A More Modest Proposal

Our government is currently embroiled in the most intense political debate in recent memory over what the late Senator Ted Kennedy called one of his lifelong goals: universal healthcare. Presently, the battle rages in Washington and at town hall meetings all over the country. Americans are worried about the rising costs of healthcare, but also about the increasing deficit and what they are told will amount to government “death panels” that choose who is fit to live and who is not. Present legislation, as well as public opinion, is on increasingly unstable ground.

Enter Peter Singer. Mr. Singer, a professor of Bioethics at Princeton University, in an article for The New York Times Magazine in July, made the case for explicitly rationing health care. His argument rests upon the claim that the American healthcare system already unintentionally rations health care by one’s ability to pay for insurance and medical expenses. Since we are already doing it, we might as well let the cat out of the bag and try to do it as efficiently as possible, he argues.

A preference utilitarian, Singer subscribes to the view that “good” is defined in the fulfillment of each individual’s particular desires and preferences. In his book Rethinking Life and Death, Singer argues in favor of abortion and euthanasia and infanticide on the basis of preference. The morality of terminating or seeing through a pregnancy is a question of the preference of the mother weighed against the preference of the fetus. According to Singer, since the fetus’s ability to reason and feel is greatly diminished in comparison with the mother, her preferences outweigh any rights of the child. He applies similar reasoning to small children or those with disabilities, stating that “[s]imply killing an infant is never equivalent to killing a person.”

Singer now aims his ethical sensibilities on the present debate. In his essay entitled Why We Must Ration Health Care, Singer argues that healthcare should be evaluated on an objective basis of supply and demand – weighing the practical commodity of care itself against the value of human life. Again, his argument rests on the claim that our present system inadvertently selects which members of society receive health care and which do not, based on their ability to pay for it. Health care in the United States is among the most expensive in the world, making direct payment unthinkable for most. Even insurance costs are unattainable for many, and 45 million Americans go without, having no entitlement to health care unless they can get themselves to a hospital emergency room, which cannot refuse service.

Singer is right to point out that the present system is not working for a great many Americans. But is rationing really the answer? To answer that question, Singer points to Great Britain, which has been “rationing” for years based on cost recommendations by the National Institute for Health and Clinical Excellence (NICE). Singer points to Sutent, a drug for advanced kidney cancer that can extend the life of the patient for an average of six months. NICE found that the average cost of Sutent per patient was more than the general limit of $49,000 that they have put on extending life for one year. So, NICE made a preliminary recommendation not to offer the drug (though they later reversed the decision in the face of public outrage).

Singer recommends similar limits in American practices. He cites the standardized quality-adjusted life year, or QALY – a unit of measurement that has been used by economists for years now to determine the cost-benefits of health care procedures. As Singer explains:

“The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved, rather than simply the number of lives saved. If a teenager can be expected to live another 70 years, saving her life counts as a gain of 70 life-years, whereas if a person of 85 can be expected to live another 5 years, then saving the 85-year-old will count as a gain of only 5 life-years. That suggests that saving one teenager is equivalent to saving fourteen 85-year-olds.”

Singer is reducing life-years to a practical commodity, one that must be weighed against the cost of healthcare. But he doesn’t stop there, and goes on to discuss the value of a quadriplegic’s life versus that of the nondisabled, saying, “We might conclude that restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.”

But, wait, you might ask; what if the aforementioned teenager is a murderous psychopath and the fourteen 85-year olds are loving grandparents and faithful members of their community? Perhaps one of them is a physicist on the verge of a breakthrough; perhaps one of them is a famous writer. Should we restore three quadriplegics to nondisabled life, even if it means the death of a nondisabled person, because their lives will have 1.5 times the value of his?

