I've read and would like to share an article by Peter Singer entitled Why We Must Ration Health Care. As a medical student and a utilitarian, the ethical distribution of public resources in health is a topic close to my heart.

To sum up Singer's article, we should subsidise those medical interventions that are most cost-effective. Although some objectors claim that no price can be placed on a person's life, they offer no credible alternative.

Peter Singer said:[Rationing] is the worst method of allocating health care, except for all the others. If it isn’t possible to provide everyone with all beneficial treatments, what better way do we have of deciding what treatments people should get than by comparing the QALYs gained with the expense of the treatments?

That is, we ought to put our money where it will do the most good.

I'd recommend you read it if and only if you seek info on the contentious position of utilitarianism in health care.

I'm somehow surprised that this is turning into a left-right issue, and this way round. I was expecting to find myself fighting all my hippie buddies on this one

This is a great article. While I dont think having fully nationalized hospitals makes sense, and only would support universal health insurance, I would love it if we could have an independent agency setting rationing guidelines... and hopefully also incentives to keep one's health in check.

I am generally skeptical of most regulatory bodies, even ones designed to be "independent." Yet, I think this is clearly the best course of action... even imperfect regulators would be better than the system we have now which merely redistributes hundreds of billions to the rich to provide inefficient coverage of most, but not everyone, else. I wonder if when the people in congress are sick, if they have to put up with the same crap from their health insurers as the rest of us. I speculate that they do not, or that they are at least so rich that it doesn't matter. I heard Nancy Pelosi is worth 18 million dollars, and she is nothing compared to John Kerry and others. John McCain doesn't even know how many houses he has, so I'm sure he is oblivious regarding his health insurance policy.

The people who do oppose are just so right wing it is ridiculous.... but that has become the standard "centrist" position in the US. Consider that the conservative parties of britain and canada are fully behind their public healthcare systems. Even Reagan and Thatcher's favorite economist did not oppose the idea of social insurance.

Here are some quotes from his autobiography:

Does he support laws setting a maximum number of hours in the workday? Hayek: "Yes, if it is not carried too far. It is one of those regulations which creates equal conditions throughout the system." Does he agree with a minimum-wage law? Hayek: "A general, flat minimum-wage law for all industry is permissible, but I do not think that is a particularly wise method of achieving the end." Did he support the TVA [Tennessee Valley Authority]? Hayek: "There is a great deal of the TVA to which no economist in repute, and certainly not the laissez-faire people, will object. Flood control and building dams are recognized functions of the government." Does he think a system of social insurance is a harmful form of planning? Hayek: "Certainly not a system of social insurance as such, not even with the government helping to organize it. The only point where the problem can arise is how far to make it compulsory. . . ." Does he support a guaranteed minimum income? Hayek: "I have always said that I am in favor of a minimum income for every person in the country." Does he believe that America needs a central bank? Hayek: "That the monetary system must be under central control has never, to my mind, been denied by any sensible person." Does he oppose war-time economic controls and planning? Hayek: "No, because you might sacrifice for a time part of your freedom to preserve it in the long run. . . . During the war, we all have to go to some extent totalitarian."

http://www.fff.org/freedom/0994e.asp


Considering the extreme inefficiency of our current system, it is almost shocking that anyone opposes the idea of a Single Payer system. Of course, all we are seeing with this Obama reform is small bandaids, and the corrupt assholes in congress are squirming even at this. Inflation in healthcare is higher than the rest of the economy, so the longer we wait on Single Payer, the more we shoot ourselves in the foot.

Health care is a private good. I can understand, though disagree with, the argument that government should get involved with non-rivalrous goods, and I think the government needs to get involved with non-excludable goods, but health care is neither, so I see no reason for government intervention.

That isn't a utilitarian argument, Daniel.

If we allow people to choose how to spend their money, they will spend it better, thus creating more utility. They will also have more motivation to work, thus generating utility.

It's the same reason that the free market in general works from a utilitarian perspective.

EmbraceUnity wrote:The people who do oppose are just so right wing it is ridiculous.... but that has become the standard "centrist" position in the US. Consider that the conservative parties of britain and canada are fully behind their public healthcare systems. Even Reagan and Thatcher's favorite economist did not oppose the idea of social insurance.

