Saving the World, and Healing the Sick

[Part EA ori­gin story, part in­tro­duc­tion to EA. I’ve ex­per­i­mented with a more dis­cur­sive style, but it may come off as flabby, ver­bose, etc. Prob­a­bly won’t cover any­thing new. Hope folks en­joy read­ing it as much as I en­joyed writ­ing it.]

When I ap­plied to med­i­cal school, I had to write a per­sonal state­ment: sel­l­ing how ex­cep­tional my achieve­ments were, what won­der­ful per­sonal qual­ities I had, and my no­ble mo­ti­va­tions for want­ing to be a doc­tor. The last of these is the most em­bar­rass­ing in ret­ro­spect:

I want to study medicine be­cause of a de­sire I have to help oth­ers, and so the chance of spend­ing a ca­reer do­ing some­thing worth­while I can­not re­sist. Of course, Doc­tors [sic] don’t have a monopoly on al­tru­ism, but I be­lieve the at­tributes I have lend them­selves best to medicine, as op­posed to all the work I could do in­stead.

Th­ese “I like sci­ence and I want to help peo­ple” sen­ti­ments are com­mon in bud­ding doc­tors: when I re­cite this bit of my per­sonal state­ment in a talk (gen­er­ally as a self-flag­el­lat­ing open­ing gam­bit) I get a mix of laughs and groans of recog­ni­tion – most wrote some­thing similar. The im­pres­sion I get from those who have to read this ju­ve­na­lia is the “I like sci­ence and I want to help peo­ple” wannabe doc­tor is re­garded akin to a child zoom­ing around on their bike with sta­bi­liz­ers – an en­dear­ing work in progress. As they be­came sea­soned in the blood sweat and tears of clini­cal prac­tice, the vain­glo­ri­ous naivete will trans­form into a more griz­zled, re­al­is­tic, hu­mane com­pas­sion. Less dy­ing nobly, more liv­ing humbly; less JD, and more Perry Cox.

I still have a long way to go.

A por­trait of the al­tru­ist as a young man

My other in­ter­est back then was philos­o­phy, so much so that it was a toss-up whether I should try and study medicine or philos­o­phy. Along the way I read ethics, which led to util­i­tar­i­anism, which led to Singer’s ‘Famine, Affluence, and Mo­ral­ity‘. I re­mem­ber at the time think­ing how aus­tere and de­mand­ing it was, but af­ter some wrestling with my con­science I de­cided it was the right thing to do. So at around the age of six­teen I de­cided I would de­vote my life to­wards mak­ing the world bet­ter: of course, that would mean giv­ing lots of my money to char­ity; and of course I had to spend my life do­ing some­thing im­por­tant (I set­tled on cur­ing AIDS as a suit­ably wor­thy goal); and so, of course, the rather painful to read per­sonal state­ment above.

I chose medicine, and kept philos­o­phy around as an af­fec­ta­tion dur­ing med­i­cal school. My al­tru­is­tic zeal faded un­der the pres­sure of work. It took an­other philos­o­phy book – Liv­ing High and Let­ting Die (iron­i­cally bought at a char­ity shop) – to prod these thoughts back into the front of my mind.

The moral case made by Singer and Unger (and many oth­ers) has a sim­ple sum­mary. Very large num­bers of peo­ple are suffer­ing and dy­ing from so-called ‘dis­eases of poverty’ – dis­eases that would be cured, or pre­vented, or ame­lio­rated if only those af­flicted could af­ford to. If you are rich – which, rel­a­tive to those suffer­ing from dis­eases of poverty, vir­tu­ally ev­ery­one read­ing this will be – you canaf­ford to. So you could give some of your money to help these peo­ple: you would still be very well off, and you’d make some of them a lot bet­ter. Why not?

