7 THE (NUMERICAL) VALUE OF HUMAN LIFE

There are well-meaning people who say that you can’t put a numerical or monetary value on human life. How far can we get with this idea?

Number of Lives Saved

Even if we don’t put a particular numerical value on a human life, we can at least count the number of people who live or die. So a first pass might be that we can value human life in terms of the number of lives saved. Though not detailed enough for many analyses, it’s not a bad way to think about goodness for the average person, simply because many good things we do clearly don’t save any lives at all. For example, donating money to your local art museum is going to have an impact on the well-being of people, but nobody’s life is in the balance. In this way, lives saved is a decent first pass to give you a rough idea of what matters and what unmatters.

In practice, saving lives often involves spending money for this or that intervention, which means that saving lives has some knowable financial cost. This brings us to the admittedly distasteful notion of putting a dollar value on human life.

If you are resistant about this, I get it. However, when anyone makes decisions about policy, charity, and other moral choices, one is acting as though there is some specific dollar value of a human life, even if one is oblivious to what that value is. That is, you can often look at someone’s actions and infer what their value of human life must be for those actions to make any sense.

For example, the United States makes decisions about the highest allowed speed limits for motor vehicles. Speed limits have gone up over the years, which makes people get around faster, making the economy more efficient. But there are costs here—not just in terms of greenhouse gases (driving faster requires more fuel per unit traveled) but in terms of lives lost on the road. In 2017, for example, 37,133 people died in American motor accidents, but that is 1,934 higher than it would have been if we’d stayed with the speed limits we had in 1993.¹ The U.S. sacrificed almost two thousand people a year so that everybody could drive faster. Is it worth it? If we could calculate the increased speed limit’s value to the economy, we could see exactly how much the U.S. valued the lives of those extra people who died on the road. (One analysis suggests that this isn’t worth it, and that the social benefits of faster driving are two to seven times smaller than the costs due to death.)²

If we (perhaps grudgingly) accept that we have to make a decision about the monetary value of human life, we can investigate what is the best way to do it. For people who don’t like to think in terms of numbers, this can be annoying, but it seems to me that there’s no way around it. If you want to enter the best-person-you-can-be club, thinking in terms of numbers is the cover charge.

One way to look at it would be to try to estimate how much a person’s life is worth to them. We can get numbers like this by looking at their choices regarding how much risk they are willing to take for a given amount of money. People take risky jobs, for example, and expect to get paid more for them. By looking at how much more, we can estimate the dollar value they place on their own lives. Various economists have made these calculations, and the value of life ends up being estimated at being around $9 million. In New Zealand and Australia, it’s around $4 million.³

Government interventions also reveal how much they are willing to invest to save a life. Let’s look at the government of the United States, which has many agencies in the business of life saving. It turns out that regulations vary enormously in the cost incurred to the government to expect to save one human life. A review showed that the costs of saving one life ranges from $100,000 (for the Childproof lighters regulation) to one billion dollars (for the Solid Waste Disposal Facility Criteria regulation). The average is around eight million dollars.⁴ It’s interesting that the revealed preference of the government for a human life is in the same ballpark (millions of dollars) as Americans themselves value their own lives.

Big organizations basically have to make estimates like this to function in anything close to a rational way. When governments decide what programs to invest in, they often compare the number of lives saved. As distasteful as putting a dollar value on a human life might feel, isn’t it more distasteful to be spending a billion dollars over there to save one life, when over here you can save ten thousand people for the same cost?

As we will see later, even the low-end government cost of $100,000 for life-saving is about twenty times more expensive than saving the life of someone in the developing world—that is, if the United States saves an American life with the cheapest method its government has, a good aid organization can save twenty sub-Saharan African lives with the same money.

We’ve established that many people have an in-group bias. They feel that the people in their community deserve to be helped before people outside the community. I’ve tried to convince you that this is a morally irrelevant factor, but maybe you’re unconvinced. Maybe you still feel that you’d rather help other people in your country than poorer people elsewhere.

