WHO

The economic impact of chronic illness

pnrj core principles, ethics, inequality, market failure, personal, public policy , , , , , , , , , ,

Mar 27 JDN 2459666

This topic is quite personal for me, as someone who has suffered from chronic migraines since adolescence. Some days, weeks, and months are better than others. This past month has been the worst I have felt since 2019, when we moved into an apartment that turned out to be full of mold. This time, there is no clear trigger—which also means no easy escape.

The economic impact of chronic illness is enormous. 90% of US healthcare spending is on people with chronic illnesses, including mental illnesses—and the US has the most expensive healthcare system in the world by almost any measure. Over 55% of adult Medicaid beneficiaries have two or more chronic illnesses.

The total annual cost of all chronic illnesses is hard to estimate, but it’s definitely somewhere in the trillions of dollars per year. The World Economic Forum estimated that number at $47 trillion over the next 20 years, which I actually consider conservative. I think this is counting how much we actually spend and some notion of lost productivity, as well as the (fraught) concept of the value of a statistical life—but I don’t think it’s putting a sensible value on the actual suffering. This will effectively undervalue poor people who are suffering severely but can’t get treated—because they spend little and can’t put a large dollar value on their lives. In the US, where the data is the best, the total cost of chronic illness comes to nearly $4 trillion per year—20% of GDP. If other countries are as bad or worse (and I don’t see why they would be better), then we’re looking at something like $17 trillion in real cost every single year; so over the next 20 years that’s not $47 trillion—it’s over $340 trillion.

Over half of US adults have at least one of the following, and over a quarter have two or more: arthritis, cancer, chronic obstructive pulmonary disease, coronary heart disease, current asthma, diabetes, hepatitis, hypertension, stroke, or kidney disease. (Actually the former very nearly implies the latter, unless chronic conditions somehow prevented one another. Two statistically independent events with 50% probability will jointly occur 25% of the time: Flip two coins.)

Unsurprisingly, age is positively correlated with chronic illness. Income is negatively correlated, both because chronic illnesses reduce job opportunities and because poorer people have more trouble getting good treatment. I am the exception that proves the rule, the upper-middle-class professional with both a PhD and a severe chronic illness.

There seems to be a common perception that chronic illness is largely a “First World problem”, but in fact chronic illnesses are more common—and much less poorly treated—in countries with low and moderate levels of development than they are in the most highly-developed countries. Over 75% of all deaths by non-communicable disease are in low- and middle-income countries. The proportion of deaths that is caused by non-communicable diseases is higher in high-income countries—but that’s because other diseases have been basically eradicated from high-income countries. People in rich countries actually suffer less from chronic illness than people in poor countries (on average).

It’s always a good idea to be careful of the distinction between incidence and prevalence, but with chronic illness this is particularly important, because (almost by definition) chronic illnesses last longer and so can have very high prevalence even with low incidence. Indeed, the odds of someone getting their first migraine (incidence) are low precisely because the odds of being someone who gets migraines (prevalence) is so high.

Quite high in fact: About 10% of men and 20% of women get migraines at least occasionally—though only about 8% of these (so 1% of men and 2% of women) get chronic migraines. Indeed, because ti is both common and can be quite severe, migraine is the second-most disabling condition worldwide as measured by years lived with disability (YLD), after low back pain. Neurologists are particularly likely to get migraines; the paper I linked speculates that they are better at realizing they have migraines, but I think we also need to consider the possibility of self-selection bias where people with migraines may be more likely to become neurologists. (I considered it, and it seems at least as good a reason as becoming a dentist because your name is Denise.)

If you order causes by the number of disability-adjusted life years (DALYs) they cost, chronic conditions rank quite high: while cardiovascular disease and cancer rate by far the highest, diabetes and kidney disease, mental disorders, neurological disorders, and musculoskeletal disorders all rate higher than malaria, HIV, or any other infection except respiratory infections (read: tuberculosis, influenza, and, once these charts are updated for the next few years, COVID). Note also that at the very bottom is “conflict and terrorism”—that’s all organized violence in the world—and natural disasters. Mental disorders alone cost the world 20 times as many DALYs as all conflict and terrorism combined.

