Sunday, April 11, 2010

What's wrong with death panels, anyway?

The Democrats promise that a government health care system will reduce the cost of health care, but as the economist Thomas Sowell has pointed out, government health care will not reduce the cost; it will simply refuse to pay the cost. And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.- Sarah Palin.

Most people begin the discussion of all of this by claiming that Obama's bill isn't committed to this, and I agree. But let's pose a philosophical question. Why is such a system evil? Exactly? By what moral principles do we condemn it? Utilitarianism? Rawlsianism? Kant's theory? Relativism? Divine Command Theory?

Isn't this just like triage on MASH? 

31 comments:

bossmanham said...

It impinges on people's personal liberties. If one wants health care and another wants to provide that health care after agreeing on a price, a government should not have a say in that process. It is and should be between private individuals, not bureaucrats. If the government pays for these procedures, it becomes the one who determines who to pay for.

The decrease in the availability of doctors per individual also poses a problem for these panels to consider. If there isn't enough doctors for several people who need the same procedure, then the payer (Uncle Sam) chooses whose life is worth more.

The system should be increasingly privatized, not nationalized.

David said...

1. there are much better alternatives
2. it changes the relation between the citizen and the state
3. all government programs have not worked as planned
4. we're broke

David said...

let me rephrase in more philosophical terms:
1. let's use our brains
2. I like being free
3. I don't trust the sonabitches (I've been here for the decline of California)
4. we own too much to the damned Chinese Commies

Victor Reppert said...

Do we avoid death panels simply by excluding people from health care because they can't afford it and aren't insured?

It looks like we have bureaucrats, anyway. Why are privately employed bureaucrats worse than ones on the public dime. A bureaucrat is a bureaucrat.

If you have a scarce resource, then you can put it on the open market and make it a matter of affordability, in which case some people are SOL because they don't have the dough or the benefits.

Clayton said...

I love this line, "And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course."

Of course they lose out. That's just analytic. When we run out of some finite commodity, it is those who needed that commodity who will not have their needs met. Those who don't have that need have no needs left unmet.

Anyway, I think it's worth remembering that Sarah Palin loved free, public health care. She loved it when she needed it. That's why she went to Canada to get it. Of course, she then became a public official and got more free health care on the tax payer's dime. She probably pays for her own health care now that she's abandoned public office to sell her books. But, she's been a big fan of free, public health care for a while. Up until the point it became politically expedient to say she was against it.

Here:
http://www.theglobeandmail.com/news/national/sarah-palin-sees-eye-to-eye-with-albertans-in-calgary-speech/article1492634/

Key quote, "The vocal opponent of health-care reform in the U.S. steered largely clear of the topic except to reveal a tidbit about her life growing up not far from Whitehorse.

“We used to hustle over the border for health care we received in Canada,” she said. “And I think now, isn't that ironic?” "

"Ironic" isn't the word that comes to my mind.

Victor Reppert said...

One could argue that what Obama is at least trying to do is to shut down death panels. The death panels that exclude people from coverage because of pre-existing conditions. The death panels that drop you from coverage when you get sick. The death panels that say that a battered woman has a pre-existing condition, and can be denied coverage on that account.

BMH: If one wants health care and another wants to provide that health care after agreeing on a price, a government should not have a say in that process. It is and should be between private individuals, not bureaucrats. If the government pays for these procedures, it becomes the one who determines who to pay for.

VR: This precisely presumes that insurance companies do not exist. Why assume that? Do you think that the people who make these decisions for the health insurance companies aren't bureaucrats? At least public bureaucrats don't have stockholders to answer to, and don't have to pay an exorbitant salary to a CEO.

Fishermage said...

The difference is between the free exchange between an owner of a product and the customer vs. an agent that has the power to eventually bring violent force upon the customer or the owner of the product.

It's not the bureaucrats -- it's the coercive power.

Now, granted, the agent with the power to unleash deadly force is ALREADY heavily involved in this area, and that is probably the primary reason that the costs have gotten out of control.

What morality is it that sees this difference? Not sure what one would call it but it's mine.

