Rationing By Any Other Name?

What possible motive could legislators have to force people not to top up their own healthcare on the private market to the degree that they deem prudent?

I don’t know what the motives were, but I think cases like Linda O’Boyle here in the UK somewhat undermine your short-cut to an impossibility proof.

http://www.timesonline.co.uk/tol/life_and_style/health/article4040146.ece

“A woman dying of cancer was denied free National Health Service treatment in her final months because she had paid privately for a drug to try to prolong her life.

Linda O’Boyle was told that as she had paid for private treatment she was banned from free NHS care. “

(similarly, I’ve bought myself an awesome new prosthetic robot hand with built in lasers that can vaporise a man at ten paces, but those statist bastards at the NHS are refusing to attach it.)

Ummm, of course you can go and buy that pacemaker yourself, with your own money, but that’s still rationing within the plan. So, I think (contra McArdle) that it’s fair to say that there is rationing in the current system and there would be rationing in a public plan as well. Not that anything is wrong with that, every program has its limits.

Rationing is the wrong word for it, but I think Megan’s successfully pointing at a group of people who would get less care in a single-payer system. Picture a pretty good public plan, and a middle-class person who doesn’t have much money in the bank, but now has a gold-plated health-care plan. That person probably won’t buy additional insurance on top of a public plan, because they don’t have the money for it and the public plan is pretty good. If they get some disease for which there is a dubiously effective and wildly expensive end of life treatment, I’d believe both that it would be likely that a public plan wouldn’t pay for it and the private insurance they have now would, and that they won’t have the resources to just pay for it (rather than have it paid for by insurance) when they want it. That class of people will perceive some treatments as being withheld by a public plan that they would have received under a private plan.

If that’s who she’s talking about, I think it’s clear that it’s not a significant problem. People who didn’t have gold-plated insurance are better off with the public plan; people who can pay for the treatment they want can still pay for whatever they like. The problem is limited to a leveling of inequality (mostly leveling up, but in this one situation leveling down) between people who now have no or lousy insurance and people who now have great insurance, but can’t afford to pay for their own healthcare outside their current employer-paid insurance. I can’t see that as something to worry a great deal about.

“@1, only if you’re a lying right-wing hack.”

Not really. If you remember the Boyle case led to a massive scandal which has since forced the NHS to change its policy of refusing treatment to people who top up with private medecine. They could hardl; have reformed the polcy if there had not been such a policy to begin with:

http://www.guardian.co.uk/politics/2008/nov/04/nhs-health-cancer-topup-treatment

Bob Somerby wrote about this a little while ago, albiet in a slightly different context http://www.dailyhowler.com/dh061909.shtml .

If they get some disease for which there is a dubiously effective and wildly expensive end of life treatment, I’d believe both that it would be likely that a public plan wouldn’t pay for it and the private insurance they have now would

Private insuer? Pay for expensive treaments? Ha, ha, ha!

http://www.sunjournal.com/node/101075

Coming from one of those socialist hell holes, I am suprised how easily people say “but of course you can always buy more on top, if you want to”.

Over here, a two-tier health care system with better care for people who pay extra is considered American Practices, something even right-wing parties stay quiet about in fear of losing votes.

The general fear, and very justified too in my opinion, is that in a situation where the middle classes have their own more expensive health care system, funding for the universal part will decline year over year, as no one with power or influence actually depends on the universal system.

We have the same problem with private schooling: if the leading classes don’t have their kids in public schools, you can’t rely on them to keep the public system working well. Vocational training suffers from this problem all over the world.

Coming from one of those soc1alist hell holes, I am suprised how easily people say “but of course you can always buy more on top, if you want to”.

Over here, a two-tier health care system with better care for people who pay extra is considered American Practices, something even right-wing parties stay quiet about in fear of losing votes.

The general fear, and very justified too in my opinion, is that in a situation where the middle classes have their own more expensive health care system, funding for the universal part will decline year over year, as no one with power or influence actually depends on the universal system.

We have the same problem with private schooling: if the leading classes don’t have their kids in public schools, you can’t rely on them to keep the public system working well. Vocational training suffers from this problem all over the world.

resubmitted without the offensive term

Which socialist hell hole do you come from Zamfir? The French one seems to do OK with a pretty explicitly multi-tier approach.

