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Speaker 1: Pushkin, Freeland is a village in the English countryside, a

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Speaker 1: few miles north of Oxford, where I live. It boasts

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Speaker 1: a nineteenth century church, a cricket team and a pub

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Speaker 1: called the Oxfordshire Yeoman. It has about fifteen hundred residents.

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Speaker 1: In two thousand and seven, one of them, Clive Stone,

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Speaker 1: went to see his doctor. Stone was a bank manager

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Speaker 1: recently retired. It joined the bank straight from school and

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Speaker 1: worked his way up. Now he was concerned about a

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Speaker 1: mysterious pain in his chest. Renal cell carcinoma is cancer

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Speaker 1: of the kidney. If you have it, you don't normally

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Speaker 1: discover that because you have a pain in your chest. Nevertheless,

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Speaker 1: is what happened to Clive Stone, and the prognosis was bad.

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Speaker 1: The diagnosis was a great shock to me. Stone later wrote,

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Speaker 1: both my wife Jan and I were regular walkers who

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Speaker 1: kept ourselves fit with visits to the gym, and I

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Speaker 1: was a swimmer. I could find no trace of any

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Speaker 1: hereditary renal cancer in my family. Stone was only fifty

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Speaker 1: nine years old. There was some good news. New drug

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Speaker 1: that showed promise, sunitinib or sutent, had been approved in

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Speaker 1: America the previous year. It wouldn't cure Stone's cancer, but

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Speaker 1: it might extend his life. And then some bad news.

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Speaker 1: Stone would not be offered the drug. It was too expensive.

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Speaker 1: The UK's National Health Service, the NHS, refused to pay

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Speaker 1: for it. To Stone, that seemed wrong. He set up

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Speaker 1: a campaign called Justice for Kidney Cancer Patients. That humble

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Speaker 1: sounding cause soon kicked up a storm, one that offers

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Speaker 1: a lesson about how we made life or death decisions

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Speaker 1: the world over. I'm Tim Harford and you're listening to

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Speaker 1: another cautionary tale. There are many ways to decide if

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Speaker 1: a sick person can get a medical treatment that might help.

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Speaker 1: The most common is can you pay for it? Or

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Speaker 1: will you're insurer pay for it? In state funded health

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Speaker 1: systems such as the UK's NHS, it's will the taxpayer

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Speaker 1: pay for it? What the NHS will and won't pay

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Speaker 1: for is guided by a body called NICE, the National

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Speaker 1: Institute for Health and Care Excellence. A new treatment comes along,

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Speaker 1: like sue tent for kidney cancer. It'll benefit some patience

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Speaker 1: like mister Stone, but the British taxpayer has limited money

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Speaker 1: and it's nicest job to make sure it's spent wisely.

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Speaker 1: It is an ironic acronym the decisions the Institute must make.

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Speaker 1: Afar from NICE, Clive Stone and a hundred fellow campaigners

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Speaker 1: turned up at nice's headquarters in Hoburn, Central London. They

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Speaker 1: carried placards with a slogan Kidney cancer Patience Deserve the

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Speaker 1: right to Life. Among them was an outspoken talk radio

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Speaker 1: host at kidney cancer survivor himself. He had come along

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Speaker 1: to lend his support. I want the chairman of NICE

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Speaker 1: to come down and speak to these people, he said.

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Speaker 1: I want him to look into the eyes of the

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Speaker 1: people whose lives he would cut short. These faceless bureaucrats

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Speaker 1: are trying to stop people's lives. To his credit, the

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Speaker 1: chairman of NICE did come down and meet the protesters.

