The Runaway Trolley thought experiment was introduced in a previous Topic, on this Blog.The basic lesson was that there are situations where it is quite ethical to take an action that saves (or benefits) a number of people, even if that action has, as an inevitable side effect, the death (or detriment) of a smaller number of people.
This posting has to do with End of Life Issues, and how we might apply the lesson of the Runaway Trolley to the public-funded medical care system. An earlier posting related the Runaway Tolley to Criminal Recidivism
POWERPOINT SHOW AVAILABLE
Click HERE to download a narrated PowerPoint Show that includes animated charts for the Runaway Trolley thought experiment. After the Runaway Trolley is explored, the charts continue and apply the ethical lesson to two real-world issues: 1) Criminal Recidivism and 2) End of Life Issues. The PowerPoint Show is based on a talk I gave to The Philosophy Club at The Villages, FL, on 04 February 2011. NOTE: The Powerpoint Show is Narrated and plays and advances automatically after download to your computer.
PRESIDENT OBAMA'S VIEWS
President Obama, in a moment of unusual candor, expressed his views on end-of-life health care for those with chronic or terminal illness, published in the New York Times Magazine in April 2009. (full text from NY Times website, see section V). I have reproduced the text of that section at the end of this posting. [Some material here is from my earlier posting END-OF-LIFE: Honest Brokers (not Death Panels :^)]
DIRECT OBAMA QUOTES
“… government can … be an honest broker in assessing and evaluating treatment options. … when it comes to Medicare and Medicade, where the taxpayers are footing the bill …
“… using comparative-effectiveness studies as a way of reining in costs, …
“… the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here. …
“…there is going to have to be a conversation that is guided by doctors, scientists, ethicists. … you have to have some independent group that can give you guidance.”
PRESIDENT OBAMA'S GRANDMOTHER
As a case-in-point, the President brought up the hip replacement received by his terminally-ill grandmother mere weeks before she passed away. During his campaign, she was diagnosed with terminal cancer and then, probably due to a mild stroke, she fell and broke her hip. Her condition was analyzed by her doctors who told her she had three to nine months to live due to the cancer. They also told her that a weak heart posed risks for the invasive surgery hip replacement.
In the absence of cost-effectiveness data or guidelines to the contrary, she chose the hip replacement, which was approved by Medicare and done mostly at public expense. She passed away two weeks later, sadly just days before Obama won. It appears the stress of the operation may have shortened her life by several months.
I don't know if Obama's grandmother got approval for the hip replacement because she was related to a prominent person. That would be bad enough, but it would be even worse if we are giving hip replacements and other stressful and expensive treatments to all terminally ill grandmothers and grandfathers.
QUOTING THE PRESIDENT AGAIN
"... in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. ... So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here."
QUALITY ADUSTED LIFE YEARS
A concept called "Quality Adjusted Life Years" (QALY) is in use in the UK and, IMHO, should be adapted for use in the US. The basic idea is to estimate, before approving very expensive, public-funded medical procedures, the probability the procedure will be successful, and, if successful, the number of years the recipient is likely to live and the subjective quality of those years.
Subjective quality is a difficult measure. Fortunately for us, based on experience and practice in the UK and elsewhere, there are fairly well-established guidelines. For example, mobility is an issue in quality of life. If a person is able to walk without assistance that is better than being wheelchair-bound, and a wheel chair is better than being bedridden. Being alert and awake and mentally competent is better than lack of those qualities. Being able to take food by mouth is better than IV, etc.
In the UK, if each QALY is estimated to cost less than about $40,000, and if the recipient wants the medical procedure, it is approved for public funding. On the other hand, if the cost is more than $40,000 per QALY, or if the recipient does not want the procedure, only palliative care, consisting of pain management along with love and attention, is provided, even if this level of care will reduce the likely life span of the patient.
The QALY concept may also be utilized to compare alternative treatment options. For example, if medical treatment procedure A will cost substantially more per QALY than medical treatment procedure B, only B will be approved, even if both are under the $40,000 limit.
Examples:
1) Alice is a candidate for treatment A that is estimated to cost $150K for the treatment and care, has a probability of success of 80%, and, if successful, will provide a subjective quality of life of 60%. Based on her age and medical condition, if the procedure is successful, Alice has a life expectancy of 10 years. The calculation gives her QALY = 5 years, so each QALY will cost about $31,000, which is below the limit of $40,000. The Treatment A is therefore approved for public funding if Alice is willing to accept it.
