Part Two – Using Resources Fairly

Part Two in Paul Dolan’s six-part series ‘Making Policy Better‘

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We all care about how long we live and the quality of the life we have. We also care about inequalities in life expectancy and life experience across society. We care about fairness and the various claims that different people might have on publicly funded interventions.

The three most legitimate claims on resources

The following three points represent the most legitimate and morally relevant claims that an individual might have for being moved further towards the front of the queue for interventions that would improve their life.

1. Those who have the most to gain (capacity to benefit)

The more you can expect to benefit from intervention, the closer to the front of the queue you should be. Imagine you would gain 10 years from treatment in comparison to Person A who would gain only 10 months. All else being equal, you have a greater claim on resources than they do. Allocating resources only on this basis would mean that resources were being used in such a way as to maximise the bang for the buck.

2. Those who are currently suffering the most (severity of condition)

Imagine now that Person A will die within five months without an intervention, whereas you will live for another five years without intervention. There are now good ethical grounds for putting Person A in front of you in the queue because their prospects are more severe than yours in the absence of intervention. Whether you or Person A gets priority will be determined by the trade-off between claims based on benefit and those based on severity.

3. Those who will suffer the most over the lifetime

Capacity to benefit and severity of condition assess what future wellbeing might look like in the presence and absence of intervention. But some people might have a legitimate ethical claim to be further up the queue based on what will happen over their lifetime, which additionally accounts for what has happened in the past. Imagine that you are 20 years younger than Person A, or that you have suffered more over a given lifespan. You now have an additional claim on resources based on the prospects of a shorter life expectancy or fewer life experiences.

There is no simple way to resolve these competing claims, but public preferences can illuminate the degree of support for different philosophical positions, and the trade-offs between them. I have conducted various empirical investigations into what the public thinks about these trade-offs. In a nutshell, capacity to benefit and severity of condition both matter in every decision context I have enquired into, from triage decisions to macro resource allocations. Context matters, of course, and policymakers should be accounting for what happens to people both in the presence and in the absence of an intervention when deciding what to do.

It is also clear from public preference data that members of the public wish to account for wellbeing over the lifetime. From some of my own empirical work, “having lived less” life was the main reason for prioritising younger people. This is consistent with the fair innings argument (FIA) – the egalitarian principle that everyone is entitled to some ‘normal’ span of health (usually expressed by life years) and anyone failing to achieve it has been “cheated”.

Claims in the context of COVID-19

We would expect policymakers to account for capacity to benefit, severity of condition and lifetime suffering in their prioritisation decisions. And yet, arguably only severity has been considered. It has been very interesting to me, to say the least, that any attempts to raise concerns about capacity to benefit and lifetime wellbeing have been greeted with moral outrage. But risks from dying from Covid increase significantly with age and, despite the outrage, this is morally relevant.

The average life expectancy for an 18-year-old in the UK today is 81. According to the ONS, around 60% of the deaths from COVID-19 in the UK have been in people who are this age or older. Most of those bearing the biggest burden from COVID-19 will not live as long as those who are dying from it. When we look at a cohort of older people, we are subject to “survivorship bias” – we see only the lucky ones who have survived, and do not properly consider all those who have been cheated out of fair innings.

If people’s lifetime prospects are an important measure of human welfare, then we are likely to have engaged in one of the biggest redistributions of resources in human history, from those who have the least to those who have the most.

It is baffling to me that there has not been more – any – moral outrage about the injustice of this. It is even more baffling given that we have gathered our own public preference data during the pandemic which shows that, if we count the relative value of mortality above age 70 as 1, the value of mortality below age 35 is roughly 24. These preferences were stable across the two surveys in May 2020 and February 2021, and across respondents of different ages.

Data of these kind and the arguments I present here do not suggest that older people should simply be allowed to die because they have already achieved a fair innings, only that they should be afforded less priority for life-saving interventions than those who have not yet lived as long. And we must do more to manage deaths properly, to create as much benefit as possible for the dying person – and, crucially, for those left behind. We must do more to accept death (one of life’s two certainties), especially in old age, and to minimise the impact death has on family and friends.

I should add that a more sophisticated version of the FIA would account for life experience as well as life expectancy. As private individuals and public citizens, all of us care not just about how long we and other people survive, but also about how well we thrive. This would mean that people who had suffered most over their lifetime would be given greater priority than those who have lived well. Therefore, younger people with pre-existing conditions at high risk from COVID-19 would be afforded great priority. This makes clear that our priorities should not be determined by Covid per se, or by any new virus or crisis we might face, but by the impact on wellbeing over the lifetimes of those affected by it and the policy responses to it.

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Click here to read Part One, Measure the Ripples, Not Just the Splash.

Paul Dolan is Professor of Behavioural Science at London School of Economics and Political Science. He is the best-selling author of Happiness by Design and Happy Ever After, and the host of the new Duck-Rabbit podcast. www.pauldolan.co.uk.

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