Democrats have a majority in Congress; those holding up the Congressional bills are Democrats, not right wingers. Hayek was against the institution of a state-run healthcare system, because, well, I'll let him tell you:

“But there are strong arguments against a single scheme of state insurance; and there seems to be an overwhelming case against free health service for all. From what we have seen of such schemes, it is probable that their inexpediency will become evident in the countries that have adopted them, although political circumstances make it unlikely that they can ever be abandoned, not that they have been adopted. One of the strongest arguments against them is, indeed, that their introduction is the kind of politically irrevocable measure that will have to be continued, whether it proves a mistake or not.”

That last part is what convinces me that this plan is a mistake. Why the rush? Placing the government in charge of a huge sector of the economy should not be a situation which we debate for a month and don't read the bills-- this should take years and should really be thoroughly talked about beforehand.

One of the reasons why state-run health care systems are so popular is people simply don't want to pay for healthcare and like getting something for "free"; one of the Canadian provinces used to send out "bills" each month saying how much each family member's healthcare had cost the state that month. People just didn't want to know, and the program was quickly ended. I lived in Britain for six months, and every working Brit I know constantly complains about council taxes and payroll taxes-- they don't connect this directly to the NHS, though. They don't pay an "NHS tax"-- they just pay their taxes. And the NHS is always in debt and has doctor shortages as a result. If we go for a system like that, we will just be complaining about taxes rather than health insurance. That's fine if it's better, but it seems to me there are drawbacks and benefits to both styles of systems that should be considered.

I just read someone making a comment about having to pay $200 for a medicine and thinking it was criminal. That medicine probably cost $800 billion for the company to develop, and while I won't jump for joy, if it's going to help me in some way I'll pay the $200. The same person probably wouldn't think twice about waiting in line to get a $400 Wii or paying $100 for cable TV every month. Yet, how dare a company sell a lifesaving drug for that price! Yes, people in other countries pay less, and that's because we in the US subsidize them. If we have single payer, that might have to change, but then we might get less R&D in exchange-- or their prices would have to go up, too.

Considering the extreme inefficiency of our current system, it is almost shocking that anyone opposes the idea of a Single Payer system. Of course, all we are seeing with this Obama reform is small bandaids, and the corrupt assholes in congress are squirming even at this. Inflation in healthcare is higher than the rest of the economy, so the longer we wait on Single Payer, the more we shoot ourselves in the foot.

The bills before Congress are not single payer. I would support single payer in a minute over the bills Obama is proposing. His bill just mandates that people have to have insurance with those "evil" insurance companies, which to me is a huge corporate handout.

Singer's article is generally sound, though sometimes presents one side of an argument without considering the other. He mentions that the US pays more for drugs without mentioning that this is not just because the UK NICE has set drug limits-- it's also precisely because of those limits that Americans pay more. We make up the difference, just as we do with petrol. If we mass-negotiate drug prices, drug prices will either increase for other countries or fewer drugs will be made. That certainly has utilitarian consequences.

American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That’s rationing too, by ability to pay.

I don't see how that's solved by Obama's plan. Many people have said that the public option will be modeled on Medicare (Singer says this himself later in the article). If instituting a "token copay" for cost-effective medicines is such a great idea, why hasn't that been done for seniors already? I know many people who struggle to meet their Medicare premiums and copays, so past history that doesn't bode well for "Medicare For All". Medicare has driven up prices of the marketplace since its inception so that copays are more now than a full doctor's visit would have cost out of pocket in the '60s. That could have had side benefits (more money spent in the marketplace might mean more technology produced in response to those dollars) but it is definitely what's responsible for our high healthcare inflation. Obama's plan doesn't solve this problem at all.

In response to his story of the woman who died from not taking her bp medicine-- more explanation is needed on this. Did she have access to Medicaid coverage? If not, why not? If it truly was a choice between food and lifesaving medicine, it seems she'd qualify for Medicaid. That's a Georgia Medicaid reform that's needed, not a whole-system reform. If American had an NHS, perhaps the blood pressure medicine and Gleevec and Chuck Stauffer's Temodar wouldn't have existed in the first place. These are the important questions that we need to be asking.

"For Medicare patients drug costs can be even higher, because Medicare can require a copayment of 25 percent of the cost of the drug."

Isn't that basically the system we'll have with the public option? If things are not working now with Medicare, what about the public option will be better? Medicare has, with SS, sent America careening straight toward bankruptcy as it is. If right now Medicare can't afford to give seniors full coverage of drugs, how will the public plan take a different approach for coverage? How will it contain costs?

