it seems that most advocates for the use of wellbeing in healthcare reject the narrow welfarist conception of utility, while retaining fairly standard, utility-maximising CEA methods—perhaps with some post-hoc adjustments to address particularly pressing distributional issues. So it seems reasonable to consider it a distinct (albeit heterogenous) perspective.

For the purpose of exposition, I will assume that the objective is to maximise total SWB (remaining agnostic between affect, evaluations, or some combination). This is not because I am confident it’s the right goal; in fact, I think healthcare decision-making should probably, at least in public institutions, give some weight to other conceptions of wellbeing, and perhaps to distributional concerns such as fairness. One reason to do so is normative uncertainty—we can’t be sure that the quasi-utilitarianism implied by that approach is correct—but it’s also a pragmatic response to the diversity of opinions among stakeholders and the challenges of obtaining good SWB measurements, as discussed in later posts.

However, I am fairly confident that SWB-maximization—or indeed any sensible wellbeing-focused strategy—would be an improvement over current practice, so it seems like a reasonable foundation on which to build. Moreover, most of these criticisms should hold considerable force from a welfarist, extra-welfarist, or simply “common sense” perspective. One certainly does not have to be a die-hard utilitarian to appreciate that reform is needed.

Changed the first two problem headings to avoid ambiguity and, in the first case, to focus on the result of the problem rather than the cause, which helps distinguish it from 5.

Hi Michael. Thanks for the feedback.

A few general points to begin with:

1. I think it’s generally fine to use terminology any way you like as long as you’re clear about what you mean.
2. In this piece I was summarising debates in health economics, and my framing reflects that literature.
3. The main objective of these posts is to highlight particular issues that may deserve further attention from researchers, and sometimes that has to come at the expense of conceptual rigour (or at least I couldn’t think of a way to avoid that tradeoff). Like you, my natural inclination is to put everything in mutually exclusive and collectively exhaustive categories, but that doesn’t always result in the most action-relevant information being front and centre.

To address your specific points:

I try to make it very clear what I mean by “welfarism” and its alternatives:

The QALY originally emerged from welfare economics, grounded in expected utility theory (EUT), which defined welfare in terms of the satisfaction of individual preferences. QALYs were intended to reflect, at least approximately, the preferences of a rational individual decision-maker (as described by the von Neumann-Morgenstern [vNM] axioms) concerning their own health, and could therefore properly be called utilities.

Others have argued that QALYs should not represent utility in this sense. These “non-welfarists” or “extra-welfarists” typically believe things like equity, capability, or health itself are of intrinsic value (Brouwer et al., 2008; Coast, Smith, & Lorgelly, 2008; Birch & Donaldson, 2003; Buchanan & Wordsworth, 2015). If such considerations are included in the QALY, the (welfarist) utility of patients may not change proportionally with the size of QALY gains.

Most criticism of HALYs has come from three broad camps: welfare economics (which aims to maximise the satisfaction of individual preferences), extra-welfarism (which has other objectives), and wellbeing (often but not always from a classical utilitarian perspective).

In a nutshell, welfarists complain that QALYs, and CEAs based on them, do not reflect the preferences of rational, self-interested utility-maximizers.

Extra-welfarists, on the other hand, generally think the QALY (and CEA more broadly) is currently too welfarist. Though extra-welfarism is ill-defined and encompasses a broad range of views, the uniting belief is that there is inherent value in things other than the satisfaction of individuals’ preferences (Brouwer et al., 2008).

For the welfarist, there are broader efficiency-related issues with using cost-per-HALY CEAs for resource allocation […]  Therefore, counting everyone’s health the same does not maximise utility in the welfarist sense, even within the health sector.

