The New York Times had an article in the Sunday Magazine about why we must ration health care. The author, Peter Singer a Princeton bioethecist, wrote more cogently on many of the same issues that I tried to develop in previous posts. One interesting point that he made with some statistics to back up his statement, is that we are rationing health care currently by our access to health care. He points out that the big difference between the rationing in Britain is that we know the names of the people dying due to the denial of care, while in our system, the people who die are unnamed and unknown.
Professor Singer points out that there is a clear bias to save a named person, so rationed national health care is a hard sell. He also notes that it is hard to be sure exactly how many people are dying due to lack of insurance, since this population has many confounding variables. In particular, people without insurance tend to smoke more than those with insurance, and the additional mortality masks other subtler effects.
Both of these points also raise another difficult issue. You might not like all of the people who do better under a national health care system. Your mother or spouse may have treatment denied in favor of someone with unhealthy habits or with a lifestyle you object to. Physicians (ideally) treat all patients equally and don't make moral judgments. A national health care system must do the same.
The method Professor Singer proposes for making the choices required is the Value of a Statistical Life and the Quality Adjusted Life Year (QALY). The first is the amount of money people would be willing to spend to lower the number of fatalities in the population by 1 person, and the second is a portion of a completely healthy life available to a person for one year. Professor Singer acknowledges that both measures of value have serious issues and that they give an appearance of precision where there is none. However, he argues that they are the least bad methods for apportioning medical care. He also notes that various value judgments society makes, e.g., the life of a teenager is worth more than the life of an 85-year old, can be incorporated into adjusted versions of these measures.
I am not sure that I agree with the least bad argument. An imperfect measure of the value to place on a medical treatment will warp how health care is dispensed. It is clear that there is already warping in health care, but we don't know a-priori that we will have a more acceptable warping with a bad but different procedure. This gets back to one of the questions of fundamental interest to me. Is there an appropriate way to determine whether we are making a good decision when we are making that decision in the absence of knowledge?
Monday, July 20, 2009
Saturday, July 18, 2009
A Riff On Music
I really like Billy Joel's It's Still Rock and Roll to Me, so I was taken aback to discover that it is the "epitome of B.J. badness" by "The Worst Pop Singer Ever."
My feelings for It's Still Rock and Roll to Me have nothing to do with the merits of the song. I like the song because it came out the summer I turned 16 and the last summer that my brother spent the entire break at home. It is forever associated with being very young, learning to drive, and getting to hang out with my brother who was unbelievably cool and who I worshiped.
I am hard pressed to think of any music that I like that I don't like because it brings back some great memory or reminds me of someone. My brother's musical tastes included jazz, Jethro Tull, and The Eagles. If you poke through my CDs, you will find that all are in my collection. When I listen to Aqualung, I am actually thinking about listening to the albums my brother let me borrow while he was away at college.
My father's taste ran toward big band, and he is responsible for my copy of the 1938 Carnegie Hall Concert. About five years ago, I began to listen to a lot of Art Tatum. I brought the CD over for my father to borrow and found that the CD I wanted to give him was actually the very first album he had bought for himself.
My mother introduced me to opera and to Handel's Messiah. I cannot argue the merits of opera and choral music, but listening to it reminds me of going into Kansas City with my mom to the Lyric Opera. She would generally take us to the Italian Gardens for supper, and I always felt very grown up being on the town with her. As a small repayment of this debt I have been taking my mom to performances in Boston for birthday and Christmas presents. So far we have seen The Messiah and Don Giovanni. I hope to take her to see either Carmen or The Soweto Gospel Choir this Christmas.
My roommate in college had the biggest impact on my taste in music. Fred was really into the LA Punk scene, Ska, and Devo. I can't explain why I enjoy this music as much as I do, but it probably has to do with breaking away from suburbia and Top 40 radio. To this day I will listen to anything by the Clash or Elvis Costello or the Ramones.
From my wife I developed a taste for folk, Tom Rush, and The Chipmunks. My children have absorbed a portion of my varied musical tastes, but they have also started introducing me to music that they like.
Like so much in my life, my favorite music is just random bits from the lives of people I have bumped against. If they bumped against me at a time holding some special significance, the music seems to be strongly embedded in my psyche.
