Thursday, August 13, 2009

Musing: Ethics and Economics

Dark was the operative word this morning. I dressed in it, so as to preserve my night vision, thinking all the while of how much harder it is to do these days, now that labels are printed on clothes instead of sewn in, then Koko and I walked in it, beneath dense clouds that obliterated both sky and mountains.

The only light came from the reflections cast by street lamps and headlights on the rivulets and pools of dark water deposited by rain that fell all night and paused just moments before we went outside. Felicia was kind enough to provide us with a good soaking, rather than a drenching, and a friend on the North Shore said he hoped it would be enough to send the 'o'opu down in earnest. He’d already begun hooking a few.

One of the big hooks in the Obama campaign was the promise of health care, and not just for those with good jobs and lots of money, or no jobs and no money, but even for the tens of millions who fall somewhere in between.

Instead, what we’re likely to get is something far less. As Hendrick Hertzberg so eloquently observed in The New Yorker:

Pretty much everybody who believes that health care should be a human right, not a commercial commodity, and who makes a serious study of the abstract substance of the matter, concludes that the best solution would be (to borrow Obama’s words at the press conference) “what’s called a single-payer system, in which everybody is automatically covered.” But, by the same token, pretty much everybody who believes the same thing, and who makes a serious study of the concrete politics of the matter, concludes that a change so sudden and so wrenching—and so threatening to so many powerful interests—is beyond the capacities of our ramshackle political mechanisms.

The cry most often heard is that we simply can’t afford it. But even as we’re claiming we can’t provide basic care to all, we’re providing extraordinary care to some. Among them are the tiny premature babies, many of whom, according to a nurse friend, will require extensive medical assistance for the rest of their lives, and the elderly, who are often subjected to expensive, invasive and ultimately futile procedures at what would, without these interventions, be the natural end of their lives.

And then there are the transplant patients. In a riveting New Yorker article entitled ”The Kindest Cut,” Larissa MacFarquhar discusses the emotional, ethical and practical complexities of organ transplants, focusing on kidneys. She writes about the advent of dialysis:

….a federal entitlement through Medicare was passed that secured access to dialysis for nearly everyone. The result of this has been that thousands of kidney patients who forty years ago would have died quickly now die slowly while waiting on the [transplant] list.

The article was fascinating because it showed how we've got the technology to perform these organ transplants, but in so many of the cases involving live donors, there are all sorts of psychological jam-ups on both ends that have not been resolved or even dealt with in a comprehensive way. And even with organs taken from cadavers, there's a big dispute over how to dispense them fairly.

Similarly, people struggle with guilt and other intense emotions when faced with having to decide if they really want their loved ones to receive all the care that hospitals are willing, even bound, to provide.

As a result, we're providing some people with an extended life that is often poor quality, while withholding care that could actually improve the quality of life for others.

Once again, technology seems to have outpaced humanity.

We all know that if we weren't spending so much on the military, we'd have more to spend on health care. But those misguided priorities don't seem likely to change any time soon. And currently, we don't have either the facilities or trained professionals to provide the ultimate level of care to everyone.

So some choices need to be made.

I’m not saying that any of the groups used as examples in this post should be denied care. But I would really like to see us, as a society, having discussions on how health care resources should be allocated, and not just from the standpoint of economics, but ethics. Right now, millions are being excluded, and millions are being included, without any social debate as to who should get what, and why.

As our technology advances, these questions will become ever more compelling, and our need to address them ever more urgent. But if we continue to focus only on the money side of health care, which is, at its core, a human and social issue, our efforts to reform the current unweildy system are bound to fall terribly short.

Perhaps where we really need to start is by examining our seeming reluctance as a society to face up to the one truth of our existence: none of us will escape alive.

35 comments:

Anonymous said...

It costs a fortune to be ethical as a nation.

In reading some comments to news articles addressing the health care "canada bashing" and "UK bashing" being done by some factions in the USA, a writer from Belgium said that there, fantastic health and other social benefits like virtually free university education exist, but the tax rate is 55%.

A writer from Canada told of horror stories about many-month waits each to: 1) see a doc, then: 2)see a specialist, then: 3) get an operation.

Another told of paying a doc $500 to be seen "next week" versus 5 months out.


Canadians and Brits come here for med help all the time. How many USA folks go there, although they do go to Thailand and Mexico sometimes.

It all depends on where you are individually. I have never needed med support and am not likely to, therefore I would not want a 55% tax rate to support others.

I really don't know how a "single payer" system would work here and not be perceived as an overall reduction in the quantity and quality and timeliness of med support.

Anonymous said...

There's not enough health care to go around to everybody who would show up at a doc office or hospital if it were free to them.

So what is the "formula" for "ethical allocation"? The govn't says when to pull the plug on grandma because her future is less contributory to society than others? Palin's "death panels"?