What do we mean by “obesity”?

pnrj development economics, public policy , , , , , , , , , , , , , , , , ,

Nov 25 JDN 2458448

I thought this topic would be particularly appropriate for the week of Thanksgiving, since as a matter of public ritual, this time every year, we eat too much and don’t get enough exercise.

No doubt you have heard the term “obesity epidemic”: It’s not just used by WebMD or mainstream news; it’s also used by the American Heart Association, the Center for Disease Control, the World Health Organization, and sometimes even published in peer-reviewed journal articles.

This is kind of weird, because the formal meaning of the term “epidemic” clearly does not apply here. I feel uncomfortable going against public health officials in what is clearly their area of expertise rather than my own, but everything I’ve ever read about the official definition of the word “epidemic” requires it to be an infectious disease. You can’t “catch” obesity. Hanging out with people who are obese may slightly raise your risk of obesity, but not in the way that hanging out with people with influenza gives you influenza. It’s not caused by bacteria or viruses. Eating food touched by a fat person won’t cause you to catch the fat. Therefore, whatever else it is, this is not an epidemic. (I guess sometimes we use the term more metaphorically, “an epidemic of bankruptcies” or an “epidemic of video game consumption”; but I feel like the WHO and CDC of all people should be more careful.)

Indeed, before we decide what exactly this is, I think we should first ask ourselves a deeper question: What do we mean by “obesity”?

The standard definition of “obesity” relies upon the body mass index (BMI), a very crude measure that simply takes your body mass and divides by the square of your height. It’s easy to measure, but that’s basically its only redeeming quality.

Anyone who has studied dimensional analysis should immediately see a problem here: That isn’t a unit of density. It’s a unit of… density-length? If you take the exact same individual and scale them up by 10%, their BMI will increase by 10%. Do we really intend to say that simply being larger makes you obese, for the exact same ratios of muscle, fat, and bone?

Because of this, the taller you are, the more likely your BMI is going to register as “obese”, holding constant your actual level of health and fitness. And worldwide, average height has been increasing. This isn’t enough to account for the entire trend in rising BMI, but it reduces it substantially; average height has increased by about 10% since the 1950s, which is enough to raise our average BMI by about 2 points of the 5-point observed increase.

And of course BMI doesn’t say anything about your actual ratios of fat and muscle; all it says is how many total kilograms are in your body. As a result, there is a systematic bias against athletes in the calculation of BMI—and any health measure that is biased against athletes is clearly doing something wrong. All those doctors telling us to exercise more may not realize it, but if we actually took their advice, our BMIs would very likely get higher, not lower—especially for men, especially for strength-building exercise.

It’s also quite clear that our standards for “healthy weight” are distorted by social norms. Feminists have been talking about this for years; most women will never look like supermodels no matter how much weight they lose—and eating disorders are much more dangerous than being even 50 pounds overweight. We’re starting to figure out that similar principles hold for men: A six-pack of abs doesn’t actually mean you’re healthy; it means you are dangerously depleted of fatty acids.

To compensate for this, it seems like the most sensible methodology would be to figure out empirically what sort of weight is most strongly correlated with good health and long lifespan—what BMI maximizes your expected QALY.

You might think that this is what public health officials did when defining what is currently categorized as “normal weight”—but you would be wrong. They used social norms and general intuition, and as a result, our standards for “normal weight” are systematically miscalibrated.

In fact, the empirical evidence is quite clear: The people with the highest expected QALY are those who are classified as “overweight”, with BMI between 25 and 30. Those of “normal weight” (20 to 25) fare slightly worse, followed by those classified as “obese class I” (30 to 35)—but we don’t actually see large effects until either “underweight” (18.5-20) or “obese class II” (35 to 40). And the really severe drops in life and health expectancy don’t happen until “obese class III” (>40); and we see the same severe drops at “very underweight” (<18.5).
With that in mind, consider that the global average BMI increased from 21.7 in men and 21.4 in women in 1975 to 24.2 in men and 24.4 in women in 2014. That is, the world average increased from the low end of “normal weight” which is actually too light, to the high end of “normal weight” which is probably optimal. The global prevalence of “morbid obesity”, the kind that actually has severely detrimental effects on health, is only 0.64% in men and 1.6% in men. Even including “severe obesity”, the kind that has a noticeable but not dramatic effect on health, is only 2.3% in men and 5.0% in women. That’s your epidemic? Reporting often says things like “2/3 of American adults are overweight or obese”; but all that “overweight” proportion should be utterly disregarded, since it is beneficial to health. The actual prevalence of obesity in the US—even including class I obesity which is not very harmful—is less than 40%.

