In Which I Am Shocked – Shocked – To Be Supporting Peter Singer

So Peter Singer – whose past writings have been, to put it mildly, odious to me – has an oped in the NY Times that’s triggering a bit of reaction: ‘Why We Must Ration Health Care

The reactions are, overall, kinda scathing:

From Tammy Bruce (Please, Tammy – finger outside the triggerguard until the sights are on the target, OK?):

Obama moral relativist begin making fascist argument for rationing health care which is what this has been about from the beginning – eliminating “costs” from the budget. For fascists, people are the budget.

From Don Surber:

I have been saying that the Democratic Party does not want to save lives with their hideous, expensive and bureaucratic plan to take over health care.

The plan is to “save” money….

He is a sick, sick man. He puts money ahead of human life. He may be bio, but he has no ethics – or at least any that I would want to be associated with.

From Steve Gilbert at Sweetness and Light:

…it is worth going to the link and reading the full tract.

It is great nightmare fuel.

By the way, in case Mr. Singer’s name doesn’t strike a bell, he is that famed bioethicist who believes in sex with animals and abortion, euthanasia and infanticide for humans.

Maybe Mr. Obama will make him his Health Care Czar.

…and so on.

So I’m gonna go pretty far out on a limb here, and say that while I may or may not agree with his prescription, I think that his diagnosis is one that we can’t afford to avoid dealing with in some way.

Here’s a personal – and painful story. This is how my dad died.

My dad had never been in great health – he’d had a heart attack in his 40’s, been a three-pack-a-day smoker until then, and a pipe smoker afterward. He walked, which was his form of exercise, but it didn’t make a huge dent in the family genetics. His dad had died of a heart attack in his late 50’s, the year before I was born, and his brother had a heart attack in his 30’s. His brother died – of a stroke – in his early 60’s, and my cousin, writer Paula Danziger, died of a heart attack at 59.

You get the picture. (In case you’re concerned, I get a treadmill test every two years – I got to do a technicium one this year – and pass with flying colors each time. My BP was 120/80 when I was checked two weeks ago, and so I’m assuming I got my mom’s cardiovascular system instead of my dad’s.)

So my dad had his first bypass when he was 53 – three years younger than my age. He had another about ten years later, retired at 64, and at age 67 had a major stroke, followed by a mild heart attack and kidney failure.

He started permanent dialysis, and spent about eight years in relative stability, until he had another heart attack and needed yet another bypass. At this point he was too frail to live on his own, even with the ongoing two shifts of help that had burned through his savings, and I moved him to a board-and-care facility near my house so the boys and I could spend time with him.

Then he needed another bypass, and we had a long debate about whether to do it or not. To be honest, I pushed him toward doing it, because I felt that withholding treatment would have been immoral.

After that he had two decent years, and then he began a series of abdominal bleeds, which led to three emergency surgeries in seven months. Two months after the third surgery, he started bleeding slowly again, and I had a conference with his doctors.

They could keep operating, and he’d eventually die on the table, or painfully from abdominal bleeding. He was sedated for pain, and when we roused him, not coherent.

When he’d started dialysis, the nephrologist had told him that he could stop any time, and that dying from kidney failure was one of the most painless ways to die. He’d noted that and frequently talked about just stopping dialysis when things became too much for him. So I made the decision to discontinue his dialysis, and a day later he went into a coma and a day later he died.

The day I made that decision and called my aunt and mother and informed them was one of the worst days of my life; my own responsibility still sits heavily on my shoulder.

But I didn’t see any alternatives, and really still don’t. Adulthood is, I’ve come to believe, a matter of making choices between terrible alternatives and moving forward.

And now to the point of this exercise. When I was talking to my dad about his second bypass – at 75, three years before he died – we discussed how lucky we were that money didn’t enter into the equation; between medicare and retirement insurance benefits from his employer, his healthcare was essentially free. We both wondered if he would have had the third bypass if I had had to take money from my kids college funds for it.

And that’s really where the nub of the problem becomes.