If this is the case, let’s put it in terms of numbers. Here’s a tough question: how many foreign lives are worth one life of someone in your own country? Let’s say you’re American, and you value American lives over Nigerian lives. Let’s say that, for the same cost, you have the opportunity to save one American life, or some number of Nigerian lives. How many Nigerian lives would you need to save to make this a difficult choice? This is a one-sided conversation. You don’t need to actually tell me your answer, so be honest with yourself. You can be unsure of your answer, but make your guess precise—meaning, actually pick a number before you read on.

Let’s say you come up with five lives. This would mean that an American life is five times more valuable to you than the life of a Nigerian.

When we look at charities, we can see how much it costs to save lives in America versus Nigeria, using the most cost-effective methods available. Evidence suggests that saving a life in Nigeria with the best charities costs about $5,000, and we just saw that saving a life in America costs about $100,000, if we go by the cost of the government’s most efficient means. American lives, then, are twenty times more expensive to save. So even if you think American lives are five times more valuable as Nigerian lives, it still makes more sense for you to invest your charitable money to save Nigerians! Even at a moral exchange rate of 1:5, by saving Nigerians you’d still be doing four times as much good according to a moral stance that heavily biases in favor of Americans.

Now, maybe you picked a different number. But if that number was less than twenty, then the conclusion is the same: you’d be doing more good by saving Nigerians than your fellow Americans, even if your moral values say that one American life is worth, say, as many as nineteen Nigerian ones.

I would hope that you believe that an American life is worth exactly one Nigerian life, in which case you’d be doing twenty times more good saving Nigerian lives than American ones.

Some of you might be thinking that your currently preferred charity doesn’t save any lives at all. Maybe you donate to a local kindergarten, food bank, or arts organization. The same logic applies to these efforts: the cost of education, the arts, and everything is far cheaper in poor countries than in yours! You could probably put on many plays in Nigeria for the same cost as a single production in your own country. So ask yourself the analogous question: how many Nigerian theater productions does it take to have the same positive impact on the world as a single American one? Even if you wanted to help the world’s state of theater, it’s still better to invest in the theater of a poor country.⁵

Another thing to consider is that improving health is one of the best ways to promote education and the arts, when a country is so poor that health problems get in the way of basically everything. Preventing kids from getting sick, and making sure they have enough nutrition, is more important than direct educational or arts investments, such as buying textbooks, computers, or lighting rigs for theaters—I’ll discuss the evidence for this in a bit. So even if you ultimately really care about the arts (or education), you’d probably help the world of theater (or education) more by improving health than by funding the arts directly.

HELPING DISTANT PEOPLE AND DEONTOLOGY

I’m a utilitarian, but you can’t avoid these problems simply by rejecting utilitarianism. All the major theories can lead to the same conclusions, with different justifications.

We might think of deontology as classifying acts into those that are forbidden, permissible, and required. Murder is forbidden, having a glass of iced tea is permissible, and feeding your children is required. Let’s talk about helping others in the context of deontology. (Note that there are many different deontological theories; I’m just using a generic one.) We can assume that no reasonable deontology says that helping others is forbidden, so we are left with the two other categories: permissible and required. If helping others is required, then the conclusions of this book hold to be just as applicable as they would be under utilitarianism.

But many people believe that helping others, particularly those far away from us, is not required. It is permissible, but a good thing to do. They even have a term for this: “supererogatory acts.” In this case, if you want to be better, and improve your goodness, then you should be doing not only the acts required of you, but more supererogatory acts, as well. In this case, too, the recommendations in this book also apply.

In short, if you want to be as good as you can be, deontologists and utilitarians would need to behave in much the same way.

Number of Years of Life Saved

Back to the practicalities of lifesaving. Utilitarianism typically says that everybody’s life is equally valuable.⁶ I think this makes sense when we think of race or nationality, but there are other considerations. A life saved is a simple concept that raises a lot of important questions. For one, how long is the life saved going to be? If you save the life of a forty-five-year-old female, you might be adding 38.72 years of life to that person’s life. If you save a male infant, you are expected to add eighty years.⁷ If, for the same cost, we can save the life of an eighty-year-old or a twenty-year-old, it seems to most people that we should save the younger one. This suggests that a better way to look at lifesaving isn’t in terms of number of lives saved, but the number of years of life saved. This would suggest, for example, that adding twenty years to one person’s life might be better than adding five years to two different people’s lives. It would follow that saving a life in America, where the life expectancy is 79.3 years, is better than saving life of a person of the same age in Angola, where the life expectancy is only 52.4—assuming that the cost of saving a life is the same in both countries. But this assumption is false, because the cost of saving lives turns out to vary widely. If you can pay the same price to save more years of life, then it would make sense to save an American over an Angolan. But because it is much, much cheaper to save an Angolan’s life, utilitarianism suggests that, on the basis of the cost of saving one year of human life, we should help the Angolan.

