8 ms·

Love and Death: “Quality of life” calculations leave out much that matters

93 points by neonate 6y ago

jlos 6y ago
I think the main reason for the investment differential between the young and the old is that spending on the elderly is typically urgent. Problems for the elderly are mostly health related and if left unfunded will means someone, somewhere will be blamed. Problems for the young will show up later in some second order effect or missed opportunity. That's really hard to hold someone accountable for (especially public officials) and so its much easier to ignore. That and kids don't vote or own property.
- ouid 6y ago
  You should always vote against improving the lives of those younger than you at the cost of your own well-being, since you will never be younger than you are now.
  - david-gpu 6y ago
    ...if you only care about your wellbeing. Some people care about the wellbeing of others. Even strangers (gasp!).
  - imtringued 6y ago
    This often leads to local maxima where even the person who is optimizing for his own selfishness is losing overall.
  - ndiscussion 6y ago
    Pretty sure this was a satirical post you guys, of course the youth are more important than the old. They're the only ones who can reproduce and ensure we have a strong civilization for thousands of years to come.
deleted 6y ago
[deleted]
joubert 6y ago
Beautiful. Thanks for sharing.
abellerose 6y ago
> But are these life-endings [of a young person and an old person] equivalent? Perhaps, on a philosophical level, they are. On a practical level, however, the death of an 85-year-old person from a preventable cause has cost them a few years at the end of life, while a 25-year-old has, on the same calculation, lost over 60 years of life, including their most active and event-filled years. Every time I think about the USA, I get a strong feeling that the current structure of systems are designed for the old to flourish and at a heavy cost of the young. I would be surprised if my feeling is actually wrong and everything isn't actually designed for the older population to continue flourishing the longest at the cost of the young. I'm curious what HN thinks. I personally think the value of the young should be set higher to flourish than the old and the systems of society should be designed that way.
- lumost 6y ago
  The more accurate picture is that the US is designed for the wealthy to flourish. As it happens, the wealthy tend to be older for a variety of reasons. A wealthy 25 year old is unlikely to face any significant risk that they will miss out on a medical procedure vs. an older adult, or ultimately face any existential risk for that matter. How many billionaires have had multiple bankruptcies?
  - EchoAce 6y ago
    I don’t understand the logic here. Yes, of course a wealthy person will be able to pay for procedures and avoid going broke. Isn’t this universally true? Perhaps you meant the US is poorly designed for poor people, which is not something you can say about every country.
- ozborn 6y ago
  My impression of the US in the pandemic era is that the value of the old is not held in high regard. Even prior, culture was focused on the young. However the value of money (which on average the old may have more of?) and catering to those who have it is definitely real and may be what you are suggesting.
wk_end 6y ago
I really disliked this essay. It seems to not be saying very much; what little it's saying doesn't really need to be said; and moreover what little it's saying doesn't need to be said, of all times, right now. It strikes me as a kind of mawkish attempt to rebut the comments of two doctors about weighing the lives and well-being of younger people more heavily than that of older people when forced to make public policy choices. I'm not sure why these particular doctors need rebutting; the more extreme of them, Ezekiel Emanuel, made some comments seven years ago and a year and a half ago that are being responded to; the other, John Lee, published an essay on Unherd recently, which is a fairly fringe site I think? Looking at Wikipedia it's British, so maybe it's not so fringe in the the UK? But The Hedgehog Review and Alan Jacobs, the author of this piece are both American. At any rate, neither of them are prominent or influential. And truth be told, it seems like Emanuel - who seems to have said some pretty unpleasant things and is the primary target here - was roped in as a way to tarnish Lee's more recent, more relevant, more even-handed comments. The upshot is, old people can do meaningful things, like go on vacation and have a fun time, too! ...which is so banal as to not really be worth saying. Of course they can! They just...can do a lot less of it in the remainder of their lives, on average, across the entirety of the population; and