Because in the last three years of my life, my dad’s medical bills (not his chronic care bills, but his bills for physicians and surgeons) probably was close to three quarters of a million dollars. Figure close to $250K for each bypass and postoperative care, $125K each for the three operations and postoperative care, and about $1K/month for medical visits, tests, etc. (not including dialysis). So $500K in surgery, $360K in overall medical care. In the last nine months – during all of which he was in postoperative acute care – we probably spent (or his insurers spent) $370K – to what end, exactly?

And so that’s the question we’re looking at in rationing and talking about health care. Because we’re only willing to spend so much on healthcare overall; but as long as it doesn’t cost me anything, I’m prepared to spend whatever it takes until there’s no further point.

And so there’s the rub. On one hand, I’d be blowing buildings up if some cubedwelling functionary told me I couldn’t get treatment for my dad. On the other, I have to ask – as cooly and dispassionately as I can – if the money I caused to be spent on him in those final months – even those final years – is money he or I would have spent if we’d had to write the checks.

And there’s the rub; we have a system which largely removes cost as a factor either because you’re in a protected class like my father, where there are no costs – or because the costs are so great that they don’t matter and they are an insurmountable barrier. There is no “this much and no more” in healthcare as it’s structured today.

Should there be? Thinking about my dad, I honestly don’t know. But we need to talk about it, and so I have to – grudgingly, holding my nose – tip my hat to Professor Singer.
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23 thoughts on “In Which I Am Shocked – Shocked – To Be Supporting Peter Singer”

  1. Okay, talk about it with whom?

    The Obama people will entertain no such debate. They talk endlessly about “debate”, but they do not do it. (Like the girl in Sophie’s Choice, who liked to say the word “f–k” but could not do it.)

    They certainly won’t debate rationing. Here the reverse is true – They might do it, or create a system that makes it inevitable, but they sure as hell won’t talk about it. Obama says we’re going to have huge savings. Since we’re all going to get rich out of this deal, why in the world would we limit anyone’s care?

    Of course that’s not true, but that’s their story and no fact or argument will make a dent in it.

    Suppose your father had not had insurance, and had been forced to accept death years earlier? This does indeed happen to people. But your father’s extra years were not a gift, he earned them in his years of health, and the sizable chunk that was deducted from his salary paid for the care of others.

    You seem ambivalent about the choices you made, but should someone have made them for you? Should someone have decided that your father should die so that someone else could live? Or vice versa?

    How about someone who decided that there are too many Jews in the world, just like the people who ensure that there are not too many Jews in the freshman class at Princeton? You think I’m kidding? In a world of Peter
    Singers, you think I’m kidding?

  2. “Why we should ration health care”

    So who makes the decisions? Naturally, if the government pays, then you are a expense and a rational government will try to determine your utility vs your cost. If, on the other hand, the government is dominated by idealistic sentiments, then care will simply be unavailable due to shortages. The latter seems to be the case in countries of the more socialist sort.

    If I had to choose, I would choose shortages as the fairest approach. At some point the utilitarian approach is likely to tie in with eugenics and euthanasia of the disabled because, well, because disabled folks have lesser utility on average and cost money. Sound familiar? People tend to forget that the Nazis were a progressive bunch.

    However, in either approach the powerful will find ways to benefit themselves, that is just how it works. In other words, you will end up with all the downsides of a market driven system, but instead of productive folks the system will benefit politicians and bureaucrats. Add to that a likely decrease in medical innovation and the loss of personal choice and perhaps government health care doesn’t look like the best way to go.

  3. I’m not impressed with the article at all. Probably for two reasons:

    1) I’ve already had all the worthwhile thoughts in there on my own, including all the realizations about the bottomless sink of spending that healthcare can become, will become, is becoming. So that’s not at all novel to me.

    2) Although he states plainly the problem– Health care is a scarce resource– he does not once, that I saw, address the problem by giving mechanisms to increase the supply and decrease scarcity.

    He is right that we can either ration by price or ration by government fiat, but he gives me no justification to believe that the government will magically do a better job than the current scheme, and I can see many ways in which it could perform far worse…. especially if it degenerates into a system of rent-seeking, which time and again acts to throttle supply increases in whatever market it is applied to.