So it should be clear that welfarism, as the term is used in modern (health) economics, offers a very specific theory of value (satisfaction of rational, self-regarding preferences that adhere to the axioms of expected utility theory) that is much more narrow than most desire theories. That said, I agree welfarism, extra-welfarism, and wellbeing-oriented ideas are not entirely distinct categories, and note overlaps between them:

Hedonism: … This is associated with the classical utilitarianism of Jeremy Bentham and John Stuart Mill, classical economics (mid-18th to late 19th century)…

Desire theories: Wellbeing consists in the satisfaction of preferences or desires. This is linked with neoclassical (welfare) economics, which began defining utility/welfare in terms of preferences around 1900 (largely because they were easier to measure than hedonic states), preference utilitarianism, …

Objective list theories: Wellbeing consists in the attainment of goods that do not consist in merely pleasurable experience nor in desire-satisfaction (though those can be on the list). … These have influenced some conceptions of psychological wellbeing,[46] and many extra-welfarist ideas. The capabilities approach also falls under this heading…

I mention distributional issues in the context of extra-welfarism:

These “non-welfarists” or “extra-welfarists” typically believe things like equity, capability, or health itself are of intrinsic value (Brouwer et al., 2008; Coast, Smith, & Lorgelly, 2008; Birch & Donaldson, 2003; Buchanan & Wordsworth, 2015). If such considerations are included in the QALY, the (welfarist) utility of patients may not change proportionally with the size of QALY gains.

Descriptively, it seems the extra-welfarists are winning. Although QALYs, and CEA as a whole, do not generally include overt consideration of distributional factors, they do depart from traditional welfare economics in a number of ways ...

This “QALY egalitarianism” is often challenged by welfarists on the grounds that WTP varies among individuals, but many extra-welfarists reject it for other reasons. For example, some have argued that more value should be attached to health gained by the young—those who have not yet had their “fair innings”—than by the elderly (Williams, 1997); by those in a worse initial state of health, or for larger individual health gains[43] (e.g., Nord, 2005); by those who were not responsible for their illness (e.g., Dworkin, 1981a, 1981b); by those at the end of life, as currently implemented by NICE; or by people of low socioeconomic status.[44]

They are addressed further in Part 2 when I discussed how HALYs should be aggregated.

I do think I could perhaps have been clearer about the distinction between HALYs and economic evaluation (the latter is typically HALY-maximising, but doesn’t have to be), and analogously between the unit of value (e.g. wellbeing, health) and moral theory (utilitarianism, egalitarianism, etc). I may edit the post later if I have time.

What you call problem 2 I'd reframe as expectations =/= reality.

“Preferences =/= value” was intended as shorthand for something like “the preferences on which current HALY weights are based do not accurately reflect the value of the states to people experiencing them”. Or as I put it elsewhere: “They are based on ill-informed judgements of the general public”. It wasn’t a philosophical comment on desire theories. Still, I can see how it might be misleading (plus it doesn’t strictly apply to DALYs, which arguably aren’t preference-based), so I may change it to your suggestion...though "expectations" doesn't really fit DALYs either, so I'd welcome alternative ideas.

I agree problem 3 (suffering/happiness) is about inadequate scaling and doesn’t presuppose hedonism, but I don’t think I imply otherwise. I decided to include it as a separate problem, even though it’s applicable to more than one type of scale/theory, because it’s an issue that is very neglected—in health economics and elsewhere. As noted above, the aim of this series is to draw attention to issues that I think more people should be working on, not make a conceptually/philosophically rigorous analysis.

That’s also why I didn’t have distributional issues as a separate “problem”. I note at the the start of the list that “The criticisms assume the objective is to maximize aggregate SWB” (while also noting that they “should also hold some force from a welfarist, extra-welfarist, or simply 'common sense' perspective”) and from that standpoint the current default (in most HALY-based analyses/guidelines) of HALY maximisation is not a “problem,” so long as they better reflect SWB. That said, as noted above, I do mention distributional issues earlier in the post and in Part 2, in case someone does want to work on those.

Problem 4 is not that HALYs don’t include spillovers; it’s that “They are difficult to interpret, capturing some but not all spillover effects.” (When I say “Neglect of spillover effects,” I mean that the issue of spillovers is problematically neglected in the literature, not that HALYs don’t measure them at all.) This should be clear from the text:

there is some evidence that people valuing health states take into account other factors, especially impact on relatives … On the other hand, it seems reasonable to assume health state values do not fully reflect the consequences for the rest of society—something that would be impossible for most respondents to predict, even if they were wholly altruistic.

