We Americans like to pride ourselves in our belief that we hold human life to be precious and will go to enormous lengths to save a life. Many times we see Americans insinuate their superiority over other cultures because we hold the individual to be so valuable, and they hold human life cheap (in the opinion of the speaker).
This belief in the sanctity of human life is partly true and partly sham. In some cases, we go to ridiculous extremes to save a life. Consider the case some years back of the woman who was brain dead but some people didn't want to pull the plug. Even Congress got into the brouhaha by passing an absurd ad hoc law to save the life of the woman. The whole country had conniptions over the issue of saving the life of one brain-dead woman.
We do much the same when it comes to the final stages of life. We spend enormous amounts of money on medical care to provide old sick people with a few more months of life. It's a terrible waste, and it's one reason why our health care costs are so high.
However, Americans are hypocrites on this question. While mouthing all the sanctimonious pap about the infinite value of a human life, they turn around and kill people or let people die for trivial reasons. Let me list some examples:
1. The death penalty. If life is so precious, why kill people?
2. "Collateral damage". Whenever we execute a military operation, innocents die. We shrug our shoulders and say "Oh, well, too bad, it was unavoidable." But it was avoidable -- all we had to do was refrain from executing the military operation. If life is so precious, why do we use our military when we know that it will surely kill innocents?
3. The bloodthirsty rhetoric of some conservatives. Now, perhaps they are entirely consistent, rejecting the notion that human life is precious while calling for the elimination of various bad people. I don't know. But the likelihood is that there is some hypocrisy here.
4. The refusal to spend money to help save foreign lives.
Here we come to one of the finer points on this issue. Many Americans think that it is *American* lives that are precious; foreign lives are another matter entirely. Indeed, this point is clearly driven home by the differentials in spending on health and safety. A few million dollars on food and medicine can save many thousands of lives overseas, but we instead spend that money on, say, safety improvements for our roads that might save a few dozen lives. Indeed, it is on highway safety spending that Americans really put their money where their mouths are. Every year we tens of thousands of lives are lost on America's roads. We spend many millions of dollars making those roads safer, and we have good measures for the efficacy of many safety measures. This permits us to get an estimate of exactly how much Americans really care about life.
First, some background. We don't just count lives in calculations such as these. Instead, we use the "quality-adjusted life year". This is a measure of how many years of life (at what quality of life) are saved by a policy. It turns out that driver's side air bags cost about $70,000 per quality-adjusted life year saved, compared to seat belts. In other words, mandating driver's side air bags in all cars costs $X, saves Y lives, and when you run through the numbers, you find that we're spending about $70,000 for each quality-adjusted life year saved. Does that number sound about right to you? Would you be willing to spend $70,000 to get an additional year of full health? You do. Every time you buy a new car, you pay additional money for the air bag, and the chances of that air bag saving you work out to this number.
But let's extend the idea. Would you be willing to spend $70,000 of your tax money to provide a fellow citizen with one year of additional healthy life? You would? But that $70,000 could probably buy 10,000 additional years of healthy life for children in Third World countries. Are American lives really worth 10,000 times as much as foreigners' lives?
Let's get really messy. You would think that our policies would be consistent in how much money we pay for additional years of healthy life. You would be wrong. Our standards are all over the map. We spend millions of dollars for each quality-adjusted life year for nuclear power plants, terrorist prevention, and airplane safety. But we spend far less money for each quality-adjusted life year obtained by free medical programs for the indigent. Perhaps this can be justified with the observation that airplane crashes kill richer people who would have paid higher taxes, but medical care for the indigent doesn't add to the tax base at all. This argument collapses when you consider the children. How do we know that the 6-year old whom we deny medical check-ups to isn't going to grow up to be filthy rich and paying millions of dollars in taxes?
All of this leads up to a rather odd proposal: I suggest that Congress pass a law declaring the value of one quality-adjusted life year of one American citizen. With this number established, we can then use it to guide all other policymaking. We can bring different programs into conformance so that we can get the best return for our money.
The implications of this would be staggering. Next week I shall use this concept to address health care. In the meantime, I invite commentary on the value of a human life. Do I hear $80,000? $90,000?
Saturday, May 24, 2008
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11 comments:
Interesting post, one of those that leaves you cold with the apparent morality of it.
You're oversimplifying a lot of this though. Teri Chiavo, the most notable case of not "pulling the plug", doesn't really have to do with the financial value of a human life. It was an ideological struggle: religious conservatives were using the publicity to make a point about human life, and others were trying to convince them that she was a baked potato by the time they actually pulled the plug. I don't think it really falls into the "value of a human life" category very neatly.
As for the death penalty, I'd like to believe its inconsistent, the fact is that those who are being put to death are presumably very bad people, to which the "value of a human life" law doesn't apply. This is not a reflection of my own personal beliefs, I am completely opposed to the death penalty by the belief that it is unnecessary and unjustifiable, but I'm just stating the logic of why it doesn't conflict with the "value of a human life."
