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.