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Speaker 1: Clive Stone told him I'm dying. You're taking any hope

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Speaker 1: away from me. A few months later, NICE changed its

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Speaker 1: guidance fiser, the drug company which makes Sutent, agreed to

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Speaker 1: lower the cost. Nice said the NHS could now pay

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Speaker 1: for it, although only in certain circumstances. It depended what

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Speaker 1: else might be afflicting the patient. By now this was

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Speaker 1: no longer about just one drug. Clive Stone's campaign had

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Speaker 1: caught on all over the country. Other patients with other

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Speaker 1: kinds of cancer were pleading for the NHS to pay

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Speaker 1: for their own expensive new drugs. Stone's work had also

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Speaker 1: caught the attention of his local member of Parliament, a

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Speaker 1: man called David Cameron. Mister Cameron was suave, self assured

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Speaker 1: and young, just thirty nine years old when he became

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Speaker 1: leader of the UK's opposition party, the Conservatives. A general

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Speaker 1: election was imminent, and in the spring of twenty ten,

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Speaker 1: Cameron fa staff against the incumbent Prime Minister Gordon Brown

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Speaker 1: in the first of the televised debates. He's what, he said.

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Speaker 1: I have a man in my constituency called Clive Stone

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Speaker 1: who had kidney cancer, who came to see me with

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Speaker 1: seven others. Tragically, two of them have died because they

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Speaker 1: couldn't get the drug suitant that they wanted that was

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Speaker 1: on the market, that people knew was a good drug.

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Speaker 1: That's a scandal in our country today. Cameron made a

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Speaker 1: promise elect me, he said, and I'll set up a

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Speaker 1: special new fund to pay for cancer drugs. Clive Stone's

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Speaker 1: kidney cancer had become political. How much money is society

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Speaker 1: willing to spend to keep someone alive? What is a

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Speaker 1: life worth. It's an uncomfortable question to ask, but what

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Speaker 1: is a life worth is also an uncomfortable question not

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Speaker 1: to ask. Decades ago, one of the twentieth centuries most

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Speaker 1: brilliant brains conspicuously did not ask it. His name was

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Speaker 1: John von Neumann. Von Neumann was interested in game theory, computers,

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Speaker 1: and bombs. He was perhaps a little too interested in bombs.

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Speaker 1: Von Neuman is said to have partly inspired the most

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Speaker 1: famous mad scientist in movie history, doctor Strange Love. In

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Speaker 1: nineteen forty nine, von Neumann was working for the Rand Corporation,

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Speaker 1: advising the US Air Force on military strategy. Rand had

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Speaker 1: one of the very first computers and edvac, you know

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Speaker 1: the kind It filled the room and cost a fortune.

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Speaker 1: Von Neumann was using the computer to answer a very

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Speaker 1: strange Love youan question, what would be the most cost

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Speaker 1: efficient way to nuke the Soviet Union? You've had the

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Speaker 1: computer variables about the number of bombs, the cost of

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Speaker 1: different types of planes, land bases, logistics, and so on.

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Speaker 1: The computer crunched through four hundred thousand permutations, and it

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Speaker 1: showed von Neuman clearly what the US Air Force should do.

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Speaker 1: Imagine the conversation in the cockpit on a mission to

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Speaker 1: bomb the Soviet Union. If von Neumann's plan had come

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Speaker 1: to pass, this plane feels so flimsy. Yeah, they were

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Speaker 1: built on the cheap. We don't actually have a bomb

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Speaker 1: on board, right, No, bombs were expensive. We're a decoy.

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Speaker 1: Most of these planes don't have bombs. Why are there

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Speaker 1: so many planes Because even if the Soviet shot most

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Speaker 1: of us down, the chances are some bombs will get through,

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Speaker 1: so you and I are likely to get shot down. Well,

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Speaker 1: that's why they don't want to spend too much on

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Speaker 1: the planes. It was a clever plan, too clever by half,

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Speaker 1: said air force chiefs. When they read von Neumann's proposal.

