How Should We Value the Lives of Those Most at Risk?

4 April 2020. Updated 7 May 2020.

Generations to come are being saddled with high levels of public and private debt. These things kill, too. If all this is the price of saving human life, we have to ask whether it is worth paying.

The truth is that in public policy there are no absolute values, not even the preservation of life. There are only pros and cons. Do we not allow cars, among the most lethal weapons ever devised, although we know for certain that every year thousands will be killed or maimed by them? We do this because we judge that it is a price worth paying to get about in speed and comfort. Every one of us who drives is a tacit party to that Faustian bargain.

A similar calculation about the coronavirus might justify a very short period of lockdown and business closures, if it helped the critical care capacity of the NHS to catch up. It may even be that tough social distancing measures would be acceptable as applied only to vulnerable categories.

But as soon as the scientists start talking about a month or even three or six months, we are entering a realm of sinister fantasy in which the cure has taken over as the biggest threat to our society. Lockdowns are at best only a way of buying time anyway. Viruses don’t just go away. Ultimately, we will emerge from this crisis when we acquire some collective (or “herd”) immunity. That is how epidemics burn themselves out.

Jonathan Sumption, The Sunday Times, April 5th 2020

Attempting to place a monetary value on human life, using that quantum to calculate the financial benefit of extreme social distancing, and then weighing that benefit against the financial cost of the lockdown is always going to upset a lot of people, as I discovered when I had a stab at it in the Critic. There are those who think it’s morally wrong to attach a price tag to a human life – and some people reacted to my back-of-the-envelope calculation as if no decent person would ever attempt such an exercise. But it’s worth pointing out that all British governments put a cash value on the cost of extending people’s lives, including Labour governments. This may shock those unfamiliar with health economics, but there has to be an upper limit on what taxpayers can reasonably be expected to pay to keep people alive. As Dominic Lawson pointed out in the Sunday Times, “This is especially true of the NHS, a centralised, free-at-the-point-of-use system unique in the western world, which can only function on the basis of rationing (since demand for healthcare is, in effect, limitless if ‘free’).”

In my calculation, I took as a given Professor Neil Ferguson’s prediction that there would be 230,000 additional deaths from coronavirus if the Government didn’t move from a mitigation strategy to suppression and then tried to work out how many years, on average, those 230,000 had left to live. Putting to one side the issue of whether people who’ve died with COVID-19 have died from COVID-19, the average age of those patients recorded by the NHS as having died of coronavirus is 79.5. For reasons you can interrogate here, I concluded they had an average of six years left to live, so a total of 1,380,000 additional years. The National Institute for Health and Care Excellence (NICE) values a quality-adjusted life year (QALY) at between £15,000 and £30,000 when deciding how much money to spend on new medicines, with an additional year of perfect health being valued at the top end. My assumption that each of the people who would otherwise die of COVID-19 will live another six years is based on data from Wuhan showing that 67% of patients who’ve died have had comorbidities – but I haven’t factored in the 37% of them that didn’t and would have had longer to live, on average, than six years. But to compensate for this, I’ve attached the upper limit of £30,000 to each QALY (unrealistically high, given that a majority of the people in question have underlying health conditions), giving a total value of the lives saved of £41.4 billion. So the question is: Will the lockdown cost more or less than £41.4 billion?

Actually, £41.4 billion is probably an under-estimate. For one, Professor Ferguson predicted an additional 230,000 would die if we didn’t introduce extreme social distancing and if everyone who become critically ill with COVID-19 received the hospital care they required. In fact, according to Imperial College’s modelling, the demand for critical care in the mitigation scenario would be eight times greater than the NHS’s emergency surge capacity. And even if we inflate that 230,000 to allow for this, that still doesn’t account for the number of deaths that pursuing a mitigation strategy would result in because it doesn’t include the increase in the number of people dying from other diseases because the NHS would be overwhelmed. According to Fraser Nelson, the Government has calculated that 150,000 non-COVID-19 patients will die if the lockdown remains in place because hospitals are prioritising patients with the virus. As far as I know, no one has calculated how many non-COVID-19 patients will die if the lockdown is ended.

So the financial benefit of keeping the lockdown in place, in terms of the monetary value of the additional years of life granted to those people who would otherwise die of the virus, is greater than £41.4 billion. But then, so is the cost of the lockdown. According to the Resolution Foundation, it could cost the Treasury as much as £40 billion every three months just to pay the wages of furloughed workers. The Centre for Economics and Business Research estimates the lockdown is costing £2.4 billion-a-day. That means that by April 12th we were already £50bn out of pocket. Of course, the Treasury would have to be paying out some of that money anyway even if we’d stuck with the mitigation strategy. As Sam Bowman said in his reply to my article in the Critic, “the relevant counterfactual is not business as usual, but some unavoidable level of economic slowdown caused by the virus and people’s individual attempts to avoid it”.

