Valuing harm without devaluing the harmed

June 9 JDN 2458644

In last week’s post I talked about the matter of “putting a value on a human life”. I explained how we don’t actually need to make a transparently absurd statement like “a human life is worth $5 million” to do cost-benefit analysis; we simply need to ask ourselves what else we could do with any given amount of money. We don’t actually need to put a dollar value on human lives; we need only value them in terms of other lives.

But there is a deeper problem to face here, which is how we ought to value not simply life, but quality of life. The notion is built into the concept of quality-adjusted life-years (QALY), but how exactly do we make such a quality adjustment?

Indeed, much like cost-benefit analysis in general or the value of a statistical life, the very concept of QALY can be repugnant to many people. The problem seems to be that it violates our deeply-held belief that all lives are of equal value: If I say that saving one person adds 2.5 QALY and saving another adds 68 QALY, I seem to be saying that the second person is worth more than the first.

But this is not really true. QALY aren’t associated with a particular individual. They are associated with the duration and quality of life.

It should be fairly easy to convince yourself that duration matters: Saving a newborn baby who will go on to live to be 84 years old adds an awful lot more in terms of human happiness than extending the life of a dying person by a single hour. To call each of these things “saving a life” is actually very unequal: It’s implying that 1 hour for the second person is worth 84 years for the first.

Quality, on the other hand, poses much thornier problems. Presumably, we’d like to be able to say that being wheelchair-bound is a bad thing, and if we can make people able to walk we should want to do that. But this means that we need to assign some sort of QALY cost to being in a wheelchair, which then seems to imply that people in wheelchairs are worth less than people who can walk.

And the same goes for any disability or disorder: Assigning a QALY cost to depression, or migraine, or cystic fibrosis, or diabetes, or blindness, or pneumonia, always seems to imply that people with the condition are worth less than people without. This is a deeply unsettling result.

Yet I think the mistake is in how we are using the concept of “worth”. We are not saying that the happiness of someone with depression is less important than the happiness of someone without; we are saying that the person with depression experiences less happiness—which, in this case of depression especially, is basically true by construction.

Does this imply, however, that if we are given the choice between saving two people, one of whom has a disability, we should save the one without?

Well, here’s an extreme example: Suppose there is a plague which kills 50% of its victims within one year. There are two people in a burning building. One of them has the plague, the other does not. You only have time to save one: Which do you save? I think it’s quite obvious you save the person who doesn’t have the plague.

But that only relies upon duration, which wasn’t so difficult. All right, fine; say the plague doesn’t kill you. Instead, it renders you paralyzed and in constant pain for the rest of your life. Is it really that far-fetched to say that we should save the person who won’t have that experience?

We really shouldn’t think of it as valuing people; we should think of it as valuing actions. QALY are a way of deciding which actions we should take, not which people are more important or more worthy. “Is a person who can walk worth more than a person who needs a wheelchair?” is a fundamentally bizarre and ultimately useless question. ‘Worth more’ in what sense? “Should we spend $100 million developing this technology that will allow people who use wheelchairs to walk?” is the question we should be asking. The QALY cost we assign to a condition isn’t about how much people with that condition are worth; it’s about what resources we should be willing to commit in order to treat that condition. If you have a given condition, you should want us to assign a high QALY cost to it, to motivate us to find better treatments.

I think it’s also important to consider which individuals are having QALY added or subtracted. In last week’s post I talked about how some people read “the value of a statistical life is $5 million” to mean “it’s okay to kill someone as long as you profit at least $5 million”; but this doesn’t follow at all. We don’t say that it’s all right to steal $1,000 from someone just because they lose $1,000 and you gain $1,000. We wouldn’t say it was all right if you had a better investment strategy and would end up with $1,100 afterward. We probably wouldn’t even say it was all right if you were much poorer and desperate for the money (though then we might at least be tempted). If a billionaire kills people to make $10 million each (sadly I’m quite sure that oil executives have killed for far less), that’s still killing people. And in fact since he is a billionaire, his marginal utility of wealth is so low that his value of a statistical life isn’t $5 million; it’s got to be in the billions. So the net happiness of the world has not increased, in fact.