If I am generous, I would like to think maybe 10% of my life is under my control. My family and my roommates were selected by pure happenstance. There were bits of their personalities which affected me strongly and I tried to absorb. I met my wife through a ridiculous set of coincidences, and my only contribution was the determination to not let go of this person who was willing to go out with me more than once. (See John Hodgman's proof that aliens exist.) The particular children I ended up with were the result of a particularly fascinating lottery (talk to my friend Doug Sweetser about lotteries and children.) Again my only contribution to this random event is the effort to spend as much time as possible with such cool people.
The importance of random events and music in my life is why I think the MP3 player is the ultimate piece of Western technology (actually, it ties with the closely related flash drive.) I have an eclectic music collection. There are many CDs that I own, that I really wouldn't want to listen to more than one song at a time. Shuffle mode on an MP3 player is perfection. I enjoy listening to a steel band playing Eine Kleine Nacht Musik, followed by Ernie singing Put Down The Ducky, followed by California Uber Alles, followed by Habonera.
It was actually the odd conjunction of The Shangri Las singing Remember followed by Blood, Sweat, & Tears singing That Old Sweet Roll this morning which led to this post. The last time I heard this combination was about 25 years ago on the mix tape that my future wife had sent me.
My feelings for It's Still Rock and Roll to Me have nothing to do with the merits of the song. I like the song because it came out the summer I turned 16 and the last summer that my brother spent the entire break at home. It is forever associated with being very young, learning to drive, and getting to hang out with my brother who was unbelievably cool and who I worshiped.
I am hard pressed to think of any music that I like that I don't like because it brings back some great memory or reminds me of someone. My brother's musical tastes included jazz, Jethro Tull, and The Eagles. If you poke through my CDs, you will find that all are in my collection. When I listen to Aqualung, I am actually thinking about listening to the albums my brother let me borrow while he was away at college.
My father's taste ran toward big band, and he is responsible for my copy of the 1938 Carnegie Hall Concert. About five years ago, I began to listen to a lot of Art Tatum. I brought the CD over for my father to borrow and found that the CD I wanted to give him was actually the very first album he had bought for himself.
My mother introduced me to opera and to Handel's Messiah. I cannot argue the merits of opera and choral music, but listening to it reminds me of going into Kansas City with my mom to the Lyric Opera. She would generally take us to the Italian Gardens for supper, and I always felt very grown up being on the town with her. As a small repayment of this debt I have been taking my mom to performances in Boston for birthday and Christmas presents. So far we have seen The Messiah and Don Giovanni. I hope to take her to see either Carmen or The Soweto Gospel Choir this Christmas.
My roommate in college had the biggest impact on my taste in music. Fred was really into the LA Punk scene, Ska, and Devo. I can't explain why I enjoy this music as much as I do, but it probably has to do with breaking away from suburbia and Top 40 radio. To this day I will listen to anything by the Clash or Elvis Costello or the Ramones.
From my wife I developed a taste for folk, Tom Rush, and The Chipmunks. My children have absorbed a portion of my varied musical tastes, but they have also started introducing me to music that they like.
Like so much in my life, my favorite music is just random bits from the lives of people I have bumped against. If they bumped against me at a time holding some special significance, the music seems to be strongly embedded in my psyche.
If I am generous, I would like to think maybe 10% of my life is under my control. My family and my roommates were selected by pure happenstance. There were bits of their personalities which affected me strongly and I tried to absorb. I met my wife through a ridiculous set of coincidences, and my only contribution was the determination to not let go of this person who was willing to go out with me more than once. (See John Hodgman's proof that aliens exist.) The particular children I ended up with were the result of a particularly fascinating lottery (talk to my friend Doug Sweetser about lotteries and children.) Again my only contribution to this random event is the effort to spend as much time as possible with such cool people.
The importance of random events and music in my life is why I think the MP3 player is the ultimate piece of Western technology (actually, it ties with the closely related flash drive.) I have an eclectic music collection. There are many CDs that I own, that I really wouldn't want to listen to more than one song at a time. Shuffle mode on an MP3 player is perfection. I enjoy listening to a steel band playing Eine Kleine Nacht Musik, followed by Ernie singing Put Down The Ducky, followed by California Uber Alles, followed by Habonera.
It was actually the odd conjunction of The Shangri Las singing Remember followed by Blood, Sweat, & Tears singing That Old Sweet Roll this morning which led to this post. The last time I heard this combination was about 25 years ago on the mix tape that my future wife had sent me.
Friday, July 10, 2009
What do we value?
Why do we owe people health care?
