How do leaders choose between lives and money?

Question

Amid the current pandemic many governments imposed heavy social restrictions in an attempt to flatten the curve and thereby save lives, and those restrictions take their toll on the economies. For instance, the US sees an order of magnitude rise in the weekly rate of applications for unemployment benefits.

Thinking about that, I eventually found myself pondering what decisions would have been taken by governments if the virus were less deadlier than it is. That is, what if the expected number of saved lives due to the imposed restrictions were 2, 4, 10, or 100 times lower? Clearly, no government will bother messing with the economy just to save a couple of lives, so there must be some threshold warranting a drastic intervention, but what is that threshold?

And that, in turn, has led me to a fundamental question, the one stated in the title of my post. I have no idea how governments compare the incomparable - lives and money - in their decision-making processes. I guess governments have to make such comparisons pretty often, because, for instance, speed limits are a kind of compromise between saving people's lives and saving people's time, and time is money. Governments routinely decide on speed limits, aircraft safety standards, and so on. And each time they weigh lives against money. How do they do that, in general? How much money is my life worth from the government's standpoint?

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UPDATE: I'd like to make two clarifications to make it clear what I am asking about:

1. @Renard says, "Part of the picture here is that unemployment and business failure increases mortality on its own." That's an important point that warrants clarifying my question, and I'd like to quote @preferred_anon, who perfectly put what I mean to ask: "In both scenarios, people die - and in both scenarios, money is lost. But the number of people and the amount of money in each situation is different. It's easy to compare lives for lives or money for money (if you simplify to say all lives are equal). But once you've done that, there will (generally) be a deficit of money on one side, and of lives on the other. And that's what the OP is asking for."

2. I understand that politicians see everything through the prism of their own career prospects, reelection chances, and personal goals, and I do not mean to ask how that prism works. Rather, I'm curious to learn fundamental principles to choose between lives and money. Let's suppose the government of a nation has to choose between two scenarios and is presented with clear and reliable figures as to how much money and how many lives will be lost in each of the two scenarios. The figures are publicly available, and the whole nation is waiting to see which decision will be taken by the government and how it will explain it. Are there any fundamental principles the government can refer to when explaining its decision to the nation? Are there any fundamental principles the rightness of the decision can be judged by? What is the dominating view on such a philosophic matter among political experts?

Answer 1

The question is looking for policy decisions made based on purely rational, apolitical calculations. This is rarely (if ever) the case. Policy making is always (at least in part) political, and so in practice, lives are valued accordingly.

There are nonetheless economists and others who try to make such calculations. For example here is an article discussing the concept of a "value of statistical life" (VSL) which it says is about $7 million.

Here is another article that deals with the question from a public health perspective. It focuses on four general aspects or approaches to the problem:

1. Valuing a given duration of life
2. Valuing future life compared with present life
3. Valuing life in terms of economic or social productivity
4. Valuing equity in relation to efficiency (cost-effectiveness)

I do not want to overemphasize the extent to which these calculations bear on actual policy decisions, but yes, such calculations are made.

Answer 2

Part of the picture here is that unemployment and business failure increases mortality on its own.

Here's an article summary: "Our big finding is that unemployment does increase the risk of premature mortality by 63 percent," said Eran Shor, a member of the study's research team and a sociology professor at McGill University." https://www.livescience.com/13578-unemployment-health-mortality.html

Here's another: "Unemployment was associated with a significant all-cause mortality risk relative to employment for men (hazard ratio 1.85 95% CI 1.33-2.55). This effect was robust to controlling for prior health and socio-demographic characteristics. Effects for women were smaller and statistically insignificant (HR 1.51 95% CI 0.68-3.37)." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677456/

If you google "mortality rate of unemployment" you will find hundreds of references. The estimated effects are not small.

Because of this, it is disingenuous to claim that there is not a trade-off between lives lost due to the coronavirus itself, versus the livelihoods that will be severely diminished and prematurely ended by the recession. You don't even need to compare the dollars to lives: you can compare lives to lives. There is absolutely a trade-off.