This is progress. We’ve moved from simply saving lives to being able to think about the number of life-years saved. When we save someone’s life, we can subtract their current age from the life expectancy to estimate how many years of life we are actually getting them.

But we need to go even deeper because we have the problem of how good that person’s life is going to be. Extending someone’s life so they can continue to be miserable is not as valuable as extending someone’s life who will live happily. And if someone’s life is so bad that it’s not worth living, then adding years of life only increases suffering, making the world a worse place. Not only do we have to account for the number of years saved, but the quality of those years.⁸ Can science help with this?

It’s not straightforward to do, because, as we’ve discussed, human life has several ways it can be good. There’s health, long life, happiness, etc. A good candidate measure is known as the Disability-Adjusted Life-Year, or DALY. It’s the metric used by the World Health Organization to think about the global burden of disease. It tries to combine loss of years of life and the cost of living with a disease into a single number. One DALY is one year of healthy life lost. If a healthy person has a life expectancy of eighty, and they die from an accident at seventy, then they have ten years of life lost, or ten DALYs. According to this metric, averting DALYs is a way to decrease human suffering.⁹

EXAMPLE OF CALCULATING WITH DALYS

Alzheimer’s disease and schizophrenia are not preventable, but let’s suppose they were. Let’s say that for the same cost, in England, we could prevent a sixty-three-year-old man from getting Alzheimer’s or a twenty-year-old woman from getting schizophrenia. Which one should we prioritize?

For an individual, we calculate DALYs by adding two things. First is how many years of life are lost due to an early death caused by disease. The second, “years lost due to disability,” is how many years before death they lived with the disease, multiplied by the disability weight.

Let’s say a man gets Alzheimer’s disease when he is sixty-three, and will die seven years later at seventy. Let’s assume that life expectancy for most men is eighty. This means that with Alzheimer’s he will be dead ten years earlier than he would have without Alzheimer’s. But he is also suffering with Alzheimer’s for seven years. Having Alzheimer’s for a year is estimated as being 0.67 as bad as being dead for a year,¹⁰ so we multiply 0.67 by 7 and get 4.66. That is, having Alzheimer’s for seven years is about as bad as losing 4.66 years healthy life. Ten life-years lost plus 4.67 “years” lost due to disability is 14.66 DALYs worth of suffering.

A woman gets schizophrenia when she is twenty. This disease shortens a woman’s life by an estimated 13.6 years.¹¹ If we assume a healthy woman will live to 83, this means our patient is expected to die at 69.4 years of age, which means she’ll be living with schizophrenia for 49.4 years. The disability weight for schizophrenia is 0.58, which gives us 28.45 additional “years” lost due to disability. We add years lost (13.6) to this and get 42.05 DALYs.

Preventing disease in the man would avert 14.66 DALYs and preventing disease in the woman would avert 42.05 DALYs. The choice is clear: prevent schizophrenia in the woman.

The WHO uses this kind of calculation when looking at health interventions for thousands of people at a time.

Of course, being “diseased” shouldn’t be looked at as an on-off switch, because some diseases are worse than others in terms of how it affects one’s quality of life. Scholars use a variety of methods, including attitude surveys, to come up with numbers to account for this, too. Living for a year with blindness, for example, isn’t as bad as not living that year at all, but it’s not as good as living that same year with good vision. It’s estimated a year lived with blindness is 60 percent as bad as not living that year at all. So if losing a year of life is 1 DALY, losing a year of your life with blindness is 0.6 DALYs. Another way to look at it is that this measure says that if someone had to choose between losing three healthy years of life and living five of their life’s years with blindness, we would expect it to be a tough choice, because they represent the same loss of happiness.

