Is it that there is a difference between how you apply QUALYs to populations
and their subgroups, and how you apply them, or try to apply them, to
individuals? In particular when you are dealing with individuals you are
dealing with a type of consent and decision making which cannot be reproduced
in the same and unconditional way on a population basis. In individual cases
QUALYs aren't the only or the best decision making tool.
Consider the language you use in your example:
"Most members of the public would I think prefer to be in full health than
paralysed from the waist down" might well be true - but A and/or B may be in
the minority of the population.
A clinician confronted with this hypothetical dilema, would, should or could
explain the situation and prognosis in full to both A and B. It only then
becomes a dilema if, when fully informed, both A and B want treatment. In many
cases either A or B - especially where there is an emotional or famillial
attachment between the two - may withold their consent and the dilema
A and B may both have the right to be treated, but they also have the right to
withold consent to treatment. If after explanation both A and B continue to
demand treatment then a much more detailed impact assement/judgement of their
individual cases would need to be made. In the UK would this happen in a court
If for any reason this could not be done, then the fairest way to allocate the
treatment would be by lot, not by the creation of spurious or arbitrary
criteria of "health" which override all others. The simple equation of
physical impairment with health implied in your example doesn't work, and is
A (say a creative genius) physically impaired is not necessarilly
better/healthier/more worthwhile than B (say a genocidal politician) able
What's more interesting is that I have met people for whom impairment was a
positive life changing experience. These are people who would not necessarily
accept the validity of the statement that A abled bodied is better than A
impaired, and I think I would agree with them.
The reason that this is interesting is that this is in fact the thinking
behind the reason that "most people" would say that remaining able bodied is
better than becoming impaired.
The problem may lie not with using quality of life as a determinant of public
policy or clinical judgment, but in having a well-rounded and ethically
competent understanding of life quality and its relationship with quantity of
health, happiness and physical ability.