With no certainty about what lies on the other side of death, we all must place the greatest value on our continued existence. Yet there are limits to what people spend to preserve themselves. Most of us have finite funds, so at some point we exhaust our individual capacity for buying continued life in any increment. We value our family's survival, and most of us reach a point where we won't beggar our family for additional life. This is particularly true, since when we have reached that point in our illness, the additional life that can be purchased has little value. Sometimes life can be bought through another person's suffering. Again, most people are unwilling to pay this price if the cost is obvious.
Conversely, people will sometimes sacrifice themselves for others. Parents face danger for their children, soldiers for their comrades, firemen or police officers for civilians.
The point is there are limits to what a typical (mentally healthy) person is willing to spend on his continued existence. Given that the person most interested has limits, it must be acceptable for society to accept limits as well.
Your family also places a value on your life. Some people contribute to the support of the family, so they have true economic value. Courts consider this when determining liability in a wrongful death lawsuit. Family members have tremendous emotional value (again typically) to the rest of the family. Anecdotally, it appears that family emotional attachment leads to more extreme efforts to preserve a life than a person would expend on themselves. I would guess that the value a family puts on an individual's life is the largest any concerned party would assign.
Employers also have an economic interest in your health. Most likely, a company has some contractual obligation to insure your health. This obligation is strictly limited, since both your employer and its insurer are interested in maintaining profitability. In addition, your contribution to the company has economic value which would be disrupted by illness or death. Even when you are easily replaceable, your absence will disrupt the company's smooth operation. Loss of someone with unique skills will be correspondingly more devastating.
Your health also concerns your community. At a minimum, you are a source of tax revenue and consumption. To the extent that you volunteer, beautify your home, or participate in politics you enhance your city's quality of life, desirability, and stability. Your death or illness decreases the city's well-being.
There is a more tenuous connection between your life and health and the nation. I half-remember the idea of the social contract, where the nation provides benefits to me, which includes protecting my health and welfare to some extent and in turn, I perform my duty as a citizen by voting, paying taxes, and defending the nation if called upon.
It seems reasonable that the nation acts as insurance for my family and myself. Catastrophic health issues are relatively rare, so together, we should be able to afford some level of health coverage for all people.
There must be an explicit limit to the care that the nation is willing to provide. At some point additional care would require too much money. These limitations seem reasonable to me. Our current system has implicit limits to care that largely fall on anyone who is unfortunate enough to suffer some catastrophic illness. It seems that our system only offers choice and quality care to people who don't yet need it.
This has been a long, rambling, and delayed post. I am trying to develop the notion that the more distant a connection between you and any other person in the US, the less reason they have to support you during illness. However, there are more and more people as you get further from a direct connection, so adequate protection from illness should only require a small commitment from them. I have yet to address how much the nation owes you or provided an proof that such a debt exists. I have not yet addressed how much faith we can put in our existing valuation of life and health. I hope to write more cogently and often about these questions in the future.
With no certainty about what lies on the other side of death, we all must place the greatest value on our continued existence. Yet there are limits to what people spend to preserve themselves. Most of us have finite funds, so at some point we exhaust our individual capacity for buying continued life in any increment. We value our family's survival, and most of us reach a point where we won't beggar our family for additional life. This is particularly true, since when we have reached that point in our illness, the additional life that can be purchased has little value. Sometimes life can be bought through another person's suffering. Again, most people are unwilling to pay this price if the cost is obvious.
Conversely, people will sometimes sacrifice themselves for others. Parents face danger for their children, soldiers for their comrades, firemen or police officers for civilians.
The point is there are limits to what a typical (mentally healthy) person is willing to spend on his continued existence. Given that the person most interested has limits, it must be acceptable for society to accept limits as well.
Your family also places a value on your life. Some people contribute to the support of the family, so they have true economic value. Courts consider this when determining liability in a wrongful death lawsuit. Family members have tremendous emotional value (again typically) to the rest of the family. Anecdotally, it appears that family emotional attachment leads to more extreme efforts to preserve a life than a person would expend on themselves. I would guess that the value a family puts on an individual's life is the largest any concerned party would assign.
Employers also have an economic interest in your health. Most likely, a company has some contractual obligation to insure your health. This obligation is strictly limited, since both your employer and its insurer are interested in maintaining profitability. In addition, your contribution to the company has economic value which would be disrupted by illness or death. Even when you are easily replaceable, your absence will disrupt the company's smooth operation. Loss of someone with unique skills will be correspondingly more devastating.
Your health also concerns your community. At a minimum, you are a source of tax revenue and consumption. To the extent that you volunteer, beautify your home, or participate in politics you enhance your city's quality of life, desirability, and stability. Your death or illness decreases the city's well-being.