If obesity were the health crisis it were made out to be, we should expect that global life expectancy is decreasing, or at the very least not increasing. On the contrary, it is rapidly increasing: In 1955, global life expectancy was only 55 years, while it is now over 70.

Worldwide, the countries with the highest obesity rates are those with the longest life expectancy, because both of these things are strongly correlated with high levels of economic development. But it may not just be that: Smoking reduces obesity while also reducing lifespan, and a lot of those countries with very high obesity (including the US) have very low rates of smoking.

There’s some evidence that within the set of rich, highly-developed countries, obesity rates are positively correlated with lower life expectancy, but these effects are much smaller than the effects of high development itself. Going from the highest obesity in the world (the US, of course) to the lowest among all highly-developed countries (Japan) requires reducing the obesity rate by 34 percentage points but only increases life expectancy by about 5 years. You’d get the same increase by raising overall economic development from the level of Turkey to the level of Greece, about 10 points on the 100-point HDI scale.

 

Now, am I saying that we should all be 400 pounds? No, there does come a point where excess weight is clearly detrimental to health. But this threshold is considerably higher than you have probably been led to believe. If you are 15 or 20 pounds “overweight” by what our society (or even your doctor!) tells you, you are probably actually at the optimal weight for your body type. If you are 30 or 40 pounds “overweight”, you may want to try to lose some weight, but don’t make yourself suffer to achieve it. Only if you are 50 pounds or more “overweight” should you really be considering drastic action. If you do try to lose weight, be realistic about your goal: Losing 5% to 10% of your initial weight is a roaring success.

There are also reasons to be particularly concerned about obesity and lack of exercise in children, which is why Michelle Obama’s “Let’s Move!” campaign was a good thing.

And yes, exercise more! Don’t do it to try to lose weight (exercise does not actually cause much weight loss). Just do it. Exercise has so many health benefits it’s honestly kind of ridiculous.

But why am I complaining about this, anyway? Even if we cause some people to worry more about eating less than is strictly necessary, what’s the harm in that? At least we’re getting people to exercise, and Thanksgiving was already ruined by politics anyway.

Well, here’s the thing: I don’t think this obesity panic is actually making us any less obese.

The United States is the most obese country in the world—and you can’t so much as call up Facebook or step into a subway car in the US without someone telling you that you’re too fat and you need to lose weight. The people who really are obese and may need medical help losing weight are the ones most likely to be publicly shamed and harassed for their weight—and there’s no evidence that this actually does anything to reduce their weight. People who experience shaming and harassment for their weight are actually less likely to achieve sustained weight loss.

Teenagers—both boys and girls—who are perceived to be “overweight” are at substantially elevated risk of depression and suicide. People who more fully internalize feelings of shame about their weight have higher blood pressure and higher triglicerides, though once you control for other factors the effect is not huge. There’s even evidence that fat shaming by medical professionals leads to worse treatment outcomes among obese patients.

If we want to actually reduce obesity—and this makes sense, at least for the upper-tail obesity of BMI above 35—then we should be looking at what sort of interventions are actually effective at doing that. Medicine has an important role to play of course, but I actually think economics might be stronger here (though I suppose I would, wouldn’t I?).

Number 1: Stop subsidizing meat and feed grains. There is now quite clear evidence that direct and indirect government subsidies for meat production are a contributing factor in our high fat consumption and thus high obesity rate, though obviously other factors matter too. If you’re worried about farmers, subsidize vegetables instead, or pay for active labor market programs that will train those farmers to work in new industries. This thing we do where we try to save the job instead of the worker is fundamentally idiotic and destructive. Jobs are supposed to be destroyed; that’s what technological improvement is. If you stop destroying jobs, you will stop economic growth.