How did scientists come up with these numbers? They asked people who were living with the disease to rate how bad it is in five ways: mobility, self-care, usual activities, physical pain, and mental pain. They then gave these numbers to people who weren’t sick, and asked them, “Suppose you had this illness for ten years. How many years of healthy life would you consider as of equivalent value to you?” From these answers they calculate the weighting.¹²

People who have never been on dialysis estimate their life would be 39 percent as good as if it were healthy, but people actually on dialysis say it’s 56 percent as good. In general, the public thinks that having this or that medical condition is going to be worse than it is.¹³ This is likely due to the impact bias, which makes us overestimate the emotional impact of future events.¹⁴

On the other hand, asking sick people how happy they are sometimes gives us unintuitive answers because of adaptation. That is, after a few years, with some diseases, people aren’t any less happy (there are exceptions). One interview study of 150 people showed that about half of them reported having a good or excellent quality of life—this is in comparison to people without disabilities, 80 percent of whom reported a good or excellent life.¹⁵ Most people would expect the differences to be greater. These two forces are working against one another, so in some sense they cancel each other out. But research on how much they cancel out has not been done.

Although people overestimate the happiness effects of physical disease, healthy people vastly underestimate how much mental pain affects happiness. They think it’s worse to have diabetes than to be depressed, and they are very wrong about that.¹⁶ So healthy people overestimate the happiness reduction due to physical illness, and underestimate the happiness reduction due to mental illness.

The DALY measure takes into account disease, which means that the normal variance in happiness isn’t accounted for at all, unless it’s manifested in a disease, like schizophrenia or depression. But we can get ballpark idea about happiness by looking at their measures for depression. A year of mild depression is 14 percent as bad as being dead, moderate depression is 35 percent, and severe depression is even worse than being blind, estimated to be 76 percent as bad as being dead (for one year that you normally would have been expected to live). From this we might extrapolate. Is being mildly clinically depressed, say, twice as bad as being generically miserable for a year? If so, I estimate that a year of being generically miserable is 7 percent as bad as being dead for one year.

DISABILITY AND FAIRNESS

One critique of the use of DALYs is that it feels like it is unfair to people who already have a disease.¹⁷ Here’s how it works: suppose we have two groups of people in danger of getting diabetes, and you have an intervention that can prevent this. The first group is otherwise healthy. The second group is exactly like the first group in every way you can measure, except that they are also blind. Which group should you help?

The paradox is that we have two different, sensible conclusions. First, we should help the blind group, because they are already suffering and helping those most in need sounds morally justified. On the other hand, if we calculate the value of, say, ten years of life for a blind person, it’s only got a value of averting six DALYs, not ten, because of the 0.6 disability adjustment for blindness. So a naive DALY calculation points us toward helping the otherwise healthy group because they would enjoy the rest of their lives more than people in the blind group would.

I’m not the only one who finds this disturbing. However, I should note that this is really only a theoretical problem at this point—actual analyses using adjusted life-years do not take into account preexisting medical conditions, so in practice this problem does not happen, for now. However, it’s an interesting theoretical problem that might need to be solved in the future. Similarly, nationality, race, education, etc., are also not considered, only age and gender.¹⁸

Is there a way out of this? I have an idea, but it might be wrong because it hasn’t been studied. Remember how money is worth more to poor people than to rich people? That is, giving a poor person $1,000 gives them ten times more happiness than giving it to someone ten times richer? Could the same thing be going on with health? That is, could it be that the loss of happiness or utility is greater if you’re already suffering?

To my knowledge, this has not been studied. I did an informal poll of my friends on Facebook about this: “Lets say you were going to be blind for a few months, and have a broken hand that would take a few months to heal. I’m taking a poll—click ‘like’ (thumbs up) if you would rather have them at the same time, and click the heart if you’d rather have them one after the other.”

Thirty-seven people responded, and it was split right down the middle. This seriously needs scientific study.

Nor does the DALY take into account extreme happiness. The value of one healthy year is the same as the value of an ecstatically happy year. (Even the flip side of the DALY, the Quality-Adjusted Life-Year, or QALY, considers a healthy life as good as it gets. But is living an extraordinarily happy life for one year worth more than 1 QALY?) So the DALY isn’t perfect. However, it has the advantages of being in common use, which allows us to compare interventions.