Answer 3

They don't make a choice between lives and money. They have to worry about other factors instead.

If we assume the decision lies with moral politicians, a few individuals have to weigh the risks of economic losses, risk of lives lost, based on their own moral compass, and combine this with the risk of an unpopular decision removing them from power. Because they are moral, their removal might cause them to be replaced with someone less moral who will cause harm, and thus is something they desire to avoid.

If we assume the decision lies with immoral politicians, a few individuals have to weigh any personal benefits either approach could bring, along with the risk of an unpopular decision removing them from power. Their removal would impede their ability to generate and retain wealth and prestige, and thus is something them desire to avoid

Luckily, the two are similar enough, so we can make a general statement:

1. Any approach they take will be based on their expectation of public perception.
2. The key decisions are made by few individuals based on their own values and goals.

Condensed even further, the economy vs lives balance depends both on the general public, and a few key individuals in power, and thus can in no way be considered a constant.

A universal, or even a local, consistent x money = y lives equation does not exist. Governments will assign vastly different values to a motorcycle accident fatality, a drug overdose, a pandemic victim, a terrorist victim, or a smoking fatality.

While some may put a semi-random number like $7 million , or £1.69 million on a life, reality has countless examples like the Ipley Cross, where fatal road accidents are either waiting to happen, or keep happening, because "the public/the government" is unwilling to spend even £100'000. Examples like this one are plentiful and are not limited to road traffic.

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This answer applies to North Korea as well.

Answer 4

Something not discussed here is that, in this specific situation, death and full recovery are not the only outcomes of having COVID-19. There is a range between these two where one can require medical attention for the rest of one’s life, or be pretty much fine.

The scarring to lungs caused by the infection can be severe enough to require care for over a year in the worst cases.

“Once the pandemic is over, there will be a group of patients with new health needs: the survivors. Doctors, respiratory therapists and other health care providers will need to help these patients recover their lung function as much as possible.”

— Hopkins Medicine

Given the early nature of this pandemic, it’s hard to calculate the numbers. However, if we do a back of the napkin calculation and assume the following:

1. That everyone who dies in hospital was on a ventilator

2. Everyone on a ventilator who survives will have long term lung damage

In England to date there have been ~25k hospital deaths and ~ 30% survive once they were put on a ventilator. That gives us a conservative estimate of 8k patients with lungs damage

There are also other areas of the body damaged, and this comparison to pneumonia is helpful:

After any severe case of pneumonia, a combination of underlying chronic diseases and prolonged inflammation seems to increase the risk of future illnesses, including heart attack, stroke, and kidney disease, says Sachin Yende, an epidemiologist and critical care physician at the University of Pittsburgh Medical Center. His team reported in 2015, for example, that people hospitalized for pneumonia have a risk of heart disease about four times as high as that of age-matched controls in the year after their release, and about 1.5 times as high in each of the next 9 years. COVID-19 might prompt “a big increase in these sorts of events,” he says.

— Sci Mag

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There are also the “hidden deaths”.

These are deaths which are not being diagnosed as COVID-19, but are above the expected baseline. This includes those untested and undiagnosed, as well as other impacts of the lockdowns imposed to prevent the spread.

The U.K., for example, as of the 19th of May had had around 55,000 excess deaths compared to the 35,000 COVID-19 deaths.

This is particularly due to under diagnosing the total number of COVID cases, and partially due to people avoiding A&E, due to fear of catching COVID-19, or not wanting to be a burden on the NHS.

“Consultants in cardiology and emergency medicine are reporting significant reductions in admissions with heart attack symptoms.”

... University College London hospitals NHS foundation trust, where he works, saw a 30% reduction in people being referred with stroke, or treated for stroke, compared with the same period last year.