they've had more opportunity to do so already compared to the young. Under normal circumstances this doesn't really matter. But when circumstances are forcing a choice...well. Jacobs acknowledges that maybe we do have to make some kind of brutal calculations, but doesn't really suggest how; he just pleads sentimentally. Which isn't surprising, because if you're ever actually willing to make that kind of brutal calculation, it's hard to imagine a moral calculus that says "killing young people with their lives ahead of them so the elderly can get a few more golden years in" is the right way to go. And there's the kicker, in the conclusion: "it would be good if some of our public-health experts would find a way to incorporate those ineffable but vital things into their calculations", as though any public-health experts anywhere seem to be willing to make the trade-off he seems to be accusing them of making. And - admittedly this is more of an emotional reaction - the paragraph about how "['Covidtide'] has offered opportunities for renewed connection and a deepening of affection" feels, to me, borderline offensive in light of everything "Covidtide" (ugh) has wrought: the deaths from the disease itself, the mental health disaster of isolation, the poverty from economic shutdown, the debt we'll spend decades paying off (at the cost to social services), abuse victims trapped in their homes with their abusers...I guess it's just an attempt to look for a silver lining in a bad situation, but looking all that in the face and saying, "ah, but it's so nice that I got to spend a bit of extra time with my grandkids!" smells faintly repulsive.
jlos 6y ago
> These people who live a vigorous life to 70, 80, 90 years of age—when I look at what those people “do,” almost all of it is what I classify as play. It’s not meaningful work. They’re riding motorcycles; they’re hiking. Which can all have value—don’t get me wrong. But if it’s the main thing in your life? Ummm, that’s not probably a meaningful life. I'm never really to sure which to find more shocking about these kind of public intellectuals, their hubris in thinking they can define what makes a life meaningful for someone-- everyone--else or that they are often given positions of actual influence. Then again, maybe things makes more sense if the people running the world think the only thing giving other peoples lives meaning is work.
- mongol 6y ago
  Seems they think that those lives serve no utility for others, thus they are not meaningful. Forgetting that a life is most meaningful for the person whose it is. Would have expected more stringency from an intellectual.
- deleted 6y ago
  [deleted]
- conjectures 6y ago
  I'd like to agree and note that assuming we get to post-scarcity conditioning quality of life on work will be a bad definition. On the other hand I recall, as a PhD student, David Cox lightly napping in the audience of a conference (he'd have been about 90), only to wake up for the questions and fire off some insights. So there is certainly some merit in the theory of a nexus between 'meaningful work' and living a long and engaged life, at least for some people.
  - incrudible 6y ago
    QUALY is not conditioned on work productivity, Ezekiel Emanuel has done a poor job of representing it to the public. The truth of the matter for most people though is that if they are unable to do meaningful (to them) work this leads to depression. For the anecdote given by the author, the grandmother could perform meaningful work (counseling) still.
theptip 6y ago
An important conversation, but I don’t feel this piece contributes anything. Hand-waving words are not going to solve the hard problems of where to allocate limited dollars. Quality Adjusted Life Years (QALY) are a widely used tool for measuring and reasoning about health care trade offs. They let you make utilitarian estimations on welfare to evaluate outcomes. There are plenty of objections to this system; I’d hope for a recounting of some of these longstanding arguments, eg see https://en.m.wikipedia.org/wiki/Quality-adjusted_life_year#Debate https://en.m.wikipedia.org/wiki/Quality-adjusted_life_year#D... for links to papers from the last few decades on this subject. The author is basically using a sentiment-driven “think of the children!” style argument, without making any attempt to weigh or quantify harms on either branch of the decision tree. That isn’t a particularly helpful approach in public health policy in my opinion. To be fair they seem to be responding to opinion pieces (not data driven arguments) from the other side of the argument so maybe I’m setting too high a bar. But I feel the QALY based approach is not the mainstream idea, particularly in the USA, so it warrants a bit more defending.
EvilEy3 6y ago
