Peter Singer’s Kind Of Health Care?
My post last week criticizing Princeton ethics professor Peter Singer received a storm of protest, including comments from a much more respectable ethicist professor as well as email that I am fairly confident came from one of Singer’s own adoring graduate students. The primary charge from these defenders of Singer was that I was being unfair to the great man by calling his ethical views morally reprehensible.
Almost on cue, however, a story has emerged that provides a concrete illustration of what health care reform using Singer’s principles would look like. Recall that Singer was suggesting that $50,000 was far too much to pay for a cancer treatment that merely extended life rather than actually curing the cancer. Singer argued quite bluntly that some lives are not worth the cost of extension. Well, it appears that the state of Oregon agrees, denying coverage for a chemotherapy treatment that would extend life for up to several years at the cost of $4000 a month ($48,000 for a year). Oregon was quite willing to pay for the much more cost-effective option of assisted suicide, however. In short, this story reports on a real-world case that mirrors Singer’s analysis almost exactly.
Bottom line: The state is willing to pay the bill to kill the patient, but not to extend the patient’s life. And even the defending interpretation of Peter Singer’s “ethical” mandate would appear to endorse this kind of analysis.
Beyond merely our natural shock at such a callous attitude towards a human life, the relevant question is how this attitude from Oregon’s state-run health care system might be extended to a federal health care system that many pro-reform advocates are insisting is the only socially justifiable way to honor human life. We are owed direct answers to questions about what criteria their government system would use to determine which lives were worth extending and what the exact dollars-per-month they would be willing to authorize spending to extend those lives. Darker questions also come up here, such as concerns about whether the criteria used to measure the cost-benefit ratios in the government’s health care bureaucracy might be manipulated to reward some groups while reducing coverage to those less politically well-connected to either the bureaucracy or whatever party was currently in power.
Are some lives more valuable to extend than others? If so, which lives and by how much more are those lives to be valued by the state?
Isn’t the fact that we even have to ask such questions scary? What this reveals is that so-called “single-payer” health care means not only granting the government ownership of up to 1/5 of the entire U.S. economy, but it means granting the government unaccountable ownership of its citizens lives, with the value of those lives being determined on criteria that many single-payer advocates won’t even disclose or talk about. In fact, they are insisting that the health care reform bill needs to be passed before in can even be read, let alone analyzed and debated.
And that’s just Orwellian.
it doesnt matter because Americas REAL 2 party system is washington and wall st
http://rawdawgb.blogspot.com/2009/08/americas-real-2-party-system.html
It’s nice of Mr. Arvak to care enough about this to write a follow-up.
He says the “primary charge” in the criticisms of the previous article is his being “unfair” to Singer “by calling his ethical views reprehensible.” I don’t think name calling was the problem, though.
In that piece, Mr. Arvak made statements about Singer that are untrue (such as that he reversed his position about our obligation to assist the poor, and that he is unwilling to defend his views). That does not move the debate forward.
In the Oregon case discussed here, a treatment was denied that, if it had not been denied, would have reduced the funds available for other lifesaving treatment, particularly treatments for other ailments that extend lives further because of their lesser cost per year. So either way you are choosing to deny coverage, and thus to place life into a calculation. We can’t evade that, so we might as well face it and try to think about it as clearly as possible. That is Singer’s point.
And I hope Mr. Arvak wasn’t referring about me as being one of Singer’s graduate students. I’m an undergraduate and I don’t go to Princeton. My favorite writer is Steven Pinker.
Mark
But every single treatment can be objected to with this argument. So that brings me back to the question you (and Singer) persistently fail to answer — where’s the line? Should all chemotherapy patients be refused in favor of assisted suicide (which is always cheaper)? Just some of them? Which ones? What criteria should be used to declare some lives more valuable than others? Age? Race? Political affiliations? Donations to charity? Donations to the Democratic Party? Donations to endowed chairs at Princeton?
The cost-effectiveness argument is almost infinitely reductionist, since assisted suicide only costs about $100 per patient. Is this what you (and Singer) propose as the foundational assumption for medical care — just kill all the sick ones? Alternatively, it is open to serious abuse if we start saying that some lives are worth saving, others worth extending, and still others worth neither.