Some soft num­bers make the con­se­quen­tial­ist case harder to re­sist. Although it is hard to es­ti­mate (on which more later) it is con­ser­va­tively reck­oned a few thou­sand pounds, given well, could save a child’s life. It seems hard to pre­tend that any­one’s few grand is worth more than a child’s life: if we could choose be­tween de­priv­ing Richard the rich per­son of a few thou­sand pounds worth of stuff (a cou­ple of nice holi­days, say) or de­priv­ing Pauline the pau­per of her 2 year old child, the choice that should be made is ob­vi­ous. Noth­ing morally rele­vant changes when the few thou­sand pounds are not Richard’s but our own. Giv­ing lots of our money away is thus a moral bar­gain, and few of us are tak­ing ad­van­tage of it as much as we should.

You needn’t be a thor­ough­go­ing con­se­quen­tial­ist to ac­cept this sort of rea­son­ing. Singer et al. strive to show as­sent to much weaker moral prin­ci­ples (e.g. “If you can se­cure a re­ally great good for some­one else via a much smaller sac­ri­fice on your part, you ought to make this sac­ri­fice”) are enough to drive a much greater con­cern for char­ity. Be­sides, other ways of think­ing con­verge here: per­haps one should give lots be­cause it be­gins to live up to Je­sus’s com­mand­ment to love your neigh­bour as your­self – I un­der­stand most world re­li­gions are similarly keen on char­ity; or per­haps one should give lots be­cause what made us rich and made them poor is un­just, and giv­ing goes part way to cor­rect­ing this in­equity – per­haps it should even be viewed as repa­ra­tions for prior colo­nial in­jus­tices; or per­haps some­thing else.

In any case, I re­newed my faith in the ‘giv­ing lots’ prin­ci­ple of char­ity. It was around this time I first heard of Giv­ing What We Can – a group of peo­ple who were pledg­ing to give 10% of their in­come to help beat global poverty. At the time I ig­nored them, be­cause I thought (with the easy self-as­sured righ­teous­ness of some­one liv­ing on their par­ents’ for­bear­ance and gov­ern­ment-sub­si­dized credit) that 10% wasn’t enough, and I was ob­vi­ously go­ing to give much more than that when I started earn­ing – con­ve­niently a long time away.

It took me a few more years to re­al­ize that Giv­ing What We Can was for peo­ple plan­ning to give 10% or more (and in­deed the guy who set it up was do­ing just that), and there might be benefits to join­ing a com­mu­nity of such peo­ple, and try­ing to en­courage oth­ers to do what I was plan­ning to. So I joined up in 2012 or so, gen­er­ally made a nui­sance of my­self both in my lo­cal uni­ver­sity group and the wider or­ga­ni­za­tion, and looked for­ward to com­plet­ing med­i­cal school and hav­ing a salary to start prac­tic­ing what I had been preach­ing in­ter­minably.

My Giving

N.B: This sec­tion is go­ing to talk about how much I have given to char­ity. This vi­o­lates norms about it be­ing bad, or im­mod­est, or self-ag­gran­diz­ing to talk about ones char­i­ta­ble giv­ing: Let not thy left hand know what thy right hand doeth, etc. My in­tent in do­ing so is to en­courage more char­i­ta­ble giv­ing, to nor­mal­ize bolder efforts at char­ity – and, be­sides, I don’t take what I am do­ing to be par­tic­u­larly praise­wor­thy. If you’re un­satis­fied at this defense, ac­cept my apol­ogy, and feel free to scroll through.

I’m writ­ing this af­ter around 18 months of be­ing a doc­tor, and thus 18 months of earn­ing a salary.

Last aca­demic year (Aug ’13 to Jul ’14) I earned £33,214 and gave £10,836, about a third of my (pre-tax) in­come. I put a spread­sheet of my giv­ing here: I didn’t give any­thing at first as I wanted to buy var­i­ous bits and pieces for my med­i­cal ca­reer, but steadily ramped up my giv­ing as I found I could af­ford to give quite a lot – in the last few months I was giv­ing just over half my money away. Although I do not have such good figures for the first six months of the cur­rent aca­demic year thanks to var­i­ous ad­ministrivia, I in­tend to stick with giv­ing around half, and will be giv­ing sev­eral thou­sand pounds of my (now slightly larger) salary to­wards this end.