I should say that even if the financial cost of the lockdown is higher than its financial benefit in terms of QALYs, I don’t consider that a knock-down argument for ending the lockdown. (And by “ending”, I don’t mean the total abandonment of non-pharmaceutical interventions, just something more like the Swedish approach, i.e., the quarantining of the vulnerable, banning gatherings of over 50 people, washing hands, wearing masks, working from home where possible, etc.) From a moral point of view, I can see the argument that the vulnerability of those most at risk – their advanced age, as well as their poor underlying health – means we have a greater obligation to protect them, not a lesser. But if we accept that argument, we’ll have to overhaul the current method we use for attaching a monetary value to human life, which is based on QALYs.

While this isn’t a decisive way of settling the argument about the lockdown, it’s a factor that should be taken into account and weighed alongside the others. A more important factor is the long-term damage a prolonged lockdown will do to the economy and the impact that will have on public health, ultimately leading to a greater loss of life than ending the lockdown will.

Further Reading

The Corona Dilemma‘ by Paul Frijters, Club Troppo, March 21st 2020

All lives aren’t equal, but we still want them saved‘ by Dominic Lawson, The Sunday Times, March 29th 2020

A Health Economic perspective on COVID-19‘ by Dr Malcolm Kendrick, drmalcolmkendrick.org, March 29th 2020

Has the government overreacted to the Coronavirus Crisis?‘ by Toby Young, The Critic, March 31st 2020

Why the coronavirus shutdown is worth it‘ by Sam Bowman, The Critic, April 1st 2020

A response on the cost of the coronavirus shutdown‘ by Toby Young, The Critic, April 2nd 2020

How to live with Covid-19‘ by Andrew Sullivan, New York, April 3rd 2020

The ‘False Debate’ About Reopening the Economy Is the One That Ignores the Enormous Human Cost of Sweeping COVID-19 Control Measures‘ by Jacob Sullum, Reason, April 13th 2020

Coronavirus: Nine in 10 dying have existing illness‘ by Nick Triggle, BBC News, April 16th 2020

Why are we really in lockdown?‘ by Jemima Kelly, Financial Times, April 17th 2020

“Discriminatory” lockdown should be eased for the healthy elderly, say senior doctors‘ by Chris Jewers, Mail on Sunday, May 2nd 2020

The cost of saving lives in this lockdown is too high‘ by Russell Lynch, Telegraph, May 5th 2020

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giblets
giblets
1 month ago

I’d love to question the 230,000 ‘extra’ lives lost. What defines an ‘extra’ death when the Chief Medical Officer stated that sadly 2/3 of the deaths would be people who wouldn’t last the year without COVID-19?

We need to remember that annually around 110,000 people die of coronary heart disease, 70,000 from respiratory diseases (90% of those over 65), and 65,000 from Alzheimers and dementia. These are all considered an exceptionally high risk from COVID-19, and as stated in more than 1 paper, they make up a very high % of victims. In 2017/18, 30,000 people died from seasonal flu, the one big difference appears to be that flu affects the very young and old (typically a U shaped graph), whilst COVID-19 affects predominantly the older population.

As you point out, the question then becomes how much we value people who suffer from deaths that will result directly from the lockdown. These victims will have lives that are valued FAR less than those lives we’re supposedly saving by imposing a lockdown.

Mike May
Mike May
1 month ago

Even the lockdown isn’t really there to save lives – it’s just a way of extending the deaths over a longer period in order to to smooth out the loading on the NHS. This may allow the service to save some whom it would have been unable to treat under stress conditions, and hence would have had to allow to die, but I do feel that the eventual cost in human lives is unlikely to be greatly reduced by lockdown.

Csaba
Csaba
1 month ago

I would say that spending much more on direct support and protection of vulnerable people should cost significantly less than stopping the economy. It would be interesting to do the math how much it would cost to actually support vulnerable people and see the final number. My old friends haven’t received any offer or help from the local council for shopping or helping in any other ways. But it seems to be much cheaper for me than the cost of the job retention scheme for tens of thousands. The virus only focuses on a narrow segment of the society so we should just take advantage of it and focus our forces on them too.

David Cutts
David Cutts
1 month ago

This discussion is lost in over-simplification about the value of lives. You could make exactly the same argument with different parameters about having hospitals or care homes at all, at least any equipped with 21st century medicine. But we live in a society which values lives even more than societies of the past, or at least it values the lives of the citizens of here. We give considerable value to the preservation of life until its natural end. To abandon that position in the face of this confrontation with nature is to destroy many of the premises on which our social contracts are based, even though those premises are under pressure from the dominance of economic perspectives over human and ethical ones.

