Health-related quality of life: a life of autonomous responsibility

In view of the possibilities of modern medicine, it is generally assigned a key role when it comes to optimizing life expectancy and improving the quality of life. Doctors therefore rightly deal with the demands of society for the highest quality of life and the reality of quality of life in individual cases in their medical work. Viewpoints on what can be described as quality of life or as a good life differ – depending on the starting point for such considerations.

The primary purpose of medical action is to have a positive effect on the health of the patient and also to be efficient in terms of benefits and costs. Medicine assesses the number of years of life that patients gain through medical measures and the improvements in health-related quality of life as positive effects. When defining health-related quality of life, medicine follows the general, now old definition of health of the World Health Organization, according to which health has a physical, psychological and social component. Health-related quality of life can then be determined on the basis of the satisfaction people show with regard to these three components. Patient satisfaction, Today more than ever, cost-benefit calculations and efficiency requirements need to be agreed, as scarce resources require a rational allocation. Economically limited resources, new medical intervention options and the societal desire to provide “health-related quality of life for everyone” force decisions to be made about health care services as to what should be understood by improving quality of life.

When making judgments about quality of life, medicine has to leave safe ground and nevertheless tries to regain it with cost-benefit analyzes. For example, one direction in health economics evaluates health conditions in monetary units. The value of a particular health service is assessed and the service investment recommended if the health service is considered to have a net benefit.

The size of the purely monetary net benefit is either asked about the classic economic approach with determination of the willingness to pay in the population for defined improvements in health (what is it worth to you to be free from this disease?). Or the human capital approach is chosen for decision-making and a decision is made on the basis of the productivity gain that the intervention produces by reducing the incapacity for work. In determining the utility value, not only the quality of life but also the (remaining) life span. Both sizes are aggregated to a measure. The more useful a measure is, the more it leads to a life extension and an improvement in the quality of life. Death is given a utility of zero. A condition, which is worse than death cannot, by definition, be assessed as having a negative utility value. A year in optimal quality of life corresponds to a so-called QALY (quality adjusted life year). The number of QALYs with and without medical measures and thus the QALY gain or QALY loss can be determined, and the result can be expressed mathematically as a function of quality of life and remaining life.

Problems of measurement theory
The approaches represented by health economics and their instruments for assessing quality of life are controversial with regard to unsolved problems of measurement theory and the construct logic used for quality of life. Health-related quality of life is less a medically determinable condition or finding, but rather a subjective experience and feeling. Not everyone who is healthy from a medical standpoint feels good – and of course the reverse is also true.

The measurement problems that health economics has in determining health-related quality of life are reflected in the hundreds of health indices that have been created as assessment aids over the past 30 years. This ignores the old knowledge that quality cannot be quantified. If it is tried anyway, the search for the medical “gold standard” of quality of life only ends with impressionistic measurements

In view of the possibilities of modern medicine, it is generally assigned a key role when it comes to optimizing life expectancy and improving the quality of life. Doctors therefore rightly deal with the demands of society for the highest quality of life and the reality of quality of life in individual cases in their medical work. Viewpoints on what can be described as quality of life or as a good life differ – depending on the starting point for such considerations.

The primary purpose of medical action is to have a positive effect on the health of the patient and also to be efficient in terms of benefits and costs. Medicine assesses the number of years of life that patients gain through medical measures and the improvements in health-related quality of life as positive effects. When defining health-related quality of life, medicine follows the general, now old definition of health of the World Health Organization, according to which health has a physical, psychological and social component. Health-related quality of life can then be determined on the basis of the satisfaction people show with regard to these three components. Patient satisfaction, Today more than ever, cost-benefit calculations and efficiency requirements need to be agreed, as scarce resources require a rational allocation. Economically limited resources, new medical intervention options and the societal desire to provide “health-related quality of life for everyone” force decisions to be made about health care services as to what should be understood by improving quality of life.

When making judgments about quality of life, medicine has to leave safe ground and nevertheless tries to regain it with cost-benefit analyzes. For example, one direction in health economics evaluates health conditions in monetary units. The value of a particular health service is assessed and the service investment recommended if the health service is considered to have a net benefit.

The size of the purely monetary net benefit is either asked about the classic economic approach with determination of the willingness to pay in the population for defined improvements in health (what is it worth to you to be free from this disease?). Or the human capital approach is chosen for decision-making and a decision is made on the basis of the productivity gain that the intervention produces by reducing the incapacity for work. In determining the utility value, not only the quality of life but also the (remaining) life span. Both sizes are aggregated to a measure. The more useful a measure is, the more it leads to a life extension and an improvement in the quality of life. Death is given a utility of zero. A condition, which is worse than death cannot, by definition, be assessed as having a negative utility value. A year in optimal quality of life corresponds to a so-called QALY (quality adjusted life year). The number of QALYs with and without medical measures and thus the QALY gain or QALY loss can be determined, and the result can be expressed mathematically as a function of quality of life and remaining life.

Problems of measurement theory
The approaches represented by health economics and their instruments for assessing quality of life are controversial with regard to unsolved problems of measurement theory and the construct logic used for quality of life. Health-related quality of life is less a medically determinable condition or finding, but rather a subjective experience and feeling. Not everyone who is healthy from a medical standpoint feels good – and of course the reverse is also true.

The measurement problems that health economics has in determining health-related quality of life are reflected in the hundreds of health indices that have been created as assessment aids over the past 30 years. This ignores the old knowledge that quality cannot be quantified. If it is tried anyway, the search for the medical “gold standard” of quality of life only ends with impressionistic measurements.

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