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Speaker 1: They were offended by the thought of sending their pilots

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Speaker 1: on what was tantamount to suicide missions. Von Neuman's model

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Speaker 1: had delved deep into the price of planes, but had

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Speaker 1: completely failed to consider the issue of pilots lives. This

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Speaker 1: was awkward. Rand could hardly insist that the pilots were expendable. Indeed,

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Speaker 1: it's common to say that every human life is infinitely precious,

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Speaker 1: but that can't quite be right either, because any jobs,

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Speaker 1: such as that of an air force pilot, are jobs

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Speaker 1: that bear some risk. If pilots lives must be protected

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Speaker 1: at all costs, the Air Force chiefs could never allow

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Speaker 1: them in a plane at all. So the value of

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Speaker 1: human life couldn't be infinite, and it couldn't be zero.

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Speaker 1: It had to be something in the middle. Whenever the

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Speaker 1: Air Force generals had to decide on approving omission, they

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Speaker 1: must somehow weigh the risk to pilots lives alongside the

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Speaker 1: monetary costs and the chances of success, even if they

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Speaker 1: couldn't articulate exactly how they did it. RAND felt sure

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Speaker 1: that their awesome new computing power had the potential to

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Speaker 1: improve that kind of decision, but only if they could

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Speaker 1: figure out a way to plug pilots lives into von

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Speaker 1: Neumann's equations alongside all those dollars and cents. And nobody

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Speaker 1: at RAND had a clue how to do it. They

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Speaker 1: were completely stumped. In the twenty ten UK election, David

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Speaker 1: Cameron's healthcare spending pledge paid off. He won, and the

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Speaker 1: new Prime Minister was as good as his word. Soon

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Speaker 1: the Cancer Drugs Fund was up and running with two

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Speaker 1: hundred million pounds a year to spend. At the time,

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Speaker 1: that was over three hundred million dollars. The next year,

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Speaker 1: Clive Stone was honored for his campaigning. The Queen awarded

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Speaker 1: him an MBE, a kind of miniature knighthood, with Prince

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Speaker 1: Charles pinning a medal on his chest. Unfortunately, by now

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Speaker 1: Stone's wife jan had developed a rare form of breast cancer,

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Speaker 1: and stone Own cancer had spread to his brain. Their

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Speaker 1: wretched medical luck was just getting worse. How much is

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Speaker 1: a pilot's life worth? The mathematical wizards at RAND kept

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Speaker 1: scratching their heads. I know, what about the cost of

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Speaker 1: the Air Force of training a replacement pilot? Maybe not?

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Speaker 1: Somehow that didn't seem any less likely to offend the

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Speaker 1: Air Force chiefs. It was twenty years before there was

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Speaker 1: an intellectual breakthrough on this problem of how to quantify

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Speaker 1: the worth of a life, and it came from the

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Speaker 1: pen of a Harvard educated economist with a Nobel Prize

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Speaker 1: in his future. Thomas Shelling knew that Rand's pilot problem

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Speaker 1: was far from unique. Economists also needed a clearer way

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Speaker 1: to think about situations where decision makers have to balance

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Speaker 1: prosper with risks to life. In nineteen sixty eight, Thomas

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Speaker 1: Shelling sat down to write an essay on the worth

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Speaker 1: of a human life. This is a treacherous topic, he began.

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Speaker 1: You can say that again. Shelling considered all the usual

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Speaker 1: ways one might try to value an asset, gently mocking

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Speaker 1: how inappropriate they would be when applied to someone's life,

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Speaker 1: the loss of future productivity. For example, if a Harvard

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Speaker 1: professor dies, his family will miss him, and it will

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Speaker 1: miss his earnings. We do not know which of the two.

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Speaker 1: In the end it will miss most, Shelling wrote, And

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Speaker 1: if he died recently, this is a disagreeable time to inquire.

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Speaker 1: It was hopeless, Shelling said. Nobody can sensibly answer the

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Speaker 1: question how much would you pay not to die? But

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Speaker 1: what we can do, and implicitly we do all the time,

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Speaker 1: is to weigh up small risks, like a one in

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Speaker 1: a million chance of death. Here's an example. Your friend

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Speaker 1: invites you for a weekend visit. She lives a hundred

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Speaker 1: miles away, so that's a two hundred mile round trip journey.

