GiveDirectly gives out unconditional cash transfers to some of the poorest people in the world. It’s clearly an outstanding organisation that is exceptionally data driven and transparent. However, according to GiveWell’s cost-effectiveness estimates (which represent a weighted average of the diverse views of GiveWell staffers), it is significantly less cost-effective than other recommended charities. For example, the Against Malaria Foundation (AMF) is ~4 times as cost-effective, and Deworm the World (DtW) is ~10 times as cost-effective. This is a big difference in terms of welfare. (The welfare can derive from averting deaths, preventing illness, increasing consumption, etc).
One prima facie reason to donate to GiveDirectly in spite of this, suggested by e.g. Matt Zwolinski and Dustin Moskovitz, is that it is not paternalistic.[1] Roughly: giving recipients cash respects their autonomy by allowing them to choose what good to buy, whereas giving recipients bednets or deworming drugs makes the choice for them in the name of enhancing their welfare. On the version of the anti-paternalism argument I’m considering, paternalism is non-instrumentally bad, i.e. it is bad regardless of whether it produces bad outcomes.
I’ll attempt to rebut the argument from anti-paternalism with two main arguments.
(i) Reasonable anti-paternalists should value welfare to some extent. Since bednets and deworming are so much more cost-effective than GiveDirectly, only someone who put a very high, arguably implausible, weight on anti-paternalism would support GiveDirectly.
(ii) More importantly, the premise that GiveDirectly is much better from an anti-paternalistic perspective probably does not hold. My main arguments here are that: the vast majority of beneficiaries of deworming and bednets are children; deworming and bednets yield cash benefits for others that probably exceed the direct and indirect benefits of cash transfers; and the health benefits of deworming and bednets produce long-term autonomy benefits.
Some of the arguments made here have been discussed before e.g. by Will MacAskill and GiveWell, but I think it’s useful to have all the arguments brought together in one place.
It is important to bear in mind in what follows that according to GiveWell, their cost-effectiveness estimates are highly uncertain, not meant to be taken literally, and that the outcomes are very sensitive to different assumptions. Nonetheless, for the purposes of this post, I assume that the cost-effectiveness estimates are representative of the actual relative cost-effectiveness of these interventions, noting that some of my conclusions may not hold if this assumption is relaxed.
[Cross-posted from my blog]
1. What is paternalism and why is it bad?
A sketch of the paternalism argument for cash transfers goes as follows:
· Anti-malaria and deworming charities offer recipients a specific good, rather than giving them the cash and allowing them to buy whatever they want. This is justified by the fact that anti-malaria and deworming charities enhance recipients’ welfare more than cash. Thus, donating to anti-malaria or deworming charities to some extent bypasses the autonomous judgement of recipients in the name of enhancing their welfare. Thus, anti-malaria and deworming charities are more paternalistic than GiveDirectly.
This kind of paternalism, the argument goes, is non-instrumentally bad: even if deworming and anti-malaria charities in fact produce more welfare, their relative paternalism counts against them. Paternalism is often justified by appeal to the value of autonomy. Autonomy is roughly the capacity for self-governance; it is the ability to decide for oneself and pursue one’s own chosen projects.
Even if the argument outlined in this section is sound, deworming and bednets improve the autonomy of recipients relative to no aid because they give them additional opportunities which they may take or decline if they (or their parents) wish. Giving people new opportunities and options is widely agreed to be autonomy-enhancing. This marks out an important difference between these and other welfare-enhancing interventions. For example, tobacco taxes reduce the (short-term) autonomy and liberty of those subject to them by using threats of force to encourage a welfare-enhancing behaviour.
2. How bad is paternalism?
Even if one accepted the argument in section 1, this would only show that donating to GiveDirectly is less paternalistic than donating to bednets or deworming. This does not necessarily entail that anti-paternalists ought to donate to GiveDirectly. Whether that’s true depends on how we ought to trade off paternalism and welfare. With respect to AMF for example, paternalism would have to be bad enough that it is worth losing ~75% of the welfare gains from a donation; with respect to DtW, ~90%.
It might be argued that anti-paternalism has ‘trumping’ force such that it always triumphs over welfarist considerations. However, ‘trumping’ is usually reserved for rights violations, and neither deworming nor anti-malaria charities violates rights. So, trumping is hard to justify here.