Above all, it’s vital to appreciate the benefits of doing good cost-benefit analysis. Cost-benefit analysis tells us to stop fighting wars. It tells us to focus our spending on medical research and foreign aid instead of yet more corporate subsidies or aircraft carriers. It tells us how to allocate our public health resources so as to save the most lives. It emphasizes how vital our environmental regulations are in making our lives better and longer.

Could we do all these things without QALY? Maybe—but I suspect we would not do them as well, and when millions of lives are on the line, “not as well” is thousands of innocent people dead. Sometimes we really are faced with two choices for a public health intervention, and we need to decide which one will help the most people. Sometimes we really do have to set a pollution target, and decide just what amount of risk is worth accepting for the economic benefits of industry. These are very difficult questions, and without good cost-benefit analysis we could get the answers dangerously wrong.

How much should we value statistical lives?

June 9 JDN 2458644

The very concept of putting a dollar value on a human life offends most people. I understand why: It suggests that human lives are fungible, and also seems to imply that killing people is just fine as long as it produces sufficient profit.

In next week’s post I’ll try to assuage some of those fears: Saying that a life is worth say $5 million doesn’t actually mean that it’s justifiable to kill someone as long as it pays you $5 million.

But for now let me say that we really have no choice but to do this. There are a huge number of interventions we could make in the world that all have the same basic form: They could save lives, but they cost money. We need to be able to say when we are justified in spending more money to save more lives, and when we are not.

No, it simply won’t do to say that “money is no object”. Because money isn’t just money—money is human happiness. A willingness to spend unlimited amounts to save even a single life, if it could be coherently implemented at all, would result in, if not complete chaos or deadlock, a joyless, empty world where we all live to be 100 by being contained in protective foam and fed by machines. It may be uncomfortable to ask a question like “How many people should we be willing to let die to let ourselves have Disneyland?”; but if that answer were zero, we should not have Disneyland. The same is true for almost everything in our lives: From automobiles to chocolate, almost any product you buy, any service you consume, has resulted in some person’s death at some point.

And there is an even more urgent reason, in fact: There are many things we are currently not doing that could save many lives for very little money. Targeted foreign aid or donations to top charities could save lives for as little as $1000 each. Foreign aid is so cost-effective that even if the only thing foreign aid had ever accomplished was curing smallpox, it would be twice as cost-effective as the UK National Health Service (which is one of the best healthcare systems in the world). Tighter environmental regulations save an additional life for about $200,000 in compliance cost, which is less than we would have spent in health care costs; the Clean Air Act added about $12 trillion to the US economy over the last 30 years.

Reduced military spending could literally pay us money to save people’s lives—based on the cost of the Afghanistan War, we are currently paying as much as $1 million per person to kill people that we really have very little reason to kill.

Most of the lives we could save are statistical lives: We can’t point to a particular individual who will or will not die because of the decision, but we can do the math and say approximately how many people will or will not die. We know that approximately 11,000 people will die each year if we loosen regulations on mercury pollution; we can’t say who they are, but they’re out there. Human beings have a lot of trouble thinking this way; it’s just not how our brains evolved to work. But when we’re talking about policy on a national or global scale, it’s quite simply the only way to do things. Anything else is talking nonsense.

Standard estimates of the value of a statistical life range from about $4 million to $9 million. These estimates are based on how much people are willing to pay for reductions in risk. So for instance if people would pay $100 to reduce their chances of dying by 0.01%, we divide the former by the latter to say that a life is worth about $1 million.

It’s a weird question: You clearly can’t just multiply like that. How much would you be willing to accept for a 100% chance of death? Presumably there isn’t really such an amount, because you would be dead. So your willingness-to-accept is undefined. And there’s no particular reason for it to be linear below that: Since marginal utility of wealth is decreasing, the amount you would demand for a 50% chance of death is a lot more than 50 times as much as what you would demand for a 1% chance of death.
Say for instance that utility of wealth is logarithmic. Say your currently lifetime wealth is $1 million, and your current utility is about 70 QALY. Then if we measure wealth in thousands of dollars, we have W = 1000 and U = 10 ln W.

How much would you be willing to accept for a 1% chance of death? Your utility when dead is presumably zero, so we are asking for an amount m such that 0.99 U(W+m) = U(W). 0.99 (10 ln (W+m)) = 10 ln (W) means (W+m)^0.99 = W, so m = W^(1/0.99) – W. We started with W = 1000, so m = 72. You would be willing to accept $72,000 for a 1% chance of death. So we would estimate the value of a statistical life at $7.2 million.