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Speaker 1: Statistics tell us that driving two hundred miles gives you

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Speaker 1: a roughly one and a million chance of a fatal accident.

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Speaker 1: Do you refuse to go, even though you'd like to

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Speaker 1: see your friend? Of course, not a few of us

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Speaker 1: would let that risk deter us. We take it for granted.

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Speaker 1: Economists now have a fancy piece of jargon. For a

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Speaker 1: one in a million chance of death, it's a micro mort.

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Speaker 1: So driving two hundred miles is one micro mort. It's

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Speaker 1: thirty four micromorts if you do it on a motorbike.

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Speaker 1: Giving birth is a hundred and seventy micromorts in the US.

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Speaker 1: In a lot of European countries, it's safer. Going under

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Speaker 1: general anesthetic is ten micro morts. The fun stuff in

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Speaker 1: life can be risky too. A day of skiing is

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Speaker 1: half a micromort. Scuba diving is five micromorts, hand gliding

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Speaker 1: eight micromorts. But these are risks that we, or at

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Speaker 1: least some of us, are willing to take. In some cases,

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Speaker 1: jobs pose risk, and we're also willing to take those

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Speaker 1: risks for a price. In other cases, we might choose

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Speaker 1: to pay for something that will reduce our risk of death,

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Speaker 1: such as a bike helmet. The details are difficult. There

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Speaker 1: are many situations like this, and we don't always think

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Speaker 1: consistently about them. But the principle Shelling said is quite straightforward,

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Speaker 1: and it gives us a sensible way to talk about

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Speaker 1: the value of life. First, determine, as best you can

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Speaker 1: how much people are willing to pay to avoid a micromort.

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Speaker 1: Then multiply that figure by a million, and that must

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Speaker 1: be what we think our own lives are worth. In America,

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Speaker 1: economists reckon that people value micromorts at roughly ten dollars.

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Speaker 1: That implies we think our lives are worth about ten

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Speaker 1: million dollars. Shelling's idea is known as the value of

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Speaker 1: statistical life. Economists use that idea to advise on everything

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Speaker 1: from pollution to product safety regulations to speed limits on

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Speaker 1: the roads. In two thousand and three, the Bush administration

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Speaker 1: floated the idea of putting more weight on saving younger lives.

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Speaker 1: That kind of logic might lead us to put polluting

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Speaker 1: factories in a part of town with more nursing homes

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Speaker 1: rather than apart with more nursery schools, or more generally,

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Speaker 1: it might persuade us to accept risks to people who

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Speaker 1: are already nearer the end of their lives. The logic

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Speaker 1: is obvious, but the idea was hugely unpopular. Critics dubbed

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Speaker 1: it to the senior death discount. It was quickly dropped,

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Speaker 1: but in healthcare its standard practice to value younger lives more.

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Speaker 1: Imagine you have two patients who need a heart transplant

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Speaker 1: and only one donated heart. Do you give the transplant

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Speaker 1: to the nineteen year old or the ninety one year old,

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Speaker 1: or flip a coin. I think most of us would

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Speaker 1: give it to the teenager. Medical resources are seldom unlimited,

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Speaker 1: and doctors have to prioritize somehow, So economists in the

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Speaker 1: health sector came up with a different method to try

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Speaker 1: to formalize the kind of intuition we have about the

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Speaker 1: heart transplant. They ask how long a given treatment might

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Speaker 1: prolong a patient's life, along with the quality of that

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Speaker 1: extended life. The jargon here is qualities. That's quality adjusted

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Speaker 1: life years. The reason Clive Stone initially couldn't get the

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Speaker 1: drug treatment he wanted was in large part because Nice

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Speaker 1: had calculated the cost per quality was too high, and

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Speaker 1: now mister Stone was bumping up against the brutal logic

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Speaker 1: of the spreadsheet once again. Stone's brain tumors could be

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Speaker 1: treated with something called gamma knife surgery, a kind of

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Speaker 1: highly targeted radiotherapy. Nice said the NHS could pay for

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Speaker 1: it sometimes, but not when patients had a poor prognosis

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Speaker 1: from other cancers. It wasn't worth it, not enough qualities.

