The Value of Life, III

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?