    I would love to live in a world where, for the most part, medical care is as cheap and affordable as food. But I do not see government health care as the road to that wonderful world.

  4. Let’s look at this from the gevernments perspective with you Father’s history as an example.

    Male, age 45, heart attack, poor family history, smoker. Do we cut our losses?

    Male, age 53, one prior heart attack, poor family history, ex-smoker needs bypass. Do we cut our losses?

    Male, age 67, stroke, one prior heart attack, one bypass, poor family history, ex-smoker. Do we cut our losses?

    Male, 67, one prior heart attack, one bypass, one stroke, poor family history, ex-smoker, needs dialysis. Do we cut our losses?

    Male, age 75, one prior heart attack, one bypass, one stroke, 8 years of dialysis, poor family history, ex-smoker, needs second bypass. Do we cut our losses?

    The idea that someone other than the patient or the family would even come close to providing this level of care is laughable. The government might pay for most first heart attacks but after that, all bets are on them looking at the increasing cost curve and pulling the plug.

  5. On a related note, I cannot, I simply cannot understand the strategic thinking going on in the Democrat halls of power, these days.

    When this goes wrong, somehow– and inevitably, this will go wrong at least enough to provide Republicans with a constant drumbeat of anecdotal failures– there will be no one to shoulder the blame for them other than Democrats…. because this will have been a plan passed through an overwhelming majority Democrat House, a filibuster-proof Democrat Senate, signed into law by a Democrat President.

    This really has the potential to be the gift that keeps on giving. I guess the Democrats are so convinced that anything– anything at all– would be better than what we have today, that they’re willing to go forward with it. Or that the electorate will be forgiving of failures.

    I’m not convinced of either of those.

  6. Government obviously is too slow acting to be the rationing agent. The government as a rationing agent is also in the position to ban non-rationed care (in the private sector) as illegal (such as to preserve an egalitarian appearance).

    However, many individuals cannot afford care on their own.

    So we need an alternative financing source, such as medical loans. A government, or non-profit entity, can provide the loans and re-sell them as packaged loans (CDO fiascos notwithstanding). By adding co-signers, we ensure repayment, and makes this a true family decision. Using a long loan term (50 years+), we make the loan more payable. By not hiding the true cost of care, we restore the decision to the patients, family, and physicians, instead of burearucrats in gov’t and in insurance.

    Some hospitals are already offering loans and installment payments, but we can make this bigger scale.

    “Here is a link”http://americanmohist.blogspot.com/2009/06/health-financing-alternative-in.html

  7. One of my ideas for healthcare has been to have a federal catastrophic benefit, and that beyond a certain age, if you die within a given year, the last year’s medical expenses are charged to the deceased’s estate. If they consume the estate, the taxpayers eat the rest.

    In this case, for hugely expensive late-in-life procedures, the family and the person do have to think about costs and likelihood of surviving the procedure.

  8. bq. I guess the Democrats are so convinced that anything– anything at all– would be better than what we have today, that they’re willing to go forward with it. Or that the electorate will be forgiving of failures.

    The Democratic Party believes they can convince the voters than any problems are because of the GOP. After all, they convinced the majority that the GOP ran Congress in the 2006-2008 period. Seriously – go out and ask your associated who controlled Congress in the last two Bush years.

  9. Dr. Singer mis leads us. Sutent does not extend life by 6 months. Only the 36% of patients who have a partial response have an increased survival. in other words, 64% have no increased survival.

  10. _”One of my ideas for healthcare has been to have a federal catastrophic benefit, and that beyond a certain age, if you die within a given year, the last year’s medical expenses are charged to the deceased’s estate. If they consume the estate, the taxpayers eat the rest.”_

    How about turning social security and Medicare into the actual individual accounts they are sold as. After all- there is a sick perversity in a system that forces people to pay into a retirement system they may not live to see… and then pays nothing to their beneficiaries even though they have earned that money over the years.