I tend to see Jesus as being as against the initiation of violent force as I am, so I am in good company if we wish to go with divine command, although I am of the opinion with Lewis that God loves a thing because it is good, not the other way around.

I begin with the idea that we are God-owned beings (who have been set free by Him, especially in Christ) and as such no man ought to act as our owners. From that I take it to most of the Classical Liberal or libertarian system of negative rights.

Mark said...

It impinges on people's personal liberties. If one wants health care and another wants to provide that health care after agreeing on a price, a government should not have a say in that process. It is and should be between private individuals, not bureaucrats. If the government pays for these procedures, it becomes the one who determines who to pay for.

Huh? Universal health care != abolition of private health care. The "death panels" would not decide whether individuals are fit to obtain private insurance.

Gordon Knight said...

The conservative view: Gov't bureacracy: BAD. Big Insurance Bureacracy; GOOD

As a practical matter those of us who are not millionaires have our access to health care determined by the private insurance industry.

Thousands of people die each year because they do not have insurance.


What we have now is rationing.

Mark Frank said...

"The decrease in the availability of doctors per individual also poses a problem for these panels to consider. "

Why would the availability decrease? The USA does not currently have a particularly high ratio.

Physicians per 1000 people.

France: 3.37

Germany: 3.4

United States: 2.3

United Kingdom: 2.2

Michael S. Pearl said...

What I find very interesting is that the notion of charity has been so very absent from the health care debate. Instead of charity, there are entitlements. Of course, charity has come to be regarded as rather quaint, given its impracticality in light of the extent of health care cost and expenditure inflation. And, instead of in-depth investigation into and consideration of the factors which contribute to this inflation, what has been implemented is ways in which to cap and cut off spending.

Maybe what is wrong with the so-called "death panels" is that the derived policy is based on indolent thinking.

It just so happens that I recently started a blog series about morality and health care reform (see http://www.galilean-library.org/site/index.php?app=blog&module=display&section=blog&blogid=26& ) -- with a new installment coming presently.

Michael

bossmanham said...

I hope Dr. Reppert doesn't mind multiple posts, but I have a lot to respond to.

Dr. Reppert,

Do we avoid death panels simply by excluding people from health care because they can't afford it and aren't insured?

I'm not sure that happens. One reason health costs are so high is because of uninsured people who can't pay their ER bills. You walk into an ER and you get treated. I know people who do it.

It looks like we have bureaucrats, anyway. Why are privately employed bureaucrats worse than ones on the public dime. A bureaucrat is a bureaucrat.

I agree. If conservative approaches to health reform were taken, such as allowing purchasing across state lines, the insurance companies would have far less compulsion to do this, since people would use the free market to purchase better insurance. I personally think health insurance should only be for big procedures, not for everything. The rest should be on a free market system, where prices would have to be competitive and care would have to be quality.

some people are SOL because they don't have the dough or the benefits

Because prices are artificially inflated by the insurance companies paying for everything.

One could argue that what Obama is at least trying to do is to shut down death panels.

Well if he is, then he's going about it the wrong way.

The death panels that exclude people from coverage because of pre-existing conditions.

I agree that something should be done differently here, and I believe the conservative approaches (ie. tort reform, allowing people to buy insurance across state lines, HSA's, etc) are far better ideas, as David pointed out.

This precisely presumes that insurance companies do not exist.

Ideally, the individual should have control over the service provided by the insurance company. Of course I realize that the current system is not perfect and should be reformed, just not in the way it is. Also, as Charles Krauthammer points out,

this law doesn't eliminate the insurance companies, it just makes them arms of the government. We'll have universal healthcare with more beurocracy.

In my perfect world (call it Bossmanham's Conservative Paradise) health care would be on a free market system where providers would have to keep prices competitive and provide quality care in order to survive as a business with very little government regulation (other than safety standards, perhaps).

bossmanham said...

Clayton,

Of course they lose out. That's just analytic. When we run out of some finite commodity, it is those who needed that commodity who will not have their needs met. Those who don't have that need have no needs left unmet.

You'd need to provide an argument that these people somehow don't have as much intrinsic worth as one who is healthier in order to convince me that rationing their care is warranted. But, as it seems that the health care system exists to care for sick people, then they should have first priority over those who are healthier. That seems to be the logical progression for a field where people are treated for illness; the sicker ones need it more.

