LW - Adverse Selection by Life-Saving Charities by vaishnav92

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Welcome to The Nonlinear Library, where we use Text-to-Speech software to convert the best writing from the Rationalist and EA communities into audio. This is: Adverse Selection by Life-Saving Charities, published by vaishnav92 on August 16, 2024 on LessWrong.
GiveWell, and the EA community at large, often emphasize the "cost of saving a life" as a key metric, $5,000 being the most commonly cited approximation. At first glance, GiveWell might seem to be in the business of finding the cheapest lives that can be saved, and then saving them. More precisely, GiveWell is in the business of finding the cheapest DALY it can buy.
But implicit in that is the assumption that all DALYs are equal, or that disability or health effects are the only factors that we need to adjust for while assessing the value of a life year.. However, If DALYs vary significantly in quality (as I'll argue and GiveWell acknowledges we have substantial evidence for), then simply minimizing the cost of buying a DALY risks
adverse selection.
It's indisputable that each dollar goes much further in the poorest parts of the world. But it goes further towards saving lives in one the poorest parts of the world, often countries with terrible political institutions, fewer individual freedoms and oppressive social norms. More importantly, these conditions are not exogenous to the cost of saving a life. They are precisely what drive that cost down.
Most EAs won't need convincing of the fact that the average life in New Zealand is much, much better than the average life in the Democratic Republic of Congo. In fact, those of us who donate to GiveDirectly do so precisely because this is the case. Extreme poverty and the suffering it entails is worth alleviating, wherever it can be found.
But acknowledging this contradicts the notion that while saving lives, philanthropists are suddenly in no position to make judgements on how anything but physical disability affects the value/quality of life.
To be clear, GiveWell won't be shocked by anything I've said so far. They've commissioned work and
published reports on this. But as you might expect, these quality of life adjustments wouldnt feature in GiveWell's calculations anyway, since the pitch to donors is about the price paid for a life, or a DALY. But the idea that life is worse in poorer countries significantly understates the problem - that the project of minimizing the cost of lives saved while making no adjustments for the quality of lives said
will systematically bias you towards saving the lives least worth living.
In advanced economies, prosperity is downstream of institutions that preserve the rule of law, guarantee basic individual freedoms, prevent the political class from raiding the country, etc. Except for the Gulf Monarchies, there are no countries that have delivered prosperity for their citizens who don't at least do this.
This doesn't need to take the form of liberal democracy; countries like China and Singapore are more authoritarian but the political institutions are largely non-corrupt, preserve the will of the people, and enable the creation of wealth and development of human capital. One can't say this about the countries in sub Saharan Africa.
High rates of preventable death and disease in these countries are symptoms of institutional dysfunction that touches every facet of life. The reason it's so cheap to save a life in these countries is also because of low hanging fruit that political institutions in these countries somehow managed to stand in the way of. And one has to consider all the ways in which this bad equilibrium touches the ability to live a good life.
More controversially, these political institutions aren't just levitating above local culture and customs. They interact and shape each other. The oppressive conditions that women (50% of the population) and other sexual minorities face in these countries isn't a detail that we can gloss over. If you are both a liberal and a consequentialis...