I agree this is likely to be an issue with other metrics too (Part 6 is all about this, and it’s mentioned in Part 2), and I suspect it will mostly have to be dealt with at the aggregation stage, but it’s not the case that the content of the metrics is irrelevant. For example, the questionnaires (and therefore the descriptive system) could include items like “To what extent do you feel you’re a burden on others?” (a very common concern expressed in qualitative studies); and/or the valuation exercise could ask people to take into account the impact of their (e.g.) health condition on others (or alternatively to consider only their own health/wellbeing). If this makes a difference to the values produced, it would make HALYs/WELBYs easier to interpret, which would also inform broader evaluation methodology, like whether to administer health/wellbeing measures to relatives separately and add them to the total.

Problem 5 is not merely a restatement Problem 1, though of course they’re closely connected. Problem 1 focuses on why HALYs aren’t that good at prioritising within healthcare (i.e. achieving technical efficiency, from a fixed budget). Problem 5 is that are useless at cross-sector prioritisation (i.e. allocative efficiency). The cause is similar (health focus), and I think I combined them in an early draft; but as with states worse than dead, I wanted to have 5 as a separate issue in order to draw particular attention to it. The difference becomes especially relevant when comparing, for example, the sHALY (which assigns weight to health states based on SWB, thereby addressing Problem 1 but not 5) and the WELBY (which potentially addresses both, but probably at the expense of validity within specific domains such as healthcare, in which case it may be useful for high-level cross-sector prioritisation, e.g., setting budgets for different government departments [Problem 5], but not for priority-setting within, say, the NHS [Problem 1]). Following similar feedback from others, I did change 5 to “They are consequently of limited use in prioritising across sectors or cause areas” in my main list in order to highlight the relationship.

(Really, all of these problems are due to (a) the descriptive system, (b) the valuation method, and possibly (c) the aggregation method, so any further breakdown risks overlap and confusion—but those categories don’t really tell you why you should care about them, or what elements you should focus on, so it didn’t seem like a helpful typology for the “Problems” section.)

Still, I am not entirely happy with this way of dividing things up or framing things (e.g., some problems focus more “causes” and some on “effects”) and would welcome suggestions of alternatives that are both conceptually rigorous/consistent and draw attention to the practical implications.

As far as I can tell, it isn't possible to have line breaks in footnotes (though I may just be doing something wrong). This also precludes bulleted/numbered lists, block quotes, etc. Any chance that could be changed? 

H3s are still being converted to regular Paragraph format when I paste them in from GDocs. What am I doing wrong?

I'm sure there are many giving opportunities in global health that are better than the GiveWell top charities, and I'm pleased to see promising small or medium-sized projects like this being brought to the attention of EAs. 

However, I think you should try to get better estimates of QALYs gained (or DALYs averted)—especially if you're going to feature the cost-effectiveness ratio so prominently in your write-up. This should be possible by referring to the relevant literature. The current estimates don't seem all that plausible to me, e.g. an episode of "simple malaria" (by which you presumably mean there are no other complications like anaemia) tends to last a few weeks or less, so even if it could be immediately cured at the beginning, it wouldn't reach your lower estimate of 0.1 QALYs, let alone the upper of 5 QALYs. For life-threatening conditions, I don't think you should have the theoretical maximum of "save all lives" as the upper estimate, as that wouldn't happen in any context, and certainly not this one. If you must rely on your intuitive guesstimates, perhaps you should use 90% or 95% credible intervals.

Good luck with the project!

 

''Next" and "Previous" arrows/buttons at the bottom of a post, to move to the next/previous post - useful when you haven't read the forum for a while and want to catch up. This would obviously have to assume a certain ordering (e.g. chronological vs karma) and selection (e.g. all or excluding Community/Questions), which could perhaps be adjusted in Settings.