This dissertation research examines the decision processes underlying how people value lives saved in situations of resource scarcity. Three policies a person could use are examined: (1) treating all lives are equal, (2) prioritizing people who will gain the most benefit (e.g. additional life years) from an intervention, and (3) prioritize young people regardless of the number of years they have left to live. These metrics imply different strategies for health resource allocation, especially when such resources are scarce. Vaccination scenarios are used to probe which metrics lay people use in different situations and how the type of question influences the metric used. In direct questions, people are asked about their abstract principles (e.g., all lives are equal, prioritize the young, etc.). In indirect questions, people are given an allocation problem (e.g., there are 1000 people at risk but only 500 vaccines; who should get the vaccines?). The co-PI will test different psychological accounts for why people might express different metrics in these two types of questions. The broader impacts of this research derive from the fact that the public's support for health policies may be malleable: While the pro-young tendencies may drive support for specific policies for how to prioritize scarce health resources (i.e. the 2009 H1N1 vaccine was prioritized for people under age 25), they depart from the oft-cited moral standard that "all lives are equal". Such tendencies may be concealed in more direct measures, such as in questions directly asking whether lives of young people are more valuable than those of older people, because answering yes in this case is a more apparent contradiction to the deep-rooted "all lives equal" moral standard. Studying these inconsistencies provides important information on how to design public health policies and how to present them to the public.
Whose lives should be saved when it is impossible to save all? When medical resources need to be allocated among the population, for example, when there are not enough vaccines or organs to distribute to everyone in need, there are usually two considerations at play: Efficiency and Equality. These two considerations are often in conflict with each other: Prioritizing younger people would save more total life years in the population, thus maximizing efficiency, but doing so would compromise the principle of equality. Prioritizing people who recently joined the waiting list for a kidney transplant over those who joined a long time ago would also maximize efficiency, because the latter group of candidates have been on dialysis for too long to get as many years out of a transplant organ; however, doing so seems incredibly unfair. How do people view allocation policies that emphasize the opposing rules of efficiency and equality? This research explores how the public’s preference for these two principles shifts when the allocation policies are described in slightly different ways. Two types of descriptions were used to probe which metrics lay people use to evaluate lives. In direct questions, people were asked about their general principles (e.g., all lives are equal, prioritize the young, prioritizing transplant candidates who have waited longer for it, etc.). In indirect questions, people were given an allocation problem (e.g., there are 1000 people at risk but only 500 vaccines, who should get the vaccines? Between people who have been on the organ waiting list for 1 year, and those who have been on the list for 6 years, who should have the organ? ) We used scenarios ranging from vaccines to transplant organs, and recruited adult participants with diverse age and social backgrounds. Results show that 1) People show systematic inconsistencies in life-evaluating metrics they endorse when they are asked to express their views directly versus indirectly: They prefer equality-oriented allocation (e.g., equal allocation across age groups, first-come, first-serve) when asked about general principles, but shift to efficiency-oriented allocation (e.g., favoring younger people, prioritizing transplant candidates with shorter waiting time) when the allocation task is described in specifics. 2) Such inconsistency is caused by different goals activated in different measures—the direct measure activates a moral goal, leading to preference consistent with equality, while the indirect measure activates an efficiency goal, leading to preference consistent with maximizing life years saved among the population. 3) People’s preference for allocating to different age groups is influenced by their own age in a self-centered fashion. These findings provide important information on how to design public health policies and how to present them to the public. Given that the public leans towards equality when they evaluate policies described in general terms, policies intended to enhance efficiency in healthcare allocation should avoid such type of description. Instead, showing real numbers for specific allocation schemes may help garner support for efficient allocation. On the other hand, policies aimed at promoting equality will be best received if they are described as principles.