(my mum’s parents — who were quite calvinist — proudly insisted they never once broke the rationing rules, or even bent them: i am inclined to believe this; certainly i would be surprised and a bit saddened to discover otherwise)

Picture a pretty good public plan, and a middle-class person who doesn’t have much money in the bank, but now has a gold-plated health-care plan.

wouldn’t this middle-class person still have her private health-care plan (full disclosure; I currently have a gold-plated private health-care plan) under a universal health insurance scheme? And if not, then isn’t it quite obvious that the implicit wage cut is doing all the bad work here?

“and my patient insisted against my advice on additionally taking a course of another drug whose interaction with the first was not well known ”

I think the medical advice was that she would benfit from the top up treatemnet. Besides, the NHS policy was not concerned with medical benfit but with social equality.

in a situation where the middle classes have their own more expensive health care system, funding for the universal part will decline year over year, as no one with power or influence actually depends on the universal system.

Also see “public transport”.

then isn’t it quite obvious that the implicit wage cut is doing all the bad work here?

Quite. The step that LB omits in her example is the one where, after decent but not gold-plated public health care becomes available, our middle-class person’s employer unilaterally, and without compensating her, cancels her gold-plated private health care plan, thus leaving her with nothing but the public health care scheme.

This might well happen in reality – some employers never miss a chance to screw their employees – but it wouldn’t be legal. It’s analogous to LB coming up with an argument against public transport along the lines of: “Some people would be well off. What about someone who, right now, has a nice company car, but, if we introduced public transport, would have to get to work by bus?” To which the answer is “well, hang on, where did her company car disappear to all of a sudden?”

The O’Boyle case is a real “hard cases make bad laws” one, but let’s be clear here: there’s nothing stopping a UK citizen from having private health care insurance. The O’Boyle case was about a sort of pick and mix approach to medicine: that you get to choose your own drugs and get your free NHS care as well. The view at the time was, well, it’s either NHS or private, not both – this is still to an extent the case, as anyone who wants to buy private care will still have to go and receive it in a private hospital, not in an NHS one, as far as I understand it.

(re-post without the most offensively spelled word in the universe)

What Zamfir-18 said, but then again, I’m coming from another soc1alist hel-hol.

And what of it: if the capacity is limited then, for a given number of users, there will be limits for users. The winner is the one that manages the situation best (and rich Belgians continue support public health care precisely because it enables them to receive advanced treatments that would not even get developed if only the mega-rich were interested in them (by the way, some Russian magnate had himself treated in Belgium for his burn wounds!)).

One of the more immoral things one can do is use up valuable doctor time to get something that does not even improve one’s own life.

Do the non-Brits here understand that private health insurance in the commonest perquisite offered to middle grad and senior employees by British companies? And that there is a reason for this?

“But the scarce item in the healthcare case isn’t healthcare, it’s money.”

Spoken like a philosopher, not like an economist.

Scarcity comes from the fact that we have limited real resources, so our ability to produce (anythng) is limited. The implication of scarcity is that, if our economy is operating (more or less) at full employment, we can’t produce more (for example) health care without (a) producing less of something else or (b) acquiring more resources or (c) generating productivity-increasing technical changes.

For economists, production of health care is subject to scarcity, because it requires real resources to produce. That does not mean that the amount of (and quality of) health care we’re producing is optimal, just that it’s not free–not in a money sense, but in the sense that producing more requires more real resources.

Money isn’t scarce, or not in any practical sense. Producing more computer database entries is essentially a resource-free activity.

32: really? I would have thought it was a pension.

Well I think Somerby has got it right. What the McArdles of this world realize – correctly – is that a single payer system would end their current privileged access to health care. Right now, if I (with a silver-plated insurance) want an appointment, I get it much faster than the guy with the bare-bones HMO, while the uninsured don’t even get to see him or her. Under a reasonable single-payer system, one should hope any doctor who accepts single-payer patients at all (and most will have to do so) will have to treat all equally. This will result in less convenience for the currently privileged.

Now I happen to think that’s a very reasonable price to pay, but some might disagree, and call it “rationing”.

