Okay, he doesn't call it that, but, unlike Obama, he is honest enough to call it "rationing."His argument, as often with Singer, is simple and not very original, but I find his recent article in the NYT is eminently worth reading. It is helping me to identify the real issues involved in the medical care debate.
"Health care is a scarce resource," he says, "and all scarce resources are rationed in one way or another." Free markets determine that some people get the good and some do not. The British National Health Service does the same thing. One difference is that it is obvious that the NHS is doing this:
Last year Britain’s National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE [I love that acronym!], is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. ... NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year. Sutent, when used for advanced kidney cancer, cost more than that, and research suggested it offered only about six months extra life.The recommendation was later rescinded, after a public uproar. Not an attractive picture. That judgment would have been a death sentence of sorts for people with advanced kidney cancer.
But markets, he says, do the same thing. It is just much harder to figure out who the victims might be. He quotes a study of Wisconsin emergency room patients who had been in auto accidents. The study "estimated that those who had no health insurance received 20 percent less care and had a death rate 37 percent higher than those with health insurance."
[Rather confusingly, he also quotes with apparent approval a study that concludes "there is little evidence to suggest that extending health insurance to all Americans would have a large effect on the number of deaths in the United States." This seems to conflict with the Wisconsin study. Anyway, I am concerned with the moral principles that underlie his argument, and not with the alleged empirical facts.]
Both systems withhold care from some people, who die (or die earlier) as a result. The difference (this is not how he puts it, but this is what he means) is that when bureaucrats decide who must die, it represents a conscious decision, so that the people who die might actually be the ones who ought to die.
When the market makes the determination, more often than not, the wrong person dies. The Wisconsin ER patients had an average of 3o more years of life to live, if they had received the care that would have saved them. Compare the people sentenced by NICE: they had an average of only six months, and not a good six months at that.
Socialized medicine is superior because, in it, (at least if the right people are in power) it is more likely that the people who die are the ones who ought to die. What we need (again, this is my wording, not his) is a redistribution of death.
(I urge you to read his article to see if my characterization of it is unfair.)
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My initial reaction to this:
To call both what the market does and what the English death panel does "rationing" is close to verbal trickery. It smuggles in the idea that these two processes are on an equal moral footing, without having to argue for it. I call what the market does "allocation" and only call what the government does "rationing." The reason I use different words for them is that I see a big moral difference between them.
Part of it is a matter responsibility. The death of the untreated English cancer victim is somebody's doing. This person dies because someone decided this person should die. The death of the American auto-accident victim is -- an accident.
There is another difference that underlies this one. Singer thinks it is good, and not evil, for NICE to take responsibility for deciding who shall die because he thinks there is such a thing as the one who ought to die.
This is what I deny. I deny that the cancer victim ought to die, but it is not because I think that the accident victim ought to die. I think it is monstrous to judge that any innocent person ought to die.
Further, it is monstrous arrogance the think you have the right to decide who ought to die. And to act on that decision is tyranny itself.
5 comments:
You should submit this post as a letter to WSJ or NYT (I doubt latter would have cajones to publish it.) Very well articulated, sometimes it takes a philosopher.
BTW, John Mackey is getting some backlash for his libertarian views, I've read that boycotts of Whole Foods are being organized by some, however others who didn't shop there before are doing so now to show their support.
When you mentioned Mackay's article before, I said I wondered what my many single-payer-advocate colleagues would do if they realized that when they go to Whole Foods for their overpriced arugula, they are giving their money to a libertarian. I guess I may soon find out.
Isn't Singer's point, though, that in choosing which health care system to have, we ARE deciding which people die? At least we are "deciding" in the same sense that NICE decides -- after all, NICE does not actually make individual judgments about who lives or who dies: it just sets guidelines that have the effect of allowing some to live while letting others die. Our choices have the same effect. By choosing the status quo, we choose to continue to let the uninsured car accident victims die and to let the old and uncool live--arguably at great cost to society. Perhaps it could be argued that your deeper objection to "death panels" is just WHO is doing the choosing -- government bureaucrats -- and that this objection is perhaps more of a gut-level, instinctual objection (or, a principled objection) based on your libertarianism rather than an objection based on comparative utility of competing systems. For example, would you accept death panels if you were convinced that, on the whole, they would lead to more people leading healthier and better lives? I get the feeling you wouldn't. Perhaps you could justify this on utilitarian grounds because on the whole "death panels" are a step towards some kind of pernicious tyranny, but that's getting a little iffy...
In closing, I must quote the great philosopher Geddy Lee: "If you choose not to decide, you still have made a choice."
The market is merely the interaction of the collective bargaining power of buyers and sellers. If drugs are priced beyond my ability to pay, then wouldn't it be the tyranny of the majority (other buyers and sellers who make up the market) that condemned me to die? That would mean all of us, including you and me, who have a greater ability and willingness to pay for healthcare are responsible for the deaths of the poor who are unable to afford.
No matter what, someone or some group will decide who lives and who dies. For govt bureaucrats, it is based on various metrics such as QALY. For the market, it is based on earning power and ability to pay, and the poor is condemned to die because they don't earn enough to afford healthcare.
I don't think there is anything unusual about having the right to decide who dies, as long as we don't see the actual deaths. The US condemns plenty of mexicans to death simply by providing demand for drugs. The drug trade also affects poor Americans, drawing kids to prostitution and drug dealing, and lives are ruined. Americans have a (illegal) right to buy drugs, even though it means condemning mexican police/gang members to gunfights and deaths. It used to be in Columbia with the FARC involved, but now it's moving closer and closer to the US of A. Soon the killings will take place in America's own backyards.
bt and anonymous,
You raise some very interesting questions that go to the heart of the issue. I think they deserve a separate post, rather than just a comment by me. Right now, though, I am writing from the parking lot of a Motel 6 iu Mitchell SD, so I will have to do it later, hopefully tonight.
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