  11. _How about turning social security and Medicare into the actual individual accounts they are sold as. After all- there is a sick perversity in a system that forces people to pay into a retirement system they may not live to see… and then pays nothing to their beneficiaries even though they have earned that money over the years._

    Yeah, in a “do over” world, I’d definitely prefer that. But in today’s world, how do you get there from here? Since SS and Medicare are de facto pay-as-you-go systems (even if SS has a mythical “trust fund”), a generation has to “lose” bigtime to convert them to real pre-funded systems.

    For that matter, why not just get rid of income taxes and have a consumption tax, so people can save for their retirement without a massive tax headwind? But that’s a topic for another thread…

  12. The Democratic Party believes they can convince the voters than any problems are because of the GOP. After all, they convinced the majority that the GOP ran Congress in the 2006-2008 period. Seriously – go out and ask your associated who controlled Congress in the last two Bush years.

    It may be true that they believe that– I’ve seen some pre-emptive whining by Yglesias, as I recall, about how if only there weren’t this filibuster rule making Republican-appeasement necessary, there would be a much much infinitely double-plus-better health care reform bill.

    But I don’t think it will work. For one thing, there’s been a good amount of press dedicated to the filibuster-proof majority in the Senate now that Al Franken has been seated. Hard to put so much emphasis on that fight and then turn around and complain that it’s still Republicans at fault.

    For another, I just don’t believe the average voter is that stupid. The average partisan voter, sure– there’s 20 or 30% on either side who wouldn’t switch sides to save their mother’s life. But the rest are just not that dumb or ill-informed. The average voter knows perfectly well that with both chambers and the White House locked down, the Democrats will completely own whatever failure or success comes from this.

  13. Marc, I went through a similar progression with my own late father a few years ago. Truly a wrenching process.

    The amount of money spent in his last days was shocking – and unsustainable, as public policy.

    Now, if the public won’t continue to pay for exponential end-of-life care (and it won’t – things that can’t go on forever generally don’t), the question becomes: what will we, as a society, _allow money to buy?_

    Society reserves for itself the right to permit and to prohibit the purchase of certain things.

    Consider the trinity of sex, drugs and rock and roll: the first two are under commercial prohibition, the third has a legal market.

    Consider kidneys, which cannot be purchased, and eggs (fertility treatment), for which there is a legal market in all but name.

    Endless reams have been sacrificed to the arguments of the Libertarian vs the Ethicist, but in the end I suspect an unconscious and collective “yuck factor” is the dispositive determinant of these policy decisions.

    You observe that money was not a factor in your already difficult deliberations with your father. Neither was it a consideration for my father and I, for similar reasons: insurance.

    Once the constraint of money – and the terrible choices forced by that constraint – becomes a common and and defining experience for those deciding end of life care for their parents (or themselves… or God forbid, their children), I wonder how society is going to react.

    Will people be permitted to use money to buy _more life_, above and beyond that which is has been promoted to the status of a human right?

    I suspect that the egalitarian appetites of this age will not be easily sated.

  14. Health care, like everything, is a finite good. Unlike many other things, demand is effectively infinite, or so close that it doesn’t matter.

    The core problem is having some functionary somewhere decide that you dad’s odds aren’t that great for a bypass, based on a set of tables in front of them. So, no surgery. In a system that has systematically driven out other options.

    As the population ages, and medical costs really start to spike, the pressures of a public-only system plus demographic collapse will also push a strong euthanasia movement – and it won’t all be wholly voluntary. There are early indicators in Europe that do not foster optimism, and we’ll also see a lot of it by stealth (“yes, the bypass would work, but our tables show low ‘quality of life’ for the following years and frequent complications – so, no surgery”).

    And yet, a good with infinite demands must have its costs controlled.

