relative morality and the QuALY

If you want to know what is accelerating pandemics its probably global travel. Small pox is theorised to have killed more native Americans than the European invasion of the Americas. If you start moving people around the world lots viruses spread. If you want to go back to pre millennial risks of pandemics you probably have to go back to pre millennial levels of international travel.

In the example given, I'd excorcise the bloody demon, and go back to sleep knowing that either scenario has to happen.

Same as I'd shut down all that genetic engineering bollox, which is in and of itself, an affront against god and our own humanity, and stopping it should markedly reduce the number of new and lethal virii appearing back to more natural levels.

We've had 6 novel lethal diseases occur in the last 40 years, do you think we'd have survived this long if nature had been chucking them at the more primitive versions of ourselves us that fast throughout the previous few millenia of human history?

I note that n one place they have already cooked up a super covid, that combines the lethality of the older versions with the fecundity of the newer less lethal versions, and elsewhere they've recently managed to graft ebola and small pox together. That'll be fun...

Or is it more likely that we've just enjoyed the benefits of the gene manipulators work for the last two years?

"Death panels" here we come! (At breakneck speed too)... 

AuTriker said:

What?!!! When was this and what is the context?

eachother.org.uk/.../

Peter said:

some doctors started putting blanket ‘do not resuscitate’ notes on all autistic patients

What?!!! When was this and what is the context?

I agree with you that case by case and use of discretion is preferable, although I can see why it is problematic on a large scale. I was glad I live in a country that allowed exercise without distance limits and that I have green spaces near my house, I felt very sorry for people who couldn't reach such places, like your example.

But is utility really the best way to look at it? I prefer to think in terms of fairness. So take the hypothetical example of a 16 and 60 year old heart transplant candidate. Neither wants to die. Both have bucket lists. But one of them has had a lot longer and a lot more opportunity to tick off items on that list. It’s as general rule more unfair that a life should end at 16 as opposed to 60.

But what if the 16 year old refuses the transplant. It would be unfair to force it on him against his will. What if the 16 year old is suicidal and only needs the transplant because of a suicide attempt? Is it fair to deny an old man the opportunity for more life for some one who already tried to end theirs and might again?

These are complex ethical issues that need to be taken on a case by case basis but public health policy is usually is not case by case. In part that’s because it’s anticipatory. It’s hard to buy drugs on a case by case basis after all.

Things like social distancing could be case by case, but only if you trust the public and businesses to make good decisions (with guidance) on a case by case basis. There is a debate to be had about where rules stop and discretion should begin.

This is not hypothetical. One early lawsuit in the pandemic was for the right of a family to drive their autistic daughter to the park because time outdoors in a park was considered medically necessary to control her stress and meltdowns.

This lawsuit was only necessary because the rigidity of the rules didn’t give this family the opportunity to exercise discretion.

Another example of poorly handled discretion is when some doctors started putting blanket ‘do not resuscitate’ notes on all autistic patients in their wards.

The pandemic encouraged a one size fits all approach to healthcare where decisions are made for groups not individuals by ‘experts’ rather than patients.

This is extremely bad for autistic people.

Part of the issue is the EQ-5D. A long time ago some one tried to simplify the process of measuring quality of life. So they created the EQ-5D a 5 question survey designed to measure quality of life. Much like the PIP criteria the questions are heavily weighted to maters like mobility, ability to do daly tasks with out physical health.

There is only one question in the EQ-5D to capture mental health issues and it’s fairly vague wording means an autistic person might interpret that question very differently to a neurotypical person. The question is literally are you anxious or depressed. But an autistic person might be so chronically anxious or depressed that they might not respond in the affirmative if they are only experiencing their baseline level of depression. It also doesn’t account for a situation where an autistic person is only able to control their depression or anxiety by severely restricting their lives. By say highly isolating themselves.

The EQ-5D is a woefully inappropriate tool to use when considering autism but it’s almost universally favoured in public health research because it makes estimating quality of life easy. The government cares much more about calculations being easy than right. After all this is the government that used excel spreadsheets to track covid cases.

So while decisions in the moment generally should be made on a case by case basis with anticipatory decisions there has to be some assumption made about autistic people as a group. That being the case when it comes to decisions about provision of services for autistic people, restrictions etc, it’s very important autistic people should be included and particularly that they should be heard on the appropriate statistical measures used to asses their own well-being.

Very interesting. I think you are definitely right about autism and health economics. There would also be the issue, even if autistic input was obtained, of the huge amount of variation in disability based on those involved. Difficult to quantify. 

On the subject of utilitarianism in general, and the scenarios you posed at the beginning of your post, It can be interesting to "expand the utilitarian lense" so to speak. 

Example, the public would find euthanising 70 year olds horrific, on a visceral, emotional level. (the other example, not fun, but less awful perhaps) If you are utilitarian you could argue they are mistaken, but even if this is true, mass wrongness have to be factored into the utilitarian equation because the majority experiencing a negative emotion, is still a negative emotion, and is a harm. Then there are knock on effects on the moral landscape of society. What are the future moral repurcussions of that decision (what other decisions become acceptable by precedent?) 