Number 2: Restrict advertising of high-sugar, high-fat foods, especially to children. Food advertising is particularly effective, because it draws on such primal impulses, and children are particularly vulnerable (as the APA has publicly reported on, including specifically for food advertising). Corporations like McDonald’s and Kellogg’s know quite well what they’re doing when they advertise high-fat, high-sugar foods to kids and get them into the habit of eating them early.

Number 3: Find policies to promote exercise. Despite its small effects on weight loss, exercise has enormous effects on health. Indeed, the fact that people who successfully lose weight show long-term benefits even if they put the weight back on suggests to me that really what they gained was a habit of exercise. We need to find ways to integrate exercise into our daily lives more. The one big thing that our ancestors did do better than we do is constantly exercise—be it hunting, gathering, or farming. Standing desks and treadmill desks may seem weird, but there is evidence that they actually improve health. Right now they are quite expensive, so most people don’t buy them. If we subsidized them, they would be cheaper; if they were cheaper, more people would buy them; if more people bought them, they would seem less weird. Eventually, it could become normative to walk on a treadmill while you work and sitting might seem weird. Even a quite large subsidy could be worthwhile: say we had to spend $500 per person per year to buy every single adult a treadmill desk each year. That comes to about $80 billion per year, which is less than one fourth what we’re currently spending on diabetes or heart disease, so we’d break even if we simply managed to reduce those two conditions by 13%. Add in all the other benefits for depression, chronic pain, sleep, sexual function, and so on, and the quality of life improvement could be quite substantial.

Nuclear power is safe. Why don’t people like it?

pnrj ethics, heuristics and biases, public policy , , , , , , , , , , , , , , , , , , , , ,

Sep 24, JDN 2457656

This post will have two parts, corresponding to each sentence. First, I hope to convince you that nuclear power is safe. Second, I’ll try to analyze some of the reasons why people don’t like it and what we might be able to do about that.

Depending on how familiar you are with the statistics on nuclear power, the idea that nuclear power is safe may strike you as either a completely ridiculous claim or an egregious understatement. If your primary familiarity with nuclear power safety is via the widely-publicized examples of Chernobyl, Three Mile Island, and more recently Fukushima, you may have the impression that nuclear power carries huge, catastrophic risks. (You may also be confusing nuclear power with nuclear weapons—nuclear weapons are indeed the greatest catastrophic risk on Earth today, but equating the two is like equating automobiles and machine guns because both of them are made of metal and contain lubricant, flammable materials, and springs.)

But in fact nuclear energy is astonishingly safe. Indeed, even those examples aren’t nearly as bad as people have been led to believe. Guess how many people died as a result of Three Mile Island, including estimated increased cancer deaths from radiation exposure?

Zero. There are zero confirmed deaths and the consensus estimate of excess deaths caused by the Three Mile Island incident by all causes combined is zero.

What about Fukushima? Didn’t 10,000 people die there? From the tsunami, yes. But the nuclear accident resulted in zero fatalities. If anything, those 10,000 people were killed by coal—by climate change. They certainly weren’t killed by nuclear.

Chernobyl, on the other hand, did actually kill a lot of people. Chernobyl caused 31 confirmed direct deaths, as well as an estimated 4,000 excess deaths by all causes. On the one hand, that’s more than 9/11; on the other hand, it’s about a month of US car accidents. Imagine if people had the same level of panic and outrage at automobiles after a month of accidents that they did at nuclear power after Chernobyl.

The vast majority of nuclear accidents cause zero fatalities; other than Chernobyl, none have ever caused more than 10. Deepwater Horizon killed 11 people, and yet for some reason Americans did not unite in opposition against ever using oil (or even offshore drilling!) ever again.

In fact, even that isn’t fair to nuclear power, because we’re not including the thousands of lives saved every year by using nuclear instead of coal and oil.

