Love and Death: “Quality of life” calculations leave out much that matters
hedgehogreview.com
hedgehogreview.com
I'm never really to sure which to find more shocking about these kind of public intellectuals, their hubris in thinking they can define what makes a life meaningful for someone-- everyone--else or that they are often given positions of actual influence.
Then again, maybe things makes more sense if the people running the world think the only thing giving other peoples lives meaning is work.
On the other hand I recall, as a PhD student, David Cox lightly napping in the audience of a conference (he'd have been about 90), only to wake up for the questions and fire off some insights. So there is certainly some merit in the theory of a nexus between 'meaningful work' and living a long and engaged life, at least for some people.
The truth of the matter for most people though is that if they are unable to do meaningful (to them) work this leads to depression.
For the anecdote given by the author, the grandmother could perform meaningful work (counseling) still.
Made me think about a few Frankl's quote
> For the meaning of life differs from man to man, from day to day and from hour to hour. What matters, therefore, is not the meaning of life in general but rather the specific meaning of a person's life at a given moment. To put the question in general terms would be comparable to the question posed to a chess champion, “Tell me, Master, what is the best move in the world?” There simply is no such thing as the best or even a good move apart from a particular situation in a game and the particular personality of one's opponent. The same holds for human existence. One should not search for an abstract meaning of life. Everyone has his own specific vocation or mission in life to carry out a concrete assignment which demands fulfillment. Therein he cannot be replaced, nor can his life be repeated. Thus, everyone's task is as unique as is his specific opportunity to implement it.
The funny thing is that people shitting on other's "meaningless hobbies" are very often in the second category he talks about:
> Moreover, there are various masks and guises under which the existential vacuum appears. Sometimes the frustrated will to meaning is vicariously compensated for by a will to power, including the most primitive form of the will to power, the will to money.
Do not assume that everyone has the freedom to make such decisions. Moral decisions are ones that you can make regardless of life circumstance. Many people simply cannot afford the traditional lifestyle of getting married and having kids. I don't mean incels, I mean that all over the world there are young people who want to marry and have kids but are locked into economic situations that preclude the ability to take that "moral" path.
The modern selfish senior would rather live 5 more years in a nursing home with a bad quality of life than give their inheritance to their children. The inheritance is instead given to the state and megacorps.
Many of our parents inherited a home.
Poverty isn't what I meant. There are people, sometimes rather well off people, who are nevertheless in economic situations that preclude marriage. For instance, some people have elderly or disabled family members which they must take care of. There is huge gap, the entire middle class, between "poverty" and not having enough money to hire 24/7 care. Others have good well-paid jobs, but jobs that mean they are located in places with male/female ratio that makes finding a partner next to impossible (China's "bachelor" villages). Still others are limited by cultural norms that do not accept marriage of persons without traditional full-time employment regardless of wealth (India, Japan). Just look at the difficulties surrounding Japan's princess. The real issue there isn't that her husband is poor, he really isn't, but that he doesn't have a traditional fulltime job.
Some friends are theoretically open to committed partners, but only if they can be long-distance for the first few years while completing their adventures around the world. There's a big push against compromising even your travel agenda, let alone your career, to be with someone.
I have a hard time with the idea that there is anything moral or immoral about work or leisure. In 50 years time, it's very unlikely anything 'work' I have done will matter.
Leisure activities are only immoral if they hurt yourself or others. If your activities lead you to become an overweight shut-in in poor health with few friends, sure. You could make the argument they are immoral.
I think you can be a retired dabbler and dilettante and absolutely live a 'good life'. At the end of the day, all that matters is that we live lives true to ourselves and our relationships with others. All of our accomplishments are dust in the wind, and will be forgotten.
If you told me I will live to 100, quitting at 70 to travel the world sounds ok.
If you told me I’ll die at 50, I will be retiring before that.
By prolonging life from 80 to 90, we also encourage people to retire later. So even if “meaningful” would mean “work” (and oh boy, it doesn’t) it still is important to to prolong life.
You can always trust an intellectual to not consider anything but first order effects I guess.
Quality Adjusted Life Years (QALY) are a widely used tool for measuring and reasoning about health care trade offs. They let you make utilitarian estimations on welfare to evaluate outcomes.
There are plenty of objections to this system; I’d hope for a recounting of some of these longstanding arguments, eg see https://en.m.wikipedia.org/wiki/Quality-adjusted_life_year#D... for links to papers from the last few decades on this subject.
The author is basically using a sentiment-driven “think of the children!” style argument, without making any attempt to weigh or quantify harms on either branch of the decision tree. That isn’t a particularly helpful approach in public health policy in my opinion.
To be fair they seem to be responding to opinion pieces (not data driven arguments) from the other side of the argument so maybe I’m setting too high a bar. But I feel the QALY based approach is not the mainstream idea, particularly in the USA, so it warrants a bit more defending.
You precisely know what Emanuel and Lee mean when they quanyify that someone with 25 years is a greater loss than someone with 60 years. This emotional story about grandmother does nothing to change their statement.