Nonetheless, it’s difficult to say what weight anti-paternalism should have and giving it very large weight would, if the argument in section 1 works, push one towards donating to GiveDirectly. However, there are a number of reasons to believe that donating to deworming and bednets is actually attractive from an anti-paternalistic point of view.
3. Are anti-malaria and deworming charities paternalistic?
(a) The main beneficiaries are children
Mass deworming programmes overwhelmingly target children. According to GiveWell’s cost-effectiveness model, 100% of DtW’s recipients are children, Sightsavers ~90%, and SCI ~85%. Around a third of the modelled benefits of bednets derive from preventing deaths of under 5s, and around a third from developmental benefits to children. The final third of the modelled benefits derive from preventing deaths of people aged 5 and over. Thus, the vast majority (>66%) of the modelled benefits of bednets accrue to children under the age of 15, though it is unclear what the overall proportion is because GiveWell does not break down the ‘over 5 mortality’ estimate.
Paternalism for children is widely agreed to be justified. The concern with bednets and deworming must then stem from the extent to which they are paternalistic with respect to adults.[2]
In general, this shows that deworming and anti-malaria charities do a small or zero amount of objectionable paternalism. So, paternalism would have to be very very bad to justify donating to GiveDirectly. Moreover, anti-paternalists can play it safe by donating to DtW, which does not target adults at all.
This alone shows that anti-paternalism provides weak or zero additional reason to donate to cash transfer charities, rather than deworming or anti-malaria charities.
(b) Positive Externalities
Deworming drugs and bednets probably produce substantial positive externalities. Some of these come in the form of health benefits to others. According to GiveWell, there is pretty good evidence that there are community-level health benefits to bednets: giving A a bednet reduces his malaria risk, as well as his neighbour B’s. However, justifying giving A a bednet on the basis that it provides health benefits to B is more paternalistic towards B than giving her the cash, for the reasons outlined in section 1.
However, by saving lives and making people more productive, deworming and bednets are also likely to produce large monetary positive externalities over the long term. According to a weighted average of GiveWell staffers, for the same money, one can save ~10 equivalent lives by donating to DtW, but ~1 equivalent life by donating to GiveDirectly. (An ‘equivalent life’ is based on the "DALYs per death of a young child averted" input each GiveWell staffer uses. What a life saved equivalent represents will therefore vary between staffers because they are likely to adopt different value assumptions).
What are the indirect monetary benefits of all the health and mortality benefits that constitute these extra ‘equivalent lives’? I’m not sure if there’s hard quantitative evidence on this, but for what it’s worth, GiveWell believes that “If one believes that, on average, people tend to accomplish good when they become more empowered, it’s conceivable that the indirect benefits of one’s giving swamp the first-order effects”. What GiveWell is saying here is as follows. “Suppose that the direct benefits of a $1k donation are x. If people accomplish good when they are empowered, the indirect benefits of this $1k are plausibly >x.” If this is true, then what if the direct benefits are 10*x? This must make it very likely that the indirect benefits >>x.
So, given certain plausible assumptions, it’s plausible that the indirect monetary benefits of deworming and bednets exceed the direct and indirect monetary benefits of cash transfers. DtW and AMF are like indirect GiveDirectlys: they ensure that lots of people receive large cash dividends down the line.
As I argued in section 1, providing bednets and deworming drugs is autonomy-enhancing relative to no aid: it adds autonomy to the world. If, as I’ve suggested, bednets and deworming also produce larger overall cash benefits than GiveDirectly, then bednets and deworming dominate cash transfers in terms of autonomy-production. One possible counter to this is to discount the autonomy-enhancements brought about by future cash. I briefly discuss discounting future autonomy in (c).
This shows that anti-paternalists should arguably prefer deworming or anti-malaria charities to GiveDirectly, other things equal.
(c) Short-term and long-term autonomy
Short-term paternalism can enhance not only the welfare but also the long-term autonomy of an individual. For the same amount of money, one can save 10 equivalent lives by donating to DtW vs. 1 equivalent life by donating to GiveDirectly. The morbidity and mortality benefits that constitute these equivalent lives enable people to pursue their own autonomously chosen projects. It’s very plausible that this produces more autonomy than providing these benefits only to one person. Anti-paternalists who ultimately aim to maximise overall autonomy therefore have reason to favour deworming and bednets over GiveDirectly.