@18: In America, our right wing considers two-tier systems a feature, not a bug. Despite, or perhaps because of, the fact that the “poor people” tier may deteriorate in quality. After all, if they only worked harder to become more productive they could afford to get out of it.

The fact that hard work isn’t very economically productive when you got a lousy education is lost on them. They have a Green Lantern view of economic success: if you’re not rich, the *only* possible explanation is that you’re not trying hard enough or doing something wrong. (This is, in fact, the logical consequence of the view that you can do anything if you try hard enough: the only things you can’t do are the ones you don’t try hard enough at. I’d say this is about a third-grade view of the relationship between will and achievement, but some third-graders probably know better.)

so the associated tax is easily bearable.

To explain – PHI is a taxable benefit in kind – there’s no exclusion that I’m aware of. There’s three main significant tax breaks in the UK these days – pensions, child care and, um, bikes to work.

Yr middle-management largely get private insurance so they don’t have to get their trousers off in the same room as Teh Pooor. The actual medical treatment they get is usually the same, from the same people. It happens a couple of weeks earlier and they stay in a different wing of the hospital, is all.

Anecdotal evidence suggests that, perhaps outside one or two places in London, if you are very ill in the UK, the best place to be is in an NHS hospital, rather than a private one.

When comparing the UK and the US healthcare systems, always refer to the percentage of GDP spent on each. There’s a slight difference.

Congratulations. Up until this very moment I wasn’t giving the “destroying competition” argument any serious thought, but it seems to me from your smashing of McArdle’s use of “rationing”, that she can only be making a logical leap from the presumption that the public option will kill the competition. Because if you assume the public option, by competing unfairly, will drive out all other options, then McArdle’s take on rationing actually makes any kind of sense.

As I said, I had been dismissing the idea of the public option killing the competition, because in my experience it takes more than one good product to constitute monopolistic business practices, regardless of how good or how cheap it is. Even if apples are free some people will still want a burger. But is there something I’m missing? Is it reasonable to be worried that the public option will eventually become the only option, at least for all but the top 10%?

Is it reasonable to be worried that the public option will eventually become the only option, at least for all but the top 10%?

Worried?? That’s what a lot of us HOPE for. But never fear, if the public option even survives into the final bill it will be crippled in various ways to make sure this doesn’t happen. After all, maintaining the profits of greedy, murderous insurance companies is a paramount goal of good public policy. At least, it is when your political system is fueled by an elaborate system of legalized bribery.

Pensions are usually provided for all employees or none; BUPA is for the “elite”.

Not IMX. The large professional services partnership I’ve worked for provided pensions for employees above ‘manager’ grade, and BUPA-or-equivalent for all employees at any grade. The mid-sized listed media company I’ve worked for provided both pensions and BUPA for senior managers only. And the mid-sized privately held media company I’ve worked provided neither for anyone.

Do the non-Brits here understand that private health insurance in the commonest perquisite offered to middle grad and senior employees by British companies? And that there is a reason for this?

There is a reason, or rather a two-fold reason, but it’s got nothing to do with people being desperate to escape the clutches of the NHS:

1) it provides a small degree of fake reassurance, in the unlikely-but-tabloid-stoked event that NHS treatment isn’t good enough or carries a massive waiting list

2) it costs the employer next-to-nothing, because most people barely ever use it, because the NHS is nearly always good enough and doesn’t carry a massive waiting list. Proof of this can be seen by anyone who’s been ‘generously’ gifted private medical insurance by their employer, through the simple means of looking at their end-of-year tax statement.

Oh, and:

I think the medical advice was that she would benfit from the top up treatemnet.

Private doctor: “you would benefit from having this extremely expensive drug, whose manufacturers have coincidentally taken me out for a very nice day at the races, administered in our also extremely expensive private hospital”.

Independent statisticians who actually know what they’re talking about: “this drug is not B/CA effective”.

This is why the NHS is a Good Thing.

Besides, the NHS policy was not concerned with medical benfit but with social equality.

Some of both, I’d say. The NHS happily (or at least, “without massive chargebacks”) and frequently provides emergency and intensive care treatment to people whose private surgery has gone wrong. If it were solely driven by social equality, it would tell them to get lost and let the private hospital fix it.