What is more tragic, the death of an infant or a twenty-year-old? According to the standard DALY measure, it would be the infant, simply because they’d have more years taken away from their lives. But there are reasons to believe that a twenty-year-old’s death is more tragic than an infant’s: society has invested more into their capabilities, they have a network of people who care about them, they have memories, and a story that ends. Some have argued that all intuitive moralities agree that the value of a life increases through pregnancy and childhood, and peaks in adulthood—that is, a death at twenty is more tragic than the death of a child.¹⁹

For different reasons, some think that living from age twenty to twenty-one is more valuable than living from eighty to eighty-one. Maybe all people are created equal, but then their value changes as they age, first up, then down. To reflect these ideas, some DALY measures use age-weighting.

Another relevant question concerns the value of lives now versus lives in the future. We tend to value things more now than in the future with something called “temporal discounting.” Economists disagree on what the discounting rate should be (e.g., the rate of it and whether the shape should be hyperbolic versus exponential), and there does not, as of yet, seem to be any way to empirically know what it should be. For what it’s worth, when we test regular people (non-economists) in the lab, they seem to behave as though they are using hyperbolic discounting.²⁰ But we also know the dangers of blindly trusting our intuitions.

We touched on this in the section on whether or not to have children and the value of people yet to be born. Is averting twenty DALYs next year more valuable than averting twenty DALYs ten years from now? On the one hand, it feels a little arbitrary, and many scholars believe we shouldn’t put a discount on the value of future lives. But we might defend temporal discounting on the grounds that the future is so uncertain that treating future people like people now would be foolhardy—we don’t know what will change. When we look at what problems people of the past thought were going to be problems today, they are sometimes laughable. Another reason for discounting (money) is that we assume that future generations will be richer, and therefore get a lower value from whatever good we are allocating.²¹ Also, in a richer future people will probably live longer, and will have access to better medical technology. Without discounting future lives we should always choose future people over present people, because a year of their lives saved would have more happiness than the life-years of today.²²

Lots of scholars use temporal discounting for a very practical reason: if we count far-future lives as valuable as near-future lives, it does screwy things with the math. There are just so many more potential people than currently living people that treating them as equally valuable would lead to the conclusion that all of our resources should go to them. For example, according to this line of reasoning, we should spend money on trying to cure malaria, and spend no money at all on treating people who currently have it, and no money to prevent current people from getting it. As providing bed nets is such a reliably effective way to save lives, it seems a little discounting is in order.

THE WEIRD WORLD OF TEMPORAL DISCOUNTING

The notion of a discount rate for the future makes intuitive sense. We would rather have a dollar today than a dollar in a year, and it does seem sensible that we would regard the lives of potential, future people with a little less value than people alive right now. Unfortunately, this kind of temporal discounting looks a little bit strange when we apply it to the past, and when we think about the far future.

For example, if we go far enough back into the past, there was a point where a single individual person in the past is worth as much as every single person alive today, because relative to back when they were alive we, as future people, would be discounted. For example, the human population in 2019 was about 7.55 billion. At a 3 percent discount rate, we find that a single person living around 770 or 780 years ago has the same moral worth of everyone living today. Similarly, if we look into the far future, people seem to have very little value at all. Put another way, a single person living today would be worth 7.55 billion people born 780 years from now.

We can actually put this back into money if we want to, but we have to be careful. Money is less valuable to people who already have a lot of it. But if we are looking at how money can be used to avert DALYs for very poor people, we don’t have to worry about that so much, because all the money would go to preventing DALYs in poor people. Some organizations are really good at it, and others not so much. We’ll talk about what are the most effective organizations, and assume that the cost of averting a DALY is that of the most effective charities. So how much does it cost to avoid a loss of a year of human life for the most effective charities? $78 USD.²³

IMMORTALITY

This book explores how to maximize good feelings and minimize bad feelings. One obvious fact is that, for biological beings, a requirement for feeling good is simply being alive. Although we might argue that some people have lives so bad that they are not worth living, we tend to think that these people are rare, and in any case it’s not for us to decide that they should die. In general we think that lifesaving can be expected to increase good feelings.