Singer said it's easy to say this, so I'm going to. One problem that I think really upsets people (especially older people) is that, while on the surface saving a teenager over an 85-year-old, as Singer posits, seems like a great idea, it's just so blanket and impersonal. Is it true that every 85-year-old is worth "less" than every teenager? Charles Manson was once a teenager, and I know an 80something who acts no older than 65 and is the linchpin of her family. If (or I guess I should say when, unfortunately) she dies, her entire family will be absolutely torn apart and devastated, one relative who is mentally ill will probably sink into a deep depression that might never be gotten over (and will cost the state a lot of money), young children she raised will be missing what is basically their parent... I could go on. I will say right now that I think her life is worth more than some teenagers out there for all the reasons I've listed. She could live to be 120 like Jeanne Calment did, she's very healthy. Maybe that teenager would die of a drug overdose at 21 or kill someone in a car accident at age 23. It just all seems so calculated.

That said, I do agree that limits have to be placed somewhere, it just depends on who's setting those limits. As it is, the above 80something has no real limits on her healthcare. If there are no private plans, she would. Singer says "decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals." But that creates problems in itself, since you will have situations where Bernie Madoff is saved over Mother Theresa. When it's the government deciding this, there's no alternative. You can't go to a different one.

An added factor is that both Britain and Canada (although Canada may have modified this recently after protest) say that if their boards do not approve a treatment or drug, no one can choose to pay for it privately.

I would also point out to Singer:
Australia's 1.5% tax levy doesn't come close to paying for its Medicare system
Since 1999, Australia pays 30-40% of people's private health insurance premiums (implying what Hayek basically said above, that the public plans increase costs for private plans, that private plans therefore can't compete, and that public plans have cost issues)

brightmidnight wrote:Hayek was against the institution of a state-run healthcare system, because, well, I'll let him tell you:

That was a good quote, and I don't think it is incompatible with what he said in his autobiography Hayek on Hayek:

Does he support laws setting a maximum number of hours in the workday? Hayek: "Yes, if it is not carried too far. It is one of those regulations which creates equal conditions throughout the system." Does he agree with a minimum-wage law? Hayek: "A general, flat minimum-wage law for all industry is permissible, but I do not think that is a particularly wise method of achieving the end." Did he support the TVA [Tennessee Valley Authority]? Hayek: "There is a great deal of the TVA to which no economist in repute, and certainly not the laissez-faire people, will object. Flood control and building dams are recognized functions of the government." Does he think a system of social insurance is a harmful form of planning? Hayek: "Certainly not a system of social insurance as such, not even with the government helping to organize it. The only point where the problem can arise is how far to make it compulsory. . . ." Does he support a guaranteed minimum income? Hayek: "I have always said that I am in favor of a minimum income for every person in the country."

http://www.fff.org/freedom/0994e.asp

Basically, what he is saying is he does not want compulsory state-run insurance, but he would seem to be just fine with a Public Option, as is being proposed. I would argue that the Public Option should be the default option, but not mandatory, and one should be able to find alternative or complementary insurance if one wishes.

brightmidnight wrote:I just read someone making a comment about having to pay $200 for a medicine and thinking it was criminal. That medicine probably cost $800 billion for the company to develop, and while I won't jump for joy, if it's going to help me in some way I'll pay the $200.

Perhaps a relevant question would be why it costs $800 billion dollars. It is a fact that the major pharma companies spend twice as much on marketing as they do on R&D. On TV, you see tons of advertisements for prescription drugs, except half the time you have no idea what the drug is for. You will just see people riding around on bikes and walking on the beach, and then a brand name. "Ask your doctor about the Purple Pill" but you have no idea what that pill is. This stuff is banned in other countries.

Of course the majority of the marketing budget goes towards courting doctors. Frankly, I don't want my doctor prescribing treatments based on which company took him out to the nicest restaurant. There are plenty of lower cost treatments for disease, not to mention preventative measures, such as simple plant extracts and vitamins, but those cannot be patented, so there isn't anywhere near as much incentive for multi-billion dolar corporations to throw their weight behind these. Even when generics are allowed on the market after the patents expire, you mysteriously see new pills take over the market which don't seem to be any better.

The bills before Congress are not single payer. I would support single payer in a minute over the bills Obama is proposing.

I agree, but this thread is about why we need health care rationing under a single payer system.

Singer's article is generally sound, though sometimes presents one side of an argument without considering the other. He mentions that the US pays more for drugs without mentioning that this is not just because the UK NICE has set drug limits-- it's also precisely because of those limits that Americans pay more. We make up the difference, just as we do with petrol. If we mass-negotiate drug prices, drug prices will either increase for other countries or fewer drugs will be made. That certainly has utilitarian consequences.