Keep in mind, the WHO estimates 10 to 100 million excess deaths due to climate change over the 21st century. That’s an average of 100,000 to 1 million deaths every year. Nuclear power currently produces about 11% of the world’s energy, so let’s do a back-of-the-envelope calculation for how many lives that’s saving. Assuming that additional climate change would be worse in direct proportion to the additional carbon emissions (which is conservative), and assuming that half that energy would be replaced by coal or oil (also conservative, using Germany’s example), we’re looking at about a 6% increase in deaths due to climate change if all those nuclear power plants were closed. That’s 6,000 to 60,000 lives that nuclear power plants save every year.

I also haven’t included deaths due to pollution—note that nuclear power plants don’t pollute air or water whatsoever, and only produce very small amounts of waste that can be quite safely stored. Air pollution in all its forms is responsible for one in eight deaths worldwide. Let me say that again: One in eight of all deaths in the world is caused by air pollution—so this is on the order of 7 million deaths per year, every year. We burn our way to a biannual Holocaust. Most of this pollution is actually caused by burning wood—fireplaces, wood stoves, and bonfires are terrible for the air—and many countries would actually see a substantial reduction in their toxic pollution if they switched to oil or even coal in favor of wood. But a large part of that pollution is caused by coal, and a nontrivial amount is caused by oil. Coal-burning factories and power plants are responsible for about 1 million deaths per year in China alone. Most of that pollution could be prevented if those power plants were nuclear instead.

Factor all that in, and nuclear power currently saves tens if not hundreds of thousands of lives per year, and expanding it to replace all fossil fuels could save millions more. Indeed, a more precise estimate of the benefits of nuclear power published a few years ago in Environmental Science and Technology is that nuclear power plants have saved some 1.8 million human lives since their invention, putting them on a par with penicillin and the polio vaccine.

So, I hope I’ve convinced you of the first proposition: Nuclear power plants are safe—and not just safe, but heroic, in fact one of the greatest life-saving technologies ever invented. So, why don’t people like them?

Unfortunately, I suspect that no amount of statistical data by itself will convince those who still feel a deep-seated revulsion to nuclear power. Even many environmentalists, people who could be nuclear energy’s greatest advocates, are often opposed to it. I read all the way through Naomi Klein’s This Changes Everything and never found even a single cogent argument against nuclear power; she simply takes it as obvious that nuclear power is “more of the same line of thinking that got us in this mess”. Perhaps because nuclear power could be enormously profitable for certain corporations (which is true; but then, it’s also true of solar and wind power)? Or because it also fits this narrative of “raping and despoiling the Earth” (sort of, I guess)? She never really does explain; I’m guessing she assumes that her audience will simply share her “gut feeling” intuition that nuclear power is dangerous and untrustworthy. One of the most important inconvenient truths for environmentalists is that nuclear power is not only safe, it is almost certainly our best hope for stopping climate change.

Perhaps all this is less baffling when we recognize that other heroic technologies are often also feared or despised for similarly bizarre reasons—vaccines, for instance.

First of all, human beings fear what we cannot understand, and while the human immune system is certainly immensely complicated, nuclear power is based on quantum mechanics, a realm of scientific knowledge so difficult and esoteric that it is frequently used as the paradigm example of something that is hard to understand. (As Feynman famously said, “I think I can safely say that nobody understands quantum mechanics.”) Nor does it help that popular treatments of quantum physics typically bear about as much resemblance to the actual content of the theory as the X-Men films do to evolutionary biology, and con artists like Deepak Chopra take advantage of this confusion to peddle their quackery.

Nuclear radiation is also particularly terrifying because it is invisible and silent; while a properly-functioning nuclear power plant emits less ionizing radiation than the Capitol Building and eating a banana poses substantially higher radiation risk than talking on a cell phone, nonetheless there is real danger posed by ionizing radiation, and that danger is particularly terrifying because it takes a form that human senses cannot detect. When you are burned by fire or cut by a knife, you know immediately; but gamma rays could be coursing through you right now and you’d feel no different. (Huge quantities of neutrinos are coursing through you, but fear not, for they’re completely harmless.) The symptoms of severe acute radiation poisoning also take a particularly horrific form: After the initial phase of nausea wears off, you can enter a “walking ghost phase”, where your eventual death is almost certain due to your compromised immune and digestive systems, but your current condition is almost normal. This makes the prospect of death by nuclear accident a particularly vivid and horrible image.

