The subjective wellbeing approach in contrast with GiveWell's approach
Elie Hassenfeld: First I think it would be helpful for me to just explain what GiveWell is doing today, which is we cash everything out either in terms of increased ability to consume (i.e. people have more money) or reductions in disability-adjusted life years — some of which are health-related and some are mortality-related.
But I very much take the point that subjective wellbeing is an important consideration. We don’t view the two outcomes we use today as the only outcomes that make sense. They’re just the two outcomes that we’ve been able to use to date. I do think over time, as we continue to grow and increase the size of our team, we’ll be in a position to include more factors explicitly in that analysis.
I think the pro of subjective wellbeing measures is that it’s one more angle to use to look at the effectiveness of a programme. It seems to me it’s an important one, and I would like us to take it into consideration.
I think the downside, or the reasons not to, might be that on one level, I think it can just be harder to measure. A death is very straightforward: we know what has happened. And the measures of subjective wellbeing are squishier in ways that it makes it harder to really know what it is. Also, I think some people might say, “I really value reducing suffering and therefore I choose subjective wellbeing.” I think other people might say, “I think these measures are telling me something that is not part of my ‘view of the good,’ and I don’t want to support that.” That would cause someone to want to leave it out of their calculus and the donations they’re making.
In some ideal world, I would love for GiveWell to be able to offer options for donors who have different philosophical perspectives about what they want to achieve. Obviously, GiveWell institutionally also needs to have a view, because there’s funds that come to us directly. But ideally, in the future vision of GiveWell, for people who have subjective wellbeing as their core focus, other moral values, or maybe even a very different tradeoff between increasing income and reducing disability-adjusted life years (or increasing DALYs, maybe, depending on how you think about it), those are programmes we’d like to be able to bring to donors and let them choose.
Because we’re not trying to add value by being particularly good philosophically. That’s not part of GiveWell’s comparative advantage. It would be better if we could, where donors want it, allow them to use their own judgements to make decisions.
The value of saving a life when that life is going to be very difficult
Rob Wiblin: I think to most people, it’s intuitive that it’s more valuable to save the life of someone who feels that they’re really flourishing and is super glad to be alive than it is to save the life of someone who thinks their life is barely worth living, who maybe doesn’t even care that much whether they live or die.
It could be useful to use some numbers to make it a bit clearer how this might end up affecting your relative priorities here. If you imagine people scoring their quality of life out of 10, that’s kind of the standard subjective wellbeing scale. Let’s say that we use the number 3 as the number at which someone is rating their existence as neutral, with the good and bad things in their life cancelling out: that’s kind of a typical answer for what people say would be the neutral point for them if they were scoring themselves.
If someone is going to report a quality of life of 4 out of 10 for the rest of their lives, then from a wellbeing-adjusted life year, a WELLBY, point of view, then it’s equally valuable to them to prevent them from dying as it is to increase their wellbeing permanently by one point out of 10. That would be from 4 to 5 in this case. On the other hand, if someone reports a quality of life of 5 out of 10, then from a WELLBY point of view, it’s twice as valuable to save their life as to increase their wellbeing permanently by one point — in this case from 5 to 6 — because the difference from 3 to 5 is twice as great as from 5 to 6.
The Happier Lives Institute notes that many people in very poor countries — who otherwise might die of malaria in the absence of additional antimalarial bednets — have unsurprisingly pretty challenging lives with plenty of hardship in them. That, as I understand it, suggests that to them it’s more likely to be cost effective to make people’s lives better than to make them longer or less equal.
What do you and GiveWell make of that line of argument?
Elie Hassenfeld: I think the place I want to start is this is a case where I feel most strongly that I would want to hear from the people themselves in low-income countries about this topic. Because if you kind of draw out this line of reasoning, it leads you to the conclusion that there is a very high proportion of people living in low-income countries who would choose death over continued living, based on their self-reported life satisfaction.
That’s a very uncomfortable conclusion, but maybe more importantly, one that is so counterintuitive that I feel the need to follow up on it before accepting it at face value. That may be a somewhat minor point about where you draw the line on the scale, but still, in this case, I think the maybe purely emotional urge I have is to say that doesn’t quite seem like it could be right. Intellectually, I know it could be right — therefore I need to follow up on it, because it’s so inconsistent with my starting point for what people would say.
Rob Wiblin: Yeah, it definitely can get uncomfortable or weird. Or maybe if you were surveying people on their subjective wellbeing, and you really said, “If you score yourself a 2, we’re going to take it that you actually mean that you would rather not be alive right now,” then maybe people would reassess. Because an interesting thing is that when you survey people, almost everywhere in the world, even people in serious poverty almost always say that they think their life is better than not existing, and they want to continue surviving and so on.
