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I Want My Death Panels!

August 19th, 2009 · 17 Comments

I don’t have particularly strong views either way about health care reform, but it’s depressing that the one part of the Obama plan that seemed like an obviously, unambiguously good idea has become a casualty of the requirement that all political disagreement be cast as a war between good and evil. There are not a whole lot of free lunches to be found in the attempt to control health care costs, but encouraging doctors to discuss end-of-life care with patients in advance is one of them. That’s because studies indicate that having those conversations usually leads people to make better decisions than having to suddenly figure out what to do when the end inevitably approaches: The advance planners have outcomes just as good as those who don’t—they live just as long, and usually are more comfortable at the end—but their costs are 36 percent lower because they don’t end up opting for a lot of desperate and futile “heroic interventions” at the end. So: lower cost, same lifespan, patient still in the driver’s seat?  If Newt Gingrich or Sarah Palin had proposed this, it would be hailed as a brilliant, choice-centered innovation.  Oh, wait, they did both propose it.

On a related note, looking at some of the sad, strained attempts to stretch advisor Zeke Emmanuel’s pretty unexceptional bioethics writings into support for “death panels” makes me wonder how an academic philosopher could ever get involved in politics. What they do, after all, is concentrate on difficult ethical dilemmas where any of the options has some morally unattractive features, and then make the case for one of them.  A vision of confirmation hearings keeps running through my head: “Isn’t it true, professor, that you’ve endorsed flinging the obese in front of runaway trolleys?” To be sure, I don’t share the horror many bioethicists seem to at the prospect of allocating scarce medical resources to the highest bidder… and I tend to think that the defensible progressive position is that this is objectionable because of background distributive injustice, not because health care is some sui generis magical good.  That said, other things equal I think it’s sort of a no-brainer that if there’s one kidney available, and you’ve got a 90-year-old and an adolescent who both need it, the morally better result is for the kid with many more decades ahead of him to get it. If anything, it’s the reverse position that seems ghoulish. Anyway, under the status quo, your “productivity in society” sure as hell does determine whether you get care—Steve Jobs is productive enough to fly out for his cancer treatment in Tennessee where the waiting list for a liver transplant is 80% shorter than in Cupertino. Obviously, there are incentives as well as the purely allocative questions to consider, and I’m not especially sanguine about passing the ball to government either. But it would be nice to see both sides talking in a way that recognized that there’s no foreseeable health care system under which resources are infinite and people don’t die eventually.

Tags: Markets · Moral Philosophy


       

 

17 responses so far ↓

  • 1 Doug // Aug 19, 2009 at 4:09 pm

    I hear you, Julian. If I’ve learned one thing from the furor over death panels, it’s that we can spare some folks.

  • 2 Steve M. // Aug 19, 2009 at 4:16 pm

    A vision of confirmation hearings keeps running through my head: “Isn’t it true, professor, that you’ve endorsed flinging the obese in front of runaway trolleys?”

    No imagination necessary. Just ask Cass Sunstein.

  • 3 Nick // Aug 19, 2009 at 4:18 pm

    there’s no foreseeable health care system under which resources are infinite and people don’t die eventually.

    You mean, aside from the technological singularity.

  • 4 The Czech // Aug 19, 2009 at 5:52 pm

    To be sure, I don’t share the horror many bioethicists seem to at the prospect of allocating scarce medical resources to the highest bidder… and I tend to think that the defensible progressive position is that this is objectionable because of background distributive injustice, not because health care is some sui generis magical good.

    I would say both. How would you argue that health care isn’t a basic societal good? The UN considers it a basic human right. I’m wondering how you would argue that position.

  • 5 jre // Aug 19, 2009 at 6:10 pm

    In opposing Megan McArdle’s argument about rationing, John Holbo made the useful point that there is no health care reform plan under serious consideration that would ration anything except taxpayer’s money. That is, since any plan that might conceivably be passed by Congress will certainly allow unlimited “topping off” with private funds, and since the supply of most health products and services is not inherently limited, that supply will reach equilibrium with demand under a public-private system just as it does today. The exceptions are things like kidneys that really are limited in supply. But, as you’ve pointed out, those have to be rationed anyway. Nothing in the bills I’ve seen will do anything to reduce the supply of kidneys — or to increase it either. Grandpa’s still going to have to arm-wrestle you for it.

  • 6 Julian Sanchez // Aug 19, 2009 at 6:23 pm

    I talk about this a bit a few posts down. Basically, I think the claim that there’s a “right to healthcare” isn’t so much wrong as it is incoherent—it doesn’t mean anything intelligible. At most it means a right to some finite amount of social assistance in getting healthcare if you can’t afford it yourself. But if we owe them the assistance, why say they MUST use it for healthcare? You can call it a “basic societal good,” whatever that means, but people routinely make choices that trade off or risk health for other kinds of enjoyment—so obviously, for some people, at some margin, other things are more important or more valuable. The coherent position, I think, is to say that people have a right to some fair share of social resources—and probably many people will decide to expend some amount of their share on securing some level of health care. (Maybe you also want to say people with the burden of some onerous health condition starting out in life deserve a larger share in compensation.) But if they don’t, or if they get less than you think they have a “right” to, well, they must not have thought it was so basic after all.

  • 7 Andy // Aug 20, 2009 at 2:14 pm

    Thank you. Yes. If “death panel” is an unfriendly term for the people who allocate a limited health care resource — funds that don’t come straight from the patient’s pockets — then most of us are already governed by death panels: they’re called the insurance industry. The only questions, then, are: do these death panels produce outcomes the public finds socially desirable? And do they do it for a reasonable price? The answer to the first question is difficult; the one to the second isn’t: you can pay a lot of Ezekiel Emmanuels with the salary of a health insurance CEO.