This view has a certain appeal from an equity point-of-view, but would be a little harsh to put into practice given that private hospitals are far inferior to the NHS at emergency and intensive treatment.

“Private doctor: “you would benefit from having this extremely expensive drug, whose manufacturers have coincidentally taken me out for a very nice day at the races, administered in our also extremely expensive private hospital”.”

No, as I understand it, she was advised by her NHS consultant that the drug was likely to prolong her life but that he was forbidden to prescribe it.

This is why the NHS is a Good Thing.

At least until the government-run death panel decides you’ve outlived your usefulness–but what then?

The NHS would hardly abandon a policy in place to protect patients’ health.

Rubbish. Most of the ‘patient choice’ agenda is precisely about allowing people’s fetish for choice to interfere with best health outcomes. See also the NHS’s willingness to bow to community wishes on hospital closures, even though large centralised sites consistently demonstrate the best patient outcomes.

@54 haha, FTW!

Independent statisticians who actually know what they’re talking about: “this drug is not B/CA effective”.

Curiously enough, those “independent statisticians” concluded in June this year that Cetuximab does work after all.

51: NHS consultants do an awful lot of private work on the side, as a rule.

The fact that private plans in the UK must charge such low prices is proof that most people are happy with the NHS. Otherwise the private companies could get away with charging much, much more.

let’s be clear here: there’s nothing stopping a UK citizen from having private health care insurance

…and nothing to stop a UK citizen who has health insurance using the NHS. Whatever the O’Boyle case was about, it certainly isn’t the case (Dan @17) that the shutters come down “the moment [one spends] a penny on health-care outside the NHS”.

If you’ve got a non-urgent condition, you can wait a while before you get to see a specialist; NHS hospital wards are quite hard to confuse with hotel rooms. But that’s about it for the debit side, as far as I’m concerned. Private healthcare provides a padded service which is rationed by price: if you want immediate treatment for a condition that isn’t getting any worse, if you want the doctor giving you a check-up to run all the tests instead of the ones [s]he believes to be necessary, or if you want any stay in hospital to be a pleasant and relaxing experience, then you’ll need to pay or have someone pay for you. But most people, most of the time, don’t want those things badly enough to pay for them. On the other hand, if you’ve got something life-threatening or urgent, a private clinic will generally hand you back over to the NHS anyway.

the proper name for a medical professional who concentrates on a single field, and is referred to as an authority in that field, is ‘spezialist’.

In what language?

The base argument seems to be that rationing can only exist in a finite zero-sum system, whereby any increase to one comes at a loss to another. Empirically at any given moment healthcare in the United States is indeed finite: one could, with sufficient time and resources, actually count up each and every doctor/hour or equipment/hour available. But two features of the system seem relevant make this seeming finite system into much less of a zero sum system. First, it is vast and complex, which enables a lot of load sharing geographically within a single time frame. Second, while there are certainly forms of emergency treatment with narrow time windows, many kinds of health care have large and flexible treatment windows, which similarly allows for load sharing across time. Here I’m thinking of load sharing as the ability to shift resources and needs around in time and space when one part of the system is over-loaded (scarcity). These features alone give the system a fair amount of flexibility that practically reduce the apparent finite nature of the system. more importantly, it is a dynamic system, adjusting over time to changes in demands. I believe this is true even of many state-run health care systems, but all the more true of a system where the production of health care is in the market economy (but part of the payment of health care becomes state run).

This gets us a far way from rationing and scarcity. And it hasnt yet even engaged the idea that changes towards universal coverage should affect logics in favor of preventative care, which should reduce the overall per person burden on the health care system by shifting from costly and time consuming emergency treatment to less costly (in time and money) preventative measures. University settings are a fascinating microcosm of this argument, because they already mandate universal coverage of all their members, and are also disproportionately likely to offer preventative care (particularly with respect to contageous illness where there are high positive externalities of preventative care).

@18 I think you raise an interesting point with respect to funding and support for political programs and the broadness of participation. Certainly there is a wide and growing support in social science literature on the welfare state that suggests that universal programs are more sustainable over the long run because they enjoy the patronage and support of middle class citizens. I believe a case often cited as an exemplar in this regard is Denmark.