2) Bob is a candidate for treatment B that is estimated to cost $90K for the treatment and care, has a probability of success of 50%, and, if successful, will provide a subjective quality of life of 40%. Based on his age and medical condition, if the procedure is successful, Bob has a life expectancy of 5 years. The calculation gives him QALY = 1 year, so each QALY will cost about $90,000, which is above the limit of $40,000. The Treatment A is therefore NOT approved for public funding and Bob is entitled to palliative care only.
3) Carl is a candidate for treatment C that is estimated to cost $50K, or treatment D that is estimated to cost $100K.
Treatment C has a probability of success of 90%, and, if successful, will provide a subjective quality of life of 60%. Based on his age and medical condition, if the procedure is successful, Carl has a life expectancy of 5 years. The calculation gives him QALY = 3 years, so each QALY will cost about $19,000, which is below the limit of $40,000.
Treatment D has a probability of success of 80%, and, if successful, will provide a subjective quality of life of 70%. Based on his age and medical condition, if the procedure is successful, Carl has a life expectancy of 5 years. The calculation gives him QALY = 3 years, so each QALY will cost about $36,000, which is below the limit of $40,000.
Both treatment C and D are below the limit of $40,000 per QALY, but C is substantially less expensive and, therefore, only treatment C is approved for public funding if Carl is willing to accept it.
A STORY MY FATHER TOLD ME
Once upon a time, there was a boy in China and he saw his father carrying a large basket on his shoulders. "What do you have in the basket?" he asked.
"Well," said the father, "It is your grandfather."
"What are you doing with grandpa?" asked the boy.
"Well," he replied sadly, "Your grandfather is quite old and he is so sick that we cannot take care of him anymore, so I am going to dump him in the river."
The boy thought about it awhile, and then he said: "OK, Dad, ... But remember to bring back the basket!"
Of course the point of the story is that the boy will learn from his father's actions and will, when the time comes, uses that same basket to dispatch his father.
When my mom's cancer roared up after a year of chemo and radiation, she decided to accept only palliative care. Our family travelled to San Francisco where they lived and said goodby. Hospice provided morphene and a hospital bed for their apartment. We spoke by phone every evening for about a month until she passed away.
My dad made it clear that was what he wanted when the time came.
About five years later he had a stroke and fell and was taken to the hospital where an MRI confirmed a major bleeding in his brain that was terminal. He could not speak or hear or see and was being kept alive with IV hydration and nutrition and oxygen to help his breathing. My brother and I asked the doctors to remove all artificial life support, including the IV and oxygen, and he passed away a few days later.
I have asked my children to do the same for me when the time comes. "Remember to bring back the basket!"
ACT! OR FATE?
If we Accept FATE?
- Do next to nothing to change US health care.
- Health care not fair.
- Given medical advances, End of Life costs escalate out of control.
- Neo-natal care and preventative care are under-funded.
- USA goes bankrupt (like Greece, hedonistic socialism).
If we ACT!
- Enact QALY End of Life guidelines.
- Health care is more fair.
- Given medical advances, End of Life costs are controlled.
- Neo-natal and preventative care are well-funded.
- USA avoids bankruptcy.
- Death with dignity and loving care.
CONCLUSIONS
Although I did not vote for him, and oppose much of his economic policy, I agree with President Obama's remarks on end-of-life treatment.
I wish he and his Democratic allies would be similarly honest and I wish the Republicans who are characterizing the issue as "pulling the plug on granny" would be more thoughtful and helpful and honest as well.
I do not like to hear people call these "honest broker" government medical and ethical tribunals "death panels". However, the 'honest broker" guidelines, when imposed on Medicare and other public-funded medical decisions, will, in effect, cause many of the terminally and chronically ill to be given palliative treatments that will undoubtedly shorten their lives.
Whatever you call them, I believe we need ethical end-of-life guidelines to prevent doctors and hospitals from ordering expensive treatments that are not cost-effective (and that may be done more for reasons of fear of malpractice suits and/or simple greed to increase their incomes).
I am not if favor of further nationalization of US health care. However, with Medicare the primary payer for nearly all of us over 65, we need national guidelines to prevent the program from going bankrupt. (See this and this for more details on my views of what we really need in cost-effective health care reform.)
Let us take the ethical lessons of the Runaway Trolley to heart and ACT! rather than accept the hand of FATE?