What am I giv­ing to, ex­actly? When I joined Giv­ing What We Can, I found out that giv­ing smart was as im­por­tant as giv­ing lots. My naive as­sump­tion was that there wasn’t much to choose be­tween differ­ent in­ter­ven­tions: Tu­ber­cu­lo­sis, Malaria, HIV, star­va­tion (and many more) are all awful things, so it made lit­tle differ­ence which par­tic­u­lar hor­ror one’s money was di­rected against. The data proved me wrong: differ­ent in­ter­ven­tions tack­ling the same dis­ease can vary in effi­cacy by or­ders of mag­ni­tude, and so there are vast div­i­dends to find­ing the most effec­tive in­ter­ven­tions, and the most effec­tive char­i­ties. Hap­pily, both Giv­ing What We Can and an­other group called Givewell tackle this very hard ques­tion, and re­as­sur­ingly their recom­men­da­tions al­ign closely. So about half of my money goes into a char­i­ta­ble trust run by Giv­ing What We Can, which in turn dis­tributes it to these ex­tremely high perform­ing char­i­ties. 1

The other half is di­rected to more ‘be­hind the scenes’ work. An­swer­ing the ‘what does the most good?’ ques­tion is ex­tremely hard, and rides on top of sev­eral other ex­tremely hard ques­tions, yet get­ting bet­ter an­swers could be ex­tremely valuable. So last year the other half was given to fund­ing re­search into these ques­tions. I plan to do the same sort of thing this year: half of my giv­ing to­wards effec­tive char­i­ties, and the other half aimed at ‘be­hind the scenes’ work, in the hope this will lead to even bet­ter out­comes (and more dona­tions!) fur­ther down the road. 2

I’m no Superman

N.B. This sec­tion is go­ing to talk (among other things) about how wealthy I am. Similar to above, I know do­ing so is un­seemly, but I think the ends jus­tify the means. Again, apolo­gies if I am wrong, and feel free to skip.

When peo­ple find out how much I’m giv­ing, they tend to re­act with ei­ther ad­mira­tion (one Bud­dhist FY1 I know said it was ‘amaz­ing’, and that it would earn me great merit for my next life – here’s hop­ing!); con­ster­na­tion (in the words of one med­i­cal reg­is­trar: “It re­ally up­sets me how much you’re giv­ing. Promise me you’ll stop.”); or, per­haps most com­monly, cyn­i­cism (“You’ll change your tune when you get a mort­gage/​have kids/​you have to deal with your wife’s shoe bud­get etc.”). I don’t think any of these at­ti­tudes are quite right.

I am giv­ing a larger pro­por­tion than the av­er­age house­hold in the UK (around 0.5% of gross in­come)3 but I’m also earn­ing a lot more: I doubt my ac­count­ing is perfect, but a salary of £33,000-ish last year puts me into the top 25% of UK in­di­vi­d­u­als by in­come, and well above the UK me­dian house­hold in­come of ~£23,200 – and, un­like many UK house­holds, I don’t have chil­dren or adult de­pen­dents to look af­ter. 4

This in­equity is starker on a global scale: Bri­tons are much richer than most of the world. 5 My post tax in­come of ~£26,295 puts me into the top 3% of peo­ple by wealth, and 24.7 times richer than the av­er­age per­son on the planet (you can run your own num­bers here).

It is a bit tricky to work out ex­actly where I stand ‘post giv­ing’ given Gift Aid etc., but I’m still prob­a­bly above me­dian in the UK, and com­fortably in the top decile globally. Med­i­cal salaries in­crease with se­nior­ity, so, even if I con­tinue giv­ing half, my po­si­tion in the global peck­ing or­der will im­prove still fur­ther. So even af­ter my giv­ing, I am still earn­ing more than the av­er­age ‘man on the street’ where I live, and many, many times more than the av­er­age per­son al­ive to­day.

