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The use of the Quality Adjusted Life-Year (QALY) as a measure of the benefit obtainedfrom health care expenditure has been attacked on the ground that it gives a lower value to preserving the lives ofpeople with a permanent disability or illness than to preserving the lives of those who are healthy and not disabled. We can all agree that when we spend money from the public purse on health care, we should try to get value for money. But there the agreement stops. What is value for money in health care? The outcomes of health care expenditure are so diverse that we need a common standard by which to compare them. The most promising common standard, many believe, is the Quality Adjusted LifeYear, or QALY. In essence, this standard says that the value we get from spending money on health care can be measured in terms of the number of years of life gained, as long as we provide an appropriate rate of discount for periods in which, as a result of ill-health or disability, the quality of life is poor. Several techniques have been used to establish the appropriate rate of discount. The most direct of these, the time trade-off, asks people how long a

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