Professionalism/Valuing of Human Life in Risk Analysis

Professionals make many types of decisions, but perhaps the most difficult are those that involve life and death. Sometimes fatalities are a secondary concern, for instance when a Civil Engineer designs a traffic intersection with the goal of maximizing throughput but also minimizing risk of injury or death. Other times, saving lives is the primary goal, as is the case when a governmental agency considers approving a new drug or treatment.

When organizations and individuals make these decisions, they implicitly or explicitly determine the value of a human life. This valuation varies widely depending on calculation methods and value systems. It is not always clear which approach is the most appropriate in a given situation, which has sometimes led to controversy, like the famous case of the Ford Pinto. Some would go further and argue that any approach to valuing life is inappropriate regardless of the situation. The uncertainty surrounding the value of human life presents serious ethical concerns for those tasked with making potentially fatal decisions.

Statistical Method
One way to determine the value of a human life is to calculate the value of a statistical life based on decision making in the labor market. Laborers' willingness to pay to reduce their chance of dying provides a quantitative measure of how much they value their lives. Viscusi and Gayer suggest that the best way to measure workers' attitude towards risk is to compare average pay across industries that have different risk profiles. Direct and indirect surveys could also provide the same information, but are likely to be less accurate because they are strictly hypothetical. Using Vicusi and Gayer's preferred approach, workers seem to demand about $600 to take on an additional 1 in 10,000 chance of dying. This suggests that the value of a human life is about $6 million. Other studies using willingness to pay put the range for the value of a human life at $3 to $8 million. Even using the lower end of the range, the willingness to pay approach suggests a high value for human life, particularly compared to present value of lifetime earnings (PVLE). The highest value PVLE reports is $1,517,045 for males age 20-24.

There are several important limitations to the value derived from a market based approach. First, it is based on average salary across industries. As a result, there may be variation among individuals' valuations of risk that is not captured in this figure. Also, the figure is calculated based on actual death rates and actual compensation. However, when an employee makes a judgmental decision, he or she uses perceived risk and perceived compensation. Since compensation is almost always salary, the employee is likely to have a complete understanding of the benefits. However, public perception of fatality risk may not always accurately reflect the real risk. If employees tend to underestimate risk in a given industry, then the calculated value of a human life would be too low. For example, the table to the right displays the ten deadliest occupations in the United States, several of which are typically perceived as safe jobs.

QALYs
Like any industry, the healthcare field has limited resources and therefore must make decisions about what treatments to provide and which groups will receive them. The decisions made reflect trade-offs between costs and benefits of one treatment as opposed to another. To standardize this process, decision makers use a single value that takes into account both the quality and quantity of years added to an individual’s life from a given medical procedure. One such measure is the quality-adjusted life year (QALY).

An example taken from a NYTimes.com article, provides a practical application of QALYs. “If a blind person’s quality of life is “worth” 0.75 points per year, a treatment that would restore him to perfect vision — and raise his quality of life to 1 per year — is worth 0.25 per year of life. If the person lived another 30 years, the treatment would be worth 7.5 QALYs, or 30 times 0.25. With QALYs, that treatment would produce the equivalent of keeping 10 patients on dialysis — whose lives are also “worth” 0.75 points per year — alive for a year.”

Based on this analysis, and the option to restore one blind person’s vision (who would on average continue to live for another 30 years) or to keep 10 patients alive on dialysis (for one year), the decision should be based on whichever has the lower overall cost. However, it is not typical for two cases to be compared side-by-side like the previous example. Instead, organizations like insurance companies will use dollar cost per QALY as a measure of whether or not to provide a treatment to an individual. Some may argue that it is unethical to deny someone a treatment that could save their life. However, others respond that it is unethical to provide expensive treatments to someone that (with the treatment) would only live a few more months, when, for the same cost, a number of lives could be extended for years. As an example, some cancer medicines cost as much as $1.4 million per QALY, while “some people without insurance do not have access to cholesterol-lowering drugs, which cost just a few thousand dollars per QALY.”