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Speaker 1: What about the new fund that David Cameron created. It

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Speaker 1: existed precisely to pay for treatments that Nice wouldn't approve.

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Speaker 1: Could it fund Stone's treatment? But no, the fund was

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Speaker 1: for drugs and Stone didn't need a drug. He needed surgery.

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Speaker 1: In a cruel irony, the fund he had inspired couldn't

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Speaker 1: help him. But surely that was a loophole that should

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Speaker 1: be closed. Stone went back into campaign mode, reaching out

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Speaker 1: to the Prime Minister David Cameron, but he couldn't take

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Speaker 1: a chance on waiting for a change in policy. Stone

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Speaker 1: was a widower now. Cancer had taken his wife Jan quickly.

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Speaker 1: She didn't get to meet her first grandchild. Stone wanted

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Speaker 1: to stick around. He decided to pay for the surgery himself.

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Speaker 1: I know I've got a limited time left, but apart

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Speaker 1: from this ticking time bomb in my head, I'm feeling

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Speaker 1: fit and well. I just want to keep going for

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Speaker 1: as long as I can. Economists are paid to grapple

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Speaker 1: with trade offs between money and life, but for many

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Speaker 1: people it's a taboo subject. The temptation is to say

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Speaker 1: we must save lives and shut down the conversation, and

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Speaker 1: not everything is a tradeoff. When COVID nineteen arrived, it

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Speaker 1: was never an option to let the virus run wild.

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Speaker 1: That would have crashed economy is more surely than any lockdown,

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Speaker 1: But there are trade offs we can't pretend they're aren't.

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Speaker 1: Every easing of a lockdown means more risk of infections

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Speaker 1: and deaths. How many deaths are we willing to accept

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Speaker 1: to let schools open and give children the education they

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Speaker 1: desperately need. What about swimming pools, coffee shops, hair salons.

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Speaker 1: We could view lockdowns as a kind of risk reducing

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Speaker 1: regular and think about micromortz and the value of a

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Speaker 1: statistical life that would imply every death is worth paying

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Speaker 1: ten million dollars to prevent. Or perhaps we should view

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Speaker 1: lockdowns as a kind of public health intervention and factor

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Speaker 1: in how the virus poses different risks for different ages.

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Speaker 1: In the UK, NICE typically values a single quality a

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Speaker 1: single year of a quality life prolonged in the range

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Speaker 1: of thirty thousand dollars. COVID nineteen poses vastly more risk

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Speaker 1: to the elderly. So if we're thinking through the lens

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Speaker 1: of quality years of life remaining, our decisions about how

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Speaker 1: to proceed change drastically, or maybe we need a new

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Speaker 1: measure altogether. As the UK pondered how to ease its lockdown,

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Speaker 1: a group of academics came up with a new proposal,

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Speaker 1: not a quality but a well be a well being

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Speaker 1: life year. It tries to fold in figures for things

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Speaker 1: like mental health. Is it the right approach, I don't know,

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Speaker 1: but it does at least try to ask the right questions.

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Speaker 1: I realized the spreadsheet method seems repugnant to most of us,

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Speaker 1: But as John von Neumann discovered, we can't ignore the

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Speaker 1: trade offs. In the end, we have to balance the

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Speaker 1: risks to life against the things that make life worth living.

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Speaker 1: The Cancer Drugs Fund was a popular policy. UK media

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Speaker 1: coverage was positive. Sure, there were some who grumbled that

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Speaker 1: it was diverting money from other parts of the NHS,

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Speaker 1: but the biggest criticism was that it wasn't spending enough.