Anyway, I think it's worth remembering that Sarah Palin loved free, public health care. She loved it when she needed it

But it wasn't that way when she got it. Health care was paid for privately when SP went to Canada, but this is simply a tu quoque.

bossmanham said...

Mark,

Huh? Universal health care != abolition of private health care. The "death panels" would not decide whether individuals are fit to obtain private insurance.

I never said it would initially. But, like in Canada, the private system would be so expensive and hard to access that only the super rich could afford it (or go to a country where quality care at somewhat affordable prices like the premier of Newfoundland). This is because the further government involvement in the health care system would inflate prices so much, just as it has in universities around the country. It would eventually effectively destroy the private market.

bossmanham said...

Gordon,

The conservative view: Gov't bureacracy: BAD. Big Insurance Bureacracy; GOOD

I don't think the government functions as well as the private sector in much of anything. I can't think of anything they run well today.

Michael S. Pearl said...

With regards to bureaucracies, I am in utter agreement with Hannah Arendt. In On Violence she says:

"... bureaucracy or the rule of an intricate system of bureaus in which no men, neither one nor the best, neither the few nor the many, can be held responsible, and which could be properly called rule by Nobody. (If, in accord with traditional political thought, we identify tyranny as government that is not held to give account of itself, rule by Nobody is clearly the most tyrannical of all ...) ... In a fully developed bureaucracy there is nobody left with whom one can argue, to whom one can present grievances, on whom the pressures of power can be exerted."

No matter how obstinate and thoughtless an insurance company bureaucracy may be, there are (in theory) more avenues of appeal (even internal ones) in dealing with an insurance company than there are with government bureaucracies. Here are two postings to a nephrology listserve regarding Medicaid patients that should be of interest. The first one is from a physician in Alaska.

I have a 30 year patient with a failing renal transplant. Her Hb has progressively fallen and was running above 10 until her most recent lab showed a Hb of 8.9 (asymptomatic). Her fe sat 32% ferritin 476 and B12 folate WNL. I rx'd an ESA.

About three weeks late I get a letter denying coverage with a lengthy explanation that to me at least made no sense. I then drafted a letter including copies of her labs and requested they approve the med. About three weeks later I get a second letter of denial!!!

I then phone, bounced around 'on hold' etc. before I speak with the MD who denied the claim. He then goes on to tell me how he approaches anemia in ESRD ... I suggested that the literature clearly supported initiation and while he could manage his own patients they way he wished but his approach wasn't the "gold standard" we all needed to follow. He didn't budge … I wasn't aware the patient is now essentially under the care of the Medicaid reviewer and not me.


This next one is from a physician in Arizona.

I have a very stable 44 year old, compliant dialysis patient who is on active cadaveric transplant list. Cause of her ESRD is lupus. Her lupus has not been active for over 4 years she has been on dialysis. She showed me a letter from her medicaid HMO today who wrote to her recently denying her payment for renal transplant. I quote from the letter written by the medcal director of her insurance company ... Stated cause of denial of transplant expenses is exactly as in the letter;

"Notes from your MD(not sure which MD as she is hardly seeing anyone but me and I have not provided any info ! ) shows u have lupus,this is a comorbidity disease. Kidney transplant would not change your treatment plan for lupus. Talk to your Doctor to see if there are other treatment options that can work for you."

This is an unbelievable twist in nephrology care that I have come across. Would like to seek opinion of US nephrologists, if they have come across similar absurd issues in the current climate of economic downturn for transplant patients in particular and denials ad roadblocks for nephrology care in general, which certainly are on the rise at least in this corner of US.


When all else fails, it is generally easier to sue an insurance company than it is to sue a government, especially the federal government. This situation itself helps to insulate government bureaucrats from being held accountable for their decisions. It is also frequently the case that government bureaucrats are, within the legal system, presumed to be benignly selfless as well as expert.

There is a lot wrong with bureaucracies (and essentially so), but I do not think that an argument will succeed in establishing parity (moral or otherwise) between private and governmental bureaucracies.