@23 I believe the argument was that the person would voluntarily choose to discontinue their gold plated program because they did not see its continuing relative worth to them, because the government program was “good enough” and they were tight on cash. And then some disaster comes along where (theoretically) they would have been better off keeping their gold plated plan. But this logic is all a bit too big brother for my taste.

Funny how the US right is so hellbent on using the NHS – the most underfunded and the oldest of the public health systems, with the worst outcomes in the country with the greatest inequality – rather than any of the systems developed afterwards, which learnt from its mistakes.

Also funny how all this discussion of top-ups ignores the fact that many US private health insurers would apply the same rules. If O’Boyle had a side effect from that drug what are the chances she’d have been covered for the treatment by her private insurer in the US?

Its not just that the NHS is underfunded, but also that senior doctors have an outrageous control over the system, which was part of the deal made at the NHS’s founding. We have a system that (though its improving significantly) benefits doctors over patients.

@57, but they hadn’t at the time, and therefore the decision was the correct one to make when it was made. See: “haha, that Newton was such a fuckwit for not discovering special relativity”.

The effectiveness of Cetuximab was well understood at the time on the basis of multiple clinical trials, which is precisely why O’Boyle’s consultant recommended it. The “independent” statisticians of NICE – who performed no clinical trials – were only concerned about its cost-effectiveness, which is fine if you are trying to work out what the NHS should spend its money on. However, those considerations are clearly irrelevant to the issue of whether someone should be allowed to spend their own money on a particular treatment. That is a purely ideological/political question.

In this thread you’ve cynically implied that the physician’s motive for recommending Cetuximab was purely financial, and that he/she had been effectively bribed to do so by the drug manufacturer, even though there was strong clinical evidence of the drug’s efficacy, and it had already been approved in other jurisdictions, including Scotland. You’ve told us that the “independent statisticians who actually know what they’re talking about” had given the thumbs down to the drug, though in fact NICE hadn’t actually made a decision about it at the time, and now they do support the use of the drug within the NHS for cases like O’Boyle’s. You seem to be remarkably lacking in cynicism about the “independence” of NICE’s statisticians.

I’ve worked as a physician in the UK and Canada for nearly 30 years, and never once within the private sector. I’m a passionate supporter of “socialized” health care, but I cannot see how it’s possible to have a comprehensive single-payer system without some form of evidence-based, cost-effectiveness informed “rationing”.

Linda O’Boyle’s tragic predicament perfectly exemplifies a specific concern of many Americans about universal healthcare. Although this failing has already been corrected in the UK, you seem determined to defend it, in the face of all the facts, to which you seem to be completely indifferent. Perhaps you are equally indifferent to the healthcare needs of ordinary Americans – they’re foreigners after all – but you’re just playing in to the hands of the opponents of guaranteed minimum healthcare in the US.

NICE’s decision to recommend Cetuximab was based on the final results of the CRYSTALa study, which weren’t published until April 2009 and which were substantially better *in terms of clinical effectiveness against metastatic colorectal cancer* than anything that had previously been published. It’s likely (not certain, but likely) that without CRYSTALa, NICE wouldn’t have reversed its earlier decision (note: decision, not lack of decision) to not recommend it.

O’Boyle’s physician might have heard about CRYSTALa, or he might have merely experienced the enormous marketing push that all drug companies, Merck Serono included, give to drugs for which the clinical data is less-than-settled (leaking early trial results, talking up anecdotes, the usual drill).

And yes – the fact that the NICE statisticians don’t meet patients (=> emotional reactions that mess with your judgement, exaggerating false hopes) or drug reps (=> the obvious), whilst being at least as qualified on the stats side as physicians, does indeed make me less sceptical about their decisions.

McArdle is bright if a bit stubborn

Now that’s a claim where evidence is scant indeed. I’d go with “silly, shallow, and destined to go far as a result.”

Anecdotal evidence suggests that, perhaps outside one or two places in London, if you are very ill in the UK, the best place to be is in an NHS hospital, rather than a private one.

I’m pretty sure that there’s more than anecdotal evidence on the proportion of NHS and private operations that go wrong and have to be dealt with by NHS A&E. (Anyway, there’s a thorough document on the NHS or MiniHealth website now about how the new public/private guidelines are implemented.)