    I received a transplant when I was 24. I was unconscious before I knew I might need one, and didn’t wake up until I had it, so I have no direct emotional perspective on the decision-making process. I had good insurance, and I’m glad they paid, but I’m also aware that they could have refused to cover it or stalled until I would have died. (I don’t have family that could have covered anywhere near that bill.) If I’d been asked before I became sick: Whom do you want on your death panel — health insurance employees or public servants whose work is, at least in principle, accountable to the democratic sovereign? — the answer would’ve been obvious to me. Or the other way around, I’d rather have Ezekiel Emmanuel pull the plug on me than someone at Cigna. Simple as that.

  • 8 Steve // Aug 20, 2009 at 2:32 pm

    if health care is a basic human right, then the adolescent and the old person have an equal right to the kidney, and it has to be decided by the toss of a coin. basic human rights don’t go away just because you age.

  • 9 Julian Sanchez // Aug 20, 2009 at 2:45 pm

    I doubt that strictly follows, but it’s probably a good illustration of why abstract talk about a “right to health care” is more confusing than helpful.

  • 10 paul // Aug 20, 2009 at 2:47 pm

    Finally someone who’s willing to point out the obvious but inconvenient truth that WE’RE ALL GONNA DIE EVENTUALLY. My Dad was an undertaker and take my word for it, everyone – rich, poor, famous, infamous – does. To pretend otherwise, to pretend that one side or the other has the magic elixir to circumvent death is folly of the highest nature.

  • 11 Doug // Aug 20, 2009 at 3:00 pm

    Paul, are you sure it isn’t just your father’s customers?

  • 12 Pat // Aug 20, 2009 at 5:06 pm

    It’s called what we have now. Rationing of health care, limiting it to those who are over 65 and those who are rich.

  • 13 Contribute // Aug 20, 2009 at 5:10 pm

    Some relevant info regarding DEATH PANELS

    http://deathpanels.tumblr.com/

  • 14 Tim W // Aug 21, 2009 at 2:55 am

    “At most it means a right to some finite amount of social assistance in getting healthcare if you can’t afford it yourself. But if we owe them the assistance, why say they MUST use it for healthcare?”

    Are you demanding a justification, or asserting that none can be given? It may be that no particular good rationale for a right to health care can be given, but it seems you’re resting your case in opposing this: Something we owe assistance for certain types of goods, depending on the reasons we have for the debt or providing a good.
    For example, a veteran who loses his leg in war doesn’t have a right to a cash equivalent; but it surely still makes sense (even if you disagree) to say he is entitled to an artificial limb.

    Consider a claim that there is a right to subsistence. Does that mean food stamps make no sense? It may be that there is a better way to implement this right. Indeed, it might be possible to protect a right without having legally guaranteed right (e.g. a market system might best protect against starvation in many cases). However, that is (or need not be) not a right to an equivalent sum of money.

    Julian’s case, I suppose, might best be made by saying that everyone has the right to certain means to accomplish their ends. But why is that? The very reasons for that could point to means of a certain sort (or aiming at access to functioning of a certain sort).

  • 15 Tim W // Aug 21, 2009 at 3:38 am

    Julian-

    Consider this possibility: some “rights” might be seen as compensation for being subject to state coercion.

    Nozick claiming something like that: only citizenship can provide adequate compensation for the forced boundary crossing of bringing non-consenters into the state.

    It may be possible for others to extend this and argue that health care is part of citizenship; however, that is usually linked to the idea of social citizenship, which is rather alien to the Nozickean ideas of freedom. But perhaps there might be a freedom-based cased for health care? There might not be, but I think that rather than treat people’s ideology like suits, we should ask what are the fundamental ideas motivating them… rather than try to figure out their principles from their bottom lines, we might also help other’s with different ideologies by suggesting to them the terms on which they could best ask themselves the questions about health care.

    I think the general idea of looking at a lot of rights we have in the state are the result of being subject to coercion, compensation in some sense. This assume the anarchist isn’t correct, and there can be some compensation. That doesn’t mean it is beneficience or aid. These can be called natural rights or human rights, even if they only make sense in the context of the state.

    So, consider this principle: all things being equal, an institution has more obligation to alleviate illness incidence that it is contributing to, as opposed to illnesses that stem from natural ills. This might not be an absolute principle, but to the extent our social institutions do make it so we are subject to all sorts of harms (pollution, for example) without consent or compensation, they should provide health care.

  • 16 Julian Sanchez // Aug 21, 2009 at 9:32 am

    Tim-
    It’s not really supposed to be an airtight deductive argument; more a suggestion that the intuitive appeal of a “right to healthcare” turns on background beliefs about distributive injustice. I doubt anyone finds it especially offensive if wealthy people are expected to pay for their own health care, rather than getting it provided free because it’s a fundamental right. That said, I allowed earlier that there might be practical reasons why the best way to remedy the distributive injustice (if you think there is one) is though provision of a particular good that’s highly important to most people. Food stamps, which you mention, frankly strike me as a mixture of a distributive remedy with some undisguised paternalism: The problem is that some people are too poor to afford these really basic goods, and we *could* provide a direct cash transfer, except we worry they’d blow it on booze and drugs and fuck up their lives still further. All that aside, the compensation suggestion is intriguing and probably a fruitful line of inquiry to pursue. In the same vein, there’s probably a defensive/public health line of argument for infectious diseases, and maybe something similar to be said about controls on antibiotics to prevent the development of resistance.

  • 17 Barry // Aug 21, 2009 at 12:28 pm

    Julian, as for a war between good and evil, notice which side is clearly a deliberately making up lies about ‘death panels’. Notice which side is constructing astroturf organizations.

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