Now, for the tough part, the entire expensive policy thing. The first thing is foreign policy: such an idea of "collateral damage" makes sense if the military operation is meant to promote a lasting stability in the region, of course, this is not the reality most of the time. However, one could argue that while a terrorist attack doesn't claim very many lives that:
a) We must defeat Al-Qaeda lest they get their hands on a nuclear weapon, which would mean casualties in the millions
b) A terrorist attack, while it may not take many lives directly, would damage the economy of the world's economic hub and lead to a degraded quality of life over a long span
These are not necessarily my beliefs either, but I believe they're points to think about for certain endeavors. Certainly, I think with the right thinking, terrorism could be defeated in a far less ham-fisted way and spare us the trouble of spending billions of dollars and thousands of life to defeat third-world guerrillas.
Okay, so I've left the REALLY hard part until the end, the deal with airbags being a policy that puts $70,000 on a life, where that money could safe a ton of third world children. I could use the economic argument, that safety standards for cars, roads, and planes in America are helpful to our economy by letting people travel with ease, but I'm guessing the argument would sputter after a while. I'll have to give it to you that there's no real moral justification for saving far less American lives instead of saving many more lives in other countries, but I think that what we should get out of this is that there really is no clean way to calculate the value of a human life in the same way that many other things have value. Can you honestly say that we should drop our airplane safety laws and spend all of that money on UNICEF? Personally, it just doesn't sit with me despite the logic, it doesn't seem right to leave our citizens unsafe on the road when the option is right there.
But, I think the uglier truth is that it has to do with selfishness. I don't feel like seeing my life changed because my parents' new car didn't have airbags. It's selfish, my parents are two people who have lived good lives, while there are tons of third world children starving, but for obvious reasons I wouldn't want the exchange. If I were a stronger person I wouldn't eat meat, I wouldn't illegally download music, I wouldn't be so self-indulgent in general as a citizen of the first world, but can anyone give up selfishness for a cold-eye moral calculus?
Good point about the Schiavo case. What I was driving at, rather badly, was the notion that a portion of our citizenry regards life as infinitely valuable. Even though cost itself wasn't at issue here, the controversy did expose the values of this group.
There is no getting around the fact that, for all our posturing about "the value of a human life", we are very selective about WHICH human life we're talking about -- and I get the impression that conservatives are more selective than liberals. For example, conservatives justify the death penalty with the argument that these criminals are somehow "less human" than the rest of us, so their lives aren't so precious. In the same way, reluctance to provide life-saving foreign aid is based on the belief that foreign lives are less valuable than American lives. We also see this in Iraq, where we wring our hands over 4,000 dead American soldiers and never bother about the 100,000+ dead Iraqis.
But there is a way to salve the consciences of less hypocritical Americans. If we abandon the notion that human life is priceless, and instead assign a value to human life based on its likely economic productivity, then we can justify public expenditures on safety as investments against future tax returns. In other words, we can argue that the average American generates, say, $10,000 in taxes per quality-adjusted life year. In that case, we'd be justified in spending up to $10,000 in safety measures to preserve that quality-adjusted life year. But $70,000 per QALY? That doesn't make economic sense. So we're still exposed as hypocrites.
If we're talking only about American lives, your economic idea makes sense because that will probably save more lives in the end.
But if we're talking about international lives, the implications become blurry, and the hypocrisy comes from our simple desire to watch out for our own necks.
As for the death penalty, I think it's fairly intuitive to see why someone would see a serial murderer as "less human". I don't believe particularly in retributive justice, but I certainly would cry a lot less at the death of a serial murderer or a rapist as opposed to an everyday person. I really think in general though, despite my own opposition to the death penalty, that the idea of retributive death does not show hypocrisy in the value of a human life problem; when people are talking about the value of a human life, they're talking about protecting undeserving deaths.
Also, I'm guessing you probably read my message from before, but I still am wondering if you had any interest in talking about U.S. policy towards Pakistan.
I think there are two factors you are failing to take into account.
1. Psychology. The economic justification of an airbag may not be its lifesavingness (forgive the coinage), but its ability to make people feel safe. If people who feel safer drive more, then it is a rational choice for the manufacturer to include an airbag. Didn't airbags start to become common around the same time that fuel-efficiency concerns necessitated more lightly-built cars?
2. Stability. You cannot simply say that Americans value American lives 10 000 times more than all foreign lives. Is that true of Canadians? The value set on first-world lives is evaluated relative to first-world conditions—conditions of maximum stability in the ratio of expense to QALY. In poor countries this ratio must be much less stable: both because much of the money will not go to lifesaving at all (vaporized in overhead or siphoned off by corrupt regimes); and because life there is generally more uncertain. Indeed, I imagine that any time a life can be cheaply saved—when its condition is so unstable that a little money can produce dramatic change—then it must have been so unstable to begin with that the actual lifesavingness of the expense cannot be meaningfully evaluated.