I think that framework is morally reprehensible and I stand behind my rejection of it. Even though I am generally a utilitarian, there comes a point (life-saving and significantly life-extending medical care is it) when it breaks down and becomes horrifying and dehumanizing.
Furthermore, you claim to know more than you possibly could know in your confident assertion that the denial of life-extending treatment freed up funds for other treatments that would extend lives further. There is no way you can simplify this into the zero-sum thought experiment that you are deploying to defend Singer’s framework. His (and yours) is the classic error of the abstract academic — assuming that the thought experiment is a reflection of the real world while remaining blissfully free of the real-world consequences of the “sorry, you get to die” proclamations.
In his article, Singer is intentionally not developing his own suggested health care plan. He is simply making the relatively limited point that no matter what plan we choose, we are unavoidably placing an economic value on human life and suffering, as well as that those who are making specific suggested plan would be better off recognizing this situation explicitly rather than not admitting it while doing it implicitly.
First, if health care were fully a free market system, the “ability to pay” would decide whether or not someone dies (or lives in chronic pain), and this would allow people who have the money to pay a huge sum to keep a terminal cancer patient alive for several months, while a young child with early stages of bone cancer, who could have returned to health, can painfully die because his or her parents are unable to afford treatment. Second, if we have a more government regulated system, the “ability to pay” is no longer a criteria (or is a lesser criteria, as the case may be). But since it cannot pay for everything, there would inherently have to be SOME criteria upon which to place a value on life an suffering.
As for the specific application, once again Singer is not playing know-it-all by devising his own system. Nonetheless, Singer provides preliminary suggestions for a system of criteria for “rationing” health care, based on the Quality Adjusted Life Year. It would definitely not be based on the personal characteristics of individuals (that might work among a small group of people on a sinking boat, but not in a giant bureaucratic system). Nor do I think it would provide a justification for “killing all the sick ones” because, just like the rest of us, sick people certainly have preferences for the future, which gives them an interest in their continued existence that would be taken into consideration in any calculus.
I think you’re exactly right to be concerned with the long-term effects of attempting to calculate the economic value of life and suffering. Even from a utilitarian perspective, we should consider whether such a mindset might bring about policies and practices that take life and suffering less seriously in the long term. I don’t know of consequentialist philosophers who have tackled that issue adequately. On the other hand, a calculation of suffering and life might increase people’s concern for others as we sacrifice for one another. Even if the evidence points to the former, how can a utilitarian work towards balancing it against the suffering that’s reduced at the outset via “rationing” rather than free market health care?
Nice to have spoken with you,
Mark
“Quality” as determined by whom?
This doesn’t solve the problem, it just kicks the can down the road and obscures the ultimate criteria underneath the word “quality”.
Also, because the determination is predictive, it suffers from the usual problem of consequentialism — that consequences cannot be known in advance, only guessed at. And when you are asking people to die based on a subjective and uncertain prediction about future “quality” of life, I think the case for a more deontological approach becomes much stronger.
P.S. Please stop attempting to include advertisements for Singer’s favored political/social/charitable projects in your posts. I am editing them out as off-topic anyway.
Great, so you agree with the premise that we are unavoidably rationing health care in some way, but you are unsure about what system would so do best, and you are particularly skeptical about the QALY (Quality Adjusted Life Year) idea. I agree with you on all of that.
As for “who” would make the judgments, Singer’s article suggests a system like the British NICE independent agency, operating around strict limits set into law by Congress. If we look into such systems and decide that they are so inefficient or corrupt that the consequences of their implementation would be worse that the current system, then we should not implement them. But this seems unlikely, since even the imperfect British and Canadian systems, which spend less per person, result in a much higher percentage of citizens satisfied with their health care than in the United States.
I do not see our inability to predict the future as a reason against continuing to hold “good consequences” as our goal, if that is what we value. For example, if we have to go to war, and we can’t decide which strategy would result in the fewest of our soldiers dying, we would not change our goal to a deontological one that fails take the predicted consequences into account.
However, if you think that a deontological approach would result in better consequences overall, I would be interested to hear your suggestions as to how we would apply deontology to this situation, in contrast with an approach like Singer’s. And even in the unlikely event that you are really not concerned with consequences, what kind of deontological approach are you suggesting, and how would it be applied?