Oh boy, yet another "actshually" filled with emotions that supposed to give "another view". You precisely know what Emanuel and Lee mean when they quanyify that someone with 25 years is a greater loss than someone with 60 years. This emotional story about grandmother does nothing to change their statement.
- wyattpeak 6y ago
  That's not the point that the article takes issue with. Not the difference in time, which the author acknowledges is important, but the classification of those later years as being inherently less valuable than the younger ones.
  - vixen99 6y ago
    Surely, this evaluation relates to the public sphere perspective. Along with insurance companies, every single relevant government action that requires estimations of life value, tacitly or explicitly agrees that later years are indeed less valuable than the younger ones and likely, always will. NICE - the UK medical board that decides which medicines can be used in the NHS, constantly makes calculations on quality of life for all ages. This is inevitable if public funds are involved. In the private sphere, it’s a completely different matter. This seemingly 'uncaring' stance only applies where public decisions are involved. No reason for this evaluation to necessarily work at a personal level if the state (taxpayer) does not pay for it.
  - tomatocracy 6y ago
    It's not later years per se but level of health which is adjusted for. We tend to think of this in terms of whether we should extend life with poor years or not but if you think about treatments or devices which won't extend life but might well have a dramatic effect on level of health, mobility etc during those years then it becomes clearer why this is an important consideration. I think most people would say that in a resource constrained world there still ought to be room to fund those things.
  - incrudible 6y ago
    The problem is that insurances pool everyones money for treatment. No death can be prevented, only deferred. Is it justified to extend the life of a terminal cancer patient for another miserable few months with chemotherapy, at full cost to everyone else in the pool? I dare say not, and QUALY is the measure we use to calculate this, imperfect as it may be. It also is worth noting that QUALY is not conditioned on worker productivity, as suggested in the article.
ggm 6y ago
People commenting on this story should state their age. It would be interesting to help understand aspects of the answer. Some parts of this essay worked for me but I believe in QALYS as a basic measure to keep in mind, like millimorts. Another version of this thesis is "it takes a village to rear a child" I'm 59 btw
- Filligree 6y ago
  Completely off topic, but... it does take a village to raise a child. I understand that instinctively, and I suppose I've read enough factual articles about it to believe it, but I'm missing a real explanation. Something I could point people at in lieu of trying to explain why that is, myself, which covers everything from "A higher diversity of 'parents' is helpful" to "it's not good to segregate children by age, actually". I don't suppose you'd have something? Or perhaps more likely, fiction which demonstrates the same thing would be valuable. Fictional evidence may not be evidence, but it's good at convincing people all the same. My personal favorite in the genre is Non Non Biyori; if you want to take a look, it's an excellent and relaxing story for these times.
  - ggm 6y ago
    Depends who you ask: It doesn't: * https://phys.org/news/2011-09-child-doesnt-village.html https://phys.org/news/2011-09-child-doesnt-village.html It does: * https://www.demographic-research.org/volumes/vol34/34/34-34.pdf https://www.demographic-research.org/volumes/vol34/34/34-34.... * https://link.springer.com/chapter/10.1057/9781137386724_5 https://link.springer.com/chapter/10.1057/9781137386724_5 * https://theconversation.com/it-takes-a-village-to-raise-a-child-101279 https://theconversation.com/it-takes-a-village-to-raise-a-ch... I think, if you go into genetics, you would be looking to the altruistic benefits to the gene pool of non-gene transfer roles in the community and effect on the gene overall. Lots of organisms show collective child rearing, for defense against predators, for food management, to ensure 'sneaky fucker' offspring get raised (that whole top-dog king-lion thing is a bit of a myth: everybody gets some, if they can..)
    - Filligree 6y ago
pjc50 6y ago
"Self-Taylorism" is a great phrase that I'm going to have to remember.
JoeAltmaier 6y ago
This. In the 50' we used to see Science Fiction stories about robots taking the yoke of labor from our shoulders, to allow us all to live our better, truer lives. Now that it's happening, all modern philosophers can think of is, How to get Everybody Back To Work! Like that is some end in itself.