Mark said...


I never said it would initially. But, like in Canada, the private system would be so expensive and hard to access that only the super rich could afford it


But that doesn't constitute an abridgment of personal liberties, as per your first comment, unless you think people have the right to purchase services at a certain price (quel socialiste!). No one is being prevented from offering anyone else health care. And it's not the case that only the super rich can afford private health care in Canada.

bossmanham said...

Mark,

But that doesn't constitute an abridgment of personal liberties, as per your first comment

If, because of the government's purposeful actions, the private health care system is torn down and I am forced to rely on a government system that will inevitably ration care, then yes it is an obstacle to my personal liberties.

unless you think people have the right to purchase services at a certain price

I think people have a right to provide unimpeded health services and for the consumer to purchase those services. For the government to get into the health care business and then to regulate its competitors is the biggest sham in American history. Can you imagine if Target was able to regulate Wal Mart?

No one is being prevented from offering anyone else health care

Yes they are, by being regulated to death.

And it's not the case that only the super rich can afford private health care in Canada.

Okay, only the somewhat rich and only the extremely lucky.

Mark said...

If, because of the government's purposeful actions, the private health care system is torn down and I am forced to rely on a government system that will inevitably ration care, then yes it is an obstacle to my personal liberties.

Which liberty? Do you think people have a right to all the health care that can possibly be provided to them? Because every system on offer has the consequence that not everyone will always be able to acquire the health coverage they want. This is a non-starter.

I think people have a right to provide unimpeded health services and for the consumer to purchase those services.

I think people's right to get basic health care is much more important than people's right to provide health care.


Okay, only the somewhat rich and only the extremely lucky.


65% of Canadians have supplementary private health insurance.

Victor Reppert said...

Was Medicare a bad idea? All the arguments against Obama's health care reform were made by Ronald Reagan against in the early 1960s, before it passed. But Reagan never tried to get rid of it when he was President.

Mark Frank said...

This is really drifting away from Victor's point but from a foreigner's point of view I am amazed by the way that US conservatives either ignore or misunderstand the evidence of other countries on health care. The USA is the only advanced economy without universal health care. It is also by far the most expensive. By almost any objective standard (anecdotes are not evidence) the average level of service is no better than other countries: life span, availability of physicians, deaths in childbirth, you name it. Yet the conservative response seems to be to want to make the US system even less like all the others. It looks like ignoring the facts in the blind faith that if something is not working it must be because the market is not free enough.

bossmanham said...

Which liberty?

My liberty to freely purchase health care and the provider's liberty to freely provide it.

Do you think people have a right to all the health care that can possibly be provided to them?

If they can afford it and if another offers it. If the government decides who gets it in spite of someone wanting it and another offering it, then personal liberties are being obstructed.

Because every system on offer has the consequence that not everyone will always be able to acquire the health coverage they want

According to whom? Sounds like an unbacked assertion to me. In the model I described earlier, whoever wanted care and whoever wanted to provide it could access it, especially when private charities and hospitals are considered.

I think people's right to get basic health care is much more important than people's right to provide health care.

Sounds like a reversal of what you just said.

Okay, only the somewhat rich and only the extremely lucky.

65% of Canadians have supplementary private health insurance.


But the supplemental insurance covers very little, and full private insurance and care is illegal, not to mention the wait times and the inability to find a family physician. Lotta good that scant supplemental insurance does there.

And BTW, your data there is over 6 years old.

bossmanham said...

Was Medicare a bad idea?

Yeah, turned out to be. Medicare is beginning to be refused by many providers because it isn't covering the costs and medicare refuses more coverage than any insurance company.

bossmanham said...

The USA is the only advanced economy without universal health care

Why is this a bad thing? Why should we need to do what other countries have done?

We don't have a 15-30% VAT (yet), we have better access to more advanced care, the private sector doesn't face the same budgetary crises that nationalized HC systems do, and we don't have the wonderful wait times that you do.

It is also by far the most expensive

Not true, but it is expensive for the individual, which is the major problem the US faces at this time, but at least the government isn't in debt because of national health care (just a truckload other junk).

