‘Valuing Health: Well-being, Freedom, and Suffering’ by Daniel M. Hausman (Oxford University Press, 2015).
Why measure health? This book begins with this fundamental question and addresses why professionals are interested in seeking a measurement for health. For those involved in the medical humanities, understanding these motivations can be difficult as they are embedded in long standing academic and policy debates over several disciplines. Hausman frames the answer to this question in terms of the clinical, epidemiological, and allocational (allocation of health-related resources), with an emphasis the demands that each of these categorical views have on health measures. For example, the clinical is concerned with the efficacy of treatments for individual patients, as well as the side effects of alternative treatments over time. The epidemiological category is concerned with how generic health measurements guide health policy and health research as well as how these policies infringe on the ethical concerns of people within different cultures. Lastly, the allocational category demands the quantification of generic health in order to discriminate among policies so that they do not deviate too much from local values. In effect, these demands are not the same and in fact conflict can arise, to which point he drops the clinical concerns for a generic health measurement all together and focuses on the two remaining categories throughout the remainder of the book. Chapter 2 sets the stage for several subsequent chapters in that it sets out to provide a definition of health ‘so that its measures informs us both about its quantity and about its policy significance’ (p. 7) while also addressing previous attempts at defining health. In exploring various definitions, Hausman argues that what connects health and health measurement is not so clear-cut and that what is at issue is how measurement evaluations sustain ‘what people care about’ (p. 17). Chapters 3, 4 and 5 go into greater depth to point out the missing aspect of values of health with respect to current policy and tools, such as the Health Utilities Index Mark 3 (HUI (3)), the EQ-5D and the Global Burden of Disease Study 2010 (GBD 2010), used as a generic measurement of health.
Up to this point, Hausman questions and clarifies the purposes and outcomes of the history of the generic measurement of health in a clear and logical manner. Throughout, he points out the need to address the explicit values involved in measuring health. In Chapter 6, Hausman stretches the discussion by arguing that health can be valued as integral to and the cause of well-being. The two are connected in a fundamental way and this chapter investigates this connection in detail. For those in the medical humanities exploring the connection between health and well-being this discussion can offer in-depth insight on how to negotiate these two concepts. For instance, Haussman critiques the Quality-adjusted life year (QALYs) method (a measurement of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life) and how this is seen to be effective in operationalizing this connection between health and well-being. Building on essential points made in Chapter 6, the subsequent chapters (7, 8, and 9) go into greater detail of the debates surrounding the measurements used in valuing health, health states, preferences and subjective evaluation. In the context of ‘subjective evaluation’ (the measurement of health and health states in terms of subjective experience), Hausman points out how ‘[…] it is important to recognise that subjective states have a dual relationship to well-being: they are among the constituents of well-being, and they are indicators of well-being’ (p. 105). For those working in well-being this suggests that it is useful and even necessary to be clear about which aspect of the subjective evaluation of well-being your research is focused on: the constituents, such as happiness, or the indicators, such as opinions. Hausman ends Chapter 9 with a warning, ‘[…] perhaps we should reconsider whether health should be measured by its impact on well-being’ (p. 119).
In response to his own warning, Haussman dedicates Chapters 10, 11, and 12 to the question of the why and how of measuring health and its impact on well-being. First he addresses his provocation as to whether or not well-being can be measured and then he proposes a possible solution as a ranking of alternatives from the actions of individuals to their identities, as well as their judgements and feelings. This is a fruitful discussion for those interested in well-being from a Medical Humanities approach. In a sense, he substantiates what constitutes the necessarily important location of the factors of well-being for research, for example in mapping actions, identities, judgements and feelings. While this can be seen as broad, these factors are prevalent for many researchers in the medical humanities from literature to history to sociology. Recognising the deeply flawed nature of the practical methods for measuring well-being, Haussman argues that ‘identifying health with well-being has seriously mistaken (and harmful) implications concerning disabilities’ (p. 145).
The remaining chapters are quite explicit in addressing these debates and arguments for measurement of health in relation to well-being in the following relation to public value (Chapter 13), the public value of health states (Chapter 14), population health (Chapter 15), health policy (Chapter 16) and public policy (Chapter 17). The examples employed in these chapters are real world, ethical and practical considerations that allow one to easily follow his arguments. In the end, he concludes that no measure is perfect; all have inherent flaws, however, he suggests a measure is better than no measure in terms of the epidemiological and allocational categories introduced in the beginning of the book. Similarly, what guidance these measures can provide for policy is guidance that is better than having no guidance at all. His considerations are ethical and concise. If you are grappling with ways in which to consider ethical considerations of certain health conditions and how they can be contextualised alongside policy, these chapters will help to illuminate these research challenges.
Much of what Hausman discusses throughout these chapters is useful for the medical humanities. For instance, a useful aspect of this book is the very nature of his thorough investigation of the debates surrounding the measurement of health and the impact on measurement of well-being. For scholars in the medical humanities this can provide a deeply rooted introduction to these debates. Furthermore, by questioning whether or not well-being can be measured, Hausman gets to the heart of many debates currently taking place in conferences and workshops throughout higher education and organisations responsible for creating effective policy in the healthcare sector. In attending these meetings, it is becoming increasingly clear that to be involved in the study of well-being as a medical humanities scholar, it will be necessary to at least be familiar with, if not involved in, these debates. If that is where you stand in your work, then this book is a good place to start.
Reviewed by Dr Dori Beeler, who came to Durham in 2010 to study Anthropology. In 2012 she became familiar with the Centre for Medical Humanities and since then her research interests have expanded and include: well-being, health and illness, ethics, Complementary and Alternative Medicine, boundary work, phenomenology, the body and ethnography. Dori received an MA in Socio-Cultural Anthropology (2011) and a PhD in Medical Anthropology (2015) at Durham University. Her PhD research involves Complementary and Alternative Medicine, with an emphasis on the ethnographic study of Reiki practice within Britain and the intersection between spiritual practice and well-being.
Correspondence to Dr Dori Beeler.