    Which means:

    * Don’t add unnecessary costs to the system. America’s medieval tort law approach is an unaffordable burden, whether the system is private or public.
    * You must link individual costs to individual behaviour. A reward system is best, expressed as increased benefits, lower deductibles, or what have you.
    * Early/ preventitive care is usually cheaper overall, and can be directed to cheaper venues as well. Adding behaviour links multiplies its effectiveness, by promoting required behavioural changes once problems start – or before. The current system in America especially fails on these first 3 points.
    * People have to own the care they receive, and some responsibility for its costs. The best monitoring is at the point of service. Nobody goes out of their way to care for a rental, and all of liberalism’s structural failings (ratchet effect, regulatory capture, etc.) will prevent effective monitoring. Insurance firms aren’t a whole lot better at this than governments, either; they just offer the ability to find a better “jurisdiction.”
    * Make sure the system doesn’t just allow those who are willing to have supplemental coverage, it actively fosters a competitive, robust environment for that coverage.
    * All health care systems suck (infinite demand/ finite resources). The decision involves which ways a given country’s system will do so.

    Within those principles, there are a number of viable approaches.

  15. Marc,
    As usual, I’m a little confused by the lack of a moral conclusion to your personal story.
    My question is; if you and your fathers estate had “just” enough money to cover all of his medical expenses on a cash basis, at what point would you’ve said “no more”!

    Also, with most all private insurance plans there’s what’s termed a “preferred provider discount”, this is a discount that the cash payer of services cannot receive. In my case, I recently had $4,200 orthopedic surgeon costs discounted to $2,400 to my insurance company in addition to which anasthesia cost of $1,275 was discounted to $625 (in each instance I was responsible for 80% of the discounted costs).
    I’d like to see these discounts offered to the cash payer of services as well!
    Mike

    BTW, why has the Libertarian idea of HSA’s completely disappeared from the health care debate?

  16. According to Arnold Relman’s review of Ezeikel Emanuel’s Book in the New York Review of Books, July 2, 2009, health care reform is stillborn, yet again.

    Here is “the short version”:http://www.npr.org/templates/story/story.php?storyId=106470889

    The problem is excessive costs, and these are the result of a for profit health care model. A number cited in the article is $500 million annual revenues concentrated in the Blue Cross type of health plans. Up to 20 percent of our premiums go straight to profits. [I’ve no idea if this is correct] While companies administering these plans are looking for hefty profits, doctors are compensated through fee for service, with a premium on expensive procedures. The result is very expensive health care plans and very expensive service. The system is rigged to optimize profits first, results second.

    According to Relman, the plans being discussed in Congress now will help with increasing coverage for the nearly 50 million uninsured, but it will do nothing to takle the high cost of medical care in this country. As we will be subsidizing more of the unisured, costs will only continue to increase.

    If Relman is correct, the best hope we may have is for the private sector to find a better model. Kaiser does some of the things that can help lower costs: doctors are salaried and not paid by the procedure, care is evaluated system wide for effectiveness, and the profit motive is lined up to eliminate needless care, not provide needless procedures. To the extent that Kaiser like plans are successful in delivering quality care for lower costs, they will win out in the long run. This will help to start control costs.

    If the market can find a way to get the bulk of costs lower for those who can pay, Congress may be able to devise a solution for the uninsured, and assuring that you can continue with your inisurance indefinitely when you change or loose your job, and to enable us to obtain reasonalbe coverage even with pre-existing conditions.

  17. Every plan has it’s costs, and it’s rationing. Which is satirized by the daily show “here”:http://www.thedailyshow.com/watch/wed-july-15-2009/drag-me-to-health—universal-health-care

    The problem with a corporate insurance plan is that instead of clearly identifying the cost of their rationing, many companies put a ‘best face’ on their plans, knowing that many will never be able to continue insurance after a drastic medical procedure. Furthermore, many companies control costs by rejecting valid claims. For most americans those rejections (or service price outs) are rarely known in advance. If a client does challenge them, the company is unlikely:

    a) to lose in court and
    b) face intense media scrutiny (especially national insurance companies, which pull ad time if any criticism of their company is made).

    Short of a national scandal (unlikely), a theoretical company gains more by preying on its clients than by actually doing it’s job. I’m not saying that every company does this (or even that any company does this overwhelmingly), but it happens often enough to be a serious problem.

