Well-Being and the Calculus of Lives Under COVID-19
A total-lives-saved approach could help guide pandemic decision-making.
Posted Jul 14, 2020
The COVID-19 pandemic has presented cities, countries, and the world, with a series of difficult trade-offs: Should they prevent more infection or reduce unemployment? Limit contagion to lessen mortality or cease social isolation? Re-open schools, and if so, under what conditions, and at what cost to the worsening of a second wave of the pandemic?
These are difficult decisions. They arguably involve incommensurable goods: life, health, social connection, knowledge/education, and the economy. Moreover, the trade-offs between these goods are likely to differ in different regions.
Calculus of Lives in COVID-19 Decisions
A JAMA article just published by the Human Flourishing Program at Harvard proposes an approach to navigating these decisions that takes well-being into account while prioritizing life itself. It can feel harsh, unreasonable, or even immoral to value economic consequences or personal happiness against the number of lives lost. Our approach avoids doing so. Instead, it acknowledges and makes use of the fact that many other aspects of well-being contribute to the preservation of life.
For example, meta-analyses (combining evidence across numerous rigorous longitudinal studies) estimate that unemployment increases mortality risk by 1.63-fold; social isolation increases mortality risk by 1.29-fold; and depression increases mortality risk by 1.34-fold. Many of the things that matter most to us in reality also affect survival and longevity. That fact may prove useful in constructing arguments concerning COVID-19 pandemic policies that may sometimes be persuasive to numerous parties potentially holding different priorities and values.
The idea would be to attempt to estimate the total lives saved or lost, due to all causes of death, from different lock-down, social distancing, workplace, school re-opening, and other policies. Such a “total lives-saved” approach would include not only lives saved or lost due to infection, but also lives saved or lost due to the consequences of unemployment, social isolation, depression, and other factors. While there are methodological challenges to this approach (described below), evaluating total lives saved has significant advantages. Such an approach takes well-being seriously, yet also acknowledges that life itself is the highest good at stake in these decisions.
Other approaches may be helpful for some purposes but not others
Other approaches that incorporate well-being have been used in the past to make difficult decisions when life is at stake. One of the most widely used approaches within the medical decision-making literature makes use of a metric called “quality-adjusted life years” (QALYs). QALYs are calculated using the years of life remaining but weighting each year with a quality-of-life score (on a 0 to 1 scale), often determined by an individual’s ability to carry out daily activities and their freedom from pain and mental disturbance. The measure is sometimes used to decide which treatments to prioritize when financial resources are constrained.
A related metric, well-being years (WELLBYs), instead uses a more general evaluation of life satisfaction for its weighting of each year of life, and it has recently been proposed to help make decisions as to when to end lock-down in the United Kingdom.
Those of us at the Human Flourishing Program at Harvard certainly think happiness and life satisfaction are important, but we also think that human flourishing extends beyond this and includes meaning and purpose, health, character, and social relationships We have proposed a 10-item measure to help assess these various domains of flourishing. Such a measure could likewise be alternatively used in weighting, to provide a broader picture of flourishing. The resulting metric, obtained by weighting each year of life by the flourishing measure, might be referred to as “flourishing years” (FLRYs).
When there is no question that lives are being lost, and when the actions or decisions under consideration only concern enhancing well-being, these measures might be usefully employed. For example, if for two different actions requiring the same financial resources, one could either increase someone’s well-being for one year, versus alternatively for three years, then the latter would clearly be preferable. One could use QALYs or WELLBYs or FLRYs for such evaluation, depending on how broad the scope of well-being one wants to consider. QALYs or WELLBYs or FLRYs might then be helpful in evaluating different actions, decisions, treatments, or policies.
However, when life itself is at stake, these measures are inadequate. The use of QALYs (or WELLBYs or FLRYs) in such decisions then effectively presupposes a trade-off between life and well-being, and it is not at all clear that this is reasonable. Important criticisms have thus been leveled against the use of QALYs on several accounts. The use of QALYs has been criticized for not properly handling the question of death, and improperly handling the value of life. The use of QALYs in decision-making has also been criticized because it effectively down-weights the lives of the poor, suffering, disabled, and vulnerable since their “quality of life” tends to be lower. These are important criticisms. Moreover, these very same criticisms would apply also to the use of WELLBYs or FLRYs if employed in decisions in which life itself is at stake.
Total Lives Saved Approach and Its Challenges
The advantage of the total lives-saved approach is that it avoids a number of these moral difficulties. It treats all lives as being of equal worth. It still takes into account well-being, but it does so through its effects on life itself. However, as noted above, the effects of well-being on mortality are considerable.
There are methodological challenges that accompany this total lives-saved approach. While we have decades of data on the effects of unemployment, depression, and social isolation on mortality, we have much less data on the effects of different pandemic policies on these economic, social, psychological outcomes. However, in the past few months, with different cities and countries making different pandemic decisions, there is now a wealth of new data that might be used to formally evaluate the effects of these policy decisions. Such evaluation could also include the effects of different policies on other aspects of life such as lower use of preventive medical services, delayed cancer treatment, and less participation in religious communities and other communities, each of which also has effects on mortality.
Further challenges also remain, such as estimating not just the number of unemployed, but the length of unemployment, and also the possibility of common mortality pathways (e.g. part of the effect of unemployment on mortality may be through depression; a very conservative approach would be to focus on the lives lost or saved from different policies through the single economic, social, or psychological mechanism that seemed to quantitatively matter most).
The total lives-saved approach is moreover conservative in its deference to infection-related mortality because it does not directly take into account social and other goods, viewed as distinct ends, which they are, but rather places them subordinate to life. However, the conservative nature of this approach may also be an asset. If there comes a point at which the number of lives lost from economic, social, and psychological consequences of different policy decisions outweighs the number of lives lost from infection, then it should be clear that it is time for policy-makers to take these into account. Because the total lives saved approach prioritizes life itself, and because it is conservative in its deference to infection-related mortality, it might then be possible to construct arguments for policy decisions that are persuasive to various groups that may potentially otherwise hold very different priorities and values.
Well-being is important for its own sake. It is also important in its consequences for mortality. It is important in constructing arguments and evaluating policies related to the difficulties we now face. It is important in thinking through trade-offs in the present COVID-19 calculus of lives. A total lives-saved approach can provide a means of accounting for well-being that prioritizes human life.
The Human Flourishing Program at Harvard’s Institute for Quantitative Social Science aims to study and promote human flourishing, and to develop systematic approaches to the synthesis of knowledge across disciplines. For past postings please see our Psychology Today Human Flourishing Blog.
VanderWeele, T.J. (2020). Challenges estimating total lives lost in COVID-19 decisions: consideration of mortality related to unemployment, social isolation, and depression. JAMA, in press. doi:10.1001/jama.2020.12187.