This partly ex­plains why I don’t feel poorly off or des­ti­tute. There are other parts. One is that giv­ing gen­er­ally makes you hap­pier, and of­ten more hap­pier than buy­ing things for your­self. Another is that I am for­tu­nate in non-mon­e­tary re­spects: my biggest med­i­cal prob­lem is dan­druff, I have a lov­ing fam­ily, a wide and in­ter­est­ing cir­cle of friends, a fulfilling job, an e-reader which I can use to store (and oc­ca­sion­ally read) the finest works of west­ern liter­a­ture, an in­ter­net con­nec­tion I should use for bet­ter things than loi­ter­ing on so­cial me­dia, and so on, and so on, and so on. I am blessed be­yond all mea­sure of desert.

So I don’t think that my giv­ing has made me ‘worse off’. If you put a gun to my head and said, “Here’s the money you gave away back. You must spend it solely to fur­ther your own hap­piness”, I prob­a­bly wouldn’t give it away: I guess a mix of holi­days, sav­ings, books, mu­sic and trips to the the­atre might make me even hap­pier (but who knows? peo­ple are bad at af­fec­tive fore­cast­ing). But I’m pretty con­fi­dent giv­ing has made me hap­pier com­pared to the case where I never had the money in the first place. So the down­side looks like, “By giv­ing, I have made my­self even hap­pier from an already very happy baseline, but fore­gone op­por­tu­ni­ties to give my­self a larger hap­piness in­cre­ment still”. This seems a triv­ial down­side at worst, and not worth men­tion­ing across the scales from the up­side, which might be sev­eral lives saved, or a larger num­ber of lives im­proved and hor­rible dis­eases pre­vented.

I agree with the cyn­ics that these sorts of ‘sac­ri­fices’ are pretty easy when you are as un­justly priv­ileged as I am. And of course my cir­cum­stances might change: maybe my good run is in­ter­rupted by some mis­for­tune, or (as I hope is more likely) maybe ‘life gets in the way’ – mar­riage, kids, and mid­dle England might come knock­ing. If things change, then they change – al­though I hope in the lat­ter case I could fol­low ex­am­ples of Toby Ord and Ber­nadette Young, or Ju­lia Wise and Jeff Kauf­mann in terms of com­bin­ing a fam­ily with char­i­ta­ble giv­ing. But in the mean­while, I plan to make the best of my cur­rent lot.

A tale of two sickies

The “I like sci­ence and I want to help peo­ple” sen­ti­ment tends to go hand-in-hand with a ro­man­ti­cized image of what medicine is and what doc­tors do: sav­ing lives ev­ery epi­sode of your own pri­vate med­i­cal melo­drama, the pa­tients and their suffer­ing hand-picked as if by the pa­tron saint of the vain­glo­ri­ous to be strewn in front of you as your own Potemkin vale of soul-mak­ing 6, and the self-in­dul­gent moan­ing of work­ing un­paid over­time and be­ing ex­hausted but deep down you’re okay with it be­cause you’re mak­ing a differ­ence.

In re­al­ity, ex­pan­sion of mor­bidity and other doc­tors as­si­du­ously pick­ing low-hang­ing fruit for their pa­tients makes med­i­cal prac­tice, to a first ap­prox­i­ma­tion, ei­ther try­ing to snatch glimpses of bet­ter health for those with chronic, de­te­ri­o­rat­ing con­di­tions med­i­cal sci­ence can­not cure, or ex­tremely risk-ad­verse screen­ing to pick up, among those who are es­sen­tially well, the un­for­tu­nate few who re­ally need help. You gen­er­ally don’t save lives, es­pe­cially if you’re ju­nior, be­cause there’s a long hi­er­ar­chy of su­per­vis­ing doc­tors who are poised to leap in and save the day in case you don’t.