93 points by neonate 6y ago

jlos 6y ago

I think the main reason for the investment differential between the young and the old is that spending on the elderly is typically urgent. Problems for the elderly are mostly health related and if left unfunded will means someone, somewhere will be blamed. Problems for the young will show up later in some second order effect or missed opportunity. That's really hard to hold someone accountable for (especially public officials) and so its much easier to ignore. That and kids don't vote or own property.

ouid 6y ago
You should always vote against improving the lives of those younger than you at the cost of your own well-being, since you will never be younger than you are now.
- david-gpu 6y ago
  ...if you only care about your wellbeing. Some people care about the wellbeing of others. Even strangers (gasp!).
- imtringued 6y ago
  This often leads to local maxima where even the person who is optimizing for his own selfishness is losing overall.
- ndiscussion 6y ago
  Pretty sure this was a satirical post you guys, of course the youth are more important than the old. They're the only ones who can reproduce and ensure we have a strong civilization for thousands of years to come.

deleted 6y ago

[deleted]

joubert 6y ago

Beautiful. Thanks for sharing.

abellerose 6y ago

> But are these life-endings [of a young person and an old person] equivalent? Perhaps, on a philosophical level, they are. On a practical level, however, the death of an 85-year-old person from a preventable cause has cost them a few years at the end of life, while a 25-year-old has, on the same calculation, lost over 60 years of life, including their most active and event-filled years. Every time I think about the USA, I get a strong feeling that the current structure of systems are designed for the old to flourish and at a heavy cost of the young. I would be surprised if my feeling is actually wrong and everything isn't actually designed for the older population to continue flourishing the longest at the cost of the young. I'm curious what HN thinks. I personally think the value of the young should be set higher to flourish than the old and the systems of society should be designed that way.

lumost 6y ago
The more accurate picture is that the US is designed for the wealthy to flourish. As it happens, the wealthy tend to be older for a variety of reasons. A wealthy 25 year old is unlikely to face any significant risk that they will miss out on a medical procedure vs. an older adult, or ultimately face any existential risk for that matter. How many billionaires have had multiple bankruptcies?
- EchoAce 6y ago
  I don’t understand the logic here. Yes, of course a wealthy person will be able to pay for procedures and avoid going broke. Isn’t this universally true? Perhaps you meant the US is poorly designed for poor people, which is not something you can say about every country.
ozborn 6y ago
My impression of the US in the pandemic era is that the value of the old is not held in high regard. Even prior, culture was focused on the young. However the value of money (which on average the old may have more of?) and catering to those who have it is definitely real and may be what you are suggesting.

wk_end 6y ago

I really disliked this essay. It seems to not be saying very much; what little it's saying doesn't really need to be said; and moreover what little it's saying doesn't need to be said, of all times, right now. It strikes me as a kind of mawkish attempt to rebut the comments of two doctors about weighing the lives and well-being of younger people more heavily than that of older people when forced to make public policy choices. I'm not sure why these particular doctors need rebutting; the more extreme of them, Ezekiel Emanuel, made some comments seven years ago and a year and a half ago that are being responded to; the other, John Lee, published an essay on Unherd recently, which is a fairly fringe site I think? Looking at Wikipedia it's British, so maybe it's not so fringe in the the UK? But The Hedgehog Review and Alan Jacobs, the author of this piece are both American. At any rate, neither of them are prominent or influential. And truth be told, it seems like Emanuel - who seems to have said some pretty unpleasant things and is the primary target here - was roped in as a way to tarnish Lee's more recent, more relevant, more even-handed comments. The upshot is, old people can do meaningful things, like go on vacation and have a fun time, too! ...which is so banal as to not really be worth saying. Of course they can! They just...can do a lot less of it in the remainder of their lives, on average, across the entirety of the population; and they've had more opportunity to do so already compared to the young. Under normal circumstances this doesn't really matter. But when circumstances are forcing a choice...well. Jacobs acknowledges that maybe we do have to make some kind of brutal calculations, but doesn't really suggest how; he just pleads sentimentally. Which isn't surprising, because if you're ever actually willing to make that kind of brutal calculation, it's hard to imagine a moral calculus that says "killing young people with their lives ahead of them so the elderly can get a few more golden years in" is the right way to go. And there's the kicker, in the conclusion: "it would be good if some of our public-health experts would find a way to incorporate those ineffable but vital things into their calculations", as though any public-health experts anywhere seem to be willing to make the trade-off he seems to be accusing them of making. And - admittedly this is more of an emotional reaction - the paragraph about how "['Covidtide'] has offered opportunities for renewed connection and a deepening of affection" feels, to me, borderline offensive in light of everything "Covidtide" (ugh) has wrought: the deaths from the disease itself, the mental health disaster of isolation, the poverty from economic shutdown, the debt we'll spend decades paying off (at the cost to social services), abuse victims trapped in their homes with their abusers...I guess it's just an attempt to look for a silver lining in a bad situation, but looking all that in the face and saying, "ah, but it's so nice that I got to spend a bit of extra time with my grandkids!" smells faintly repulsive.