You can get some cancer treatments but not others? Or is lots more supplemental insurance required for that? Can't afford it? Then you're right where you are in this system, yet possibly paying more taxes.

Do you really want the govn't in change of your healthcare? Look what a great job they've done with the post office, etc.

The more I learn about "single payer" systems in other countries, the less I favor them.

Anonymous said...

Even the UK admits a huge money shortfall coming in a couple of years to support their healthcare.

In the end, it will be money talking and those without walking.

Anonymous said...

The solution to organ shortages is simple and elegant. Let there be a free, unfettered market in live organ sales. The shortage will disappear.

Anonymous said...

"We all know that if we weren't spending so much on the military, we'd have more to spend on health care."

-- cite the military budget, add cia/nsa, and a bit more (all kinda the same stuff)....then cite this as a percentage of 2008 gdp...and/or then as a percentage of 2008 irs tax revenues. would provide a better context

could then contrast against vietnam and WWI era budget allotments, if truly interested in the question


"great job they've done with the post office"

-- ya, its actually fairly fantastic that all sorts of material and communications can be sent over such great distances so quickly at such a low cost


dwps

Anonymous said...

I personally know many Canadians and British citizens that love their health care, but citing their positive stories is as meaningless as those that cite negative horror stories. Unfortunately that is hearsay not science.

Both Canadians and British citizens live longer than Americans. So does Cuba! Those are World Health Org stats. Same for infant mortality.

How with such poor health care can they have less infant mortality and live longer than Americans?

Anonymous said...

"I have never needed med support and am not likely to, therefore I would not want a 55% tax rate to support others."

So you are immune from accident and disease? Rest assured something will kill you and before you go and if you go slow, a group of parasites will pick over and take everything you have.

Anonymous said...

"I really don't know how a "single payer" system would work here and not be perceived as an overall reduction in the quantity and quality and timeliness of med support."

If you have no health care how could it be reduced?

Anonymous said...

"The more I learn about "single payer" systems in other countries, the less I favor them."

Learn? Go to the CIA factbook and look up life expectancy for Britian and Canada. But the CIA is no doubt lying to make the USA look bad.

Anonymous said...

Bottom line: I'm satisfied with the current system and would never vote for any change.

Anonymous said...

"If you have no health care how could it be reduced?"

But if you have acceptable health care, it WILL be reduced.

I don't want that!

Anonymous said...

In no version of reality will military or quasi-military spending be significantly cut to pay for health care.

Given that, it's still unaffordable to mount a "free" health care for all program.

Unless you raise taxes. Belgium. No significant mil spending. Smaller population to contribute, but smaller population to serve.

Still, 55% taxes.

How long do you think anything close to THAT will fly here in America??

We are the land of haves and have-nots. We are not, nor are we guaranteed social, economic, health or educational equality.

Health care, beyond the very basics, is a privilege, not a right. The cost of making it a right appears to be unacceptable to most Americans.

Our constitution gives us the right to "pursue happiness". It does not guarantee the attainment thereof in any area: career, education, health care...

Hey, I didn't make the rules. I just learned them, accepted them and did what needed to be done to achieve happiness in all areas.

Anonymous said...

Brits have healthier lifestyles. Smaller food portions (well, it IS British food, after all). Into walking a real lot.

The longevity could very well have more to do with personal lifestyle choices than the quality/timeliness of their health care.

Dawson said...

"We all know that if we weren't spending so much on the military, we'd have more to spend on health care. But those misguided priorities don't seem likely to change any time soon. And currently, we don't have either the facilities or trained professionals to provide the ultimate level of care to everyone.

So some choices need to be made.

I’m not saying that any of the groups used as examples in this post should be denied care. But I would really like to see us, as a society, having discussions on how health care resources should be allocated, and not just from the standpoint of economics, but ethics. Right now, millions are being excluded, and millions are being included, without any social debate as to who should get what, and why.

As our technology advances, these questions will become ever more compelling, and our need to address them ever more urgent. But if we continue to focus only on the money side of health care, which is, at its core, a human and social issue, our efforts to reform the current unweildy system are bound to fall terribly short."


Well said, and key. In all the words the President has expended on health care, it's unfortunate -- and telling -- that the issues you raise are the ones that he, his administration and the Congress most studiously avoid.

Anonymous said...

I'm not against universal health care, but only if the country can afford it. It is, unfortunately, a luxury, not a necessity. Like it or not, that's how it's seen by most decision-makers.

Ethical issues certainly exist, not the least of which is the logic decision tree used to apportion not-enough care-givers with too-many patients.

Again, unfortunately, financing this endeavor is the single most important factor. We're not going to do this because it's "the right thing to do", "whatever it takes".

All countries are, essentially, businesses. The income statement and balance sheet are the bottom lines.