Ira Glickstein
PS: For the record, and in case the NY Times takes the page linked above out of their free access, here is the full text of the applicable section of the document from which I quoted Pressident Obama's words.
You have suggested that health care is now the No. 1 legislative priority. It seems to me this is only a small generalization — to say that the way the medical system works now is, people go to the doctor; the doctor tells them what treatments they need; they get those treatments, regardless of cost or, frankly, regardless of whether they’re effective. I wonder if you could talk to people about how going to the doctor will be different in the future; how they will experience medical care differently on the other side of health care reform.
THE PRESIDENT: First of all, I do think consumers have gotten more active in their own treatments in a way that’s very useful. And I think that should continue to be encouraged, to the extent that we can provide consumers with more information about their own well-being — that, I think, can be helpful.
I have always said, though, that we should not overstate the degree to which consumers rather than doctors are going to be driving treatment, because, I just speak from my own experience, I’m a pretty-well-educated layperson when it comes to medical care; I know how to ask good questions of my doctor. But ultimately, he’s the guy with the medical degree. So, if he tells me, You know what, you’ve got such-and-such and you need to take such-and-such, I don’t go around arguing with him or go online to see if I can find a better opinion than his.
And so, in that sense, there’s always going to be an asymmetry of information between patient and provider. And part of what I think government can do effectively is to be an honest broker in assessing and evaluating treatment options. And certainly that’s true when it comes to Medicare and Medicaid, where the taxpayers are footing the bill and we have an obligation to get those costs under control.
And right now we’re footing the bill for a lot of things that don’t make people healthier.
THE PRESIDENT: That don’t make people healthier. So when Peter Orszag and I talk about the importance of using comparative-effectiveness studies (see note below) as a way of reining in costs, that’s not an attempt to micromanage the doctor-patient relationship. It is an attempt to say to patients, you know what, we’ve looked at some objective studies out here, people who know about this stuff, concluding that the blue pill, which costs half as much as the red pill, is just as effective, and you might want to go ahead and get the blue one. And if a provider is pushing the red one on you, then you should at least ask some important questions.
Won’t that be hard, because of the trust that people put in their doctors, just as you said? Won’t people say, Wait a second, my doctor is telling me to take the red pill, and the government is saving money by saying take the blue —
THE PRESIDENT: Let me put it this way: I actually think that most doctors want to do right by their patients. And if they’ve got good information, I think they will act on that good information.
Now, there are distortions in the system, everything from the drug salesmen and junkets to how reimbursements occur. Some of those things government has control over; some of those things are just more embedded in our medical culture. But the doctors I know — both ones who treat me as well as friends of mine — I think take their job very seriously and are thinking in terms of what’s best for the patient. They operate within particular incentive structures, like anybody else, and particular habits, like anybody else.
And so if it turns out that doctors in Florida are spending 25 percent more on treating their patients as doctors in Minnesota, and the doctors in Minnesota are getting outcomes that are just as good — then us going down to Florida and pointing out that this is how folks in Minnesota are doing it and they seem to be getting pretty good outcomes, and are there particular reasons why you’re doing what you’re doing? — I think that conversation will ultimately yield some significant savings and some significant benefits.
Now, I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care —
Yes, where it’s $20,000 for an extra week of life.
THE PRESIDENT: Exactly. And I just recently went through this. I mean, I’ve told this story, maybe not publicly, but when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.
So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.
And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.
I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.
And it’s going to be hard for people who don’t have the option of paying for it.
THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?
I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.
So how do you — how do we deal with it?
THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.
Note: Comparative-effective studies — which are now done by academic researchers, but not systematically across the medical system — review data to determine which widely used treatments do not improve outcomes and which effective treatments are not used often enough.
25 comments:
Sorry Ira, but I can't agree with your terminology. The term "Death Panel" is much more accurate than "Honest Broker." An honest broker is an intermediary between two parties and tries to be helpful in the decision making process that each party must make in order to come to agreement. There is nothing like that going on here. There is nothing optional in the nature of this deal. If you take the patient as party A and the taxpayer as party B, you would have to take a internet vote à la Ross Perot for the public to agree or not. The patient would also need to agree, having no alternative. No, your "broker" is a judge and jury rolled into one, who DECIDES not facilitates. We cannot really debate the other aspects of this policy until we get rid of what I would call verbal camouflage.
I agree that President Obama's "honest brokers" will, in effect, decide who will get certain expensive public-funded medical treatments, and thus, at least potentially, live longer; and who will get only palliative care, and thus, most likely, die sooner.