jlos 6y ago

> These people who live a vigorous life to 70, 80, 90 years of age—when I look at what those people “do,” almost all of it is what I classify as play. It’s not meaningful work. They’re riding motorcycles; they’re hiking. Which can all have value—don’t get me wrong. But if it’s the main thing in your life? Ummm, that’s not probably a meaningful life. I'm never really to sure which to find more shocking about these kind of public intellectuals, their hubris in thinking they can define what makes a life meaningful for someone-- everyone--else or that they are often given positions of actual influence. Then again, maybe things makes more sense if the people running the world think the only thing giving other peoples lives meaning is work.

mongol 6y ago
Seems they think that those lives serve no utility for others, thus they are not meaningful. Forgetting that a life is most meaningful for the person whose it is. Would have expected more stringency from an intellectual.
deleted 6y ago
[deleted]
conjectures 6y ago
I'd like to agree and note that assuming we get to post-scarcity conditioning quality of life on work will be a bad definition. On the other hand I recall, as a PhD student, David Cox lightly napping in the audience of a conference (he'd have been about 90), only to wake up for the questions and fire off some insights. So there is certainly some merit in the theory of a nexus between 'meaningful work' and living a long and engaged life, at least for some people.
- incrudible 6y ago
  QUALY is not conditioned on work productivity, Ezekiel Emanuel has done a poor job of representing it to the public. The truth of the matter for most people though is that if they are unable to do meaningful (to them) work this leads to depression. For the anecdote given by the author, the grandmother could perform meaningful work (counseling) still.

theptip 6y ago

An important conversation, but I don’t feel this piece contributes anything. Hand-waving words are not going to solve the hard problems of where to allocate limited dollars. Quality Adjusted Life Years (QALY) are a widely used tool for measuring and reasoning about health care trade offs. They let you make utilitarian estimations on welfare to evaluate outcomes. There are plenty of objections to this system; I’d hope for a recounting of some of these longstanding arguments, eg see https://en.m.wikipedia.org/wiki/Quality-adjusted_life_year#Debate https://en.m.wikipedia.org/wiki/Quality-adjusted_life_year#D... for links to papers from the last few decades on this subject. The author is basically using a sentiment-driven “think of the children!” style argument, without making any attempt to weigh or quantify harms on either branch of the decision tree. That isn’t a particularly helpful approach in public health policy in my opinion. To be fair they seem to be responding to opinion pieces (not data driven arguments) from the other side of the argument so maybe I’m setting too high a bar. But I feel the QALY based approach is not the mainstream idea, particularly in the USA, so it warrants a bit more defending.