To be honest, a lot of the disease specific treatments which we spend so much money on is an incredibly inefficient use of money from a utilitarian perspective. Thus, I would not be very sad to see them go away. Robin Hanson explained this very well in this article at Cato. Instead of these costly, experimental, disease-specific treatments which often fail, and even if they succeed often merely prolong someone's sad bedridden existence. Is this really the highest and best use?

Shouldn't we devote more money to repairing the damange of aging, as Aubrey de Grey recommends? Shouldn't we devote more money to prevention and lifestyle counseling? Instead of paying for expert care for minor healthcare checkups, shouldn't we instead prefer cheaper community clinics? Instead of patented medicine, shouldn't we provide incentives for open source medicine?

Very interesting; I didn't know Singer had weighed in on this, but this position is exactly what I'd expect from him.

I think it would help the U.S. government to explicitly acknowledge and promote a utilitarian goal, such that while individual rights are for the most part fully justified by utilitarian standards (e.g. free speech is vital for a vibrant and healthy society even if it does involve some negativity that's not immediately "happiness producing), the util standard can tell us when these rights should be abridged, e.g. the unlimited right for a single private individual to own vast vast quantities of land or the questionable attribution of "personhood" to corporations which would then allow them unlimited "free speech" in the form of corporate campaign contributions.

Read some of the papers on healthcare from Robin Hanson - marginal healthcare is mostly useless and is only bought because we are irrational and want to signal that we care for the sick.

Irrational about death: http://hanson.gmu.edu/feardie.pdf

Signalling care for the sick: http://hanson.gmu.edu/showcare.pdf

Lots more with a Google search.

We should be glad so many resources are currently being wasted - means we can easily be richer!

While I doubt health-care's anywhere near the most utilitarian use of government dollars, I have serious doubts about Hanson's analysis. Aside from anything else, he seems to assert far more than he gives figures, which seems like the wrong approach when so much of his argument relies on correct interpretation of data.

Possibly more to the point, he accepts that there's a general trend of increasing lifespans that roughly correlates with our (apparent) improvements in medicine, sanitation and other such things that he disparages. And he points to some problems with drug trials... ok, but so what? Drug trials seem to have far fewer variables (and to be more scrupulously represented, even if the papers published are biased by omission) than the macro-economic analysis he's levelling at them.

In other words, if we accept that something is making us live longer, then if there's a lot of weak evidence to suggest it's medicine, a lot of even weaker evidence to suggest it isn't, and no better explanation, I'm going to assume it is.

EmbraceUnity wrote:Perhaps a relevant question would be why it costs $800 billion dollars. It is a fact that the major pharma companies spend twice as much on marketing as they do on R&D.

If spending on marketing is a problem, wouldn't the logical thing to do be to discourage marketing, rather than make the government do things where large amounts of money would be otherwise spent on marketing?

Daniel,

If the ridiculous marketing budgets of Big Pharma were the only problem, then I would agree.

The insurance side of things is probably the most backward of all. Here are just some of the problems off the top of my head:

1) There are tens of millions of people who are uninsured, which is a moral crisis. Costs continue to rise much faster than inflation, which threatens to increase the number of uninsured. This trend is not occurring under foreign healthcare systems.

2) Insurance companies have a habit of rejecting virtually every claim the first time, no matter what it is, at least in my personal experience and from what I have read. Every claim thus becomes a fight.

3) Insurers will drop people for ridiculous technicalities and "pre-existing conditions," especially when the insurance is needed most, which is nullifying the entire service they are supposed to be providing.

4) Bureaucratic inefficiency, likely related to their numerous technicalities and constant fights on the phone with angry customers.

5) The fact that people cannot depend on insurance to actually pay their expenses often forces patients out of economic necessity to file malpractice suits that they otherwise wouldn't. Thus, the issue of defensive medicine and insurance reform overlap quite a bit.

Beyond the issues with insurance we have a uninspiring life expectancies despite paying almost double what other countries pay. We have an archaic patent system and an archaic disease-specific approach to medical research.

Even though we are beginning to digitize medical records there are absolutely no regulations mandating that they be digitized using the open standards which have been developed. Thus, our medical records cannot be easily shared between institutions.

Our healthcare system sucks, and major reform is needed. The Public Option is the only thing being proposed which can give reforms teeth and ensure prices are kept under control once dropping people for pre-existing conditions is illegal. Furthermore, if health insurance becomes mandatory but no public option is available, this is corporatism pure and simple. Though truly we need far greater reforms than what is being proposed.