— The Guardian

There are some situations likely to be happening less - for example, major trauma is expected to be much lower due to much lower numbers of people driving, and subsequently experiencing accidents. This is good, but, on the other hand, means that the excess deaths are even higher than first appear, as some deaths which would have happened, haven’t.

Clearly, even if it were a simple COVID-19 deaths vs money calculation, it would be hard enough, but it isn’t. It’s a complex balancing act, where every option will cause some excess deaths / health problems.

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Deaths cost money, for example via lost productivity, and lost money causes deaths, for example due to lower quality healthcare available. The unenviable job of government is to decide which deaths, and how many, they allow to occur.

Answer 5

There is no simple answer to this question. Although BrianZ's answer is to-the-point when it comes to some basic economics assumptions about the value of life, that's hardly the end of the story or every terribly relevant in the Covid-19 context because of the large uncertainties involved in the latter as well as the complex interdependence between pandemic control and the economy. (See this econ SE question for some models. But don't assume politicians delve deeply into that.)

The former simple statistical-value-of-life model is used e.g. by the EPA in deciding whether to clean-up a site, and even that model is somewhat politically influenced, e.g.

In 2002, the EPA decided the value of elderly people was 38 percent less than that of people under 70. After the move became public, the agency reversed itself.

Some academic commentators have declared it "numerology not science" (especially since various parts of the EPA use different figures.)

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As far as politicians' decision making in this context, it's probably as varied as politicians are: besides hopefully/presumably relying on [some] expert advice, ideological and pragmatic influences (like are my actual voters affected?) surely play a role too.

And there's the issue that sometimes when there's too high uncertainty, a politician (or group thereof) can go "expert fishing" to find the experts that back their ideological viewpoint or predisposition. A recent and surely revelvat example, as reported in People magazine:

President Donald Trump's 2020 re-election campaign is rounding up "extremely pro-Trump" doctors to appear on television and elsewhere in the media, unpaid, in the coming months to promote the president's push to reopen the U.S. economy as quickly as possible, despite health officials' warnings that doing so could fuel another COVID-19 outbreak and cost lives.

The Associated Press first reported Tuesday that Republican political operatives raised the idea on a call with a senior member of the Trump campaign earlier this month, per a leaked recording of the conversation. The president's re-election campaign confirmed the report with PEOPLE.

The AP reports that on the leaked recording of the May 11 conference call between the Trump campaign and the conservative advocacy group CNP Action, Nancy Schulze, a Republican political activist, said, "There is a coalition of doctors who are extremely pro-Trump that have been preparing and coming together for the war ahead in the campaign on health care."

"And we have doctors that are … in the trenches, that are saying ‘It’s time to reopen.’ ”

And even the government experts can have somewhat different ideas between countries in the Covid-19 case. Another often talked about case in the media is Sweden, which its less stringent lockdown approach. Their government's health experts have said that in the end others' countries death toll (appropriately scaled, e.g. per capita) will eventually approach Sweden's so a more strict lockdown is pointless since it won't be respected in a democratic country.

The head of analysis at the Swedish public health institute recently commented on international criticism from media and other experts: ‘We do not believe it is possible to keep society closed until a vaccine is developed […] the economy will collapse long before that […] and people will not follow the recommendations.’

Obviously there are some heuristics being used in that decision.

Alas, even if the Swedish experts are correct, that might not help their economy much, at least this year, with projections not better from those the neighboring countries, surely in good part because of the interdependence of European economies.

At the opposite pole are probably countries like Taiwan or New Zealand, which took more drastic measures have very few cases now. But they might have to keep their border restrictions on for a long time. Such countries with low cases are discussing various form of travel bubble between each other, and more interestingly made proposals to other countries that they are "low risk". (I guess we'll see if the "high risk" countries will accept a one-way lifting of travel restrictions, reciprocity in visas etc. usually being the standard in international relations; it has even been invoked recently in some quarantine decisions. And perhaps more interestingly, if there's prospect of being quarantined upon return back home, will people from "low risk" countries travel to the "high risk" oned [in significant numbers again] even if they allowed?) More to the point here: how could a politician know the answers such questions beforehand?