EvilEy3 6y ago

Oh boy, yet another "actshually" filled with emotions that supposed to give "another view". You precisely know what Emanuel and Lee mean when they quanyify that someone with 25 years is a greater loss than someone with 60 years. This emotional story about grandmother does nothing to change their statement.

wyattpeak 6y ago
That's not the point that the article takes issue with. Not the difference in time, which the author acknowledges is important, but the classification of those later years as being inherently less valuable than the younger ones.
- vixen99 6y ago
  Surely, this evaluation relates to the public sphere perspective. Along with insurance companies, every single relevant government action that requires estimations of life value, tacitly or explicitly agrees that later years are indeed less valuable than the younger ones and likely, always will. NICE - the UK medical board that decides which medicines can be used in the NHS, constantly makes calculations on quality of life for all ages. This is inevitable if public funds are involved. In the private sphere, it’s a completely different matter. This seemingly 'uncaring' stance only applies where public decisions are involved. No reason for this evaluation to necessarily work at a personal level if the state (taxpayer) does not pay for it.
- tomatocracy 6y ago
  It's not later years per se but level of health which is adjusted for. We tend to think of this in terms of whether we should extend life with poor years or not but if you think about treatments or devices which won't extend life but might well have a dramatic effect on level of health, mobility etc during those years then it becomes clearer why this is an important consideration. I think most people would say that in a resource constrained world there still ought to be room to fund those things.
- incrudible 6y ago
  The problem is that insurances pool everyones money for treatment. No death can be prevented, only deferred. Is it justified to extend the life of a terminal cancer patient for another miserable few months with chemotherapy, at full cost to everyone else in the pool? I dare say not, and QUALY is the measure we use to calculate this, imperfect as it may be. It also is worth noting that QUALY is not conditioned on worker productivity, as suggested in the article.

ggm 6y ago

People commenting on this story should state their age. It would be interesting to help understand aspects of the answer. Some parts of this essay worked for me but I believe in QALYS as a basic measure to keep in mind, like millimorts. Another version of this thesis is "it takes a village to rear a child" I'm 59 btw

Filligree 6y ago
Completely off topic, but... it does take a village to raise a child. I understand that instinctively, and I suppose I've read enough factual articles about it to believe it, but I'm missing a real explanation. Something I could point people at in lieu of trying to explain why that is, myself, which covers everything from "A higher diversity of 'parents' is helpful" to "it's not good to segregate children by age, actually". I don't suppose you'd have something? Or perhaps more likely, fiction which demonstrates the same thing would be valuable. Fictional evidence may not be evidence, but it's good at convincing people all the same. My personal favorite in the genre is Non Non Biyori; if you want to take a look, it's an excellent and relaxing story for these times.
- ggm 6y ago
  Depends who you ask: It doesn't: * https://phys.org/news/2011-09-child-doesnt-village.html https://phys.org/news/2011-09-child-doesnt-village.html It does: * https://www.demographic-research.org/volumes/vol34/34/34-34.pdf https://www.demographic-research.org/volumes/vol34/34/34-34.... * https://link.springer.com/chapter/10.1057/9781137386724_5 https://link.springer.com/chapter/10.1057/9781137386724_5 * https://theconversation.com/it-takes-a-village-to-raise-a-child-101279 https://theconversation.com/it-takes-a-village-to-raise-a-ch... I think, if you go into genetics, you would be looking to the altruistic benefits to the gene pool of non-gene transfer roles in the community and effect on the gene overall. Lots of organisms show collective child rearing, for defense against predators, for food management, to ensure 'sneaky fucker' offspring get raised (that whole top-dog king-lion thing is a bit of a myth: everybody gets some, if they can..)
  - Filligree 6y ago

pjc50 6y ago

"Self-Taylorism" is a great phrase that I'm going to have to remember.

JoeAltmaier 6y ago

This. In the 50' we used to see Science Fiction stories about robots taking the yoke of labor from our shoulders, to allow us all to live our better, truer lives. Now that it's happening, all modern philosophers can think of is, How to get Everybody Back To Work! Like that is some end in itself.