Indeed, I said as much in my main topic:
I do not like to hear people call these "honest broker" government medical and ethical tribunals "death panels". However, the 'honest broker" guidelines, when imposed on Medicare and other public-funded medical decisions, will, in effect, cause many of the terminally and chronically ill to be given palliative treatments that will undoubtedly shorten their lives.
Whatever you call them, I believe we need ethical end-of-life guidelines to prevent doctors and hospitals from ordering expensive treatments that are not cost-effective (and that may be done more for reasons of fear of malpractice suits and/or simple greed to increase their incomes).
So, call the panels that formulate the guidelines what you like, but do you agree we need guidelines for sustainable spendig of public money on end of life treatments for those of us with chronic and/or terminal conditions?
Ira Glickstein
Actually I don't agree that we should spend public money on anything but Medicaid. Death panels or rationing committees if you prefer, are only a necessity only outside the free market.
Private insurance companies have done the job pretty well for many years. Crazy government requirements like taking new subscribers with pre-existing commitments is the bureaucrats way of destroying private insurance in order to force us into a single payer system. Health insurance needs to be more like fire insurance. Those who want to take the risk are welcome to do so, but don't expect to join the mutual after the fire starts.
We conservatives, Joel, have to face facts, even if, like me, some of us are attracted to the libertarian view. For example, I would allow homeowners to refuse to pay for fire insurance and then have the fire company let their home burn down, protecting only their covered neighbors. But, that approach does not work that well in the medical arena when children are involved or when medical action is needed to prevent mass contagion.
Vitually ALL the people in the US who have chronic or terminal medical conditions are under the Medicare/Medicade umbrella (qualifying as old or disabled). Even those in the free-market insurance arena are subject to government agency set rules that require the coverage of pregnancy, for example, even for those who are past breeding age. There are also rules about transplanted organs that cannot discriminate against people due to their short life expectancy if they get the organ. Our legal system penalizes doctors who use common sense means to reduce medical costs if, in one instance, that cost-saving happens to cause a bad outcome for someone (or if a sharp lawyer can buy an "expert" to testify that it did).
A US QALY system, adapted from the well-established the UK system by some US agency (NIH perhaps?) would set guidelines for public-funded reimbursement to medical providers. Given, say, a $40,000 limit per QALY, some surgeons and other providers of expensive treatments, would find themselves "priced out of the market" when it came to some percentage of their public-funded reimbursement. To stay in business, and make use of their high capital investment facilities, they would be forced to reduce their profit margins, like providers in the free market have to.
As you point out, the insurance companies are already enforcing some types of rationing and cost-effectiveness by denying reimbursement. However, I get the impression that their rules are squishy, and they deny reimbursmement to some who justly deserve the expensive treatment, hoping they will take no for an answer, and, on the other side, they approve unjustified expensive treatments when the patients are persistent and their doctors know how to game the system. And then there is the always present risk or a lawsuit against the insurance company if treatment is denied and the patient dies.
Given a US version of QALY, with legal protection for providers who deny service based on it, free-market insurance companies would likely hop on the bandwagon "voluntarily" and offer Plan A coverage that followed the US QALY limit of $40,000, and more expensive Plan B coverage that was more generous, for a higher premium of course. All insurance companies and medical providers would be protected from lawsuits if their plans were at least as good as the US QALY levels. The free market in action!
Ira Glickstein
I'm not looking for private insurance companies to jump on the QUALY bandwagon. That's just giving an appearance of competition and free market. I want to be able to be offered a cafeteria of choices which are precomputed by statisticians to be fair. If I don't want to to receive more that $50,000 per year after age seventy-eighty-ninety. I should be able to find that. If I want pregnancy to be excluded because I intend to remain a bachelor, I should be able to find that. If I want a high deductable, I should be able to find that. If I want to pay a high price and be protected until I wither into dust, why not offer that at a premium price. You can get almost anything you want in auto or fire insurance. Why not medical insurance? The key is competition. Medicare is anti-competitive and look at what has happened. You should get what you are willing to pay for. (Pardon the dangling participle.)
Joel said, “Private insurance companies have done the job pretty well for many years.”
Ira said, “We conservatives, Joel, have to face facts, even if, like me, some of us are attracted to the libertarian view.”
My facts show that a large majority of doctors and medical schools agree that US private insurance is a mess. Overall, it is unfair, administratively costly and inefficient. Health care in the US is “one of a kind.” That is, no other developed nation has such a poor system.