There is a more tenuous connection between your life and health and the nation. I half-remember the idea of the social contract, where the nation provides benefits to me, which includes protecting my health and welfare to some extent and in turn, I perform my duty as a citizen by voting, paying taxes, and defending the nation if called upon.
It seems reasonable that the nation acts as insurance for my family and myself. Catastrophic health issues are relatively rare, so together, we should be able to afford some level of health coverage for all people.
There must be an explicit limit to the care that the nation is willing to provide. At some point additional care would require too much money. These limitations seem reasonable to me. Our current system has implicit limits to care that largely fall on anyone who is unfortunate enough to suffer some catastrophic illness. It seems that our system only offers choice and quality care to people who don't yet need it.
This has been a long, rambling, and delayed post. I am trying to develop the notion that the more distant a connection between you and any other person in the US, the less reason they have to support you during illness. However, there are more and more people as you get further from a direct connection, so adequate protection from illness should only require a small commitment from them. I have yet to address how much the nation owes you or provided an proof that such a debt exists. I have not yet addressed how much faith we can put in our existing valuation of life and health. I hope to write more cogently and often about these questions in the future.
Thursday, July 2, 2009
The Measure of Man
A life considered in a courtroom has a different value than one considered in an FDA meeting room. The courts are concerned with a particular person who has already suffered death or injury, while federal agencies are concerned with an unknown group of people who may suffer or die in the future.
The court wants to determine the amount of liability incurred by the defendant. The compensation has an economic and a non-economic part. The economic portion covers the income lost if the person is still alive; otherwise, it covers the money the person would have provided to their heirs. People in this situation are typically valued by the amount people in their demographic would earn. This approach assigns little value to children or people over age 70, since they have no income.
There is a second punitive portion of a court award as well. This can be used to compensate the family for their grief. It can also be used to compensate an injured, but living, person for the "pain and suffering" of their injury. There have been some studies, primarily aimed at evaluating medical care, which attempt to assign a dollar value to health. Finally, the non-economic portion can be used to compensate the lawyers involved in the case.
Public policy depends upon a different valuation. People setting policy are trying to weigh the cost of regulations against the corresponding reduction in risk. Law requires the executive branch perform cost/benefit analyses to justify new regulations. These analyses depend upon the Value of a Statistical Life (VSL). One thought experiment (Reference 285), explains VSL as follows: Assume you are in a stadium with 10,000 people, and one randomly selected person attending the event will die. Ask everyone how much they would be willing to pay to save that person. The total amount spent by the 10,000 people is the value of one statistical life.
There are a number of methods for determining these valuations. The value of a statistical life is often found by looking at the difference in pay rates for jobs with similar qualifications and duties but varying risks of death. Surveys seem to be another source of information about how much a life is worth, particularly for looking at how much life of a given quality is worth.
I will look further at the validity of these methods of valuing human life, but we should also consider whether these approaches really capture how we want to measure the worth of a person.
The court wants to determine the amount of liability incurred by the defendant. The compensation has an economic and a non-economic part. The economic portion covers the income lost if the person is still alive; otherwise, it covers the money the person would have provided to their heirs. People in this situation are typically valued by the amount people in their demographic would earn. This approach assigns little value to children or people over age 70, since they have no income.
There is a second punitive portion of a court award as well. This can be used to compensate the family for their grief. It can also be used to compensate an injured, but living, person for the "pain and suffering" of their injury. There have been some studies, primarily aimed at evaluating medical care, which attempt to assign a dollar value to health. Finally, the non-economic portion can be used to compensate the lawyers involved in the case.
Public policy depends upon a different valuation. People setting policy are trying to weigh the cost of regulations against the corresponding reduction in risk. Law requires the executive branch perform cost/benefit analyses to justify new regulations. These analyses depend upon the Value of a Statistical Life (VSL). One thought experiment (Reference 285), explains VSL as follows: Assume you are in a stadium with 10,000 people, and one randomly selected person attending the event will die. Ask everyone how much they would be willing to pay to save that person. The total amount spent by the 10,000 people is the value of one statistical life.
There are a number of methods for determining these valuations. The value of a statistical life is often found by looking at the difference in pay rates for jobs with similar qualifications and duties but varying risks of death. Surveys seem to be another source of information about how much a life is worth, particularly for looking at how much life of a given quality is worth.
I will look further at the validity of these methods of valuing human life, but we should also consider whether these approaches really capture how we want to measure the worth of a person.
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