How much for a 0.0001% chance of death? W^(1/0.999999)-W = 0.0069. So you would demand $6.90 for such a risk, and we’d estimate your value of a statistical life at $6.9 million. Pretty close, though not the same.

But how much would you be willing to accept for a 50% chance of death? W^(1/0.5) – W = 999,000. That is, $999 million. So if we multiplied that out, we’d say that your value of a statistical life has now risen to a staggering (and ridiculous) $2 billion.

Mathematically, the estimates are more consistent if we use small probabilities—but all this assumes that people actually know their own utility of wealth and calculate it correctly, which is a very unreasonable assumption.

The much bigger problem with this method is that human beings are terrible at dealing with small probabilities. When asked how much they’d be willing to pay to reduce their chances of dying by 0.01%, most people probably have absolutely no idea and may literally just say a random number.

We need to rethink our entire approach for judging such numbers. Honestly we shouldn’t be trying to put a dollar value on a human life; we should be asking about the dollar cost of saving a human life. We should be asking what else we could do with that money. Indeed, for the time being, I think the best thing to do is actually to compare lives to lives: How many lives could we save for this amount of money?

Thus, if we’re considering starting a war that will cost $1 trillion, we need to ask ourselves: How many innocent people would die if we don’t do that? How many will die if we do? And what else could we do with a trillion dollars? If the war is against Nazi Germany, okay, sure; we’re talking about killing millions to save tens of millions. But if it’s against ISIS, or Iran, those numbers don’t come out so great.

If we have a choice between two policies, each of which will cost $10 billion, and one of them will save 1,000 lives while the other will save 100,000, the obvious answer is to pick the second one. Yet this is exactly the world we live in, and we’re not doing that. We are throwing money at military spending and tax cuts (things that many not save any lives at all) and denying it from climate change adaptation, foreign aid, and poverty relief.

Instead of asking whether a given intervention is cost-effective based upon some notion of a dollar value of a human life, we should be asking what the current cost of saving a human life is, and we should devote all available resources into whatever means saves the most lives for the least money. Most likely that means some sort of foreign aid, public health intervention, or poverty relief in Third World countries. It clearly does not mean cutting taxes on billionaires or starting another war in the Middle East.

Just how poor is poor?

June 2 JDN 2458637

In last week’s post I told you about the richest of the rich, the billionaires with ten, eleven, or even twelve-figure net wealth. My concern about them is only indirect: I care that we have concentrated so many of the resources of our society into this handful of people instead of spreading it around where it would do more good. But it is not inherently bad for billionaires to exist; all other things equal, people having more wealth is good.

Today my topic is the poorest of the poor. Their status is inherently bad. No one deserves it, and while for much of history we may have been powerless to prevent it, we are no longer. We could help these people—quite substantially quite cheaply, as you’ll see—and we are simply choosing not to. Perhaps you as an individual are not making this choice; perhaps, like me, you vote for candidates who support international aid and donate to top-rated international charities. But as a society, we are making this choice. Voters in the First World could all agree—or even 51% agree—that this problem really should be fixed, and we could fix it.

If asked, most people would say they care about world hunger, but either they are deeply ignorant about the solutions we now have availble to us, or they can’t really care about world hunger, or they would have voted for politicians who were committed to actually implementing the spending necessary to fix it. Maybe people would prefer to fix world hunger as long as it didn’t cost them a cent; but ask them to pay even a little bit, and suddenly they’re not so sure.

At current prices, the official UN threshold for “extreme poverty” is $1.90 in real consumption per person per day. I want to be absolutely clear about this: This is adjusted for inflation and local purchasing power. They account for all consumption, including hunting, fishing, gathering, and goods made at home or obtained through bartering. This is not an artifact of failing to adjust for prices or not including goods that aren’t bought with money. These people really do live on less than $700 per year.

Shockingly, they are not all in Third World countries. While the majority of what we call “poverty” in the United States is well above the standard of living of UN “extreme poverty”, there are exceptions to this; there are about 5 million people in the US who are genuinely so poor that they are accurately categorized as at or near that $1.90 per day threshold.