Finally, I was bringing up humanitarian aid previously because I think it’s based on the same principles that we are applying here, of reducing the people who we allow to suffer and die, so that our conclusions on this issue force us to accept conclusions on that issue.
Mark
Interesting that the percentage of Americans satisfied with their health care is on the rise now that the threat of a British/Canadian-like system is potentially drawing closer.
There is also the question of when to draw the line in providing care to the elderly, given that we are rationing health care and that 30% of Medicare spending takes place during a “client”’s last year of life. If we’re talking about directing health care dollars, most of that money would be better spent on the very young rather than the very old.
Yeah, I suspect that the increased percentage of Americans who are self-reporting satisfaction with their health care is related to the attack campaigns being run by reform opponents.
Yeah, I suppose you can just assume that everyone who responds in a way that contradicts your beliefs is just being tricked/coerced.
Or you could question whether your beliefs are universal. But nah, that’s bad for your ego. Don’t ever do that.
Why are you stooping to personal attacks? I never did that. I’ve been very respectful. Nor do I believe I have a big ego. I’m trying to think clearly about what policies I should support, and discuss the arguments with other informed people. Isn’t that what this site is for?
Since our health care system has not changed yet, the alteration in reported satisfaction levels could not be based on a change in the level of care. The most parsimonious explanation would seem to be that it is a response to those campaigns, which is certainly what they were intended to elicit.
You didn’t respond to my previous post (#6, directly above the “marc moore” post) about what deontological approach you would choose over a consequentialist one like Singer’s, and how it would be applied to health care. That would be enlightening.
Criticizing your argument (or more accurately, your presumption that everyone who disagrees with your assessment of the U.S. health care system is some kind of easily-coerced mental defective) is not the same as “personal attacks”, Mark. Perhaps your inability to see the distinctions between criticizing speech/behavior and attacking the person is also why you misunderstand my criticism of Singer’s arguments and his contradictory behaviors.
“Yeah, I suspect that the increased percentage of Americans who are self-reporting satisfaction with their health care is related to the attack campaigns being run by reform opponents”
Well YEAH….If something I liked (or was happy with) was being attacked by the majority party in my government, I would certainly self report satisfaction. That is to put it lightly… (more likely probably vehemently tell them absolutely no single payer system).. That is certainly what seems to be happening with most American voters anyway in regards to healthcare. When you see people at these town hall meetings…
Oh right, according to MSM these meetings are “fabricated”, “astroturf” I forgot.
Where and when do we live again? did I go back in time and move to the USSR?
At the point that a White House official openly asks people to report their neighbors who dissent from its public health care proposals, it is a disturbingly valid question.
Not to get off point, but, yeah Jason, so, that is for real huh? I heard that in passing this morning on my way to work on the radio. The folks on the radio sounded like they were half joking around so I didn’t pay it much attention, but I looked it up, yup they said it. What the heck??
Yeah, I linked to it in my post about health care reform protests this morning. I doubt that it was truly intended in the Orwellian straight-out-of-Maoist-China “neighborhood monitors” way that it sounded, but it is real.
Then again, at the point that leftist pressure groups sue to force the release of the names and addresses of people who signed a petition they disagree with in Washington State for the explicit purpose of publishing their personal information on the web and encouraging readers to confront and harass them, I think the desire on the left to use the government as a tool for the coercive suppression of political dissent is very real.
By criticizing that minor side-comment of mine, you seem to be ducking my actual objections to your arguments.
You suggested that we cannot apply consequentialism to health care because the situation is too unpredictable. I responded that unpredictability does not seem to be an inherent reason against consequentialism, and I provided the example of warfare (if we cannot be sure which decision will allow fewer soldiers to be killed, it does not mean that we should switch to a deontological view that fails to take those consequences into account).
I asked you to explain why we should still choose a deontological approach in light of that objection, and what deontological approach you would choose/how it would apply to health care. I don’t think I’m “misunderstanding [your] criticisms of Singer’s arguments,” but rather that I objected to your criticisms in each post, and you lack a response to my last objection.
If you really made a criticism of Singer that I didn’t understand/respond to, or if you can point to an actual “contradictory behavior” that Singer is engaging in, I’d be very happy to hear about either one. Otherwise, I’ll read the newspaper for more discussion of this topic, and I’ll continue reading your and others’ articles about other topics on this site. Keep up the good work with everything else.
Mark