Objections to Assessing the Magnitude of the Harm of Death on the Basis of QALYs

Original text Luciano Carlos Cunha · Volume III, p. 23 of the PDF edition · English translation

6.1. The objection from absurd implications

In the previous chapter we saw an approach that assesses the magnitude of the harm of death solely on the basis of how much someone has already enjoyed and/or would still have to enjoy, estimating this in terms of QALYs (Quality-Adjusted Life Years).

One objection to this approach claims that it leads to absurd conclusions. Among these conclusions are: (1) that in certain cases a nonhuman animal would be more harmed by death than a human; (2) that in most cases children would be more harmed by death than adults; (3) that the moment at which someone would be most harmed by death is the very first instant at which the fetus becomes sentient (since it has not yet enjoyed anything and would still have everything ahead of it to enjoy) and, therefore, already-sentient fetuses would be more harmed by death than those already born²⁶.

Before we look at the main response to this objection, it is important to note that measuring the magnitude of the harm of death on the basis of QALYs does not imply that each and every already-sentient fetus is more harmed by death than each and every individual already born. Depending on how many more positive future QALYs (and/or how many more negative past QALYs) the already-born individual had, they could be more harmed by death than the already-sentient fetus. The same would hold for the comparison between the harm of death for adults and children, and between humans and nonhuman animals. This is in fact a virtue of assessing the magnitude of the harm of death on the basis of QALYs: it takes into account the complexities of each case, avoiding generalizations of the type "this or that kind of being is always more harmed by death".

However, the proponent of the objection could insist that, in most cases, assessing the magnitude of the harm of death on the basis of QALYs would have those allegedly absurd implications. That being so, the main response to this objection is to point out the following: saying that an implication is absurd is not offering any reason to show that it is in fact

absurd. An explanation of why they would be absurd must be provided. Below we will discuss some attempts to do so.

6.2. Discussing the appeal to intuitions

One way of arguing that those implications are absurd is to point out that they are counterintuitive, in the sense of contradicting the beliefs we hold before reflecting on the matter. According to this approach, if a conclusion we reach through reflection contradicts our prior beliefs, there must be something wrong with the conclusion.

There is an obvious problem with this approach: it would only make sense if our prior beliefs were always correct. But if that were so, it would make no sense to reflect on anything, since the purpose of reflection is precisely to investigate which of our prior beliefs hold up after examination. If prior beliefs are to be the criterion for assessing reflection, then why reflect? It is one thing to say that, if an approach has a strange implication, we should test the approach further. It is another to say that the conclusions we draw after reflecting are wrong if they contradict our prior beliefs.

Another possibility is to agree that a conclusion's being counterintuitive does not show that it is wrong, but to maintain that the burden of proof lies with whoever goes against the intuition. This may make sense with regard to basic beliefs that we all hold. For example, if someone claims that the Earth is shaped like a guitar, the burden of proof certainly lies with that person. However, in ethical matters intuitions vary greatly from person to person. Consider the intuitions we are discussing regarding the magnitude of the harm of death. Many people have exactly the opposite intuitions. The way the proponents of the objection put it suggests that everyone has those intuitions, but this is not true. Therefore, even if we assumed that the burden of proof lies with whoever challenges the intuition, we still would not know who bears the burden of proof, since intuition varies widely.

It is also possible to question the idea that the burden of proof lies with whoever goes against intuitions. One can argue for exactly the opposite, that is, that if an approach fits our initial beliefs, that is a reason to be suspicious of it, since we may believe it simply because it spares us the discomfort of questioning our initial beliefs²⁷. Reliance on intuitions in ethics would only make sense if we had some special kind of "sensor" that automatically revealed to us, without any reflection, what is right and wrong in ethics. There seems to be no reason to think that anything of the sort exists. On the contrary, our intuitions (that is, the beliefs we hold before reflecting) are probably the result of ideas we have cultivated all our lives and that our society also cultivates, which may very well be prejudices.

Moreover, many intuitions may be the result of biases due to the way the brain operates²⁸. One example is the bias known as an availability cascade, which occurs when a collective belief gains more and more acceptance through its increasing repetition in public discourse, even if it is not plausible. This is one more reason to be suspicious of our intuitions. One does not show that an idea is plausible merely by pointing out that it seems plausible (which is what the appeal to intuitions does).

It is also interesting to note that some proponents of the objection we are discussing defend other positions that sound highly counterintuitive to many people, such as veganism²⁹ and intervention in nature to help wild animals when they are victims of natural processes³⁰ (two positions that I, in fact, also defend³¹). Quite possibly these authors did not always hold these positions, and it was reflection that made them change (just as happened in my case). But if in this case prior beliefs were abandoned in the light of reflection, why should prior beliefs about the harm of death function as a kind of authority over reflection?

6.3. Defending the QALY criterion

We will now look at a reason to think that the burden of proof, in the case of the magnitude of the harm of death, lies with whoever contradicts the conclusions of measurement based on QALYs. The reason is that measuring the magnitude of the harm of death in terms of QALYs follows directly from the account of what the harm of death consists of: if death is a harm because it prevents the positive things the individual would experience if they stayed alive,

then the more they would have to experience and/or the less they have experienced so far, the greater this harm.

If someone claims that the conclusions following from this assessment are wrong because they contradict certain intuitions, then they need to put forward a principle showing that these intuitions are correct (rather than simply assuming in advance that they are correct).

One attempt to do so is the Time-Relative Interest Account (abbreviated here as TRIA), which we will discuss in more detail in chapters 7 and 9. It holds that the magnitude of the harm of death should be measured by multiplying the value someone would be deprived of by death (as is done in the QALY approach) by the degree of psychological connectedness that person would maintain over time³². According to this approach, already-sentient fetuses, nonhuman animals, and human children have weaker psychological connectedness and would therefore be much less harmed by death.

However, in this approach the psychological connectedness criterion is not independently grounded: it is postulated because it would ground those intuitions and, on the other hand, those intuitions are defended as correct because they agree with the psychological connectedness criterion³³. If so, the reasoning is clearly circular³⁴.

Moreover, since the aim of the TRIA is to ground intuitions, it is worth noting that it has implications that are even more counterintuitive to most people than the implications of the QALY-centered approach. For example, according to the TRIA, young children would hardly be harmed by death at all³⁵.

Regardless of which approach is more intuitive or counterintuitive, it is important to take seriously the possibility that our intuitions are wrong before setting out to defend them at all costs. It is possible that the death of nonhuman animals, human children, and already-sentient fetuses (of whatever species) is something much more serious than is normally recognized.

Obviously, this does not mean that every approach that has counterintuitive implications is necessarily correct. It means only that, to show that an approach is mistaken, it is not enough to show that it has counterintuitive implications.

Of course, this also does not show that there cannot be other criteria for measuring the magnitude of the harm of death besides QALYs. It does show, however, that until such criteria are independently grounded, we have reason to rely on QALYs alone.