Military/security/etc spending are considered sacrosanct. It would be ridiculous to think a country of our size and scope could do without most of it.

Social security. Outflow is expected to exceed inflow in about 25 years. Existing medicare/medicaid also requires a "cash flow" projection into the future that is positive.

Adding to all this a universal health care plan would create incredible debt financing. Worse than a bad mortgage.

The UK did it back in the '40's, but those folks were already used to wartime rationing and actual major bombings in their country. It wasn't as hard a pill to swallow. They are facing major health care funding short-falls in the future.

Canada - much lower population to serve, but they too are facing major health care funding short-falls in the future.

You can't blame bloated mil spending ala US standards for the UK and Canada woes here.

I'm truly sorry that everyone can't just use all health care facilities as "free clinics/hospitals" with unlimited capacity. Just as I'm sorry there isn't peace on earth and adequate food and clean water for all.

I'm all for universal health care in the USA IF AND ONLY IF it can be shown beyond a shadow of a doubt that it is affordable in the long run.

If not, we can't afford it and shouldn't have it.

If that means many will die needlessly, then so be it.

Anonymous said...

Brits defend their health care system:

http://news.yahoo.com/s/ap/20090814/ap_on_re_eu/eu_britain_us_health_care

Mark said...

If you live in a state that has adopted the 2006 Uniform Anatomical Gift Act, it is presumed that you are an organ donor unless they can find information contrary to their assumptions.

This change was made expressly to increase the supply of organs, tissue and body parts so that the $20 Billion in annual revenues for organ related medical services could keep growing.

Brain death and donation after cardiac arrest for as little as 75 seconds is becoming the standard in hospitals to start the organ harvesting process.

Removing your name from any list or erasing your consent from your driver's license means absolutely nothing under the 2006 version of the act.

Even if you have a written Advance Healthcare Directive that forbids the use of machines to keep your body alive, they can do so as long as they are talking to your family to give consent to start the organ harvesting procedure.

If you don't express a preference on organ harvesting, your family has to make the decision. Organ Procurement Organizations and Tissue Banks have to follow your instructions if you register your preferences with a known donor registry.

Unfortunately, no state that has adopted the 2006 UAGA has a state donor registry that allows you to register as a "no" or allows donation on condition of just compensation to your family or estate.

If you are one of the estimated 10% of Americans who does not support organ harvesting, you can register your objection and explore your options under the law at http://www.DoNotTransplant.com.

Katy said...

And yet, Belgium has one of the highest standards of living in Europe.

Basing your judgment of a country's health care system on its tax rate seems overly reductionist to me.

Taxes, if properly applied, are simply the way that human societies (not evil, blood-sucking government leeches) have devised to pool public wealth for the benefit of all.

As I understand it, our current health care system is incredibly costly for both individuals and society as whole, and that socializing (in other words, making it a common effort) the cost will ultimately save a tremendous amount of money.

I'm also tired of hearing people whine about "losing their choices." I have had no insurance about half my adult life, and my kids have gone without it too. I would gladly give up the following "choices" that the current system affords me:

-the choice between taking my kid to the doctor or paying my rent

-the choice between paying for a prescription or keeping my power on

-the choice between a yearly dentist visit for my sons, or groceries.

And, by the way, plenty of people in the US have to wait for, or even go without, life-saving procedures as it is.

Anonymous said...

"As I understand it, our current health care system is incredibly costly for both individuals and society as whole, and that socializing (in other words, making it a common effort) the cost will ultimately save a tremendous amount of money."

-- very easy to take this further

forget about the ROI on long term health

is it so bad to endure the risk of a few more hassles and to tolerate a bit of waste when the overall program will dramatically and measurable better the physical health of a very large number of persons? they are hurting. literally. and they very often have not the tools (which are available in the market) to stop it

i am willing to reconsider my view, but i suspect this debate may also reflect personal character - some of us will sacrifice a bit to help others much, and some will not. this is not a moral judgment, or a superiority thing. the reasons for this different are probably pretty complex actually. people are just wired differently i guess. i dunno

it reminds me of taxes: it is relatively easier for the financially strong to endure (what is to them) a nominally higher burden in order to provide some substantial relief for the economically weak


dwps

Anonymous said...

"All countries are, essentially, businesses."

Unfortunately life is more than a business. If any business does not serve the higher goal of life itself then that business should be put out of business.

If some people didn't have "self-interest" they would have no interest at all. Said they call that "learning"

Anonymous said...

The British Columbia, Canada Vancouver Coastal Health Authority faced with cost overruns is planning on cutting medically necessary Neuro Surgery by 24% and closing 1/4 of their operating rooms.

You can serve all of the people some of the time, some of the people all of the time, but never all of the people all of the time.