We now have an virus around us which is very infectious, kills a high proportion of those who get it who also have old age or other problems, but has so far infected less than 3% of the population. (The idea that more than half of us have had it already and that we are thus immune is wrong. Survey and sample studies indicate low rates of overall infection at present. Many of us may have had similar symptoms derived from other things, though.)

So, given that we are heading for 20k+ deaths from an infection rate of <3% we might guess that we would reach over 0.5m if we left the thing to run unchecked. Without another means (eg an effective vaccine) of stopping the infection, we have isolation/quarantine, cure or death. In past centuries we would not have had the luxury of cure or vaccine solutions and so plagues of various sorts were handled by burying the dead and working hard at quarantine. You can tell that quarantine was the preferred strategy then, and it is now. And we have evidence from the 1918 flu outbreaks that early release from quarantine, whilst superficially attractive in short economic terms, proved ineffective over a longer term measure as resurgent disease took away the gain.

In our quarantine armoury we have both the tools of 'lockdown' and, if we can be bothered to sort them out, the tools of testing and tracing. So, rather than increased death, let us keep our current quarantine strategy going for now and aim to reduce the residual infection to a level where it is almost completely identifiable by testing and then persist in tracing and quarantining those becoming infected from that base. Note that you have to work hard at the borders of your territory as well to stop import of the disease.

What does this mean? First, continue or strengthen the lockdown. Second, put serious management logistical and financial resources into testing and tracing. Thirdly, devise policies for releasing the lockdown, step by step, in a world with an adjusted economy. Fourth, try to find that vaccine, but don't bet the world on it. My guess is that there will be fewer flights and sporting events this side of an effective vaccine, in this scenario, but that a productive and maybe even greener economy might emerge if enabled so to do. We have changed very fast this year. It is not beyond us to continue to adapt to our conditions, but to try to call a halt to the fight and hope that things return to the status quo ante to abandon our society's values.

Thomas Pelham
Thomas Pelham
1 month ago
Reply to  David Cutts

We now have an virus around us which is very infectious, kills a high proportion of those who get it who also have old age or other problems, but has so far infected less than 3% of the population. (The idea that more than half of us have had it already and that we are thus immune is wrong. Survey and sample studies indicate low rates of overall infection at present. Many of us may have had similar symptoms derived from other things, though.)”

“So, given that we are heading for 20k+ deaths from an infection rate of <3% we might guess that we would reach over 0.5m if we left the thing to run unchecked.

Hi, please quote a source for this; most antibody tests so far are finding far more prevalence than that. Half is an overestimate, I agree, but let’s see what data there is around:

1) Stockholm has a lower bound of 10%, but an estimate of up to 30%:
https://www.spectator.co.uk/article/the-swedish-experiment-looks-like-it-s-paying-off
https://www.medrxiv.org/content/10.1101/2020.04.15.20066050v1?fbclid=IwAR1Xl7FOTVhwDPOmsbMzsTIZIvPi3IY_25_h077NQecV-iEOKyfFn8I8n5U Lower bound would give an IFR of about 0.1

2) Studies in Scotland, Finland and Denmark are compared here, all found a IFR in the 0.05-0.2 range. I'm not sure about the actual antibody tests used, I think the Scottish ones were rerun to avoid false positives and in any case wern't using the quick antibody tests that have been critisised:
https://covmodel.org/2020/04/17/sars-cov-2-preliminary-serology-test-reports-from-scotland-denmark-and-finland-give-contradictory-results-on-infection-fatality-ratio/

3) This is being sneered at by some, but as far as I know they're serious, and suggest that up to 10% of the uk has had symptomatic COVID, by looking at the unique symptom footprint of the disease:
https://covid.joinzoe.com/blog That would give a IFR in the 0.1- 0.2% range.

4) Iceland, Diamond Princess and the Aircraft Carriers all seem to point to similar low IFRs (and therefore high R0 and spread).

What does this mean? First, continue or strengthen the lockdown

How are you anticipating this working? How long do you anticipate this taking? What sort of economic price is on this? Do you know that the lockdown works?

This paper
https://www.rki.de/DE/Content/Infekt/EpidBull/Archiv/2020/Ausgaben/17_20_SARS-CoV2_vorab.pdf?__blob=publicationFile
from the German authorities shows that the effective rate of transmission was under 1 before the lockdown. Why was that?

Why did the UK's own peak happen before the lockdown had effect (peak deaths 8th April, average length from infection to death around 22-24 days, gives peak infections on 16th March – a full 5 days before the lockdown).

So is the lockdown helpful? Why? Demonstrate this please.

SteveB
SteveB
1 month ago
Reply to  David Cutts

The idea that more than half of us have had it already and that we are thus immune is wrong.

