Month: January 2006

Economist Steven Landsburg had an interesting piece at Slate yesterday on the case of Tirhas Habtegiris, a terminal cancer patient whose ventilator was disconnected after she proved unable to pay her hospital bills. Various bloggers on the left howled that “economic considerations” factored in such a decision—while Landsburg argues that they should. Kevin Drum calls it a “condescending, juvenile, obtuse, and soul cankered” effort that reads like “it was written by a native of Alpha Centauri trying to parody Ayn Rand,” and his commenters trot out some predictable tongue clucking about heartless economists who know the price of everything and the value of nothing. While here the critics are mostly on the left, the argument parallels closely what you’ll hear from opponents of assisted suicide on the right: revulsion at the prospect that terminal patients might make decisions about when to end their lives on the basis of “economic considerations.” I’m with Landsburg: It seems mad not to allow economic considerations to play a role—that’s not heartlessness so much as the ethical equivalent of refusing to let your genitals do the thinking for you.

RESCUE RANGERS: What’s at issue here, in part, is what bioethicists sometimes call the “rescue principle”: the idea that scarce (medical) resources are to be devoted to the cases in the most dire need, rather than in the way they’ll produce the greatest overall benefit. And that has some intuitive appeal, but some equally intuitively unappealing results—not to mention, as Landsburg notes, being wildly out of whack with how most ordinary people make decisions the rest of the time. Every time you drive or take a bus rather than flying somewhere because driving is cheaper, you’re implicitly accepting a higher risk of accident as part of that tradeoff. For that matter, every time you catch a movie instead of jogging or have that slice of chocolate cake instead of a salad, you’re making an “economic” decision about allocation of scarce resources, and not allocating in favor of maximizing lifespan. Someone who actually consistently acted as though health were lexically prior to all other values would probably strike us as a bit loopy. But we then have this weirdly asymmetric attitude when dealing not with risks prospectively but with remedies for conditions that have actually manifested. In the hospital room, we say life is priceless. But a hundred times a day, our decisions suggest we don’t really think so.

Medicine—despite the popularity of the phrase—never actually “saves” lives; at best it leases them back from oblivion for a while longer. So the actual choices we face in medicine aren’t ever really of the form “how much is this life worth?” but rather “how much is it worth to prolong this life another day, or week, or month?” And, of course, since there’s not an objective answer to that question, it’s just as well that mostly those are decisions made by each person about her own life. But we’ve also got cases like these, where someone else has to make the call. The rhetorically appealing answer is that we should treat the value of life as infinite for each increment. But it’s also a slightly crazy answer. As Landsburg points out, pretty much nobody actually makes that call about her own life. Our public spending across the board certainly doesn’t suggest that sort of priority. And even if we did think that were the case, it would be hard to see why a rescue-principle approach would be the one we chose. Because of our time-asymmetrical attitudes, we end up willing to prolong a fading life “at any cost” when the resources devoted to that care would probably do a lot more life-prolonging in some more preventative capacity. But why does it make sense to bias outlays in favor of the most urgent cases, when this only guarantees that there will be more urgent cases—the ones who got less care at earlier stages because we were devoting vast sums to that extra month on a respirator—in the future?

TIME’S WINGED CHARIOT GETS STUCK IN TRAFFIC: The question becomes more pointed the better our medical technology gets. If my colleague Ron Bailey is right, eventually we’ll all just be nanotech-enhanced cyborgs who stay physically about 30 years old for centuries. I’m looking forward to it. But in the meantime, we’re facing the prospect of being able to prolong life in tiny increments at ever higher costs. If we took the rescue principle seriously in its most extreme form, we could probably, eventually, devote all our medical resources to eking out a few more days for people on the verge of death.

If we could, but wouldn’t, then we’re already dealing in the language of tradeoffs. And that, more or less by definition, means paying attention to “economic considerations.” What really bothers most people about this case, I assume, is not that they think people always ought to have their lives prolonged at any cost for any increment, but that there was something unjust about the poverty that prevented this particular woman from having insurance. And that’s a fair objection, but it’s super important, I think, to keep the spheres of argument distinct to the extent possible: There’s one question about economic justice, whether someone has a share of resources we think is adequate to give someone a fair range of real options—to put food on the table and also, if she wants it, provide for medical insurance. There’s a distinct question about how we react once people have disposed of just shares as they see fit and still find themselves in dire medical straits. As I suggested, technology will eventually make that an issue even for the affluent, as it increasingly becomes possible to squeeze out a few more weeks for a few more millions.

With that in mind, we can reframe the question this way: Do we really have one question, about economic justice, where there’s only a further, distinct-seeming question about justice in health care because people are trying to correct for perceived injustice on that front. Or is it, rather, that there’s a really distinct sphere of justice for healthcare, where even after someone’s disposed of their fair share of wealth, we’re obligated to treat life extension (and maybe only or especially at the verge of death) as of infinite value, even if the person herself didn’t or wouldn’t have? Landsburg’s catching flak for having answered the second question, I think correctly, in the negative, without really acknowledging the first question properly. But the answer to the second question still ought to be in the negative, and we’re apt to arrive at some profoundly screwed up ideas about medical ethics and health policy if concerns on the first front push us to confuse it with the second.

– posted by Julian.

I see Cato is hosting (and streaming over the Web) an interesting looking event next week with Columbia’s Jack Snyder and U Penn’s Edward Mansfield about their new book Electing to Fight: Why Emerging Democracies Go to War. I spoke briefly to Snyder, after reading a chunk of his previous book on this topic, about a year back while working on a short squib on the rather more radical ideas of Princeton political scientist Joanne Gowa, a skeptic of the democratic peace hypothesis. Without going so far as to endorse Gowa’s critique in all its particulars, she and Snyder are a useful antidote to the assumption that, from the point of view of promoting stability and security, “spreading democracy” (in the formal sense of popular elections) is some kind of silver bullet. What would likely be effective to that end is the spread of liberal democracy—which entails cultivating a whole complex of mores and institutions. It is, of course, much easier to focus on flashier, more photogenic milestones like lines of purple-fingered voters outside polling stations. But as Snyder and Mansfield make clear, it may also be dangerous.

—posted by Julian