Here is where Singer runs into the most trouble. When confronted with questions like the ones above, he states that “decisions about the allocation of health care resources should be kept separate from the judgments of moral character of social value of individuals.” But using QALY as the standard of value for human life is begging the question that economic value is an acceptable standard, whereas social value and moral character are not. Why should we choose to merely value human beings on one aspect of their person, especially something as nebulous and variable as their economic worth? Why not ration care to people who are morally corrupt as well, or insane? This is certainly something that has been done by other governments in the past, using economic value, social status, class, caste, and race as their standard of measurement – to the devastation of all involved.

Is this really a road that we want to follow?

And this is precisely what is most troubling about Singer’s recommendation. As we ask more questions like the ones above, comparing one person’s life against another, we begin to sense that there can be no objective standard for measuring human life. Weigh a person in love against a person who has just been fired; weigh an old poet against a young, handsome engineer who is also a drunk and pervert. The value of life and any numerical standard are completely incommensurable, like trying to determine whether ambition or memory is saltier. We do not measure human life in this way, because you simply cannot.

But perhaps the strongest criticism of Singer’s reasoning is that it is largely irrelevant. As it turns out, drugs like Sudent are not even where most healthcare costs come from.

Atul Gawande, in an excellent piece in the New Yorker entitled “The Cost Conundrum”, argues that the exorbitant costs of American health care owe less to drugs like Sudent and more to a healthcare system that rewards medical providers based not on the quality of care, but on the amount of procedures, tests and doctors visits they are able to wring out of the patient. Gawande says:

“There are the physicians who see their practice primarily as a revenue stream. They instruct their secretary to have patients who call with follow-up questions schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash . . . They figure out ways to increase their high-margin work and decrease their low-margin work. This is a business, after all.”

Sure, but doesn’t this mean that people are getting better quality of care? The answer is often no. In many cases, there are a number of options for care that are equally effective, but doctors choose the more expensive, either to raise costs or because they have been trained to do so.

But there is hope. Gawande cites the community of Grand Junction, Colorado, where quality of healthcare is very high but costs are low. This is because several years ago, the doctors and hospitals on Grand Junction decided on a system that would pay them a similar fee regardless of the insurance of the patient, or the procedure performed. It amounted to a salary-like system in which doctors no longer had an incentive to “cherry pick” patients. A committee was also formed in the city so that healthcare providers could meet regularly to discuss patient charts together. By creating a community based system that put the patient first, costs were kept low while quality was kept high. The only thing being rationed is the money going the pockets of doctors.

Gawande notes that this would necessarily be experimental, and we would need to work to find the best accountability systems. But this is surely better than our government determining what constitutes a valuable life, and what people are no longer worth protecting based on QALY or any other standard. If we are a culture that values one another, our relationships and communities over the bottom line or profit margins, and if this stretches from our legislation to the healthcare providers themselves, then building accountable healthcare communities is worth the experimentation. The alternative veers between misguided and dangerous. Surely we can do better than Mr. Singer’s modest proposal.

Big Food vs. Big Insurance

From the New York Times: Michael Pollan on Big Food vs. Big Insurance.

According to the Centers for Disease Control and Prevention, three-quarters of health care spending now goes to treat “preventable chronic diseases.” Not all of these diseases are linked to diet – there’s smoking, for instance – but many, if not most, of them are.

We’re spending $147 billion to treat obesity, $116 billion to treat diabetes, and hundreds of billions more to treat cardiovascular disease and the many types of cancer that have been linked to the so-called Western diet. One recent study estimated that 30 percent of the increase in health care spending over the past 20 years could be attributed to the soaring rate of obesity, a condition that now accounts for nearly a tenth of all spending on health care.

The American way of eating has become the elephant in the room in the debate over health care. The president has made a few notable allusions to it, and, by planting her vegetable garden on the South Lawn, Michelle Obama has tried to focus our attention on it. Just last month, Mr. Obama talked about putting a farmers’ market in front of the White House, and building new distribution networks to connect local farmers to public schools so that student lunches might offer more fresh produce and fewer Tater Tots. He’s even floated the idea of taxing soda.