Some anti-paternalists may not want to maximise overall autonomy. Rather, they may argue that we should maximise autonomy with respect to some specific near-term choices. When we are deciding what to do with $100, we should maximise autonomy with respect to that $100. So, we should give them $100 rather than using the $100 to buy bednets.
This argument shows that how one justifies anti-paternalism is important. If you’re concerned with the overall long-term autonomy of recipients, you have reason to favour bednets or deworming. If you’re especially concerned with near-term autonomy over a particular subset of choices, the case for GiveDirectly is a bit stronger, but still probably defeated by argument (a).
(d) Missing markets
Deworming charities receive deworming drugs at subsidised prices from drug companies. Deworming charities can also take advantage of economies of scale in order to make the cost per treatment very low – around $0.50. I’m not sure how much it would cost recipients to purchase deworming drugs at market rates, but it seems likely to be much higher than $0.50. Similar things are likely true of bednets. The market cost of bednets is likely to be much greater than what it would cost AMF to get one. Indeed, GiveWell mentions some anecdotal evidence that the long-lasting insecticide-treated bednets that AMF gives out are simply not available in local markets.
From the point of view of anti-paternalists, this is arguably important if the following is true: recipients would have purchased bednets or deworming drugs if they were available at the cost that AMF and DtW pay for them. Suppose that if Mike could buy a bednet for the same price that AMF can deliver them – about $5 – he would buy one, but that they aren’t available at anywhere near that price. If this were true, then giving Mike cash would deprive him of an option he autonomously prefers, and therefore ought to be avoided by anti-paternalists. This shows that cash is not necessarily the best way to leave it to the individual – it all depends on what you can do with cash.
However, the limited evidence may suggest that most recipients would not in fact buy deworming drugs or bednets even if they were available at the price at which deworming and anti-malaria charities can get them. This may in part be because recipients expect to get them for free. However, Poor Economics outlines a lot of evidence showing that the very poor do not spend their money in the most welfare-enhancing way possible. (Neither do the very rich). The paper ‘Testing Paternalism’ presents some evidence in the other direction.
In sum, for anti-paternalists, concerns about missing markets may have limited force.
Conclusion
Deworming and anti-malaria charities target children, probably provide large long-term indirect monetary benefits, and enhance the long-term autonomy of beneficiaries. This suggests that anti-paternalism provides at best very weak reasons to donate to GiveDirectly over deworming and anti-malaria charities, and may favour deworming and anti-malaria charities, depending on how anti-paternalism is justified. Concerns about missing markets for deworming drugs and bednets may also count against cash transfers to some extent.
Nonetheless, even if GiveDirectly is less cost-effective than other charities, there may be other reasons to donate to GiveDirectly. One could for example argue, as George Howlett does, that GiveDirectly promises substantial systemic benefits and that its model is a great way to attract more people to the idea of effective charity.
Thanks to Catherine Hollander, James Snowden, Stefan Schubert, Michael Plant for thorough and very helpful comments.
[1] See this excellent discussion of paternalism by the philosopher Gerald Dworkin.
[2] It’s an interesting and difficult question what we are permitted to do to parents in order to help their children. We can discuss this in the comments.
Consider paternalism as a proxy for model error rather than an intrinsic dispreference. We should wonder whether maybe the things we do to people are more likely to cause hidden harm or lack supposed benefits, than things they do for examples.
Deworming is an especially stark example. The mass drug administration program is to go to schools and force all the children, whether sick or healthy, to swallow giant poisonous pills that give them bellyaches, because we hope killing the worms in this way buys big life outcome improvements. GiveWell estimates the effect at about 1.5% of what studies say, but EV is still high. This could involve a lot of unnecessary harm too via unnecessary treatments.
By contrast, the less paternalistic Living Goods (a recent GiveWell "standout charity") sells deworming pills (at or near cost) so we should expect better targeting to kids sick with worms, and repeat business is more likely if the pills seem helpful.
I wrote a bit about this here: http://benjaminrosshoffman.com/effective-altruism-not-no-brainer/
I agree that there might be instrumental concerns about paternalistic interventions, especially where we have limited information about how recipients act. However, these concerns do not always seem to be decisive about the effectiveness of interventions in terms of producing welfare. e.g. mandatory childhood vaccination is highly cost-effective notwithstanding its paternalism; same goes for tobacco taxes, mandatory seatbelt legislation, etc. When you look back at the most successful public health interventions, they have been at least as paternalistic as bednets and deworming - smallpox eradication, ORT, micronutrient foritification etc.