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Speaker 1: Over six years, the Cancer Drugs Fund bought drugs for

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Speaker 1: almost one hundred thousand cancer patients. In twenty seventeen, researchers

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Speaker 1: looked at how effective it had been. It turned out

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Speaker 1: that four fifths of the drugs it bought had no

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Speaker 1: clinical benefit at all the drugs that did have effects,

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Speaker 1: often also side effects. They extended people's lives on average

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Speaker 1: by a little more than three months. Those were precious months,

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Speaker 1: no doubt. The cost was one point two seven billion pounds,

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Speaker 1: not far shy of two billion dollars. For that money,

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Speaker 1: you could easily hire ten thousand nurses. How can we

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Speaker 1: decide if the money would have been better spent elsewhere?

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Speaker 1: The researchers used qualities They reckoned the same amount could

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Speaker 1: have done five times as much good if it had

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Speaker 1: funded other treatments for other patients with other conditions. Professor

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Speaker 1: Richard Sullivan, who led the research, said the fund had

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Speaker 1: been a major policy error and a huge waste of money.

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Speaker 1: What had gone wrong? Remember the cancer surviving talk show

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Speaker 1: host who said the faceless bureaucrats were trying to stop

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Speaker 1: people's lives. It's an emotive quote, but wrong. Nobody was

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Speaker 1: trying to stop anybody's lives. Bureaucrats were trying to decide

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Speaker 1: how to spend a limited pool of money where it

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Speaker 1: would be likely to do most good. That we're doing

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Speaker 1: their jobs. David Cameron must have known that he's a

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Speaker 1: smart guy, so it's hard to avoid the conclusion that

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Speaker 1: making Clive Stone and an election issue was a cynical calculation.

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Speaker 1: As the researcher Richard Sullivan concluded, populism doesn't work when

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Speaker 1: you're dealing with complex areas of policy like this. It

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Speaker 1: was politically and intellectually lazy, But in the end the

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Speaker 1: blames on us, the voters. We make it very hard

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Speaker 1: for our societies to have cool and rational conversations about

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Speaker 1: life and death decisions. Studies of media coverage point out

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Speaker 1: that new cancer drugs tend to get a disproportionate amount

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Speaker 1: of hype. Nobody wants to grumble about the cost, and

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Speaker 1: as the pandemic has taught us, we all want to

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Speaker 1: hope for miracle cures. By the time the report on

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Speaker 1: the Cancer Drugs Fund came out, David Cameron was no

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Speaker 1: longer Prime Minister. He'd resigned after losing a bitter referendum

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Speaker 1: campaign over Brexit. Three weeks before that crucial vote, he

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Speaker 1: took time out from the campaign to talk to his

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Speaker 1: local newspaper, The Oxford Mail. They wanted a quote about

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Speaker 1: a constituent who died, and Cameron was happy to oblige.

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Speaker 1: Clivestone was an inspiration to me and I'm sorry to

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Speaker 1: hear of his passing. He was an amazing man who

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Speaker 1: made such a difference to so many people's lives. Cameron

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Speaker 1: said clivestone story was brave and tragic. It's hard not

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Speaker 1: to react with emotion, but if we're judging policy and politicians,

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Speaker 1: we should try. Our sources included an article on the

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Speaker 1: Cold War origins of the value of statistical life by

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Speaker 1: Spencer Banshaf, and on personal testimony on the Kidney Cancer

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Speaker 1: Support Network website written by the late Clive Stone. As always,

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Speaker 1: a full list of our sources is in the show

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Speaker 1: notes on Tim Harford dot com. Cautionary Tales is written

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Speaker 1: and presented by me Tim Harford, with help from Andrew Wright.

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Speaker 1: The show was produced by Ryan Dilley with support from

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Speaker 1: Pete Norton. The music, sound design, and mixing are the

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Speaker 1: work of Pascal Wise. The scripts were edited by Julia Barton.

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Speaker 1: Special thanks to Mia LaBelle, Carlie Miliori, Heather Fane, Maya Kanig,

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Speaker 1: Jacob Weisberg, and Malcolm Gladwell. Cautionary Tales is a Pushkin

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Speaker 1: Industry's production