We tend to think of this in terms of whether we should extend life with poor years or not but if you think about treatments or devices which won't extend life but might well have a dramatic effect on level of health, mobility etc during those years then it becomes clearer why this is an important consideration. I think most people would say that in a resource constrained world there still ought to be room to fund those things.
Is it justified to extend the life of a terminal cancer patient for another miserable few months with chemotherapy, at full cost to everyone else in the pool?
I dare say not, and QUALY is the measure we use to calculate this, imperfect as it may be. It also is worth noting that QUALY is not conditioned on worker productivity, as suggested in the article.
> for another miserable few months with chemotherapy,
My grandfather hated chemo. But he did it for those few more months - and he got to see my cousin get married. How do you account for this? You can't.
If you are willing to pay extra, or out of pocket, to have your life extended to the absolute limits, that is fine with me, but please do not push this attitude as the “morally right one” unto everyone else.
I will push whatever I want to, thank you. Insurance is supposed to provide healthcare. It isn't supposed to judge what is a good life. I shouldn't have to pay extra for care that I was always paying for because you're mad your rates went up. Don't like it, don't buy the care. Ridiculous assumption to let society decide when people should live and die.
It's also unnecessary to. On the populations we are talking about, individual cases like people living long on chemo in miserable lives to die are counteracted by people who died way younger. It's easy to calculate the risk and spread that among insurance holders.
Let me rephrase that: When making an emotional appeal, you aren't making a sound argument. It's effective, but also intellectually dishonest.
> Insurance is supposed to provide healthcare.
Healthcare providers provide healthcare. They need to get paid. Insurance providers offer the insured the possibility to spread the risk of large individual healthcare costs among many participants.
If you have the opinion that health insurance should be a universal right, you will also have to consider that those countries who have such systems also put strict limits on the extent of end-of-life healthcare.
> I shouldn't have to pay extra for care that I was always paying for because you're mad your rates went up.
If costs go up, rates go up. As your individual risk goes up, your individual rates go up. The more you pay, the better your insurance is going to be able to cover you. You're going to pay extra either way.
What are you going to do if you can't afford insurance anymore, except the most basic plans that are capped at the top? You're not going to be able to afford that last round of chemo.
> Don't like it, don't buy the care.
So... let the prices rise until nobody can afford insurance anymore, then blame the people for not buying it? Medicare-for-all? I'm afraid that won't pay for everything either.
> Ridiculous assumption to let society decide when people should live and die.
That's the way it works either way. If you lived in a hypothetical society that goes to any length to extend everyone's life to the maximum extent possible, then that society decided that.
> On the populations we are talking about, individual cases like people living long on chemo in miserable lives to die are counteracted by people who died way younger.
People who died way younger also stopped paying way younger. It's also rare. The chance of developing cancer in your lifetime is 1 in 4.
Furthermore, in many cases, the effectiveness of chemotherapy is quite low, especially considering its severe impact on QOL. Many doctors refuse chemo after receiving a terminal cancer diagnosis, opting for palliative care instead.
> It's easy to calculate the risk and spread that among insurance holders.
It's easy to calculate the cost, it's not so easy to actually get it paid. Suppose your cost rises by 10%, so you raise prices by 10%. As a result, revenue goes down 5%, because people drop out of insurance. You need to raise prices again, or reduce coverage, increase co-pays, and so on.
Every time I think about the USA, I get a strong feeling that the current structure of systems are designed for the old to flourish and at a heavy cost of the young. I would be surprised if my feeling is actually wrong and everything isn't actually designed for the older population to continue flourishing the longest at the cost of the young. I'm curious what HN thinks. I personally think the value of the young should be set higher to flourish than the old and the systems of society should be designed that way.
A wealthy 25 year old is unlikely to face any significant risk that they will miss out on a medical procedure vs. an older adult, or ultimately face any existential risk for that matter.
How many billionaires have had multiple bankruptcies?
When boomers were 30, they were many times richer than millennials.
The present generation is not headed towards a happy retirement at the expense of the present.
Edit: As another poster mentioned, the US values the lives of the rich and more of the old are rich, for now.
Corporations (and the mob) generally stole the funds of the pension and used them. And they were promised pensions in line with prevailing wages, which were higher.
That and kids don't vote or own property.
Some people care about the wellbeing of others. Even strangers (gasp!).
Another version of this thesis is "it takes a village to rear a child"
I'm 59 btw
I understand that instinctively, and I suppose I've read enough factual articles about it to believe it, but I'm missing a real explanation. Something I could point people at in lieu of trying to explain why that is, myself, which covers everything from "A higher diversity of 'parents' is helpful" to "it's not good to segregate children by age, actually".
I don't suppose you'd have something?
Or perhaps more likely, fiction which demonstrates the same thing would be valuable. Fictional evidence may not be evidence, but it's good at convincing people all the same. My personal favorite in the genre is Non Non Biyori; if you want to take a look, it's an excellent and relaxing story for these times.