Stated as fact, so source please?

Basileus
Basileus
1 month ago

Thank you for this great website: excellent work. In the 1990s I worked in the area of safety critical systems. Those involved understood that there was a trade-off between risk and cost. This boils down to putting a monetary value on a human life. At the time, this figure was two million pounds, but it may have been inflated since then. Now politicians could never discuss this as they would be subject to death by a million tweets: they can only talk about ‘human life being priceless’. At least behind closed doors the cost / benefit discussion must take place, since it is clear that the cost is now disproportionately high.

The other place where human life is given a monetary value is in calculations for insurance purposes. Here is an article which discusses the monetary value placed on human life based on USA legal settlements.
https://www.bloomberg.com/graphics/2017-value-of-life/

It seems that the actual cost of this lock-down is going to be at least ten times the sort of sum these calculations would give you. Time to think again? Yes.

wendyk
wendyk
1 month ago

It might seem controversial to say so, but rationing of treatment is inevitable, given the structure of the NHS, the rising demand which follows inevitably in the wake of every clinical and medical advance and our essentially consumerist approach to treatments and assumed life span.

During my years working in hospitals, I had many discussions and disputes about blanket prolongation of life, resuscitation and the expectation that all would be treated equally, regardless of age, infirmity etc.

In the currently contentious area of QALYS and rationing, it behoves us to consider the wisest use of available resources, to balance the growing economic and social costs of a prolonged lockdown against the assumption that all those who fall ill can be saved: they can’t.

Elderly frail individuals afflicted with dementia, heart failure, loss of capacity following neurological events like strokes and general debility are unlikely to survive in the long term.

It would make far more sense for these folk to be kept comfortable and safe with a version of palliative care, rather than the heroic interventions which the media appear to be insisting on.

So, provide suitable supplies of PPE for nursing homes to afford protection, but keep the residents on site, with available medicines and nursing aides to minimise distress and ensure symptom relief and comfort where possible.

And the invaluable care assistants should have their work rewarded accordingly. Far too many are on zero hours contracts and poor wages.

The lives of the young and economically active should be the focus of the intensive care units.

No doubt many will condemn me for this, but I’ve had plenty of experience in various settings.

Finally, I think more of us should consider Advance Declarations/Living Wills. I’ve had one for many years, as have several friends and family members.

Graham Matthews
Editor
Graham Matthews
1 month ago

The concept of disease burden is well established and is measured as quality-adjusted life years, taking into account health, financial and morbidity factors. The current focus on number of deaths is misleading as each death is not equal. Some people dying may have only expected a few more months of life, and their death should not carry the same weight as someone aged 20 expecting 62 more years of high quality life. If the famous model’s outupt was expressed in this way then it would show a quite different result.

rchumpoll
rchumpoll
1 month ago

There’s another side to this which is deeply concerning to many, including me. The idea of the state deciding who gets to be locked down for longer periods of time is authoritarian in the extreme, especially since the decisions will be made by bureaucrats of limited ability. I belong to the over-70 category, but unlike many in my age bracket, I have no co-morbidities, I exercise daily, eat properly and am not overweight. Who has the right to tell me to self-isolate for an indefinite period of time? And how will this be enforced? Will there be some sort of Orwellian system or worse, where the elderly will have to wear identifying marks on clothing? Will we be arrested for defying lockdown orders in order to join in with the rest of the population? Will we be stopped in the street by officials to provide identification? Will we be denied entry to shops and later, restaurants, places of worship and venues for entertainment because we appear to be in the age category that is restricted?
There is another, as yet undiscussed in any media, side of this and that is the return of the cultural arts as we know them. Whether it’s opera, ballet, symphony, recital or lecture – let’s face the fact that it’s largely the elderly who comprise the majority of the donor base and who attend these functions. Without older people, the arts will not survive.
Think again, politicians, before you plan to lock us all away!

Barney McGrew
Barney McGrew
1 month ago

A risible article from Catherine Bennett in The Observer:
https://www.theguardian.com/commentisfree/2020/apr/25/lift-the-lockdown-on-the-say-so-of-a-tory-with-an-empathy-bypass-no-thanks-catherine-bennett

You get a mention Toby.

Her ‘argument’ seems to be that if you oppose the lockdown, you are probably a middle aged, right wing man with ulterior motives for wanting to help the virus kill lovely non-right wing people. As is typical in this type of political activism, she is attacking the man, not the ball, digging up whatever dirt she can rather than tackling the actual argument.

In a desperate move, she uses the sadness of the six mourner limit on lockdown funerals to evoke the sadness of the funerals that she claims will result from these evil men’s plans to end the lockdown. Catherine, we saw what you did there…

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