I always found these trolley problems interesting for this reason, as you are almost expected to not widen the lense. Pull a lever to save 5 others, yes, of course. Harvest the organs of one person to save 5 others, wrong. Why? "I don't know" is the normal answer, or "it feels more wrong" . Except when you widen the lense, it's obvious. Harvesting the organs has larger knock on effects, one ends up with a dystopia where people in hospital are having their organs harvested if that decision is integrated into society. Pulling a lever on a track happens very rarely (though, here, it could still lead to the organ harvesting dystopia lol). 

The point is tho, that the lense got widened. When one does this, you can run into problems.

And so to the original scenario, the social and moral implications of the decision must be weighed up. A caring society, arguably, doesn't value younger lives more than older, because when you do a sortof reductio ad absurdum on the idea, you end up in dystopia. 

This is also a reason why one must be careful with utilitarian analysis and a problem with health economics. Not only does the difficult to quantify get lost (eg the experience of autistic people), but when one expands the lense to include time, information gets more and more uncertain.. 

https://en.wikipedia.org/wiki/The_old_man_lost_his_horse

So utilitarianism can be helpful, but hard to actually use in practice, and other moral frameworks needed. 

Thank you for making this post. It got me thinking about a topic I find enjoyable and haven't thought about for a long time! 

This is an interesting and disturbing subject. I agree with some of you have written and disagree with some, some I am undecided on.

The first lockdown was not just about protecting the vulnerable but to put brakes on as hospitals were being overwhelmed and staff were dying due to immense viral load and inadequate protection. But I reckon some of the rules were wrong. I think we could have done with a somewhat less locked down lockdown, ie not closing cancer treatments etc!

Whether we needed the other lockdowns is more debatable. But i think we ought to have kept more protections once lockdown was eased, and that we ought to still be encouraging if not mandating that people still wear masks and keep their distance etc. at least in crowded areas with lots of mixing ie public transport. It would be better for public health if spread was reduced, as well as for the physically vulnerable.

Lockdown was not universally bad for mental health. Some of us liked the peace and quiet and not having to interact socially as much, and people not getting too close to us and being able to work from home! Of course there were negatives too and I am not belittling those, such as domestic violence.

As for QuALYs yes those are dangerous and some of what you wrote was shocking! I knew some but not all and not the figures you gave. I can't help thinking that if your hypothetical pm had that button then if it would never become public and apart from the logistics of burying so many bodies at once they would be glad of a solution to the pension crisis and would choose to remove so many non-wage-earners! I hadn't thought of the voting angle.

As a physically disabled and unable to work autistic, I guess i have fewer QuALYs than someone else my age, which i find deeply disturbing. As you say, who are they to put a financial value on my life? I would however say that someone who had children ought to have a higher value put on their life than mine.

I have had to make a decision about my own quality of life regarding covid. As I regard myself as being at much higher risk of long covid than an average person, and that it would have a worse effect on me if I got it as I already have so little energy and do not need any additional pain, I still live in self-imposed lockdown. We go out cycling and meet friends outside but not inside and buy everything online. We only go inside for essential medical things like blood tests and the dentist. We even still wash the food shopping! I hate this but I would hate worse what might happen if i got long covid, because it would be similar to what I lived through once already.

I was asked by a 30 year old when I refused to come out of the first lockdown how long I would do it for, he seemed to assume I would not be prepared to live like that for even one year let alone 3 or more. But when I was 20 I had freshers flu at uni which wiped me out. They thought it was post-viral fatigue as I struggled to stay awake at all and had painful joints, it took a year before i was told I had a crippling old persons' disease and it felt like my life was over. And the 30 years of my adult life since then have been a mixed bag. If I could have lived in a lockdown for 3 years or 5 years back then to not get arthritis then I would have chosen that! So yes now i will choose that rather than risk being even more crippled than I am now.

But that is my choice and I am not imposing it on anyone else. My husband has agreed to it, and we do periodically rediscuss it to see if we are still willing to choose living this way. I feel bad for him, but if he could not cope with it I would take the risk for him. Of course he is the one who would have to do my bedpans if i was bedridden, haha! So that does influence his choice! But my life is not so bad even in my own lockdown. I still get to cycle and to learn languages online and I have friends and family. But if the covid risk was a simple case of x% chance I might die a quick and painless death then I would be more inclined to take that chance!

Public health decisions are different from personal health decisions. A 1% increased risk of death is something an individual might choose to take if the cost/benefit analysis worked out. But over a population that is a lot of people dying. But I feel the govt do not take into account other factors, like mental health on the one hand or like long covid on the other. Plus the economy - they don't like things which damage that.

It is all very nuanced and complicated. But I do not feel that the govt decisions have universally benefitted the old over the mentally unwell. I don't actually think they care about either group. Both are generally expensive and don't contribute much unless they are well off.

Life length and quality are not the only factors either. I would take a hit to either if the other part of the equation was help/harm to others. If I had 10 years less AND lost a leg but doing that helped 100 people I pick that but if I had 10 years more and that in perfect health but the price was 100 people suffering I would not pick that. Not that such a point necessarily matters for QuALY calculations, but I just felt the need to say it. Although it does in a way, because people do generally care about others, but maybe more about themselves.

I hope I made some sense and didn't wander too far off topic! I don't want to spend five hours editing it though so I shall just post!