Outlook

Who lives, who dies, who decides

The virus makes us weigh the value of a life. We can’t know if we’ve gotten it right.
Javier Jaén for The Washington Post
By

In October 1987, Jessica McClure, an 18-month-old girl in Midland, Tex., fell down a well. The nation followed with rapt attention for 58 hours as rescue workers, mining experts and local volunteers drilled a shaft parallel to the well, then tunneled horizontally through dense rock to reach Baby Jessica. Nobody fretted about the costly rush to free her. No one suggested that there were better charitable causes than the generous trust fund established for her by strangers and well-wishers.

Harold Pollack @haroldpollack is a professor of social service administration at the University of Chicago.

Now imagine you receive an email inviting you to a community meeting to discuss whether to place fencing around local wells and other hazards. You are not likely to attend. Can you imagine anything more dull? Also, you wonder: Is it really smart to spend thousands of dollars blocking off small holes in the ground?

As humans, we don’t know how to weigh the tragic trade-offs among money, health and life. Right now, policymakers are deciding whether to seriously damage our economy to stop the spread of the new coronavirus, or to accept additional illnesses and deaths as the cost of warding off other suffering: Economists and public health researchers note the rising tide of suicides, fatal overdoses and other tragedies connected with deindustrialization, joblessness and poverty. Such “deaths of despair” are reminders that economic trauma, too, destroys human lives.

President Trump himself struggled with the issue this past week when he argued that “we cannot let the cure be worse than the problem” and questioned the wisdom of a prolonged and costly strategy to slow the spread of the coronavirus. His critics warned that hundreds of thousands could die if that strategy, including social distancing, business closures and stay-at-home orders, was abandoned too soon.

This seems like a monstrous choice. In fact, we make similar trade-offs all the time.

Sometimes we do spend too much to save or improve a small number of lives. Some of our fanciest medical centers, for instance, built huge, $100 million proton beam machines that provide only marginal benefit to prostate cancer patients. The cost of one such machine could have bought 100 million of the N95 masks now in short supply. Maybe shelter-in-place orders that damage the economy are another one of those measures.

Rescuers surround 18-month-old Jessica McClure on Oct. 16, 1987, in Midland, Tex., moments after pulling her from an abandoned well where she had been stuck for 58 hours. (Bettmann)

An isolation-induced recession would reduce economic activity by roughly 21 percent, compared with 9 percent under a more lax approach, according to a ballpark estimate by economists Martin Eichenbaum, Sergio Rebelo and Mathias Trabandt. It’s not unreasonable to assume that strict containment could cost $2 trillion. These same authors estimate that such measures would prevent more than half a million deaths and protect millions of other Americans from becoming infected. If their analysis is even roughly right, these are huge health benefits and huge economic costs. Which path has more value? The answer isn’t obvious.

American policymakers have rarely been forced to consider such trade-offs during a massive pandemic. But we have spent decades trying to understand other trade-offs that help put them into context: How much should Medicare pay for a new lung cancer treatment? Should we require a car to have a $700 air bag? Should a company have to spend millions of dollars to remove contaminated soil beneath a remote and abandoned industrial site?

Decades of psychology research establishes that our brains and our culture are hard-wired to botch our answers to these questions. We feel compelled to protect familiar people closest to us. We do not respond with the same urgency to more catastrophic, faraway tragedies. Mother Teresa aptly diagnosed the problem: “If I look at the mass I will never act. If I look at the one, I will.” Such “psychic numbing” kicks in depressingly quickly. In one study, people were willing to pay more to rescue one needy child than to rescue two. We’re terrible in thinking about the future, too: What could be more boring, in ordinary times, than a congressional hearing on the supply chain for respirators or surgical gowns? Planning for climate change hasn’t fared much better.

Medical decision-makers have developed tools to help fill this gap, spending many years examining what American society is willing to pay for medical and public health interventions that extend life and improve health. Policymakers and citizens are generally willing to finance interventions that provide at least one “quality-adjusted life year,” or QALY, for every $150,000 spent. (QALYs quantify the common-sense notion that we’re willing to buy one more year of healthy and happy life, as opposed to a year spent in serious pain or debilitating illness.) We are often willing to pay much more.

Armies of bioethicists and statisticians debate these efforts. Advocates for people with disabilities and for seniors express particular concerns about QALYs. Is another year of life really less valuable for the blind man who uses a wheelchair than it is for his twin brother, the recreational jogger? If an overwhelmed hospital has only one ventilator, would it be right to favor the 20-year-old waiter over the 72-year-old priest, the nurse over her intellectually disabled brother?

Safety researchers find that Americans are willing to pay even more to prevent random, statistically avoidable deaths from roadside accidents, pollution, homicide and other tragedies. Estimates of the “value of a statistical life” closely track the lifetime additional wages workers demand to perform dangerous jobs. Government regulators use these values every day, for example in deciding whether to build guardrails alongside a road or whether manufacturers must provide costly protective equipment on the factory floor to prevent rare accidents. The Environmental Protection Agency currently values a “statistical life” at about $9.6 million, “regardless of the age, income, or other population characteristics of the affected population.”

If we apply that EPA figure, the monetized value of preventing 600,000 covid-19 deaths reaches $5.8 trillion. But this estimate may be too high. An infectious disease is different from a homicide or a workplace accident. Such methods have greater intuitive appeal when applied to rare, scary outcomes than to more widespread hazards. Many Americans likely to die of covid-19 are retirees with health vulnerabilities who already expect to live fewer additional years than younger people will.

Then again, this ballpark figure leaves out many factors. Maybe 98 percent of the people who become infected with the coronavirus will get sick, possibly very sick, but will recover. Some will live with the knowledge that they infected others close to them. Many of us at low risk of dying would still pay a lot to avoid these outcomes.

That ballpark figure also doesn’t consider the national trauma we would experience after choosing policies that allow the pandemic to rage, overwhelming our medical system and causing hundreds of thousands of avoidable deaths before our eyes. We face considerable uncertainty. There’s value in extra precaution, should covid-19 prove more lethal or infectious than we surmise.

Talk of trade-offs also ignores our opportunities to buffer the worst economic and human consequences of strict containment measures. Nationwide shelter-in-place orders would produce a sharp decline in gross domestic product for several months, maybe more. But we can couple such policies with generous social insurance to protect people from hardship and businesses from bankruptcy. We can, as individuals and as a society, do many things to ameliorate the fear, loneliness and despair many Americans may feel because of social distancing policies.

None of this will be easy. Strict containment brings real pain and economic costs. It brings real benefits, too. In this frightening time, we can protect and sustain one another against an epidemiological and economic tsunami no one of us could endure if we were left to face it alone. That’s solidarity. It’s a precious thing.

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