As far as Belgium goes, the USA absolutely does not want to become a Belgium. It's just not our culture.

Besides, Belgians smell like Frenchmen. Europeans as a whole generally have distaste for both.

Anonymous said...

Even in countries like Canada and the U.K., there is no intrinsic right to health care. Rather, citizens in these countries are told by government bureaucrats what health-care treatments they are eligible to receive and when they can receive them. All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments.

Although Canada has a population smaller than California, 830,000 Canadians are currently waiting to be admitted to a hospital or to get treatment, according to a report last month in Investor’s Business Daily. In England, the waiting list is 1.8 million.

Anonymous said...

"The Whole Foods Alternative to ObamaCare" by John Mackey, CEO of Whole Foods.

http://online.wsj.com/article/SB20001424052970204251404574342170072865070.html

Sounds good to me!

Of course, libs in favor of socialized med and welfare state benes are opposed:

http://www.foxnews.com/politics/2009/08/15/foods-ceo-provokes-customers-boycottt-store-health-care-view/

Read the comments to the fox article. I think Mackey is on track with a better plan than Obama.

Anonymous said...

"...some of us will sacrifice a bit to help others much, and some will not."

Define "a bit". It's not a huge bite, but a little nibble...nothing to really worry about in the grand scheme of things.

I'd be willing to sacrifice "a bit", but not "a huge bite".

Unfortunately, I see Obamacare being more in the "bite" than "bit" category.

Anonymous said...

It's interesting that tort reform isn't part of Obamacare to reduce healthcare costs.

Maybe he knows he can't win that battle...and without it, he can't win his war.

Anonymous said...

"Life" is, indeed, more than a business. But, life is personal. Businesses, and countries, are impersonal legal entities whose lifeblood is money.

I know..it sounds cold, but it's the truth.

Without money, no well-meaning social services are possible. And you can't blame "US Imperialism" draining adequate funds away...other countries without such "imperialistic tendencies" are suffering with their own "everyone's covered" social services.

Except Belgium, maybe...but what do they produce except chocolate? I've been there many times for business (American companies with Belgian subsidies or plants). Great beer (Abby beer is wonderful...those monks know their stuff) but I wouldn't trade my American amenities for the whole Belgian lifestyle.

Anonymous said...

"Abby beer is wonderful...those monks know their stuff"

-- totally. the trappist monk beer is money


dwps

Anonymous said...

"Canadian Health Officials: Our Universal Health Care Is 'Sick,' Private Insurance Should Be Welcomed"

http://www.foxnews.com/story/0,2933,539943,00.html

==========

Let's not replace a flawed system with a broken one.

Anonymous said...

And let's not cite Fox News as a credible source.

Anonymous said...

It's not a Fox initiated story. They just picked up a Canadian press story:

http://www.google.com/hostednews/canadianpress/article/ALeqM5jbjzPEY0Y3bvRD335rGu_Z3KXoQw

So there!

Anonymous said...

I think Fox is as credible as anything else.

Anonymous said...

Face it..."universal health care" or "the public option" has one foot in the grave before it ever got started already.

I don't believe it will ever see the light of day as a law in the US.

Even Obama now says the "public option" is optional to any "reform" bill.

Anonymous said...

"Canadian Health Officials: Our Universal Health Care Is 'Sick,' Private Insurance Should Be Welcomed"

But in typical Fox News style the headline doesn't match what's actually in the story.

Anonymous said...

The story makes the same point.

If universal health care isn't working for Canada and the UK, as the Makay article referenced above states with good authority, then the US should not go down that road.

And, most likely, will not.

I don't disagree that some reforms are necessary, but a "public option" or full-blown "everybody's covered for free" is totally insane.

Anonymous said...

From the Canadian article:

SASKATOON — The incoming president of the Canadian Medical Association says this country's health-care system is sick and doctors need to develop a plan to cure it.

Dr. Anne Doig says patients are getting less than optimal care...

"We all agree that the system is imploding, we all agree that things are more precarious than perhaps Canadians realize," Doing said in an interview with The Canadian Press.

"We know that there must be change," she said. "We're all running flat out, we're all just trying to stay ahead of the immediate day-to-day demands."

The pitch for change at the conference is to start with a presentation from Dr. Robert Ouellet, the current president of the CMA, who has said there's a critical need to make Canada's health-care system patient-centred. He will present details from his fact-finding trip to Europe in January, where he met with health groups in England, Denmark, Belgium, Netherlands and France.

His thoughts on the issue are already clear. Ouellet has been saying since his return that "a health-care revolution has passed us by," that it's possible to make wait lists disappear while maintaining universal coverage and "that competition should be welcomed, not feared."

In other words, Ouellet believes there could be a role for private health-care delivery within the public system.

=========

Sounds like the text of the article supports Fox's headline.