Thursday, August 17, 2006

Over 50? - No Flu Vaccine for you!

Is this good social policy? :

The question is raised in a provocative report by two government scientists about who should get scarce medical resources. They argue that the standard policy for flu vaccinations that favors older men and women over younger adults should be changed in preparation for a possible pandemic of avian flu.

Ordinarily, people over 65 and those who have chronic illnesses are given priority. As a group, they are the most vulnerable. Protecting the most vulnerable saves the most lives.

But avian flu is not an ordinary flu. Chances are, it will never turn into a global catastrophe, but if it did, some researchers speculate that it could lead to 90 million cases and 1.9 million deaths. There is no way to manufacture enough vaccine in time to protect everyone in the United States. So who should get the potentially lifesaving vaccine?

"This is a tragic choice," says bioethicist Ezekiel J. Emanuel at the National Institutes of Health, who with his colleague Alan Wertheimer suggested an alternative policy in a report in the May 12 edition of Science magazine.

Both the rebel authors and the traditionalists (that is, the government's National Vaccine Advisory Committee and the Advisory Committee on Immunization Practices) would give top priority to those working to manufacture and distribute the vaccine and to front-line health care professionals. And both would give preference to key government leaders. The fight is over what's left for the general public.

The rebels challenge the principle of saving the most lives. What about saving people with the most years yet to live?

Their formula is based on the principle that all people deserve the chance to live out their lives and grow old -- especially teenagers and young adults who have survived childhood and face many decades ahead. Twenty-year-olds, for example, are more "valued than 1-year-olds because the older individuals have more developed interests, hopes and plans but have not had an opportunity to realize them," write the authors.

Presumably, really older individuals -- those over 65 -- have had all the opportunities they need to realize their hopes and plans and interests -- so they are less valued than 20-year-olds.

In the new formula, the winning age cohort in the vaccine rationing sweepstakes would be healthy people 13 to 40. Next in line would be those 7 to 12 and people 41 to 50. After 50, forget it!

1 comment:

Kevin T. Keith said...

In technical terms, they are seeking to maximize life-years saved, with an adjustment to favor maximal opportunity for preference satisfaction. (This is different from "Quality-Adjusted Life Years", but incorporates a similar ethos - maximizing what is good in people's lives rather than mere numbers of lives or numbers of years.) I'm a bit surprised that their main age range is as wide as it is (and very depressed that I'm just outside of it - suggesting that my opportunities for preference satisfaction are now on a downhill slope!), as well as by the fact that their cutoff point eliminates over 27% of the US population (12.3% of males and 15.0% of females). But what is really interesting is that they are coming out publicly with a recommendation to rank lives by quantitative expected benefit from treatment - a proposition that (as seen in the debate over QALYs) has usually met with great resistance.

This proposal may be better received than QALYs because the quantitative unit - expected life years - is objective, and is not further adjusted by subjective factors like "expected quality". To be really precise in their recommendation to maximize opportunity for achieving life plans, however, they would have to evaluate each person's true "opportunity" - how likely it is that that person really can achieve their own goals. Blanket equal treatment of all persons in a given age range assumes that, for instance, all 30 year olds have significantly better "opportunity" than all 50 year olds and all 12 year olds, but not better than any 13 year olds. For that matter, it assumes that all 13 year olds have the same opportunity to achieve their life goals, and that that is precisely equal to the opportunity enjoyed by all 39 year olds. These assumptions are clearly false, and appear to have been made either unthinkingly or, perhaps more likely, to avoid the consequences of bringing social inequalities into the opportunity-probability calculation (where in fact they are certainly highly relevant, though distasteful, factors).

What this policy amounts to is a partial move in the direction of maximal preference-satisfaction utility, with the utility function "rounded off" by lumping large swaths of the population into presumed equal-benefit cohorts and ignoring differences between groups or individuals at any finer level of detail. That's a very different approach to such problems from what is commonly seen, and it may make a lot of sense, but it's not without its "interesting" features.