The limits of utilitarianism in health care

Lord Sumption has come under fire for comments he made in BBC a debate about whether lockdown was “punishing too many for the greater good”, where he told a woman with stage 4 cancer that her life was “less valuable” than other people’s.

He was saying this as part of his argument against lockdown, which is broadly that it punishes the young to save the old. Others have pointed out that this argument doesn’t work, because the young are hardly going to benefit from an overwhelmed NHS, dead parents and collapsing consumer spending among the wealthiest age group. Covid policy is not, in general, a trade-off between wealth and health, and it’s certainly not a zero sum game between generations.

But I want to set that aside and look at the argument on its own merits. Do we, and should we, consider some people’s lives less valuable than others when setting health care and wider government policy?

Within health care, there are places where we are very explicit about how we value lives. When NICE looks at the cost-effectiveness of new drugs, it will only approve them for use in the NHS if they cost less than £20,000 to £30,000 for each QALY (quality adjusted life year) they deliver[i]. A lifesaving intervention for a younger and healthier person will, other things being equal, deliver more QALYs than one for an older, sicker person, so we are willing to pay more for it. When it comes to how much we pay for drugs, we are explicitly utilitarian.

When we look more broadly at health care activities, however, things get messier. While health economists and policy-makers do try to assess the cost-effectiveness of interventions in a broadly utilitarian way, the reality of delivering health care often works out differently. For all the talk of prioritising community care and prevention, funding and activity continue to be sucked into hospitals and emergency care, and the last two years of someone’s life are by far the most expensive for health care. This is partly about the difficulty of managing change in a complex system, but also because there is a moral framework at play here that isn’t strictly utilitarian – we feel obligated to help people who need it and to “save someone’s life”, even if we might get more QALYs using the money somewhere else.

The allocation of government resources beyond health care diverges even further from a utilitarian ideal. While the cost-effectiveness of policies is assessed, the concept of QALYs is largely limited to health policy evaluation and there is no grand model that ensures a pound doesn’t get spent on roads if it could deliver slightly higher marginal utility in schools. Moreover, spending isn’t really allocated according to cost-benefit analysis when it comes down to it. The Treasury coordinates a fairly rigorous spending review process with other departments, but decisions on what money goes where will ultimately be made by ministers, based on what they think the public want and what they think will win them votes.

And so we end up with our public resources distributed through a messy combination of utilitarianism, public opinion, politics and accident. While this does lead to some indefensible decisions and pork-barrel politics, the fact that we have such a mixed approach is not a regrettable failure to implement our utilitarian principles, but a reflection of what we actually believe. There is a tension between our utilitarian sensibilities and our ethical and democratic ideals that all people are equal. Although we try to formalise this to some degree by looking at equalities alongside cost-benefit analyses, “equalities impact assessments” are often a bit of an afterthought, and we don’t have a way of trading of net utility against equalities – they are two separate frames that remain in tension.

This is where Lord Sumption gets it wrong – or at least voices a fringe opinion. There is a place for utilitarianism in public policy. It’s an important part of what people believe is fair, and can be implemented pretty explicitly in narrow applications like NICE’s drug assessments. But if we let it become our whole approach for allocating resources or deciding on policy, we ignore a widespread and fundamental belief that all people are equal, with equal rights, including the right to life. The next thing you know, you are on the BBC telling people who are old or disabled (both protected characteristics in equalities law!) that they are worth less than others. It’s not clear that this is ethically sound or sustainable in a democracy. We’re better off with the messy compromise that we’ve got.

[i] The fact that the threshold is in fact a range might suggest that the process is not as strictly utilitarian as it first appears.

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