It's expensive for the government in your country, and by extension that is passed on to the individual. Just because you don't directly pay the provider doesn't mean it's costing you less (see high taxes). Plus, you pay for people who sit on their butts and don't work to get health care. You like doing that?

By almost any objective standard (anecdotes are not evidence) the average level of service is no better than other countries

Baloney. I hear this so much, but then I read of the terrible wait times, the lackluster service, the dirty hospitals, and my personal connection to people who have been refused health care and have died.

Yet the conservative response seems to be to want to make the US system even less like all the others

Yes, I want a free market where *gasp* innovations are encouraged, quality care is encouraged, and affordable prices are required to run a health care business. Just like Wal Mart and Target compete in prices and quality and selection, so too could the health care system, if only the government would get the crap out of the way.

It looks like ignoring the facts in the blind faith that if something is not working it must be because the market is not free enough.

You got it. The government has its nose in every facet of the HCS in the US, now more than ever since Obamuhh care passed. Too bad, Canadian premiers will have no place to go now.

bossmanham said...

For those interested in the wonderful accomplishments of Mark's wonderful NHS:

Kidney cancer patients denied life-saving drugs by NHS rationing body NICE

Girl, 3, has heart operation cancelled three times because of bed shortage

Cancer survivor confronts the health secretary on 62-day wait

Failing hospital 'caused deaths'

Oh there are so many more.

Mark said...

My liberty to freely purchase health care and the provider's liberty to freely provide it.

LOL, we already agreed this isn't threatened. What is threatened is your ability to purchase it at a certain price. But I see no reason why one has an inalienable right to that. Do you?

If they can afford it and if another offers it.

Great! And after the hypothetical institution of rationing of government-provided health care, if someone wants to offer you health insurance at a price you can afford, you can still buy it.

If the government decides who gets it in spite of someone wanting it and another offering it, then personal liberties are being obstructed.

But this is not at issue.

Sounds like a reversal of what you just said.

Howso? Under universal health care, more people will get more important health care, even if less people provide health care. I don't see a problem.

bossmanham said...

LOL, we already agreed this isn't threatened.

LOL, no we didn't.

What is threatened is your ability to purchase it at a certain price. But I see no reason why one has an inalienable right to that. Do you?

If the action of the government is artificially inflating the price of a public service, then it is affecting my ability to buy it, and the provider's ability to sell it. You seem to be assuming that the government should have this ability in the first place, but it isn't the government's job to decide how much stuff should cost. Yes, if it affects my ability to purchase and the provider's ability to sell, then it is obstructing personal liberties.

And after the hypothetical institution of rationing of government-provided health care, if someone wants to offer you health insurance at a price you can afford, you can still buy it.

At first, perhaps, however the system being constructed will destroy the private sector, if not completely then effectively. The government is not supposed to be regulating the price of anything.

But this is not at issue.

It's the issue.

Howso? Under universal health care, more people will get more important health care, even if less people provide health care. I don't see a problem.

You said "Do you think people have a right to all the health care that can possibly be provided to them? Because every system on offer has the consequence that not everyone will always be able to acquire the health coverage they want."

Then you said, "I think people's right to get basic health care is much more important than people's right to provide health care."

Make up your mind. LOL

bossmanham said...

And how would people get health care if other people didn't have the right to provide it?

Mark said...

If the action of the government is artificially inflating the price of a public service, then it is affecting my ability to buy it, and the provider's ability to sell it.

No kidding. But so what? How is this an abridgment of liberty? How many times am I going to have to ask this question?


You said "Do you think people have a right to all the health care that can possibly be provided to them? Because every system on offer has the consequence that not everyone will always be able to acquire the health coverage they want."

Then you said, "I think people's right to get basic health care is much more important than people's right to provide health care."

Make up your mind. LOL


You're confused. In the first quote, I denied that everyone has a right to all the medical procedures they could possibly want (mainly because health care is a scarce resource and fully satisfying everyone's wants/needs is impossible). In the second quote, I stated I believed that people do have a right to basic forms of health care. How is this different from saying, "Everyone has the right to an education, but not the right to be taught by the best 10% of all teachers?"

And how would people get health care if other people didn't have the right to provide it?

