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Imagine a dramatic choice. It can save a person who, most likely, will live another 30 years. Or it could save several people who could each live for another ten years.
Should we prioritize saving more lives — or more years of life?
This type of dilemma is at the heart of how health systems make decisions — and, as we recently reported on ZAP, it’s the principle behind hidden number mathematics that decides — and who can be saved.
But do people really agree with this principle?
A new study suggests the answer is more complex than this simple swap between two options suggests, they explain. Laurence Roope e Philip Clarkeresearchers from the University of Oxford, and Fiorella Parra-Mujicafrom Erasmus University Rotterdam, in article no.
In many countries, decisions about health spending are guided by a concept known as quality-adjusted life year, or . In simple terms, this approach attempts maximize the total number of years of life health generated by a health system.
This often means prioritize treatments that provide more years of life not total. Saving someone who has more years left in them is, as a rule, seen as something that creates more value than saving someone with fewer years of life left.
In practice, this may mean giving priority for younger patients to the detriment of older patients.
This type of reasoning is used by NICE in the United Kingdom, as well as other health assessment agencies in several countries, to decide which medicines to use. must be financed. But it is based on an implicit ethical presupposition: that maximizing total years of life is the right goal.
Our investigation asked a simple question: do ordinary people really agree with this?
To understand this, Roope, Parra-Mujica and Clarke conducted large-scale research with more than 14 thousand people in 12 countriesincluding the United Kingdom, the United States, China, Brazil and Uganda.
The results of their study were presented in a recently published in The European Journal of Health Economics.
In the study, participants were asked to imagine a vaccine that saves lives, but that could only be administered to a group. They had to choose between vaccinating a 55 year old personwith around 30 years of life ahead of him, or one or more people over 75with around ten years of life remaining each.
The scenarios were framed around the covid pandemic, but the underlying question was broader: how should we consider saving lives face to save years life?
By varying the number of older people, the three researchers were able to estimate how many lives participants were willing to “exchange” to save a younger person.
The results reveal a clear pattern, which is not entirely compatible with the QALY-based values that underpin many healthcare financing decisions: people don’t think in purely mathematical terms.
A Most people preferred to save the youngest person. About two-thirds of respondents chose to vaccinate the 55-year-old rather than a single 75-year-old. However, when faced with most difficult dilemmaspeople did not behave as if they were trying to maximize years of life.
If that were the case, they would be willing to sacrifice around three 75-year-old people to save a 55 year old persons, since 30 years compared to ten years corresponds to a ratio of 3 to 1. In practice, they agreed to exchange less.
On average, across countries, people were willing to exchange about two and a half lives older to save a younger life. In other words, the public’s preferences lie somewhere between treating all lives as equal and strictly maximize total years of life. They do not fully coincide with any of these positions.
The story even becomes more interesting when we look beyond age. In some versions of the experiment, we also varied whether the hypothetical people were they working or not.
And that turned out to be very relevant. When both had the same employment status, a 55-year-old was considered approximately equivalent just over two 75 year old people.
But when the youngest person was working and the oldest was notthe relationship changed quite drastically: people were willing to sacrifice more than three older lives to save the younger worker.
And when the situation was the opposite, that is, when the oldest person worked and the youngest didn’t, many respondents preferred to save the older person.
This suggests that people are not just thinking about life expectancy. They are also take into account broader social factorssuch as each person’s contribution, perceived need or justice.
Distance between public policy and society’s values
These conclusions raise a uncomfortable question. If healthcare systems are designed to maximize years of life, but the public values something more nuanced, there will be a mismatch between policies and preferences of society?
Os study results suggest so. People do care about life expectancy — younger lives tend, in general, to be prioritized.
But also give weight to justice, context, and social roles. Their preferences are more subtle than the strict “maximize years of life” rule embedded in many healthcare decision models.
This does not mean that health decisions should simply follow public opinion. It is about complex ethical choicesand expert judgment continues to be essential.
Still, completely ignoring the public’s values can also be problematic. Policies that seem intuitively unfair can undermine trust, and this trust is essential for the sustainability of policies and institutions.
Thus, the researchers conclude, instead of abandoning existing approaches such as QALYs, one possibility could be complement them. Decision-makers will be able to more clearly incorporate the public’s perspective, using, for example, discussion groups, citizen panels or other mechanisms that reconcile efficiency with fairness.
Another hypothesis is recognize that there is no single, correct answer. Different societies may legitimately draw the line at different points — and even within each country, opinions vary depending on age, political orientation and life experience.
The study shows that people don’t look at these decisions in simple mathematical terms. When faced with real choices, they consider together lives, years of life and social context. Ultimately, this may more realistically reflect the ethical complexity at the heart of healthcare.