I’ve heard some philosophers say that that kind of intuition that we all have about how great it is to continue existing might be suspicious, because we might have evolved to have that attitude. We necessarily almost have to evolve to have that attitude, even if our lives are very unpleasant. That kind of bias might affect all of us. But I’m not really too keen to go there, and I feel extremely uncomfortable. If someone says that saving their life is really valuable, I’m inclined to take that at face value and to trust that over some subjective wellbeing survey.
Elie Hassenfeld: Right. I think that discomfort is a good starting point, though not an ending point. Certainly something that we are very committed to internally — one of our company values or whatever you want to call it — is truth-seeking. What we mean by that is we’re going to have the hard conversations, and keep digging to try to get the answer that is correct, as far as we can see it. Therefore, in this case, I would say I am very suspicious of philosophising and reaching a conclusion that seems extremely counterintuitive and then running with it. But we’re a place that wants to go deeper and be open to strange conclusions. Or maybe I should say it differently, like: conclusions that seem strange to us today that will not seem strange to us in the future once we’ve spent more time with them and done more research on them.
Whether economic policy is what really matters overwhelmingly
Elie Hassenfeld: I think I want to start with the parts of the critique that I take on board, and what I think we would ideally be doing differently, but then move into the critiques of the critique that I have and where I think it maybe is overstating its case.
The part of this critique that I really like, and I’ve been thinking about recently, is that I don’t think that we at GiveWell have put enough time into finding ways to explore the space of possibilities in this area, given its potential importance. I think that is something that I don’t regret historically — I’ll tell you why — but I do think going forward, as we’ve grown and as we continue to grow, I’d like to be in a position where we’ve explored this enough to have a really great answer, which either is we’re doing this in this area or we’re not, because of this pretty compelling reason.
I think one of the things that explains GiveWell’s history, largely, is that GiveWell did something very unique by going very deep on charitable interventions and understanding them very well. A lot of how we’ve grown is by sticking to that core pretty intensively over a long period of time, while we expand out in many of the ways that we’ve talked about today. I think in some ways that is our greatest institutional strength and maybe our greatest institutional weakness. We’ve been very focused on maintaining quality and rigour, and that has been very hard as we’ve grown a lot. I think we’ve been successful at it, and also it has made us more deliberate in the approach that we take to things — and I think that’s a fair characterisation of GiveWell.
So when there have been ideas that are more outside of our bailiwick, I think we’ve been just less effective at engaging with them. Just looking at the trajectory we’ve been on in the last three years and how we’ve expanded, when I look out five more years with our growth, I think we will be in a much better position to be engaging more seriously with these ideas. Maybe that’s the institutional critique and what I think we could do differently. But I’m happy to move on and engage more substantively with the ideas.
Rob Wiblin: Is it maybe the case that there’s just fewer organisations who perceive this is their goal, this is their direct mission in the developing world, relative to how many health-related organisations there are?
Elie Hassenfeld: Maybe, but I think it’s also a question of how you would attack this philanthropically — like I also wonder how neglected this space truly is. There’s the World Bank, IMF, there’s other institutions. There are the Washington think tanks that are definitely focused on economic growth, and academics who focus on macroeconomics and how we can improve low income country conditions.
Dispensers for Safe Water
Elie Hassenfeld: So in many parts of low-income countries, people don’t have access to clean water, and drinking unclean water can lead to diarrhoeal disease, which most importantly leads to death among children under five. This intervention puts a small chlorine dispenser near a water point, so that when someone comes to collect water from a spring, a pipe, they quickly push down on the chlorine dispenser into the jerry can that holds the water. That puts chlorine into the storage container that they then carry home.
This intervention is potentially much more effective than other attempts at chlorination in the past, because the individual collecting water only needs to remember to put chlorine in their container one time, right at collection. Also, the chlorine remains effective while the water is in the container once they bring it back home. So it reduces the need, say, for an alternative programme, which would require someone to go to the store to purchase chlorine tablets, or get them from a nonprofit, have them at home, and then use them each time they choose to consume water. And that easier behavioural intervention makes it more effective.
Rob Wiblin: Yeah. I’m not sure how much I would sanitise my water if I had to stick something in it every time I poured a glass of water. Sounds super annoying.
What’s the prima facie or conceptual, high-level case for why this wouldn’t just be good, but it could be amazing and one of the best things for you to fund?
Elie Hassenfeld: It’s that unclean water leads to a great deal of mortality in low-income countries. Having a diarrhoeal disease not only can lead directly to death, but can exacerbate malnutrition, which itself is a risk factor for death from other infectious diseases. So it’s a major problem.
Then, this is a very low technology type of intervention. It’s very simple. I’ve used it — I’ve visited this in Kenya, and it just requires pushing down on this thing to deliver chlorine. So it’s easy to implement and easy to monitor and follow up on; it’s easy to check. You put that all together, and it’s a fairly low-cost programme that has a direct effect on a major public health problem globally.
Rob Wiblin: Yeah. Just so I can picture it in my head, people are getting a big bottle of water from a well, or from a common tap, and then they have to stick a little chlorine tablet in it? Or is it kind of a chlorine spray that they stick in the bottle once they’re done?