My facts come from sources like the
New England Journal of Medicine, and from colleagues at Stanford Medical School, the Karolinska Institute, and all the local doctors that I know.
Joel and Howard: At our ages, participles are not the only things that are dangling :^)
You are correct Howard that there are issues with the US private insurance system that affect the quality and "fairness" of care for all, as well as the job satisfaction of doctors and other medical professionals. You are correct Joel that the private insurance market should have a "cafeteria of choices", each at an appropriate premium, rather than the current all you can eat at a fixed premium that rewards overeaters and others who choose risky lifestyles and get a disproportionate share of limited health care resources.
But, neither of you have offered anything specific that is also achievable in the real world of US politics and law.
I think a "cafeteria" system would still require some kind of rationing such that the insurance pool, whether private or public funded, does not give an expensive and risky hip replacement to a person with a serious heart condition and three to six months to live due to cancer (as was done with President Obama's grandmother with a tragic outcome that cut her life short so she did not live to see him elected).
The best hope for controlling costs is some sort of baseline QALY plan, put together by medical, legal, and ethical experts, perhaps coordinated by the NIH. Given that baseline plan, which would apply uniformly to public-funded medical treatment, private plans could offer higher financial limits per QALY, as well as reductions in premiums for "cafeteria" buyers who did not need certain types of coverage.
Indeed, both the public and private plans now in place here in the US ration care by not approving 100% of reimbursements, but the decision criteria are hidden and, even within a given plan, not uniform, and are regularly gamed by persistent patients, doctors, and the insurance companies themselves.
What is your plan? Surely you do not want to continue the current system forever? Surely you realize that any modifications will be opposed by strong public and private interest groups? What is both doable and relatively fair?
Ira Glickstein
Ira said:
I think a "cafeteria" system would still require some kind of rationing such that the insurance pool, whether private or public funded, does not give an expensive and risky hip replacement to a person with a serious heart condition and three to six months to live due to cancer.
Joel responds:
I don't get your point. Why would you need rationing, if the actuaries have done their job? If you've paid for that level of care you get it. If you haven't, you don't. When you go to Las Vegas, you get paid off based upon what you bet and the odds of an outcome plus a margin for the house. No one decides after the dice are cast and you have won, whether you deserve to be paid off. The problem is that some people expect a big payoff even though they only put in a small wager. It seems to me that our political problem solvers have never heard of "divide and conquer." The problem of minors and the indigent needs to be separated out for special consideration, rather than screwing up the entire system for the sake of a few. The problem of insurance companies who don't pay off when they should, needs to be dealt with in the same way that Las Vegas deals with casinos that cheat; a hearing in which the license is at stake.
P.S. Howard, your reference (New England Journal of Medicine)doesn't seem to contain anything relevant to your argument. Can you be more specific?
Joel,
Almost all the articles on NEJM’s Health Care and Policy section are motivated by the fact that US medical care is mess. For example see here. Most of the articles show at least two sides of every issue. Practicing physicians recognize the diversity of political and religious views, and consequently you will find no articles with your extremist views about private health insurance.
I agree with Ira that some form of QALY is essential for containing costs. But the conservative Patient Protection and Affordable Care Act appears to make this approach politically impossible.
Howard
I thought this site was about philosophy not practical politics. If one keeps to the straight and narrow and refuses to look at the root causes of problems, one will never get a new idea. I think you're stuck in conservative-liberal paradigms. Sometimes you have to have to start from scratch and question basic assumptions.
Joel, here is a better reference from NEJM about the inadequacies of US health care.
Your analogy comparing buying health insurance with casino gambling or cafeteria choice makes some “basic assumptions” that I question. Your analogy assumes you could have predicted in your youth what kind of health care you would need for your family and for your retirement. A better analogy is auto insurance where states require a uniform minimum for everyone which assumes accidents are locally unpredictable, both in occurrence and cost.
First, there is no way to predict individual health care needs or costs. There is even evidence that personal screening and preventative health care do not help predict future costs. Also, the costs of individual treatments cover an enormous range depending on the technology and the disease or trauma. These costs change locally and rapidly with new knowledge and technologies. That is why selective coverage cost statistics are less reliable (and therefore require higher premiums). Only a universal minimum required and non-selective coverage will be cost-effective.
