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July 19, 2009

Is the death of the young more tragic than that of the old?

The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved, rather than simply the number of lives saved.

Why We Must Ration Health Care

Our genes make us find tragedy in deaths where people are closer to their peak productivity. The deaths of 17 year old woman are more tragic than a 47 year old or 7 year old female. This instinct looks somewhat similar to the number of life years saved measure. However, the measure of life-years saved overvalues very young people. Which may make sense. Society has an enormous amount invested in those in their teens to late twenties and has received very little return on that investment. It is far from clear to me that just maximizing the number of years that people can live as a result of dollars of treatment makes sense. Maybe we need fertility or productivity enhanced life years.

What you scream, that's not just! But if a surgeon can work for another 10 years and does a million dollars worth of irreplaceable surgery in each of those years, and faces a 50% tax rate, then treating him better than others may easily be compatible with taking the best care of the least fortunate in our society. He's contributing on the order of five million in taxes and the sick get their surgery.

This measure if taken literally discriminated against men and probably against minorities who live shorter lives. Singer has probably addressed this elsewhere but I didn't see it in the article. That's going to persist even if you switch to quality adjusted life years as your measure. Switching to fertility or economic productivity adjusted years would put the decriminalization in favor of the high earning and double marriage having white men. I don't see a measure that doesn't capture an unfairness for one group or another.

Health care does more than save lives: it also reduces pain and suffering. How can we compare saving a person’s life with, say, making it possible for someone who was confined to bed to return to an active life? We can elicit people’s values on that too. One common method is to describe medical conditions to people — let’s say being a quadriplegic — and tell them that they can choose between 10 years in that condition or some smaller number of years without it. If most would prefer, say, 10 years as a quadriplegic to 4 years of nondisabled life, but would choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life or 10 years with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life. (These are hypothetical figures, chosen to keep the math simple, and not based on any actual surveys.) If that judgment represents a rough average across the population, we might conclude that restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.

This is not a sound way of evoking quality adjusted life year valuations. You cannot ask the non-disabled to rate how they would rate their lives while disabled while making public policy. They have no idea what it is like to live with a disability and may well not know anyone who does. They also may not be seriously thinking about the alternative of a painful death. The disabled rate their lives much higher than we might be inclined to. For example, [c]hildren with cerebral palsy rate their quality of life similar to that of children in the general population..

Posted by OneEyedMan at July 19, 2009 9:32 AM

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