Vividness makes ideas more available to our memory; and thus, by the availability heuristic, we automatically infer that it must be more probable than it truly is. You can think of horrific nuclear accidents like Chernobyl, and all the carnage they caused; but all those millions of people choking to death in China don’t make for a compelling TV news segment (or at least, our TV news doesn’t seem to think so). Vividness doesn’t actually seem to make things more persuasive, but it does make them more memorable.

Yet even if we allow for the possibility that death by radiation poisoning is somewhat worse than death by coal pollution (if I had to choose between the two, okay, maybe I’d go with the coal), surely it’s not ten thousand times worse? Surely it’s not worth sacrificing entire cities full of people to coal in order to prevent a handful of deaths by nuclear energy?

Another reason that has been proposed is a sense that we can control risk from other sources, but a nuclear meltdown would be totally outside our control. Perhaps that is the perception, but if you think about it, it really doesn’t make a lot of sense. If there’s a nuclear meltdown, emergency services will report it, and you can evacuate the area. Yes, the radiation moves at the speed of light; but it also dissipates as the inverse square of distance, so if you just move further away you can get a lot safer quite quickly. (Think about the brightness of a lamp in your face versus across a football field. Radiation works the same way.) The damage is also cumulative, so the radiation risk from a meltdown is only going to be serious if you stay close to the reactor for a sustained period of time. Indeed, it’s much easier to avoid nuclear radiation than it is to avoid air pollution; you can’t just stand behind a concrete wall to shield against air pollution, and moving further away isn’t possible if you don’t know where it’s coming from. Control would explain why we fear cars less than airplanes (which is also statistically absurd), but it really can’t explain why nuclear power scares people more than coal and oil.

Another important factor may be an odd sort of bipartisan consensus: While the Left hates nuclear power because it makes corporations profitable or because it’s unnatural and despoils the Earth or something, the Right hates nuclear power because it requires substantial government involvement and might displace their beloved fossil fuels. (The Right’s deep, deep love of the fossil fuel industry now borders on the pathological. Even now that they are obviously economically inefficient and environmentally disastrous, right-wing parties around the world continue to defend enormous subsidies for oil and coal companies. Corruption and regulatory capture could partly explain this, but only partly. Campaign contributions can’t explain why someone would write a book praising how wonderful fossil fuels are and angrily denouncing anyone who would dare criticize them.) So while the two sides may hate each other in general and disagree on most other issues—including of course climate change itself—they can at least agree that nuclear power is bad and must be stopped.

Where do we go from here, then? I’m not entirely sure. As I said, statistical data by itself clearly won’t be enough. We need to find out what it is that makes people so uniquely terrified of nuclear energy, and we need to find a way to assuage those fears.

And we must do this now. For every day we don’t—every day we postpone the transition to a zero-carbon energy grid—is another thousand people dead.

The only thing necessary for the triumph of evil is that good people refuse to do cost-benefit analysis

pnrj core principles, critique of neoclassical economics, public policy , , , , , , , , , , , , , , , , ,

July 27, JDN 2457597

My title is based on a famous quote often attributed to Edmund Burke, but which we have no record of him actually saying:

The only thing necessary for the triumph of evil is that good men do nothing.

The closest he actually appears to have written is this:

When bad men combine, the good must associate; else they will fall one by one, an unpitied sacrifice in a contemptible struggle.

Burke’s intended message was about the need for cooperation and avoiding diffusion of responsibility; then his words were distorted into a duty to act against evil in general.

But my point today is going to be a little bit more specific: A great deal of real-world evils would be eliminated if good people were more willing to engage in cost-benefit analysis.

As discussed on Less Wrong awhile back, there is a common “moral” saying which comes from the Talmud (if not earlier; and of course it’s hardly unique to Judaism), which gives people a great warm and fuzzy glow whenever they say it:

Whoever saves a single life, it is as if he had saved the whole world.