Second, because some treatment costs are so high, about half of all personal bankruptcies are the result of uninsured health problems. In fact, even with average private insurance, one unpredictable accident or illness can bankrupt a family. The entire purpose of health insurance is to provide care without fear of poverty or bankruptcy. Like it or not, this amounts to deciding how much every taxpayer should spend to keep someone else solvent or alive.
Howard
Howard said:
The entire purpose of health insurance is to provide care without fear of poverty or bankruptcy. Like it or not, this amounts to deciding how much every taxpayer should spend to keep someone else solvent or alive.
Joel responds:
Quite to the contrary, the report says,"The co-occurrence of medical and job problems
was a common theme. For instance, one debtor underwent lung surgery and suffered a heart attack. Both hospitalizations were covered
by his employer-based insurance,but he was unable to return to his physically demanding job. He found new employment but was
denied coverage because of his preexisting conditions, which required costly ongoing care. Similarly, a teacher who suffered a heart attack was unable to return to work for many months, and hence her coverage lapsed. A hospital
wrote off her $20,000 debt, but she was nonetheless bankrupted by doctors’ bills and the cost of medications."
This points out that certain reforms and regulation of private health insurance is what is needed. Future payment of premiums needs to be included in the policy. Social Security already provides compensation in the case of inability to work. The point is that choosing the right policy with the right features is a key element. What we need to reform is the ability of anyone to purchase health and income insurance independent of their employer at group insurance rates. If insurance companies were free to do interstate business we could get more variety in the coverages available.
P.S. I'm not assuming predictability on the part of the individual. I assume that actuaries know how to do their job. Individuals are free to second guess the statistics, but they have to accept the consequences. F.A. Hayek makes the argument against central planning better than I can.
The citation you made refers to the United Nations World Health Organization Report health report of 2000 which has already been debunked. In fact, various countries are reforming their statistical methods, because the US rates 37th in the world based upon dollar "efficiency" not quality of care. For example, in the report, our infant mortality rate is higher than various backward countries, because our statistics count every pregnancy a potential infant no matter how they may be terminated. The WHO report rates France first or second, but if you've ever stayed in a French hospital, you know this is nonsense.
All our medical research is counted in our total medical expenditures, but there is no credit for the number of Nobel Prizes won by Americans or foreigners working in the US. The WHO report was a chance for all the socialized medicine rest of the world to throw stones at the US. You should read it, if you haven't already done so.
Joel, what Hayek do you read?
From Hayek, The Road to Serfdom:
“There is no reason why, in a society which has reached the general level of wealth ours has, the first kind of security should not be guaranteed to all without endangering general freedom; that is: some minimum of food, shelter and clothing, sufficient to preserve health. Nor is there any reason why the state should not help to organize a comprehensive system of social insurance in providing for those common hazards of life against which few can make adequate provision.”
Also, what non-ideological authority do you claim has “debunked” the WHO Report?
Howard
Howard, here's the first one I could quickly and easily lay my hands on: http://www.nwepseminar.org/blog/
Sorry wrong one: http://www.nwepseminar.org/blog/?p=33
Joel, thanks for the reference. It does help to know that we are not as bad as WHO says we are. I agree that the best US health care is the best there is anywhere. The problem is that the distribution of health care has “glaring variations” according to The Dartmouth Atlas data. Children’s care is especially poor in too many regions.
The other “glaring” problem is the lack of rational discussion of birth and death issues (as opposed to ideological dogma). The nonsense about “death panels” is counterproductive. At my age, my ability to make end-of-life decisions is very important to me. This is one of the many topics covered here in the Dartmouth Atlas.
Howard
Howard said:
Joel, what Hayek do you read?
Joel responds:
In response to your comment, I checked my hard copy of Road to Serfdom for something pithy that would express Hayek's point of view. I say pithy, because my typing is so slow. Chapter 2 is entitled "The Great Utopia" and is subtitled with the following quotation from Hölderlin: "What has always made the state a hell on earth has been precisely that man has tried to make it his heaven." Hayek applies that notion in the entire chapter if not the whole book. In the introduction to the fiftieth anniversary edition, Milton Friedman agrees that this also applies to health care. Can you tell me what chapter your quote comes from?
This is from Chapt 9 (p. 148 in U. Chicago Press 2007 edition). Here he supports a government safety net for unforeseeable disasters and “genuinely insurable risks” like bad health. However, on the next page he explains why an efficient economic system cannot satisfy the individual’s demand for a “fair wage” that may be entirely morally justified and still preserve the society’s economic or competitive interests.