What about firefighting? What is the cost per QALY for people rescued by firefighters? People trapped in burning building may be the closest we can get in the first world to third-world conditions. (If there are numbers on the Internet, they are behind the JSTOR wall and I cannot get to them.)
As far as that psychology bit goes, that's what I was trying to say about the economic productivity of road/air safety measures.
"...mandating driver's side air bags in all cars costs $X, saves Y lives, and when you run through the numbers, you find that we're spending about $70,000 for each quality-adjusted life year saved."
Yes, but. Putting it that way makes it sounds almost as if it's costing me, personally, $70,000. But what's really happened is that Americans have decided [via their elected representatives] that the $70,000 cost of a "quality-adjusted life year" is a *social* cost, well worth the additional dollars that each of pays to have driver's side air bags. We share that $70,000, willingly, knowing that it might be us who receives the full benefit.
I'll take that tradeoff any day of the week.
Alex, I have put off discussing Pakistan because I'm still organizing my thoughts on the problem.
Paul, you raise a good point about the difference between 'objective safety' and 'perceived safety'. In general, however, it tends to work in the opposite direction. That is, people generally underestimate the risk of activities in which they have control ("Of course I'm a safe driver!") and overestimate the risk of activities over which they have no control ("Are you SURE that this plane won't crash?") Thus, the psychological factors should work against the perceived value of air bags -- even though the objective factors do seem to be in their favor.
A tiny point regarding this question:
Didn't airbags start to become common around the same time that fuel-efficiency concerns necessitated more lightly-built cars?
This seems to assume that heavier cars are safer than light cars. This is only partly true. A heavy car hitting a light car has a safety advantage. Two light cars hitting each other are actually safer than two heavy cars hitting each other. In other words, the additional safety that the driver of the heavy car enjoys is purchased at the price of reduced safety for the driver of the lighter car.
That's an excellent point about the differential life expectancies between rich countries and poor countries. What's the point of feeding a starving Third World kid if he's just going to be killed in the civil war when he's twelve? While I think that argument greatly reduces the prejudice factor, I think that most Americans place far more value on an American life than a Third World life.
I was actually speculating that adding airbags was a way for manufacturers to compensate for the greater perceived safety of heavier cars. (SUV sales suggest to me that there is indeed such a perception.)
Certainly, Americans value American lives more than third world lives. My point is that the difference is not so extreme as you stated, and also largely dependent on circumstances: for example, an immigrant from the third world, once in the United States, has a much greater value in American eyes (though still not as as great as a citizen's) than that same person might have had a few days before in their native country.
"Many Americans think that it is *American* lives that are precious; foreign lives are another matter entirely."
Agreed, but are Americans any different in this respect than other nationals?
In WWII, for instance, did the German, Japanese and Russian people grieve as much over American deaths as they grieved over the deaths of German, Japanese and Russian soldiers?
Fast-forward to 2003-2008. Do the Iraqi people grieve as much over the deaths of U.S. soldiers as they grieve over the deaths of their own citizens?
Conclusion: It's all well and good to talk the talk of "one world". Out in that one world, there are hundreds of parts with different names. We all tend to think the part that has our name is more important than the others.
Excellent point, Gerald, about the universality of parochialism -- or should I say the absence of universality? ;-)
However, let me point out one difference: we Americans are especially fond of declaring our moral superiority because we care so much more about human life.
Well, SOME Americans do that.
Very interesting post, specially the part about the value of a QALY, how it is so variable even within America. When you get outside the country, values vary to the point of being meaningless.
What seems to me most important is that imagining a society where a QALY parameter is used, this should be even for everyone, at least everyone by age category. (Kids may be more valuable than really old people).
A note about criminals that just occurred to me. If criminals start being discriminated, we could have people saying "they are murderers, and so are less human, so their value to society is less, even nothing". The danger of this is starting to incriminate innocent people or inflating culpability to reduce taxes or get other benefits. Anyway, if we trust the justice, we could reduce the value of him/her for as many years as he/she is sentenced... (this has gotten too far from my idea).
The other comment I had is about something alex said on terrorists: terrorists like Al-Qaeda stem from places were their target (US in this case) is "meddling with their affairs" and making lots of people angry/uncomfortable. We should remember terrorists are a minority. So, how about dealing differently with the general people, so the terrorists get less support? That policy is more in line with life valorization and probably cheaper.
Anyway, how many people think the same way of family, neighbors, countrymen and foreigners? This could be agreed upon by law but we cannot count on people to think this way, they are too irrational most of the time.
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