Yet this is in fact the exact opposite of moral. It is a fundamental, insane perversion of morality. It amounts to saying that “saving a life” is just a binary activity, either done or not, and once you’ve done it once, congratulations, you’re off the hook for the other 7 billion. All those other lives mean literally nothing, once you’ve “done your duty”.

Indeed, it would seem to imply that you can be a mass murderer, as long as you save someone else somewhere along the line. If Mao Tse-tung at some point stopped someone from being run over by a car, it’s okay that his policies killed more people than the population of Greater Los Angeles.

Conversely, if anything you have ever done has resulted in someone’s death, you’re just as bad as Mao; in fact if you haven’t also saved someone somewhere along the line and he has, you’re worse.

Maybe this is how you get otherwise-intelligent people saying such insanely ridiculous things as “George W. Bush’s crimes are uncontroversially worse than Osama bin Laden’s.” (No, probably not, since Chomsky at least feigns something like cost-benefit analysis. I’m not sure what his failure mode is, but it’s probably not this one in particular. “Uncontroversially”… you keep using that word…)

Cost-benefit analysis is actually a very simple concept (though applying it in practice can be mind-bogglingly difficult): Try to maximize the good things minus the bad things. If an action would increase good things more than bad things, do it; if it would increase bad things more than good things, don’t do it.

What it replaces is simplistic deontological reasoning about “X is always bad” or “Y is always good”; that’s almost never true. Even great evils can be justified by greater goods, and many goods are not worth having because of the evils they would require to achieve. We seem to want all our decisions to have no downside, perhaps because that would resolve our cognitive dissonance most easily; but in the real world, most decisions have an upside and a downside, and it’s a question of which is larger.

Why is it that so many people—especially good people—have such an aversion to cost-benefit analysis?

I gained some insight into this by watching a video discussion from an online Harvard course taught by Michael Sandel (which is free, by the way, if you’d like to try it out). He was leading the discussion Socratically, which is in general a good method of teaching—but like anything else can be used to teach things that are wrong, and is in some ways more effective at doing so because it has a way of making students think they came up with the answers on their own. He says something like, “Do we really want our moral judgments to be based on cost-benefit analysis?” and gives some examples where people made judgments using cost-benefit analysis to support his suggestion that this is something bad.

But of course his examples are very specific: They all involve corporations using cost-benefit analysis to maximize profits. One of them is the Ford Pinto case, where Ford estimated the cost to them of a successful lawsuit, multiplied by the probability of such lawsuits, and then compared that with the cost of a total recall. Finding that the lawsuits were projected to be cheaper, they opted for that result, and thereby allowed several people to be killed by their known defective product.

Now, it later emerged that Ford Pintos were not actually especially dangerous, and in fact Ford didn’t just include lawsuits but also a standard estimate of the “value of a statistical human life”, and as a result of that their refusal to do the recall was probably the completely correct decision—but why let facts get in the way of a good argument?

But let’s suppose that all the facts had been as people thought they were—the product was unsafe and the company was only interested in their own profits. We don’t need to imagine this hypothetically; this is clearly what actually happened with the tobacco industry, and indeed with the oil industry. Is that evil? Of course it is. But not because it’s cost-benefit analysis.

Indeed, the reason this is evil is the same reason most things are evil: They are psychopathically selfish. They advance the interests of those who do them, while causing egregious harms to others.

Exxon is apparently prepared to sacrifice millions of lives to further their own interests, which makes them literally no better than Mao, as opposed to this bizarre “no better than Mao” that we would all be if the number of lives saved versus killed didn’t matter. Let me be absolutely clear; I am not speaking in hyperbole when I say that the board of directors of Exxon is morally no better than Mao. No, I mean they literally are willing to murder 20 million people to serve their own interests—more precisely 10 to 100 million, by WHO estimates. Maybe it matters a little bit that these people will be killed by droughts and hurricanes rather than by knives and guns; but then, most of the people Mao killed died of starvation, and plenty of the people killed by Exxon will too. But this statement wouldn’t have the force it does if I could not speak in terms of quantitative cost-benefit analysis. Killing people is one thing, and most industries would have to own up to it; being literally willing to kill as many people as history’s greatest mass murderers is quite another—and yet it is true of Exxon.

