I know this doesn’t strictly relate to this weeks’ readings, but this is something that I think is really important and hasn’t come up enough.
It’s so important, in fact, that in the style of scholars from Plato to Derrida, I shall present my thoughts as a dialectic, in the form of an actual gChat between me and my friend Andrew (who studied Economics at NYU and is currently a second year medical student at Mt. Sinai)
i have to write a “blog post” for my global health policy class
and i really wanna write about how the whole concept of rationalizing and quantifying the value of human life
the concept of which is integral to like all global health policy stuff
is so completely messed up
but my brain is too demyelinated/mildly epileptic to adequately articulate it
I don’t know if I have an intrinsic problem with that as such
me: I do!
Andrew: But I do know that the British government
Commissioned a study
of the likely economic impact of global warming
Andrew: In which they quantified precisely how much more they value British lives compared to the lives of people in the Third World
me: how can you be like: “something is only “cost effective” and thereby worthwhile if it costs $100/DALY saved”
the whole concept of the DALY is fucked
like yr life is worth less if you’re
a. a kid
b. an old person
c. a woman
d. in anyway “ill”
Andrew: No under that system kids lives are worth more
Cuz they have more years left
they do it in this weird curvey thing
where babies aren’t worth as much
Andrew: And women too actually
Cuz they live longer
me: no no
Sent at 5:32 PM on Tuesday
its about how much you’ve invested in the person
and babies haven’t really had that much yet
how can they decide how much to weigh disabilities?
like who gets to decide that a
year living blind is only worth .6 of a year?
or that being depressed is only .9 a year?
it means that the lives of ALL poor people
are inherently counted as less valuable
because they’re more likely to be sick
Andrew: Okay valuing people by how much you’ve invested in them is fucked up in principle
But I think that most people
If they had a choice between living 10 years in perfect health vs. 10 years plus one hour but all as a quadriplegic
Would choose to live in perfect health
me: yeah but usually its not that
and they present it in this totally pseudoscientific way
as if there’s anything factual or objective about it
Andrew: Well I agree with it in principle, in that kind of abstract, hypothetical scenario where everything is perfectly clear
But then in the real world
When you have to put percentages on these things
Exactly how diminished is the quality of life of a quadriplegic
Then it’s not scientific
me: i mean some kind of measure is helpful
but it’s absurd how much weight is given to this pseudomathematical formulas
that are totally subjective
Andrew: I don’t think it’s totally subjective
In the way that my dislike of the movie Taxi Driver is totally subjective
me: ask a quadriplegic if he thinks his life is worth less
if less resources should be invested in saving his life
because it wouldn’t be saving as many DALYs
me: or a mom ask her if her baby shouldn’t be saved because not as much has been invested in it
and probably it will be sick a lot
so it will have less DALYs than a baby in the US
Andrew: But it kind of raises the question
Should we spend every possible dollar on health care?
Or do we draw some line somewhere with a certain degree of arbitrariness?
me: i think we should spend all the money on ze healthcare
i know that sometimes folks have to make judgment calls
spend money on project A or project B
and metrics can be useful tools to evaluate merits of each option
but what I don’t like
is when these kinds of metrics are presented as absolutes,
when folks don’t acknowledge that quatifying the value of humyn life is inherently problematic
Andrew: I think health care is one of the best ways to spend money
And way better than military,
The Bush administration rather nakedly adjusted their DALY methodology
To make it appear less harmful when they cut some health care program
Andrew: But you’re never gonna have a way to decide how to allocate resources that’s not in some way problematic
I’d rather see it done through DALYs than done through a free market, for example
me: from each according to his ability, to each according to his need?
that’s pretty unproblematic
and DALYs do operate under market-like principles
rationalization, efficiency, trade-offs etc.
Andrew: Hey did you know like 40% of the US population think those phrases are in the Constitution?
[long, irrelevant tangent about sneaking into the National Archives to scribble on the constitution]
Andrew : Seriously though
1. I did not know DALYs said that people who have had more money spent on them are more valuable.
2. I had not considered that
when you say lives lived in sickness are less valuable then that biases the measures against poor people cuz they get sick more.
me: it doesn’t say specifically “money”
it says “resources” o
or something like that
Andrew: Yeah doesn’t matter
me: wait i’m trying to remember why it says ladies are less valuable too
Sent at 5:45 PM on Tuesday
me: oh it also counts things that don’t actually effect yr health as “disabilities”
Andrew: Oh shit really?
Like if a woman become infertile, then her life is less valuable?
1000 healthy fertile ppl = 1236 otherwise healthy infertile ppl
Andrew: Okay I think that is actually accurate for some women, and that what’s wrong is applying it universally as if that were the goal of all women’s lives
Is that actually the number they use?