Answer 6

In the UK decisions about the provision of medical treatments by the NHS are made by the National Institute for Health and Care Excellence (NICE) based on "Quality-adjusted Life Years" (QUALYs). The basic idea is to measure the effectiveness of a medical treatment in terms of the number of years of health it provides multiplied by the degree of health provided. If the number is greater than a threshold then the treatment is approved.

This decision is made for the treatment in general, not on a per-patient basis; either the treatment is generally available for free to those who need it, or it is not available on the NHS at all.

One particularly notorious decision illustrates how this works: Visudyne was not provided for a single eye, but if you had lost one eye then it would be provided for your second eye. The reasoning was that the QUALYs lost due to losing sight in one eye were not worth the cost of the drug, but the QUALYs lost to total blindness were much greater and hence made it worth the price.

NICE also illustrates one way in which politicians handle the issue: pass it on to a bunch of civil servants. That way the politician can pass the blame for unpopular decisions (such as the Visudyne one) over to the civil servants.

Answer 7

Some leaders might do a quantitative analysis (see BrianZ's answer), others rely on instinct and judgment.

See this interview with New Zealand prime minister Jacinda Ardern on her decision to impose an early lockdown.

[Jacinda Ardern] says it was instinct that helped the Government decide to implement the lockdown.

"At no point did the science and evidence say in absolute terms that this is exactly what needs to happen and this is the exact point at which it needs to happen," she told The Spinoff.

"There was a lot of judgement applied there."

Answer 8

This is the very short answer:

It is the people, represented via the parliament that decides that using budgets. Once the budgets are made then governments do the best they can using the budget they have. Usually by asking specialists like doctors.

Speedlimits are also decided by the people, represented via the parlement.

Answer 9

It depends who controls the politicians,

If it's people the politicians will prefer people. if it's money they will prefer money.

If its money, but they want you to think it's people, you get what's happening in USA.

Answer 10

It may seem intuitively reasonable — particularly in the current pandemic, because of the nature of the economic decisions being made — to think that decisions of this sort operate under a rational-economic paradigm. That is rarely (if ever) the case. Decisions of this sort are part of the moral universe played out on a sociopolitical stage, and they are based on estimates of moral value that are not reducible to simple cost/benefit ratios. In fact, purely economic decisions in the context of a crisis are generally viewed as callous, cold, and cruel. Consider (for a simple example) four men adrift in a boat with only enough water for three of them to survive. One man throwing himself overboard so the other three can live is considered heroic and noble; three men tossing one overboard so that they can live is seen as treacherous and evil. The results are exactly the same from a cost/benefit perspective — three men live, one dies — but the moral valence of the actions are in no way equivalent.

Generally speaking, when political leaders contemplate difficult decisions, they are not reducing the issue to numbers, they are reducing the issue to competing needs. For instance, when Truman was faced with the decision of staging an invasion of Japan or using the newly developed atomic bomb, he wasn't thinking about the economic loses of men and equipment that would result from an invasion. He was thinking about the demoralizing emotional impact an extended invasion and huge increase in deaths would have on an already war-weary nation. A quick strike and a display of overwhelming power would put an end to the war quickly, and the moral value of that outweighed the moral burden of killing millions of Japanese citizens.

The needs in the current crisis are clear enough. On one hand, political leaders know that the economy is the lifeblood of a community, and they cannot stifle it indefinitely or excessively without causing great harm. On the other hand, they know that people are the organic flesh of a community, and they cannot let the disease run rampant, killing as it will, merely to keep the economic lifeblood flowing. We're back to our 'lifeboat' scenario: Asking "How many people can we save with the resources we can gather?" is heroic; asking "How many people can we afford to lose to keep the wheels turning?" is odious in the extreme. The result may be the same from a cost/benefit viewpoint, but how we get to that point is what defines us as moral beings.