This is such a shocking and horrifying truth that many people will try to deny it, as at least one libertarian think-tank did in a propagandistic screed. No, the UN isn’t lying; it’s really that bad. Extreme poverty in the US could be fixed so quickly, so easily that the fact that it remains in place can only be called an atrocity. Change a few numbers in the IRS code, work out a payment distribution system to reach people without bank accounts using cash or mobile payments, and by the end of the year you would have ended extreme poverty in the United States with no more than a few billion dollars diverted—which is to say, an amount that Jeff Bezos himself could afford to pay, or an amount that could be raised by a single percentage point of capital gains tax applied to billionaires only.
Even so, life is probably better for a homeless person on the street in New York City than it is for a child with malaria whose parents died in civil war in Congo. The New Yorker has access to clean water via drinking fountains, basic sanitation via public toilets (particularly in government buildings, since private businesses often specifically try to exclude the homeless), and basic nutrition via food banks and soup kitchens. The Congolese child has none of these things.

Life for the very poorest is a constant struggle for survival, against disease, malnutrition, dehydration, and parasites. Forget having a refrigerator or a microwave (as most of the poor in the US do, and rightly so—these things are really cheap here); they often have little clothing and no reliable shelter. The idea of going to a school or seeing a doctor sounds like a pipe dream. Surprisingly, there is a good chance that they or someone they know has a smartphone; if so it is likely their most prized possession. Though in Congo in particular, smartphones are relatively rare, which is ironic because the most critical raw material for smartphones—tantalum—is quite prevalent in Congo and a major source of conflict there.

Such a hard life is also typically a short one. The average life expectancy in Congo is less than 65 years. This is mainly due to the fact that almost 15% of children will die before the age of five, though fortunately infant and child mortality in Congo is rapidly declining (though that means it used to be worse than this!).

A disease that is merely inconvenient in a rich country is often fatal in a poor one; malaria is the classic example of this. Malaria remains the cause of over one million deaths per year, but essentially no one dies of malaria in First World countries. It can be treated with quinine, which costs no more than $3 per pill. But when your total consumption is $1.50 per day, a $3 pill is still prohibitively expensive. While in rich countries antibiotic-resistant tuberculosis is a real danger, for the world’s poorest people it doesn’t much matter if the bacteria are resistant to antibiotics, because nobody can afford antibiotics.

What could we do to save these people? A great deal, as it turns out.

Ending extreme poverty worldwide wouldn’t be as easy as ending it in the United States; there’s no central taxation authority that would let us simply change a few numbers and then start writing checks.
We could implement changes through either official development aid or by supporting specific vetted non-governmental organizations, but each of these options carries drawbacks. Development aid can be embezzled by corrupt governments. NGOs can go bankrupt or have their assets expropriated.

Yet even with such challenges in mind, the total cost to end extreme poverty—not all poverty, but extreme poverty—worldwide is probably less than $200 billion per year. This is not a small sum, but it is well within our means. This is less than a third of the US military budget (not counting non-DoD military spending!), or about half what the US spends on gasoline.

Frankly I think we could safely divert that $200 billion directly from military spending without losing any national security. 21st century warfare is much less about blowing up targets and much more about winning hearts and minds. Ending world hunger would win an awful lot of hearts and minds, methinks. Obviously we can’t eliminate all military spending; those first two or three aircraft carrier battle groups really are keeping us and our allies safer. Did we really need eleven?

But all right, suppose we did need to raise additional tax revenue to fund this program. How much would taxes have to go up? Let’s say that only First World countries pay, which we can approximate using the GDP of the US and the EU (obviously we could also include Canada and Australia, but we might not want to include some of Eastern Europe, so that roughly balances out). Add up the $19 trillion of European Union GDP and $21 trillion of US GDP together and you get $40 trillion per year; $200 billion is only 0.5% of that. We would only need to raise taxes by half a percentage point to fund this program. Even if we didn’t make the tax progressive (and why wouldn’t we?), a typical family making $60,000 per year would only need to pay an extra $300 per year.

Why aren’t we doing this?

This is a completely serious question. Feel free to read it in an exasperated voice. I honestly would like to know why the world is willing to leave so many people in so much suffering when we could save them for such little cost.