The Cost of Saving a Life

The Trolley Problem is a classic problem in the philosophy of ethics. The idea of the Trolley Problem is simple. Imagine a trolley is heading for a group of five people tied to the tracks. Your only option to save their lives is to switch the track. But there's one person tied to that other track. Switching the train will save those five people, but you will cause that one person to die. Or you could do nothing, and let the five people die, sparing the person on the side track.

The public health system deals with situations that are kind of like this one all the time. It may seem cruel, but public health system has to decide who to save. There are only so many resources available to save lives, and to improve quality of life. And so, making the wrong decision can lead to a greater loss of life and to greater suffering.

Measuring Life

So how much should we spend to save a life? The answer is complicated. Public health relies on a few measures beyond raw mortality rates. A death is a loss, but not all deaths are equal. Public health science relies on the concept of years of potential life lost and QALY (quality adjusted life years) loss. The latter takes into account factors such as poor health. To see why QALYs are important, we can take an extreme example: a year of life in perfect health vs a year of life in a catatonic state. If we had the resources to save one or the other, it makes sense to save the former rather than the latter, as much as it might be painful if we focus on the individual.

Again, it's a cold analysis, but it's important, because we are trying to maximize the impact of our efforts, and we're talking about a significant number of people, rather than focusing on an individual. If we had an infinite amount of resources, we could focus on saving everyone, but we don't, so we can't.

What's it Cost?

Unfortunately there's no single answer to this question. How much it costs to save a life, or a QALY, depends on a lot of factors, including the region being discussed, the current state of technology, the number of people and QALYs we're trying to save, how willing a population is to engage in activities that can save them, and so on.

We could probably find someone, somewhere in the world, where $1 will add one QALY to their lives. We could probably find someone, somewhere in the world, where it would cost $500M to add one QALY. If we started focusing on the lowest cost issues first, then as we solve those issues, the cost per QALY would rise.

While it is difficult to get an exact price on an individual level, there are plenty of estimates for average costs that are deemed efficient. If we're spending less than that level, we're saving more lives than average, and if costs go significantly above that level, it basically means that we could be saving more lives and doing more to increase quality of life, by choosing different options.

The long standing view is that an efficient cost per QALY is roughly $50K. Neumann, P.J. et al. (2014) reject this view and suggests the use of a tiered threshold system of $50K, $100K, and $200K per QALY, with a preference based on available resources. They further suggest that if a single threshold had to be chosen, it would be closer to $100K to $150K.

These figures are for the United States. Other countries may have lower or higher thresholds that are reasonable. People in third world countries often suffer from conditions that can be treated for much less money and have healthcare workers that often are themselves paid much less. A doctor visit in India, for instance, may cost as little as 50Rs (about $0.66) and even on the extremely high end about 10,000Rs, the equivalent of about $130 (Medifee). Meanwhile the cost of a doctor visit in the United States would start around $150 (National Group Health Alliance LLC).

Because of the significant differences in resource cost and reason for the loss of QALYs, local regions would generally have to decide for themselves what options are best. The main exceptions would be humanitarian efforts to other regions and global issues where the various public health systems around the world cooperate to solve an issue.

Death Panels

I referenced the Trolley Problem in the beginning of this article. While the analogy more or less works, there is a major distinction. It shouldn't have to be said, but what I've discussed in this article is not the same as a "death panel." Nobody is deciding that someone dies.

It's a matter of allocation of public resources. Since resources or limited, we have to decide where they should go, in order to do the most good. Relying on emotion can result in the loss of a significant number of lives, all because we're trying to save a few lives. And that isn't reasonable, or fair. In the actual Trolley Problem, the person must choose who dies. In this instance, we're only deciding who we can save.

Further Reading

One way that we can help save more lives is to make the public health and healthcare systems more effective at responding to rapid changes in public health conditions, without reducing efficiency. We can do so by leveraging modern technology and redesigning hospital systems.