In 18 months of be­ing a doc­tor, I can point to one in­stance where I maybe – maybe – saved some­one’s life. She was 92, on a res­pi­ra­tory ward for pneu­mo­nia, and had sud­denly be­come breath­less on a back­ground of on-again, off-again chest pain. She was com­pro­mised, her chest sounded wet, and the X-ray showed fluid on the lungs, and the bloods later demon­strated a heart at­tack. I was on call, and the med­i­cal reg­is­trar (gen­er­ally the guardian an­gel of the hos­pi­tal wards, es­pe­cially when you’re a shit-scared first year) was with an even sicker pa­tient. I sprung into ac­tion: oxy­gen, mor­phine, GTN, CPAP, rel­a­tives, for­lorn call to ITU to con­firm that ward-based treat­ment was the ceiling of care – in other words, if this didn’t work, they wouldn’t take her, and she would die.

Hap­pily, it worked, and she got bet­ter in the next cou­ple of hours, and went home well a while later. Could I re­ally say I saved her life? At the very least I have to share credit with the nurses and as­sis­tants who read­ied all the kit and ad­ministered all the drugs I’d pre­scribed, not to men­tion be­ing as­tute enough to see she was re­ally un­well and de­mand­ing the doc­tor come quickly. Credit diffuses fur­ther if we in­clude (and we should) all the peo­ple who were needed for her to re­cover and leave hos­pi­tal: her usual team of doc­tors, and the spe­cial­ists who re­viewed her, sev­eral teams of nurs­ing staff on two differ­ent wards, phys­iother­a­pists, oc­cu­pa­tional ther­a­pists, phar­ma­cists, and many more. Be­sides, maybe all my pan­icked doc­tor­ing was co­in­ci­den­tal to her get­ting bet­ter by her­self; and even if the doc­tor­ing was vi­tal, maybe an­other doc­tor could have stepped into the breach in time had I not been able to do it my­self.

So the to­tal ‘QALY yield’ for my ‘life sav­ing’ was not that high, es­pe­cially when we add in that at 92 this lady’s ex­pected lifes­pan is fairly short even if she re­turns to good health. Of course, I did other things in the last 18 months: I could brag about (in as­cend­ing or­der of fre­quency) some atyp­i­cally as­tute di­ag­noses, perform­ing some tricky prac­ti­cal pro­ce­dures, pre­scribing anal­ge­sia, and mar­shal­ling pa­per work as some other ‘QALY pos­i­tive’ things to add to the sum to­tal of my good deeds. In sum, thought, it prob­a­bly isn’t that much – as all the caveats to my ‘sav­ing a life’ ap­ply here.

Be­sides, the life-sav­ing isn’t the thing I am most proud of in my nascent med­i­cal ca­reer. It’s this:

My first ro­ta­tion was on a gen­eral med­i­cal ward. One of the pa­tients was mid eighties ad­mit­ted af­ter a fall. He had a long list of co-mor­bidi­ties, amongst them vas­cu­lar de­men­tia. Med­i­cally, he was mak­ing an un­re­mark­able re­cov­ery, but he was up­set and mo­rose: as he kept say­ing, he had been with his wife for 60 years, and was lost with­out her. Each bed (in­clud­ing his) had a phone which could be used with cards bought in the cor­ri­dor out­side, and the ward phone was only five me­ters from his bed. Both were sev­eral steps too far for his severely im­paired cog­ni­tion: he had a digit span of 3 at best, did not re­mem­ber how to op­er­ate a phone, and had a shaky grasp of where he was and why his wife wasn’t there.

It took a cou­ple of days for me to re­al­ize I could help him out. I promised I would help him talk to his wife, but I for­got him amongst the other pa­tients. The day af­ter he told me again how how lonely he was, how much he wanted to be with his wife, how they had been mar­ried for sixty years… he had for­got­ten my promise, but it re­minded me.

Stung by my failing, I got to work. I checked with the ward clerk that the pa­tient’s phones could re­ceive calls (they could). I noted his num­ber down from his bed­side. I found his wife’s num­ber from his med­i­cal notes, and phoned her. She was also frail (al­though fac­ul­ties in­tact) and re­cov­er­ing from her own fall at their home, and so could not eas­ily visit, al­though she hoped to as soon as she was able. I gave her his num­ber, and sug­gested she call it now. I loi­tered by his bed for a cou­ple of min­utes un­til the phone rang, and I handed it to him. He thanked me tear­fully the day af­ter.