    A public option is likely to be upfront about what it will pay for, since you vote for your representatives. Still, more users means more wait time. It also tends to reward workers (doctors, nurses, technicians) lower wages, which may create a lower number of workers. It also has to be watched closely for wasteful spending, which is so common in government contracts.

    However, it’s worth noting that Sweden spends 9.1% of GDP on all healthcare. Medicaid alone spends 7.5% of our GDP.

    Still, comparing country to country is difficult, because costs even in a similar system is going to be heavily swayed by the details: How well a program is organized, how well the medical centers function, complicated procedures the state is willing/not willing to tackle.

    In fixing our system, the details need to be fixed. I’m not against a public option (I would actually prefer one) at the same time, the political rhetoric is so high, the plans so complicated and the influence of corporations so strong) that it seems unable to create a fundamentally better plan.

  18. _”and the profit motive is lined up to eliminate needless care”_

    The problem is that one person’s ‘needless care’ is another persons double checking if their 12 year old daughter has meningitis.

    Our system obviously has perverse incentives both to over-test (tort reform could help here), over-treat, and for insurance to challenge all of the above. On the other hand the alternative on the table now is to under-test, under-treat, and yet (if medicare is truly going to be the template) waste up to 15% of the budget on straight up fraud which government is awful as culling out.

    One would hope there is a medium we could reach somehow, but nobody seems to have come up with it yet.

    Our first order of business should be to fess up to what we are _really_ trying to accomplish. If its simply to insure the uninsured- well once you knock off 10 million illegals, 10 million qualified for medicare or medicaid, and 10 million that have voluntarily opted out of insurance, you come down to 10-15 million people who need help. There are far cheaper and more effective ways to help them than this huge government takeover. It would be FAR more cost-effective to simply add them to medicaid.

    As far as cost-cutting, nothing i’ve seen is likely to help more than very marginally. The emergency room problem is a good example- if you ask people without insurance why they go to the ER instead of free clinics, they tell you its because they don’t want to wait for the clinic. Ironically, by making people wait longer for healthcare ala Canada we are going to end up encouraging MORE people to go to the ER for faster service.

  19. I would add to that Mark, that many homeless/poor/illegals do not have a regular doctor, and therefore do not treat minor problems until they have become major problems. Thus requiring more medical care.

    This poor coverage is also the reason many expert predict that a major epidemic is more likely in America than in any other major industrial nation.

    Diseases can grow quickly in vagrant populations that have a low health standard. When they become strong enough, these diseases can quickly traverse into the main population, causing an epidemic that seems to appear overnight.

    You can even contrast that with some third world nations, that although have very poor health standards, have developed (though aid organizations) very efficient monitoring systems for such an outbreak.

  20. Is it fair to ask whether the poor, indigent, illegals etc will seek medical care even if it is available for routine issues?

    How many homeless shelters stand empty while people live on the streets?

    When we start talking about this strata of people, many of these are the uninsured folks that would be qualified for medicaid to begin with but dont/cant/wont sign up. Some people are too mentally deficient, or traumatized, or drug addled, or just scared to live on the grid, and I don’t see how short of institutionalization that is going to change. A lot of these are the people we are talking about, so its not a trivial point. We could end up pouring money like water on sand trying to get that last 2% to get a regular checkup. Short of force, I don’t know how you do it.

    I really think we should be concentrating our efforts instead on that strata that is left behind and genuinely out of options. But thats a few million people, and we can deal with that far more cost-effectively. Its an issue of diminishing returns.

  21. Again, you do what they do in 3rd world countries. You get a small community of individuals (aid workers) to go to them, and change the nature of the relationship. You also let them know that they will not go to prison for seeking medical advice (something that cannot be guaranteed now).

  22. My point, exactly, Mike is that the issue is fraught with moral ambiguity – which makes a joke of people on both sides of it who claim absolute moral authority for their position.

    It’s a matter of which set of hard, bad choices we want to make.

    But the one core point is that when it’s completely free to the consumer, we may distort the choices that are made.

    Marc

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