Cuz that’s a really heavy penalty for infertility
me: ya ‘m reading it off a paper
= 1025 over or underweight ppl = 1499 deaf ppl = 1686 ppl with down syndrome
Andrew: Okay that makes more sense
me: yeah, unless yr a perfectly happy person with down syndrome
who would really rather not have less invested in his health
Andrew: Oh now you’re getting utilitarian
me: that’s like hitler logic
Andrew: Yes it is actually
Or wait no
He murdered disabled people
But not because he thought they weren’t happy being disabled
But because he thought they were weak and thus diluted the strength and vigor of the nation
me: we deny them equal weight in allocating health resources
because we think that’s a more efficient way to allocate our resources
and make a “healthier” society
Andrew: The part of DALYs that I most agree with
Is that it’s inefficient to spend tens of thousands of dollars for bypass surgery in an 85-year-old American who’s dying of some other disease
When we could instead spend that money on a deworming campaign in Niger
And save a lot more lives for a lot longer
me: yeah i def think old ppl should count less
but its really really dangerous logic
Andrew: With the kind of arbitrary valuations that you’re criticizing
I’ve heard it said that the reason it’s fucked up
Is that yeah it’s rational, but it’s unfair
And we hold fairness as an independent value that we want to uphold
Andrew: Separate from maximizing health or happiness or whatever
me: frankly i think sick ppl should get MORE resources
cuz they need them more
Andrew: But what if you can spend $100 on a healthy person to keep them healthy?
Vs. $1,000 on a sick person to treat them partway?
me: do both
Andrew: Yeah actually that’s basically what I’d say
That’s also what I’d say about scientific research on rare genetic diseases of rich white people
(Which is what Sinai loves to do)
Vs. research on common infectious diseases of poor people overseas
Andrew: (No one talks about rare genetic diseases of non-white populations, but I’m sure that must be because no such diseases exist.)
me: except i think we should research rare rich white ppl diseases too
just not at the expense of everyone else
“to calculate the DALYs a standard expectation of life at birth of 82.5 years is taken for women and of 80 years for men”
“the gap is considerably smaller than the observed gender gap in life expectancy in low mortality populations, for example, Japan, which has a gender gap of some 6 years”
so the smaller the gender gap
the less DALYs you say ladies
Andrew: So by DALY logic wouldn’t that make their lives more valuable?
me: no no no “the smaller the gender gap, ceteris paribus, the smaller will be the female contribution to the burden of disease relative to the male contribution”
they underestimate how long women should be living
me: can live
so they don’t account for all fo the years lost
Andrew: I didn’t follow that
How are they underestimating how long women should live?
me: they are putting the gender gap at only 2.5 years
Andrew did not receive your chat.
me: they put the gender gap at only 2.5 years
Andrew: Oh oh oh
me: when in reality, most countries have a much bigger gap
Andrew: Cuz that’s what it is in practice on average worldwide?
But if everybody had decent health care then it would be longer?
The 2.5 years was totes arbitrary
well not totes
they decided that 2.5 years is what corresponds to “biological difference in survival potential between males and females”
factoring out everything else
“”while DALYs take account of higher female life expectancy in calculating years lost to premature mortality, the valuation of these years can be sharply reduced by age-weighting and discounting”
The female advantage in years lost of 3% is reduced by age-weighting to 1.5%, and further reduced by discounting to .3% for the calculation of DALYs”
cuz the old person years are worth less
and years in the future are worth less than years now
regardless of age
Andrew: Most of what you’re saying is objections to particular methodological decisions these orthodox economists have made about how they’ve going to calculate DALYs in practice, rather than DALYs in practice, rather than reasons why nothing like DALYs should ever be used with any methodology.
Oh and with the future years being worth less
If they do it in the usual economist’s way
By dividing by the interest rate
Then at a fairly normal interest rate
It easily ends up having the consequence that anything that happens in 20 years is only half as important as anything that happens now
Which is an amazingly short-sighted way to plan and make decisions for a society
me: yeah well frankly i think economists have NO place in deciding the value of human life
its like saying yr going to measure your height in Love
Like that interest rate future discounting business is something I object to per se, regardless of how it’s done
Except in a few like perfectly financial situations
Where it obviously does make sense to use the interest rate
me: i object to economic principles being applied to anything that’s not strictly financial
which is …
nothing is strictly financial
Andrew: Yeah well nothing is strictly anything
Andrew: War is not strictly military
Sex is not strictly sexual
me: but srsly
this is basically my big problem with science in general
the notion that something even can be strictly scientific
my problem with the way that science presents itself
the way that scientists present themselves
totes oblivious to anything outside their discipline
takin themselves all serious biznass
cuz i’d be a lot more down with the Science if it could just acknowledge its limitations
Like the rest of us do.
Sent at 5:27 PM on Tuesday
Andrew: you are going to hate med school.