Che­que­books and stethoscopes

Anec­dotes make un­re­li­able data 7; in the world of ev­i­dence based medicine, the great­est weight is given to sys­tem­atic re­views, meta-analy­ses, and ran­dom­ized con­trol­led tri­als, whilst ‘ex­pert opinion’ is right at the bot­tom – I would be still lower.

Although the ‘hard data’ on how much good doc­tors re­ally do is hard to come by, I have found it even more sober­ing than the many times ex­pe­rience have formed parables about the limits and over­sights of tech­no­cratic medicine.

The only pub­lished at­tempt I know was by Bunker, an epi­demiol­o­gist. His strat­egy was look­ing at trial data to look at the im­pact of the most com­mon med­i­cal in­ter­ven­tions, and then ex­trap­o­lat­ing them to the pop­u­la­tion. Medicine turns out pretty well – it can take credit for a few of the many years added to life ex­pec­tancy in the de­vel­oped world since the turn of the last cen­tury. Play­ing with some num­bers, you can get a fairly good-sound­ing es­ti­mate of the im­pact of a doc­tor like me over their ca­reer: ~2500 QALYs. 8

Bunker freely ad­mit­ted these es­ti­mates are “more than spec­u­la­tive and less than pre­cise”. They are also sys­tem­i­cally op­ti­mistic, and the means of de­riv­ing from them an in­di­vi­d­ual doc­tor’s im­pact even more so. We know trial data over­es­ti­mates the benefit of treat­ment when ‘out in the wild’ of clini­cal prac­tice. It is also ob­vi­ous that doc­tors can’t take sole credit for medicine (what about nurses, phar­ma­cists, porters, and, well, ev­ery­one else?); that the re­la­tion­ship be­tween doc­tors and health is con­founded (what about bet­ter ed­u­ca­tion, wealth, hy­giene, and the other so­cial de­ter­mi­nants of health?); that doc­tors should have diminish­ing marginal turns, and be re­place­able – if I was never a doc­tor, there would not be a ‘Greg shaped hole’ in the na­tional health ser­vice.

A bet­ter anal­y­sis would try and cor­rect for con­founders, try and ac­count for diminish­ing re­turns, and maybe look at macro mea­sures of health dis­ease and their re­la­tion­ships to doc­tor num­bers. I couldn’t find that, so I tried to do it my­self. The bot­tom line is bad news for medics (but per­haps bet­ter news for ev­ery­one else!) The ‘QALY im­pact’ of a med­i­cal ca­reer is not ~2500 QALYs, but maybe ~150, and as the data and meth­ods im­prove, the num­bers get smaller still (I hope it never goes nega­tive…) Rather than sav­ing lives ev­ery epi­sode, one is adding a few years of life ev­ery year.

The com­par­i­son to char­ity is hum­bling. The ‘cost per QALY’ of a lead­ing char­ity (such as the Against Malaria Foun­da­tion) may lie around ~£60/​QALY. So the good of my med­i­cal ca­reer is ap­prox­i­mately the same as £9000, given well. Pro rata, it means a year is worth around £240, each work­ing day just over £1. Not only can your cheque­book beat my stetho­scope, your pocket change can as well. 9

On sav­ing the world

The sev­en­teen year old who wanted to be a doc­tor should be dis­ap­pointed: medicine has a mod­est im­pact on peo­ple liv­ing long and be­ing healthy, and al­though an in­di­vi­d­ual doc­tor may be the mechanism through which this mod­est im­pact flows, lit­tle of it de­pended on you.