Assuming a year of life is worth living at all, having more years of life is better than fewer. Almost everybody believes this, because almost everybody uses medical interventions to help prolong their lives and the lives of those they care about. Living a long, happy, healthy life is something that really matters.

But are there limits to this? Although most people are happy with the idea of living longer, the idea of living forever makes them a bit uncomfortable. Why?

The first thing many people say is that living forever would be horrific because you’d get more and more weak in body and mind. But it’s not as though medical science is trying hard to extend life without also extending general physical and mental health. Perhaps instead of “immortality” we should use the phrase “eternal youth” to clear up this objection. Of course, it’s not really eternal; you could get killed by buffalo trampling or poisoned brussels sprouts. What we mean is that you would not die of old age, disease, or for any reason having to do with your own biology. About half of people say they’d be fine living as long as their health was still good. People generally feel better about living longer if they expect old age to be a good experience.²⁴ This suggests that as medical science improves, and people have more rosy outlooks on what life will be like when they’re older, they will want a still longer life.

The resistance to eternal youth, then, probably boils down to the naturalistic fallacy. The idea of living “forever” feels unnatural, and many things we label as unnatural we also feel is morally wrong. This is worth questioning. If people should not have eternal youth, then how long is enough? The answers people give tend to be based on their own life expectancy. In rich societies today it’s not unusual for people to live well into their eighties. This was much more uncommon in the past. People are less comfortable with the idea of living to be 400 than they are with the idea of living to 120.

But people’s opinions on how long life should be aren’t going to affect whether or not we get continued life extension, because our species has made an implicit, collective decision to live as long as possible. Each medical scientist is working in their own little niche, but collectively this means that science has and will continue to extend our life expectancy. There will never be a point where all scientists will collectively say, “Okay, we’re good. No need to try to prevent death anymore!” Scientists build on each other’s progress, but they are not a coordinated group. Even if most of them wanted to put on the brakes, there is no organization to arrange the solidarity.²⁵

The effect of this is that science will continue to increase life expectancy as much as possible, even without any overarching plan to do so. As they do, their ideas of what is natural and unnatural will change, making living longer and longer gradually more acceptable in people’s minds.

Humanity might get eternal youth without even having an explicit goal to get it.

We started by talking about how to be a good person, and we ended up talking about saving lives and fighting disease. Is this okay?

One assumption I’m making in this book is that doing good means maximizing good feelings and minimizing bad ones. In our day-to-day lives, in industrialized countries, this brings to mind being nice to people and not acting like a jerk. But on the world’s stage, hurting people’s feelings with curt remarks doesn’t matter that much when you can do things to save people years of life from disease.

Not everybody agrees that we should be focused on improving good feelings and reducing bad feelings. Many scholars, for example, like to focus on preference satisfaction. But if we’re looking at how to make this world a better place, this nuance makes little difference. Because just about everyone agrees that a person living a longer, healthier life both increases good feelings and satisfies preferences more effectively. I have my own philosophical take on these matters, but these conclusions hold even under different views.

All of this talk about numbers and money might feel like you’re swimming in foreign waters. It certainly was to me when I first heard about it. Isn’t being good more about how nice you are to the people around you, and gifts you give, and not being mean at work? That’s what our monkey brains would suggest. The monkey brain that evolved to only deal with a hundred and fifty or so people around us. The monkey brain that evolved to keep us alive and reproducing, and not necessarily maximizing the good of the people around us. This is why, in the modern world, when we have better information to understand what it really means to be good, and in a globally connected world where we can make a difference to people far away from us, thinking in terms of numbers and money is an adjustment, a difficult thing to swallow.

Being nice to the people around you is easy for some people, and more difficult for others. Some people are naturally irascible, negative, and lash out—not the kind of people their dogs believe they are. How much effort should one take to be nice if it doesn’t come naturally to them? If it takes effort, it very likely takes effort away from more effective efforts at being good. However, being nice to people around you has instrumental value. If you’re nice, people might look up to you more, and be more willing to emulate your goodness that matters. They might help you with your goals, and donate more when you hold a funding drive for buying malaria nets.