Monday, December 24, 2007

All our potential

Fraser Nelson has a brilliant post on the CoffeeHouse which sets out the tragic number of deaths among the old each winter. Excess mortality was 23,900 in 2006-07 and Norway - despite hardly being the warmest of places - typically has just over half the rate we do. There is a political conclusion that should be taken from this: measures like the Climate Change Levy, Emissions Trading Scheme and Renewables Obligation that increase the price of energy have a hefty human cost. However, I'd like to focus on a more philosophical question.

Nelson's central point is that we just don't give the deaths of pensioners the attention we should. I don't think this is merely a matter of fashion; it isn't just that other political issues have more partisan potential.

Instead, there is a cognitive bias created by the utilitarianism of the modern discourse. In modern politics we're all thinking in terms of the greatest happiness of the greatest number and approach each policy recommendation longing to ask 'how many utils?'

When we try to assess the value of saving a life we do the same and think in terms of the number of utils lost. Years of Potential Life Lost is the translation of this concept into terms that can be applied to healthcare debates. It is usually understood as the number of years that the deceased could - had they lived - have expected to live. It is the utilitarian opportunity cost to dying - the life you might otherwise have lived.

To make calculations simpler it is usually just life expectancy minus age at death. It is then often time discounted as years of life (just like monetary sums) are more valuable when we don't have to wait as long for them. Even if years of life in the future are discounted at 3 per cent - as the Americans apparently think it should be - the deaths of old people aren't going to be judged nearly as important as those of the young.

That might not seem outrageous. To a certain extent it reflects a quite ordinary moral intuition that it is somewhat more tragic when someone dies with their life ahead of, rather than largely behind, them. I think that Atonement did a great job of portraying an opportunity costs-based understanding of the tragedy of death (I'm worried I'm the only one who took that to be the film's central emotional message). Its final scenes portrayed what could have been if the couple the story revolves around had lived and this gave a real tragedy to their unnecessary deaths. However, in my view this principle is taken too far by the modern policy debate and explains the callousness with which the old are treated.

To get your around why this concept can be so toxic imagine applying it to another group: the poor. Someone living in Calton - near the centre of Glasgow - has a life expectancy of 54. I'm not sure what the life expectancy of someone from my socio-economic group is but it could well be over eighty. At 24 that means a significant difference in our Years of Potential Life Lost if we die. The utils cost if I'm allowed to die unnecessarily is significantly higher. I'm less likely to die at a relatively young age from some other cause and so have a greater expected life in front of me. I don't think that the ONS revision of its productivity figures for healthcare to take account of rising incomes is, in principle, very far from this at all.

Many economists are under the impression that policy makers don't really 'get' opportunity costs. I think that might be wrong. Perhaps policy is predicated on opportunity costs, combined with radical utilitarianism, far more than it should be?

Montaigne described the purpose of philosophy as being to prepare us for the horror of dying - a particular terrifying moment. He described this as an alternative to the viewpoint of Cicero who saw the purpose of philosophy in preparing people for death - the finality. Montaigne's view might provide us with an alternative reason why healthcare should try to avert death.

We should try to stop people dying because of the direct human tragedy of the process of death no matter how painless. While we will all have to die at some point there is still a very real imperative to spare people when we can. What happens next is a matter for fate, chance or God (take your pick).

If we can balance our opportunity costs understanding of death with a more humanitarian concern that people should avoid the mental horror of dying then we might, as a society, attach more priority to care for the elderly.

1 comment:

James Higham said...

And then there are those deaths in the mid-west snow as well.

Merry Christmas, Matt.