Professor of Youth Mental Health, University of Melbourne
Executive Director, Orygen
Professor of Health Economics, Deakin University
The COVID-19 pandemic has brought into sharp focus the question “are all human lives of equal value?” The fact that the virus disproportionately threatens the lives of the elderly, while the measures taken to protect those and other lives produce substantial harm and increased mortality risk for young people has proved the catalyst for a revival of this debate. Our society and many others have decided to give dominant priority to efforts to tackle the immediate threat that the pandemic poses to the lives of very large numbers of people across the globe. We do not question the main thrust of this decision, but it is crucial to consider other impacts.
Professor Duncan Maskell, Vice-Chancellor of the University of Melbourne, recently highlighted that economists at least have sought to introduce some objectivity into an area where values and human emotion have traditionally held sway through the use of the QALY, or quality-adjusted life year, which at its core, is a generic health measure that tries to capture both length and quality of life in a simple metric that is useful to health care decision-making.
The “value” of a QALY though is a societal choice and can vary across different societies depending on how much they may be willing or not to pay for health care. Because young people have more life years left than older people and hence are favoured by this metric, it can be argued that QALYs may be inherently discriminatory to the elderly.
Toby Hall and Dr Daniel Fleming, writing in The Age, appear to be in this camp in asserting that all lives should be seen as of equal value. The latent assumption, reinforced by the stance taken to counter the scourge of the pandemic, is that this is the norm, namely that in health care and in social policy that all lives are currently treated as of equal value.
Of course, nothing could be further from the truth. Decisions are made every day which prioritise the lives (including quality of life) of some people over others. Even the commentary post-budget has focused on this reality.
Not all lives are treated equally
The seminal work “The Spirit Level” by Richard Wilkinson and Kate Pickett published in 2009 demonstrated that inequality of income across the globe was associated with a whole range of health and social problems including life expectancy. If we focus on the health arena, it is clear that all lives are not treated as of equal value.
The mortality gap between Indigenous people and the rest of society is well known. It seems that Indigenous lives still matter less.
Less well known is the even wider mortality gap suffered by people with mental illness compared to those without. This occurs within a health system that claims to have integrated physical and mental health care, yet which denies and delays access to quality care to over one million Australians with complex mental illness – the “missing middle”. Are their lives not of equal value to those with medical illnesses of the same severity? We see this daily in our health system where people with mental illness are typically denied the timely quality care assured to most people with comparable physical health needs.
The disparity faced by young people
When we look at the health policies across the lifespan, we find the reverse of the situation feared by Hall and Fleming. The vast bulk of health expenditures are devoted to people over 50 and especially in the final months of their lives. However those elderly who reside in aged care homes are a regrettable exception to this trend, and are receiving care of highly variable and frequently unacceptable quality.
The major health issue facing young people is in fact mental ill health, and the number one cause of mortality all the way up to age 40 is suicide. Pre-pandemic, the suicide rates for 2019 showed a rise of 5.7% across the lifespan on 2018. While there was a 7% reduction in teenage suicide, the risk for young adults increased by 11.6% in the 20-24 age range. Even more concerning was the 46% increase in females between 20 and 24 years. The suicide rate for young adult males is already double that of the general population. Recent governments have begun to recognise this and built a base camp of services, notably headspace, to respond to it, yet these systems urgently need further depth and investment.
Beyond health, social and economic policies have delivered a double whammy to young people in recent times, and emerging adults are the only group in the population whose financial status has gone backwards over the past decade, according to the Productivity Commission.
The pandemic and the economic recession that is upon us will make this precarious and deteriorating situation much worse for young people in terms of their financial and mental health, with modelling predicting a consequent surge in rates of suicide and the potential scarring of a whole generation. The recent Federal Budget recognised this threat and responded with a range of policies to try to mitigate it. Yet even this affirmative action for young people was criticised by some.
Can all lives be valued equally?
Hence the reflection urged by Duncan Maskell is not only timely but essential. It simply draws attention to the lack of equal value currently placed on different human lives. The burden of disease approach which is based on disability-adjusted life years or DALYs (a similar generic health index to QALYs) did initially back the notion of a “sweet spot” where the value of DALYs of a 22 year old were weighted more heavily in terms of value or “mental wealth” to society.
This was based upon the fact that the family and the wider society had invested so heavily in supporting that young person to reach the threshold of productive life, and with many decades of this in prospect, any threat to or loss of this would be of greater significance than if such a threat occurred earlier or later. The Australian burden of disease studies subsequently retreated from this.
The use of age weights in health economics is a continuing field of research which shows that people often have a preference for health gains such as QALY in younger people compared to older people. There is not necessarily any right or wrong here, but there is a decision to be made by society.
The personal story of the centenarian, highlighted by Hall and Fleming, recently discharged from St Vincent’s Hospital is heart-warming, but contrast this with the story of Timothy Atkins, who left the Emergency Department of a major hospital having been forced to wait for 23 hours while in the grip of an acute manic episode, and went on to suffer further harm at the hands of police, whom the hospital had called to intercept him.
Young Australians who are suicidal are turned away every day from Emergency Departments to fend for themselves. The number of preventable deaths occur every day in Australia from suicide has now risen from 8 to 9 per day, more than half of whom have recently sought professional help and not received it. It is inconceivable that this would be accepted by the public and governments for any other health condition such as cancer, asthma or cardiac disease.
We might very well agree that all lives should be valued equally. This is only going to happen in health care if the resources are boosted and hypothecated, to protect the rights of those who don’t get a fair go currently.
In the absence of sufficient resources, choices will continue to be made. Because they are Sophie’s choices, it is understandable that sometimes it might be easier to keep them hidden and pretend they are not being made. But they are being made every single day, and often made on the basis of emotion and covert values. In this respect, the situation could be seen to even be prejudicial against subgroups such as the mentally ill, Indigenous Australians and young people. This is an issue which is well worth discussing with our eyes wide open and in a rational and respectful manner.
Disclosure statement: Professor McGorry is a Founding Director of the Board of headspace and Executive Director of Orygen. Orygen is the lead agency for five headspace centres across northwest Melbourne.