But doc­tor’s don’t have a monopoly on al­tru­ism, and the sev­en­teen year old me who wanted to save the world would be over­joyed. The differ­ence a doc­tor makes is sig­nifi­cant, even if it is small in QALY terms; char­ity can make a large differ­ence in QALY terms, and its ‘real’ value is larger still. I have not lost out, and only benefited from think­ing care­fully and try­ing my best to make a differ­ence – hope­fully (and ex­pect­edly) many oth­ers have benefited too. I’d en­courage any­one to start think­ing harder about these mat­ters, to get in­volved, and to give more – and bet­ter.

I hope, af­ter read­ing this, you do.

Notes:

  1. For those in­ter­ested in how this is dis­tributed via the trust: you can in­struct the trust to give to char­i­ties it in­cludes in what­ever pro­por­tions you see fit. I have stipu­lated the trust dis­tributes my money in pro­por­tion to the other char­i­ties the trust dis­penses funds to – so if half the money given via the trust goes to the Against Malaria Foun­da­tion and the other half to De­worm the World, then my dona­tion is split 50:50 be­tween the two (and mu­tatis mu­tan­dis to what­ever the ac­tual bal­ance of con­tri­bu­tions ac­tu­ally are). The un­der­ly­ing idea is to ex­ploit peer knowl­edge. Although one can iden­tify what look like very high perform­ing char­i­ties, pick­ing be­tween these for the very high­est ‘value for money’ is hard, on which sen­si­ble peo­ple dis­agree. I don’t back my­self to have a bet­ter in­sight than they, but I can ap­ply an ‘equal-weight’ type view and so try and fol­low the weighted sum of sen­si­ble opinion, which should be closer to the mark than my own guess­ing. The clos­est fi­nan­cial anal­ogy would be an in­dex fund.

  2. Another pos­si­bil­ity, given how helpful I have found this way of think­ing about things for my­self, is the fund efforts to spread the word more widely. I’m not sure yet.

  3. I couldn’t find a di­rect source of this, so I had to calcu­late it my­self, which is more er­ror prone. The av­er­age weekly dona­tion per house­hold (in 2008) was £2.42, giv­ing a yearly dona­tion of £126.27. Aver­age gross in­di­vi­d­ual in­come was £26,800, which means a some­what over­es­ti­mate of pro­por­tion would be 126.27/​26,800, or 0.47%

  4. Although, in fair­ness, the Office of Na­tional Statis­tics try and ac­count for this via equiv­al­i­sa­tion.

  5. Peo­ple of­ten re­mark, “Yeah, but this isn’t a fair com­par­i­son, be­cause your money would go a lot fur­ther in the de­vel­op­ing world”. That’s true, but this effect is already ac­counted for by pur­chas­ing par­ity ad­just­ment. So a graph like this would be even more starkly in­iquitous if ‘real’ in­come was used.

  6. Doc­tors were the most self-righ­teous peo­ple on earth, Schwartz thought. Healthy and wealthy them­selves, sur­rounded by the sick and dy­ing — it made them feel in­vin­cible, and feel­ing in­vin­cible made them pricks. They thought they un­der­stood suffer­ing be­cause they saw it ev­ery day. They didn’t un­der­stand shit.

    Chad Har­bach, The Art of Field­ing.

  7. Aside: Although they are data, thus the adage “The plu­ral of anec­dote is not data”, is – sensu stricto– false. That said, peo­ple gen­er­ally over-in­ter­pret and over­weigh ‘anec­data’, and so the im­plied norm of be­ing cau­tious us­ing it is wise.

  8. QALY – Qual­ity-ad­justed life year, a sub­set of health ad­justed life years. The idea is to pro­duce a unified met­ric of health that can be used to com­pare dis­eases (and their treat­ments) to one an­other. Calcu­lat­ing the ‘life year’ part is rel­a­tively sim­ple: look at how how dis­eases shorten life, and how well a treat­ment length­ens it, on av­er­age. The ‘Qual­ity ad­just­ment’ is harder: one tries to come up with ‘weights’ for given dis­abil­ities to see how much worse they are to live with than perfect health (so if blind­ness was weighed at 0.5, then 2 years of blind­ness are about as good as one year of healthy life). Tech­niques for get­ting weight­ings vary, and are ad­mit­tedly far from perfect. They are prob­a­bly bet­ter than other can­di­dates for weigh­ing health, hence their wide adop­tion by na­tional and global health or­ga­ni­za­tions.