It doesn't:
* https://phys.org/news/2011-09-child-doesnt-village.html
It does:
* https://www.demographic-research.org/volumes/vol34/34/34-34.... * https://link.springer.com/chapter/10.1057/9781137386724_5 * https://theconversation.com/it-takes-a-village-to-raise-a-ch...
I think, if you go into genetics, you would be looking to the altruistic benefits to the gene pool of non-gene transfer roles in the community and effect on the gene overall. Lots of organisms show collective child rearing, for defense against predators, for food management, to ensure 'sneaky fucker' offspring get raised (that whole top-dog king-lion thing is a bit of a myth: everybody gets some, if they can..)
Anyway, my personal opinion isn't so much about long-term outcomes. Those seem almost wholly determined by genetics, anyway. It's instead a question of--
How happy is the child? How much do they enjoy life?
I feel like that's a question which researchers tend to miss, and/or assume doesn't matter -- perhaps because it's harder to measure -- but isn't enjoyment of life the entire goal, in the first place? And childhood is a significant fraction of life.
It strikes me as a kind of mawkish attempt to rebut the comments of two doctors about weighing the lives and well-being of younger people more heavily than that of older people when forced to make public policy choices. I'm not sure why these particular doctors need rebutting; the more extreme of them, Ezekiel Emanuel, made some comments seven years ago and a year and a half ago that are being responded to; the other, John Lee, published an essay on Unherd recently, which is a fairly fringe site I think? Looking at Wikipedia it's British, so maybe it's not so fringe in the the UK? But The Hedgehog Review and Alan Jacobs, the author of this piece are both American. At any rate, neither of them are prominent or influential. And truth be told, it seems like Emanuel - who seems to have said some pretty unpleasant things and is the primary target here - was roped in as a way to tarnish Lee's more recent, more relevant, more even-handed comments.
The upshot is, old people can do meaningful things, like go on vacation and have a fun time, too! ...which is so banal as to not really be worth saying. Of course they can! They just...can do a lot less of it in the remainder of their lives, on average, across the entirety of the population; and they've had more opportunity to do so already compared to the young. Under normal circumstances this doesn't really matter. But when circumstances are forcing a choice...well. Jacobs acknowledges that maybe we do have to make some kind of brutal calculations, but doesn't really suggest how; he just pleads sentimentally. Which isn't surprising, because if you're ever actually willing to make that kind of brutal calculation, it's hard to imagine a moral calculus that says "killing young people with their lives ahead of them so the elderly can get a few more golden years in" is the right way to go. And there's the kicker, in the conclusion: "it would be good if some of our public-health experts would find a way to incorporate those ineffable but vital things into their calculations", as though any public-health experts anywhere seem to be willing to make the trade-off he seems to be accusing them of making.
And - admittedly this is more of an emotional reaction - the paragraph about how "['Covidtide'] has offered opportunities for renewed connection and a deepening of affection" feels, to me, borderline offensive in light of everything "Covidtide" (ugh) has wrought: the deaths from the disease itself, the mental health disaster of isolation, the poverty from economic shutdown, the debt we'll spend decades paying off (at the cost to social services), abuse victims trapped in their homes with their abusers...I guess it's just an attempt to look for a silver lining in a bad situation, but looking all that in the face and saying, "ah, but it's so nice that I got to spend a bit of extra time with my grandkids!" smells faintly repulsive.
> First of all, they evaluate the quality of life almost wholly in terms of activity, especially professional activity. Valuable years for Lee are “active and event-filled” years. Emanuel asserts, “There are not that many people who continue to be active and engaged and actually creative past 75. It’s a very small number.” It is hard to know whether this is true because he doesn’t define “active” or “engaged” or “creative,” but elsewhere in the same interview he is extremely dismissive of anything, including especially “play,” that is not “meaningful work.” He is quite explicit in his scorn for anyone, even well past retirement age, who lives for play rather than work: “But if it’s the main thing in your life? Ummm, that’s not probably a meaningful life.”
> And truth be told, it seems like Emanuel - who seems to have said some pretty unpleasant things and is the primary target here - was roped in as a way to tarnish Lee's more recent, more relevant, more even-handed comments.
Lee never defines active as having to do with professional activity (at least not in what's quoted in the article), that is Emanuel's definition.
The philosophy of life and death needs to be considered and discussed especially when humankind is faced with difficult choices of life and death. The choice of optimizing saved life-years may be the right one now, but we as human beings must not become cynical. The value of life can not be measured in terms of events and activity.
I do understand your point of view. For someone who has lost much to Covid-19 and realizes how much we will lose, it is easy to read the article as childish and arrogant. But that is not the only way to read it.
In the 50' we used to see Science Fiction stories about robots taking the yoke of labor from our shoulders, to allow us all to live our better, truer lives.
Now that it's happening, all modern philosophers can think of is, How to get Everybody Back To Work! Like that is some end in itself.