But I can understand why people would tend to associate cost-benefit analysis with psychopaths maximizing their profits; there are two reasons for this.

First, most neoclassical economists appear to believe in both cost-benefit analysis and psychopathic profit maximization. They don’t even clearly distinguish their concept of “rational” from the concept of total psychopathic selfishness—hence why I originally titled this blog “infinite identical psychopaths”. The people arguing for cost-benefit analysis are usually economists, and economists are usually neoclassical, so most of the time you hear arguments for cost-benefit analysis they are also linked with arguments for horrifically extreme levels of selfishness.

Second, most people are uncomfortable with cost-benefit analysis, and as a result don’t use it. So, most of the cost-benefit analysis you’re likely to hear is done by terrible human beings, typically at the reins of multinational corporations. This becomes self-reinforcing, as all the good people don’t do cost-benefit analysis, so they don’t see good people doing it, so they don’t do it, and so on.

Therefore, let me present you with some clear-cut cases where cost-benefit analysis can save millions of lives, and perhaps even save the world.

Imagine if our terrorism policy used cost-benefit analysis; we wouldn’t kill 100,000 innocent people and sacrifice 4,400 soldiers fighting a war that didn’t have any appreciable benefit as a bizarre form of vengeance for 3,000 innocent people being killed. Moreover, we wouldn’t sacrifice core civil liberties to prevent a cause of death that’s 300 times rarer than car accidents.

Imagine if our healthcare policy used cost-benefit analysis; we would direct research funding to maximize our chances of saving lives, not toward the form of cancer that is quite literally the sexiest. We would go to a universal healthcare system like the rest of the First World, and thereby save thousands of additional lives while spending less on healthcare.

With cost-benefit analysis, we would reform our system of taxes and subsidies to internalize the cost of carbon emissions, most likely resulting in a precipitous decline of the oil and coal industries and the rapid rise of solar and nuclear power, and thereby save millions of lives. Without cost-benefit analysis, we instead get unemployed coal miners appearing on TV to grill politicians about how awful it is to lose your job even though that job is decades obsolete and poisoning our entire planet. Would eliminating coal hurt coal miners? Yes, it would, at least in the short run. It’s also completely, totally worth it, by at least a thousandfold.

We would invest heavily in improving our transit systems, with automated cars or expanded rail networks, thereby preventing thousands of deaths per year—instead of being shocked and outraged when an automated car finally kills one person, while manual vehicles in their place would have killed half a dozen by now.

We would disarm all of our nuclear weapons, because the risk of a total nuclear apocalypse is not worth it to provide some small increment in national security above our already overwhelming conventional military. While we’re at it, we would downsize that military in order to save enough money to end world hunger.

And oh by the way, we would end world hunger. The benefits of doing so are enormous; the costs are remarkably small. We’ve actually been making a great deal of progress lately—largely due to the work of development economists, and lots and lots of cost-benefit analysis. This process involves causing a lot of economic disruption, making people unemployed, taking riches away from some people and giving them to others; if we weren’t prepared to bear those costs, we would never get these benefits.

Could we do all these things without cost-benefit analysis? I suppose so, if we go through the usual process of covering of our ears whenever a downside is presented and amplification whenever an upside is presented, until we can more or less convince ourselves that there is no downside even though there always is. We can continue having arguments where one side presents only downsides, the other side presents only upsides, and then eventually one side prevails by sheer numbers, and it could turn out to be the upside team (or should I say “tribe”?).

But I think we’d progress a lot faster if we were honest about upsides and downsides, and had the courage to stand up and say, “Yes, that downside is real; but it’s worth it.” I realize it’s not easy to tell a coal miner to his face that his job is obsolete and killing people, and I don’t really blame Hillary Clinton for being wishy-washy about it; but the truth is, we need to start doing that. If we accept that costs are real, we may be able to mitigate them (as Hillary plans to do with a $30 billion investment in coal mining communities, by the way); if we pretend they don’t exist, people will still get hurt but we will be blind to their suffering. Or worse, we will do nothing—and evil will triumph.