This does not answer the question of who pays the cost of health care and disaster insurance. Does a “fair wage” include enough for the individual to pay for this safety net, or is it paid by universal taxation?
You ask fair questions about what Hayek means in his Road to Serfdom. The trouble is that so much has changed in medicine (in terms of costs and technology) that it is difficult to guess which of Hayek's rules is appropriate to apply. I've researched the issue a bit on the internet and not found a definitive statement. Also, I hesitate to enter into a debate when I don't believe that an authoritarian approach is . It would be of no more value to us to try figure out what Hayek would have said about ObamaCare if he were alive, than Jesus or Alert Einstein.
It seems to me that many problems go away if insurance provides a cash payout to the patient rather than the service provider. Medical service suppliers then have a reason to compete. The patient has a reason to be discriminating.
Hayek was correct in his basic logic that an organization or system cannot be a complete model of itself. I find this logic expressed most clearly in his Sensory Order (1952) where Hayek cites Gödel's proof as confirmation of his view of cognitive theory.
Hayek’s “uncontrollable” economic theory is based on this logic. Of course he also supported it with Adam Smiths’ “invisible hand” model in which order “emerges” without the hands’ knowledge or control.
The weakness in this logic is that while there can be no one complete control model, there is no reason there cannot be many partial control models. Another economics Nobelist, Herbert Simon, showed much more convincingly in The Architecture of Complexity that such “partially decomposable” approximate models are actually the way we do science and economics.
Hayek’s logic would also self-defeating in the sense that a “free-market” is itself a single model, and too simple to explain a complex economics. Of course Hayek modified all of his views over the years. In The Constitution of Liberty he says, "probably nothing has done so much harm to the [classical] liberal cause as the wooden insistence of some liberals [modern conservatives] on certain rules of thumb, above all of the principle of laissez-faire capitalism."
Hi, Howard . . I haven't followed the entire thread, but I was intrigued by your reference to self-reference -- eg Godel -- and it brought to mind a conversation from quite a while back, where if I recall correctly, you cited Russell's defense against the self-referential paradox bearing his name. I believe u characterized Russell's theory of levels as simply refusing to ask the question - if attempting to answer it results in problems.
It's also very likely that my memory has failed me here, as it has on other occasions.
However, if one takes mathematics as relevant to the world - perhaps platonistically - then perhaps it is okay to bar the question. After all, I've never seen a herd of elephants that was an elephant. I'm assuming ur following . .
If there is to be a unification of mathematics, physics, and consciousness -- which I believe may be possible -- at least partially -- then mathematics cannot stand unto itself ignoring the realities that others have used to to model. That's okay for pure mathematics -- but not for its integration with mind & matter.
So much more to say, but ahh . . such little time.
Eric Schayer
NYC
PS . . I also seem to recall a reference to Copenhagen QM interpretation, from which I got the impression u might view such interpretation in a positive light. Given the continuing controversy (eg Penrose), may I ask your opinion as to an appropriate collapse model?
Thanks much, and I'm glad ur still "playing the game" . . as it never seems to end, keeps us all busy . . -- E
Hi Eric,
Just to orient other participants and lurkers, you are referring to the most important question of philosophy: What do we know and how do we know it? Or, what is in our brains, what is not in our brains, and how do they relate? Are mathematical models in the brain or out there?
Normal people and children are naive realists, but philosophers have all kinds of excuses for thinking otherwise, from solipsism to eliminative materialism.
Then quantum theory came along and made this question really difficult. It proved J. B. S. Haldane’s belief correct that, “the universe is not only stranger than we imagine but stranger than we can imagine.” Einstein thought it was crazy. What is out there is described by a coherent (entangled) complex mathematical field called the wave function that follows strict laws that are experimentally verified. The only way to know anything about a particular system’s wave function is by some kind of measurement. The problem is that any measurement process is a classical concept that is not itself describable by a wave function. What’s worse, any measurement appears to destroy the coherent states of the wave function.
Current thinking is that coherence of a system is lost by (usually) unavoidable interference with its environment (noise) as well as by measurement, which is just one form of interference. Whether it is really lost or just unobservably blurred is the issue, which may be undecidable.
If you are interested, here are two good books.
Louisa Gilder, The Age of Entanglement. New York: Alfred A. Knopf, 2008.
Amir Aczel, Entanglement. New York: Plume, 2003.
Howard
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