Young Economics.

Singer on Health Care Rationing

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Prominent utilitarian philosopher Peter Singer has an article in the New York Times arguing that the US government should explicitly ration health care according to some strict cost-benefit principles.

Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. … In the public sector, primarily Medicare, Medicaid, and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals. …

Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it? …

As a first take, we might say that the good achieved by health care is the number of lives saved. But that is too crude. The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved….

He also talks about quality of life adjustments.  I think Singer is correct to point out that these are the really important questions when it comes to health care policy.  As I have noted before, the scarce resources have to be rationed somehow.  If we decide that willingness/ability to pay isn’t the appropriate mechanism, then we have to face some tough moral choices.

I wasn’t convinced by this:

It’s easy to say, “What if the teenager is a violent criminal and the 85-year-old is still working productively?” But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.

If we are approaching this problem from a utilitarian perspective, I don’t see how we can ignore the social value of individuals.  As a practical matter, maybe he thinks that those considerations would allow for too much subjectivity in the measurement of the value of particular people, leaving it vulnerable to racism, homophobia, sexism, and other forms of discrimination on the part of the evaluators.  In principle, though, it seems clear if we’re taking this whole exercise seriously, then the value of an individual’s life should be roughly increasing in the positive size of his or her impact on the lives of others.

Admittedly, this would be hard to do.  In a large population think the best proxy would be something like the person’s real wage, but I suspect that most advocates of universal health care would not like that.  Besides, it sort of undermines the point of the whole enterprise if the universal system values the lives of the rich more highly than those of the poor (on average, and controlling for age).

Here is a video of Peter Singer discussing poverty and utilitarianism with Tyler Cowen.

On health care, Will Wilkinson asks whether socialized health care would slow medical innovation in the USA.  As an undergraduate, I saw a guy (whose name I can’t recall; I’m pretty sure he was an economist, but he may have been a philosopher) give a talk in which he argued that the answer to this problem is to socialize health care research and innovation as well.  Would this be necessary?  Is it just the road to serfdom?


Written by Alex

July 15, 2009 at 2:11 pm

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