The quality-adjusted life year is utilitarianism operationalised: one year in full health equals one QALY, and cost per QALY lets a hip replacement be compared with a cancer drug. You are the committee. Set the budget and the threshold — then move the four switches that look technical and are actually value judgements, and watch the funded list rearrange itself.
1 · The arithmetic
Annual budget
£45m
Cost-per-QALY threshold
£30k
NICE reference range
2 · The four buried judgements
Weights from the general publicWhose rating of life with an impairment sets the quality weight?
Future QALYs undiscountedIs a healthy year forty years from now worth as much as one next year?
Carers and family excludedDoes well-being outside the patient’s own body count in the total?
No equity weightingShould a QALY going to someone worse off count for more than one going to someone flourishing?