  9. Peo­ple of­ten ob­ject to con­se­quen­tial­iz­ing mea­sures like QALYs as they in­evitably don’t cap­ture all that re­ally mat­ters – the benefit of let­ting my pa­tient talk to his wife again is poorly cap­tured by ag­gre­gate mea­sures of health. It in­vites Dick­en­sian satire: the Thomas Grad­grinds of good deeds, care­fully mov­ing beads along their moral aba­cuses with­out a hu­mane grasp of what it means:

    ‘Very well, then. He is a vet­eri­nary sur­geon, a far­rier and horse­breaker. Give me your defi­ni­tion of a horse.’

    (Sissy Jupe thrown into the great­est alarm by this de­mand.)

    ‘Girl num­ber twenty un­able to define a horse!’ said Mr. Grad­grind, for the gen­eral be­hoof of all the lit­tle pitch­ers. ‘Girl num­ber twenty pos­sessed of no facts, in refer­ence to one of the com­mon­est of an­i­mals! Some boy’s defi­ni­tion of a horse. Bitzer, yours.’

    The square finger, mov­ing here and there, lighted sud­denly on Bitzer, per­haps be­cause he chanced to sit in the same ray of sun­light which, dart­ing in at one of the bare win­dows of the in­tensely white­washed room, ir­ra­di­ated Sissy. For, the boys and girls sat on face of the in­clined plane in two com­pact bod­ies, di­vided up the cen­tre by a nar­row in­ter­val; and Sissy, be­ing at the cor­ner of a row on the other side, came in for the be­gin­ning of a sun­beam, of which Bitzer, be­ing at the comer of a row on the other side, a few rows in ad­vance, caught the end. But, whereas the girl was dark-eyed and dark-haired, that she seemed to re­ceive a deeper and more lus­trous colour from the sun when it shone upon her, the boy was so light-eyed and light-haired that the self-same rays ap­peared to draw out of him what lit­tle colour he ever pos­sessed. His cold eyes would hardly have been eyes, but for the short ends of lashes which, by bring­ing them into im­me­di­ate con­trast with some­thing paler than them­selves, ex­pressed their form. His short­cropped hair might have been a mere con­tinu­a­tion of the sandy freck­les on his fore­head and face. His skin was so un­whole­somely defi­cient in the nat­u­ral tinge, that he looked as though, if he were cut, he would bleed white.

    ‘Bitzer,’ said Thomas Grad­grind. ‘Your defi­ni­tion of a horse.’

    ‘Quadruped. Gram­inivorous. Forty teeth, namely twenty-four grinders, four eye-teeth, and twelve in­ci­sive. Sheds coat in the spring; in marshy coun­tries, sheds hoofs, too. Hoofs hard, but re­quiring to be shod with iron. Age known by marks in mouth.’ Thus (and much more) Bitzer.

    ‘Now girl num­ber twenty,’ said Mr. Grad­grind. ‘You know what a horse is.’

    QALYs are im­perfect, but they do count, and al­though a QALY mea­sure of the good my med­i­cal ca­reer does fails to cap­ture all of its value, it will similarly fail to cap­ture the goods of high perform­ing char­ity. Every death of a child from malaria has its own tragic story – sto­ries which we all too sel­dom hear. We err badly if we at­tend to how vivid goods and evils are to our imag­i­na­tion, rather than to their size; first re­spon­ders to mul­ti­ple ca­su­alty in­ci­dent are told to ig­nore those who are scream­ing at first, but to look care­fully for any peo­ple who are so des­per­ately in­jured they can­not even cry for help. And if a com­mon failing of doc­tors is to be­come drunk on their apos­tolic role and self-righ­teous power, look­ing at ‘just the bare num­bers’, sober­ing as they are, may part-way provide a cure.