A utilitarian rationing system would be far superior to the profit-driven rationing system we have now. This doesn't have to be mutually exclusive with a private system. Some have proposed a single-payer system with healthcare vouchers, so that not only could you have supplemental insurance, but you could completely opt-out of the government system entirely. This seems like a good compromise, and could keep both systems competitive. I also like that under this plan the single-payer system would be the default.

EmbraceUnity wrote:1) There are tens of millions of people who are uninsured, which is a moral crisis. Costs continue to rise much faster than inflation, which threatens to increase the number of uninsured. This trend is not occurring under foreign healthcare systems.

Beyond the issues with insurance we have a uninspiring life expectancies despite paying almost double what other countries pay.

There is a large number of poor people. They get less of everything. I see no reason health care is special. I don't believe their lack of health care is the largest factor in their shorter life-expectancy.

The rising cost reflects Americans wanting more healthcare. Who am I to say whether or not that's a good idea? In any case, I doubt further distancing people from the costs of healthcare would make them stop demanding as much of it.

2) Insurance companies have a habit of rejecting virtually every claim the first time, no matter what it is, at least in my personal experience and from what I have read. Every claim thus becomes a fight.

3) Insurers will drop people for ridiculous technicalities and "pre-existing conditions," especially when the insurance is needed most, which is nullifying the entire service they are supposed to be providing.

The alternative is that they do whatever the patient wants. This can be incredible expensive and is only practical if the patient pays out of his own pocket. They could choose they're battles more, I suppose, but there's not much that can be done in that direction. Put simply, public health care won't make a difference in this area.

4) Bureaucratic inefficiency, likely related to their numerous technicalities and constant fights on the phone with angry customers.

I doubt the government, the largest bureaucracy in the world, is going to have less bureaucracy.

5) The fact that people cannot depend on insurance to actually pay their expenses often forces patients out of economic necessity to file malpractice suits that they otherwise wouldn't. Thus, the issue of defensive medicine and insurance reform overlap quite a bit.

I find it hard to believe that this is done to a significant extent. Wouldn't they just sue for the price of the surgery?

We have an archaic patent system and an archaic disease-specific approach to medical research.

Our current medical system involves paying someone to keep you healthy. If they can do it cheaper with another method, I'm sure they would.

Even though we are beginning to digitize medical records there are absolutely no regulations mandating that they be digitized using the open standards which have been developed. Thus, our medical records cannot be easily shared between institutions.

This definitely is a problem. Making it hard to switch companies will make them compete less. I doubt it's a significant problem, though.

Our healthcare system sucks, and major reform is needed. The Public Option is the only thing being proposed which can give reforms teeth and ensure prices are kept under control once dropping people for pre-existing conditions is illegal.

Changing who pays for it won't change the costs. It will change the distribution of costs, but that just comes down to distribution of wealth. If you want to redistribute wealth, do it directly.

Furthermore, if health insurance becomes mandatory but no public option is available, this is corporatism pure and simple. Though truly we need far greater reforms than what is being proposed.

Food is mandatory. Agriculture is powerful, but that's not why.

A utilitarian rationing system would be far superior...

Yes, a morally superior system would be superior. Don't assume your system is preferable under utilitarianism when trying to convince utilitarians that it is preferable.

...to the profit-driven rationing system we have now. This doesn't have to be mutually exclusive with a private system. Some have proposed a single-payer system with healthcare vouchers, so that not only could you have supplemental insurance, but you could completely opt-out of the government system entirely. This seems like a good compromise, and could keep both systems competitive. I also like that under this plan the single-payer system would be the default.

If the healthcare vouchers are equal to what the government pays, you have nothing more than mandatory insurance and wealth distribution. If it is less, you have that in addition to government subsidies to its own insurance. If there are no externalities, the government system will succeed in the market if it's better, which means that it doesn't need subsidies.

MarkLint wrote:or the questionable attribution of "personhood" to corporations which would then allow them unlimited "free speech" in the form of corporate campaign contributions

A corporation in itself is inanimate and nothing more than an agreement amongst people to recognize they resolve their momentum into the same direction and act similarly, and thusly the corporation itself does not have "personhood", and cannot speak for itself. When a corporation acts, it is as each individual member of that corporation acting individually but in all the same manner.

It is logically equivalent to distinct persons signing a petition, and presenting it to the government. Or for a group to pool their resources to hire busses to come to the nation's capital to stage a protest. Which is all accepted to be protected speech.

From a utilitarian perspective, free speech should not be assumed to be ethical, unless it raises average utility, so obviously some speech will be ethical and some will not.