This shows that paternalism isn't that reliable a marker of lack of effectiveness. Wrt deworming, the issue seems to stem from features particular to deworming, rather than the fact that it is paternalistic.
You're assuming the premise here a bit - that the data collected don't leave out important negative outcomes. In the particular cases you mentioned (tobacco taxes, mandatory seatbelt legislation, smallpox eradication, ORT, micronutrient foritification) my sense is that in most cases the benefits have been very strong, strong enough to outweigh a skeptical prior on paternalist interventions. But that doesn't show that we shouldn't have the skeptical prior in the first place. Seeing Like A State shows some failures, we should think of those too.
I think I agree with maybe having a sceptical prior for paternalistic interventions, but I'm unsure about how strong such a prior would be. The information on what has worked in the past would determine the prior I should have when assessing a new intervention. If I looked at all past public health interventions and paternalism was not correlated at all with quality of outcome, even correcting for reasonable unknown side-effects, then it seems like I should give paternalism very little weight when assessing a new intervention. My examples were a bit cherry-picked, but they do show that if you look at the tail of the distribution of interventions in terms of impact, they tend to be paternalistic.
However, I suspect there is something of a correlation between paternalism and outcomes: I suspect nearly all or all of the ineffectual/harmful interventions have been paternalistic - playpump etc. This is borne out by the fact that GD is better than most other anti-poverty interventions. Then you have to take in the risk of hidden costs/harms, as you say.
But there are also factors pushing the other way - e.g. biases about spending on personal health, positive externalities etc - that counterbalance a presumption against paternalism.
It's not obvious to me that the "near" bias about one's own health is generically worse than our "far" bias about what to do about the health of people far away. For instance, we might have a bias towards action that's not shared by, e.g., the children who feel sick after their worm chemo, or getting bit by mosquitos through their supposedly mosquito-proof bednets. (I'm not sure how bad either of these problems are relative to the benefits, and that's the problem - we really don't know. I'll note that Living Goods does sell some deworming pills, so at least some people in poor countries think it's in their interest to take them.)
It's also not obvious that positive externalities are generically more likely with paternalistic interventions. For instance, in a recent Reddit AMA, GiveDirectly basic income recipients reported that there was much less social conflict in their community once people started receiving basic income - they started imposing fewer costs on each other once they were more secure in meeting their basic needs.
It does seem to me like each of these considerations - if it points in the right direction for any given comparison - could contribute to overcoming the paternalism objection.
It sounds like we might be coming close to agreement. The main thing I think is important here, is taking seriously the notion that paternalism is evidence about the other things we care about, and thus an important instrumental proxy goal, not just something we have intrinsic preferences about. More generally the thing I'm pushing back against is treating every moral consideration as though it were purely an intrinsic value to be weighed against other intrinsic values.
I see people with a broadly utilitarian outlook doing this a lot, perhaps because people from other moral perspectives don't have a lot of practice grounding their moral intuitions in a way that is persuasive to utilitarians. Autonomy in particular is something where we need to distinguish purely intrinsic considerations (e.g. factory farmed animals are unhappy because they have little physical autonomy) from instrumental pragmatic considerations (e.g. interventions that give poor people more autonomy preserve information by letting them use local knowledge that we do not have, while paternalistic interventions overwrite local information).
Thus, we should think about requiring higher impact for paternalism interventions as building in a margin for error, not just outweighing the anti-paternalism intuition. If a paternalistic intervention has strong evidence of a large benefit, it makes sense to describe it as overcoming the paternalism objection, but not rebutting it - we should still be skeptical relative to a nonpaternalistic intervention with the same evidence, it's just that sometimes we should intervene anyway.
Yes I'm not sure I disagree with much of what you have said.
I don't want my argument to be taken to show that we should ignore paternalism as a potentially important instrumental factor. Showing the implicaitons of paternalism as a non-instrumentally important goal does not show anything about the instrumental importance of paternalism. Paternalism might not count in favour of GD as an non-instrumental goal, but count in favour of it as an instrumental goal.
It's important to separate these two types of concern. I do think some people would have the non-instrumental justification in mind, so it's important to get clear on that.
'Do No Harm - on Problem Solving and Design' talks about fixer solutions vs. solver solutions. Its key points:
Its concluding paragraph:
Highly recommended read! :D