QALY-based cost-effectiveness analysis is often justified as a tool to help decision-makers maximize the health gains possible given a constrained health sector budget. Any decision made solely on the basis of maximizing health gains across an entire population is one that implicitly givens an equal weight to one QALY gained regardless of who gains it. This a QALY is a QALY assumption can only be valid for decision-making if society has no desire to give additional weight for QALYs that accure to certain groups of people