Elie Hassenfeld: Basically, imagine that the person is carrying a jerry can. This is often a yellow, several-gallon container. They’re bringing that container up to maybe a pipe, or even without a pipe, just a spring that water is flowing from. Right next to that water point, there’s a stand that’s maybe two to three feet high with a little plastic container that holds liquid chlorine. You press down on the pump one time, almost like a soap pump that you’d find in a public bathroom, and out of that pump comes the appropriate amount of chlorine for that jerry can. So it’s just dispensing it directly into the water container.
How to avoid attributing deaths incorrectly
Rob Wiblin: Could these issues be quite widespread in investigations that you and other groups do of other interventions and other programmes? So each individual study of whatever other interventions finds no effect, but then if you added them all together, you’d find that there was a large effect? Or maybe if they focus on malaria, they look at deaths from malaria — but in fact it’s had a much larger effect on mortality than what’s apparent, because people are attributing deaths incorrectly. Did you worry about that?
Elie Hassenfeld: It’s definitely something that we’re very focused on. For a long time, when we’ve looked at malaria data, we’ve focused when we can on all-cause mortality. And of the randomised trials that were done on malaria nets, historically a large number were on malaria rates, but a number were on all-cause mortality as a whole, because of this reason exactly.
One of the lessons we took away from this is that, years ago, when we first did this analysis, we insufficiently brought our conclusions to experts outside. I think, had we done that, it’s possible that they would have raised this question in 2019 and we would have more quickly updated because we would have realised that we were too narrowly assessing the impact of the intervention. And that is a change we’ve made with some of the other programmes (which I think we’ll talk about in a minute): we’ve taken our estimates to outsiders and they’ve helped us see a broader picture of what they might be doing so we can home in on the best possible estimate we can.
Rob Wiblin: If I recall, another thing that Kremer did (who was the person who did this early aggregation of all of these different studies, and tipped you off that maybe you would want to take another look at this): he had access to a bunch of data that wasn’t entirely public, or maybe some studies that hadn’t come out yet that allowed him to get a larger sample and notice this. Is that a common problem? That studies get done and either the data is not published yet for a long time, or perhaps you don’t have access to the specific numbers that you need from that study in order to aggregate it to get a clearer picture?
Elie Hassenfeld: I think it is a pretty common issue. And in many cases, when we go deeper on analysis, we’re doing that via reaching out to authors and getting the underlying data itself, so we can understand what’s happening. We’ve done that a number of times historically. Mostly we’re relying on publicly available data because the time costs involved in trying to track down that data and get more of it are high, relative to just relying on the data that’s already out there.
Bridging the gap between abstract arguments and ways to actually move forward
Rob Wiblin: I think [some listeners might] say, at least in the cases of countries going backwards massively, we know things that countries shouldn’t do that quite consistently lead them to have economic disasters — like causing hyperinflation is one of them. They might say, even if we don’t know what the very best policy is, we at least know some things that are clearly bad, and maybe more effort should be put into preventing those, given how catastrophic they are. Do you want to react to that one?
Elie Hassenfeld: Off the cuff, they also seem like the countries that are hardest to influence. If it’s so well known, then why are they doing it? Well, they’re probably doing it because leadership in the country does not have their population’s best interests in mind. That seems like quite a challenge for philanthropy to address.
Rob Wiblin: Yeah, I think that’s probably my biggest concern with this line of argument, which in general I’m quite sympathetic to. Like you, I think there’s a lot to it, but I feel that often it’s not appreciating that there’s reasons that countries have bad policy. Very often it’s not merely just a mistake; it’s because of the political settlement within a country and who has power. And coming in and telling people that they could be richer if they change their policy one way or another — the elites often don’t want to implement those policies because they think it would weaken their position one way or another, or at least they’re not suffering from the poverty. There’s this whole other angle of political economy, trying to understand how countries end up with the policies that they do, given how the political system works.
Elie Hassenfeld: That’s why I think ultimately, where I think GiveWell has something to add to this conversation — many of the conversations we’ve had — is to say that we can look at it from the 10,000-foot view or the 50,000-foot view. That’s important because it can help us decide where to put our resources. It’s hard to figure out what’s true from such a high level.
I think to some extent what makes me really excited about our work, why I think it’s really cool, is that we’re trying to be good about thinking at the 50,000-foot level, but then dig all the way in and ask: What can we do in this case about this problem? When I think about this specifically, I have absolutely no idea what to give money to to improve economic growth in country A, B, or C. But I can imagine a proximate step of finding people to spend time on this for a while and see what they come back with.
Having watched a lot of different types of programmes over many years — from GiveWell, from Open Philanthropy — more research often leads to new ideas. And so we’re excited, I’m excited, about our opportunity to support work like that, because it can bridge this gap between very abstract arguments — where there’s good arguments on both sides — to find opportunities to actually move things forward.