It is useful, then, to have a benchmark cost per QALY against which insurance companies and other healthcare providers can assess a treatment’s added value. In Great Britain, the National Institute for Health and Clinical Excellence (NICE) values 6 additional months of life at $22,000 dollars and does not fund treatments whose cost per six months exceeds this number. In the Wall Street Journal opinion article that mentioned this benchmark, the comparison is made between Britain’s healthcare system and President Obama’s proposed “ObamaCare” and asserts that while Obama wants to spend less on healthcare, he intentionally fails to explain "how [other countries] ration care to [reduce costs]” The article concludes that “the inevitable result…will be some version of a NICE board that will tell millions of Americans that they are too young, or too old, or too sick to be worth paying to care for.” For an article with such an apparent and emotional claim, the 141 comments on the article (as of April 2011) tend to portray respondents as more reasonable and understanding of the inherent limitations of the healthcare system.  David Siktberg sums up the argument very nicely in his response to another commenter.  “You write as if it is a crime to consider the value of very expensive treatments, and their efficacy. We all must die one day, and it is inappropriate to spend public funds (or communal funds in a private health insurance system) attempting to defer inevitable death at any cost and under any circumstance."

Pinto
Shortly after the release of the 1971 Pinto, Ford Motor Company identified a defect in the fuel system that would result in destruction of the vehicle under certain circumstances. Ford was also aware of a modification that would fix this problem, at a cost of approximately $11 per vehicle. In order to assess if the modification should be implemented, Ford performed an industry standard cost-benefit analysis. Ford estimated that fixing the defect would result in a benefit to society of approximately 180 less burn deaths, 180 less serious burn injuries, and 2,100 less burned vehicles. Ford used the standard costs provided by the National Highway Transit Safety Authority (NHTSA) to complete this part of the analysis, resulting in a figure of $49.5 million. With 11 million cars and 1.5 million trucks on the road at the time of the analysis, a fix would have cost $137 million. After performing the analysis, Ford decided not to implement the fix.

When the extra accidents occurred as a result of the decision, many of the victims sued Ford. The most notable of these cases was Grimshaw v. Ford Motor Company. This case arose when Lily Gray was driving with thirteen year old Matthew Grimshaw in May of 1972. The car was rear ended, and the resulting fire killed Lily Gray and left Matthew Grimshaw with serious, disfiguring burn injuries. Predictably, both victims were awarded damages to compensate them for their losses. The family of Lily Gray was awarded $560,000, and Matthew Grimshaw was awarded $2.5 million. However, the most important aspect of the case occurred when the internal Ford cost-benefit analysis document was admitted into evidence. The jury was outraged by the cold, calculating mindset displayed in the document, and awarded $125 million in punitive damages in order to deter Ford Motor Company from similar acts. The judge later reduced these punitive damages to $3.5 million. The large discrepancy between the jury's reaction and judge's reaction may represent the difference between the emotional response and the logical response, but the point is salient nonetheless. Many members of the public find it abhorrent that companies put a price on the value of their lives.

Public Opinion on Valuing Human Life
Public opinion and professional opinion often disagree about how much a human life is worth. For instance, even after educational focus groups, 10% of respondents felt that cost effectiveness analysis should never be used to determine public health decisions. This implies an unwillingness to assign dollar values to life, even if it results in more effective health care overall. Research also suggests that common psychological decision biases affect perception of the value of a life. In particular, people are irrationally sensitive to percent savings when valuing human life, so saving 1,000 out of 2,000 people is preferred to saving 1,000 out of 90,000 although the total life saved is the same.

When it comes to the healthcare industry, it is very easy to consider the cost-benefit analysis of providing healthcare until the decisions hit home. In the comments section of the previously mentioned Wall Street Journal article about Great Britain's healthcare system, Brad Gronek says “Under the English [NICE] system, my mother, who had Multiple Sclerosis, would not have been around to raise my brother and sister.” Anthony Reid recounts that “Watching my dad suffer through his last year with cancer, I can tell you the patient has zero say in whether a treatment is worth the price.” These difficulties suggest that valuing human life will continue to be an ethical challenge for professionals for years to come.