I had in mind government-funded health care, obviously. But putting the question that way is incorrect. To privilege right A over right B (in this case, getting vs. providing health care) is not to deny the existence of right B. It's to say that considerations that would lead to better satisfying right A generally trump considerations that would lead to better satisfying right B.

Mark Frank said...

bossmanham

On costs

You write:

"Not true, but it is expensive for the individual, which is the major problem the US faces at this time, but at least the government isn't in debt because of national health care (just a truckload other junk)."

Well I am sorry but the facts are quite clear on costs. The US spends far more per capita on health than any other industrialised country. This figure includes all public and private expenditure so it takes account of what we pay in taxes towards health. To quote Michael Tanner of the Cato institute (who, not surprisingly, is making the case for a market based health system):


There is no doubt that the United States spends far more on health care than any other country, whether measured as a percentage of gross domestic product (GDP) or by expenditure per capita.



On quality

All your quotes are carefully selected by a right-wing web site with a point to prove. In addition they are all about the UK NHS - a system that has almost nothing in common with the US health care bill. There are systems such as Germany and France that are much closer to the proposed US system. Netherless the quotes are not a reasonable way of assessing the NHS and demonstrate this emphasis on anecdote and avoidance of facts. The NHS provides health services for 60 million people - there will always be stories of things that have gone wrong and they make excellent news so they will get a lot of emphasis.

Try looking at the actual figures on:

life expectancy

infant mortality

cancer death rates

The USA is not especially bad compared to UK, France, Germany etc but it is not especially good either and it is spending a lot more.

bossmanham said...

But so what? How is this an abridgment of liberty?

I've answered you three times now.

You're confused

I'm confused? I didn't contradict myself in the same exact comment then requiring obfuscation to not look so...well...confused.

In the first quote, I denied that everyone has a right to all the medical procedures they could possibly want (mainly because health care is a scarce resource and fully satisfying everyone's wants/needs is impossible)

According to who? Who says health care is a "scarce resource"? The only reason this happens anywhere is because of government regulation impinging on those who would provide health care. Health care as it is would not be so expensive if the government weren't telling providers, consumers, and insurance companies what they can and can't do. Health care isn't "scarce" in the US yet in general. Some procedures, admittedly, aren't as easy to access as others, but they are the ones that typically require other people to die to provide their organs.

But, that being said, I never claimed anyone could "fully satisfy everyone's wants/needs." That is a straw-man. No business that exists could fulfill that goal. However, the health care system that exists now can fulfill the needs and wants of consumers far better than one that is controlled by the government.

In the second quote, I stated I believed that people do have a right to basic forms of health care.

People have the right to purchase care that is provided, but health care isn't a right in the sense that everyone is entitled to it. For that to be the case you would have to force people that provide health care to do so potentially against their will. The idea that health care is a "right" is inimical to liberty.

You, however, keep missing the point. All of the nasty side effects of universal health care are just icing on the cake. The government is not meant to be the sugar daddy of all Americans, nor should it have that authority. Individuals should have control over their own businesses and their own choice in business. Limiting the number of businesses that would provide care and insurance is itself a limitation of liberties. It limits individual choice and the rights of the companies that provide these services.

How is this different from saying, "Everyone has the right to an education, but not the right to be taught by the best 10% of all teachers?"

It depends on what you mean by that. If you mean that everyone has the right to learn, that is one thing. If you mean we are entitled to someone teaching us, then someone's liberties are being obstructed, namely the one obligated to provide education. If someone chooses to provide education, then they are more than welcome to.

To privilege right A over right B (in this case, getting vs. providing health care) is not to deny the existence of right B.

And this is based on your faulty assumption that health care is a right we are entitled to. That is false. I don't feel compelled to provide for someone who will not work, yet on Obama care, I will be doing just that.

It doesn't take a degree in political theory to see the flaw in this entitlement mindset. The founders recognized that there were certain rights that are basic to humanity; life, liberty, buying property, and pursuing happiness. But these are all things we do for ourselves. We are born with certain rights that prevent others from doing things to us. Entitlements, on the other hand, cause others to have provide something for you. That is the antithesis of human liberty. That's slavery.