The fact that private plans in the UK must charge such low prices is proof that most people are happy with the NHS.

Not sure it’s “proof”, so much as there appears to be relatively consistent pricing for supplementary or premium-based healthcare payments across a number of systems, which. For individual cover, French and Dutch supplementary premiums are around €100/mo, most Australian premiums seem to hover around AUS$100, and so on. There are regulations on premium increases, but the recurrence of that “100 local currency units” mark signals to me a market where you’re hitting psychological resistance and possibly heading into medical tourism territory.

Cold comfort for Americans who regularly get to choose between plans with four-figure premiums.

antirealist, the situation with Linda O’Boyle and top-ups was spelled out clearly at the time it happened and in this thread: she can have standard chemo or she can go private for experimental chemo. In the UK her choice of chemo was considered experimental so she had to go private. Her PCT cocked up its interpretation of the rules, and told her that if she went private with her chemo she would have to take the whole regime (experimental + non-experimental) private, which her own husband admits was a PCT-specific mistake.

This is an unsurprising piece of British incompetence, it has nothing to do with the general failings of health care systems. Try getting a dentist in Britain who does root canals on the NHS – it’s difficult, because every PCT has its own interpretation of the funding rules and of how vigorously they should prosecute them.

The NHS was the only modern public health system that had the top-up rule, which was introduced because of the ideal “free at the point of care, based on clinical need rather than ability to pay”. There’s no reason it has to be implemented in an American system, as indeed it isn’t in Australia, France etc. So why the fuss?

Also, your attack on NICE is really nasty. Every system has rationing, including even the best-run private ones, and the British method simply makes it clear how they will do it. Do you think that US private systems don’t have their own threshold over which they do all they can to deny payment? Australia has the PBAC, which tells drug companies what the government will pay and doesn’t subsidize drugs which it can’t negotiate a good price for, I’m sure every other system has a method too. The difference is that the private system in the US has an ad hoc system for refusing treatment after the fact which is brutal and bankrupts people.

If anyone has a better way of containing health care costs while giving everyone a pony, I’d love to see it. Until then it’s simply a question of whether the method is transparent and rigorous, as in Oz and the UK, or arbitrary and brutal, as in most private systems.

82: The FDA approved Cetuximab in 2004.

For a doctor that has allegedly worked for the NHS you seem remarkably confused about the process.

NICE and the FDA are two completely different things. Cetuximab was approved for use in the UK, otherwise she wouldn’t have been able to take it privately.

When NICE made the original decision there was no evidence to prove that CRYSTAL was better than the existing (and cheaper) alternatives. Plenty of people thought that it was better, but then plenty of people think that crystals can cure cancer. So what?

The CRYSTAL data showing its efficacy were presented in 2007. People don’t stop dying while papers are being peer-reviewed.

Uh-huh. And plenty of papers fail to peer-review process, or have to be substantially revised. Or did you think it was some kind of rubber stamping exercise?

If it had turned out that in 2009 a paper was published showing that Cetuximab was in fact WORSE than the alternatives, what then? Doctors who had prescribed Cetuximab would, according to your somewhat hysterical logic, have been killing some of their patients.

One of the many failings of the US system is that not only are more expensive drugs often prescribed when cheaper alternatives are available; but often more expensive drugs with worse outcomes are prescribed. Most doctors (as you seem to be demonstrating on this thread) are not very good at reviewing medical data. Having a central body of experts carrying out this important task is very useful, though obviously drug companies would disagree.

And no one seems to be addressing the point that this wonderful Cetuximab stuff did not, in the end, make very much difference to the case. O’Boyle was diagnosed with bowel cancer by the NHS in December 2006 and the NHS treated her until September 2007, when they told her that, unfortunately, there was nothing else they could do. She asked if they could pay for Cetuximab, and they told her that the NHS wouldn’t cover it. So she paid to go on to Cetuximab privately, and five months later she died.
It’s not like the NHS denied her life-saving drugs.

@ajay 89, even Merck Serono don’t pretend that cetuximab [mild nitpick: cetuximab is the generic name and is written with a small C, Erbitux is the brand name and is written with a capital E] has much more effect than prolonging the last few months of life.

The question of whether it’d be better to have five months of terrible suffering and false hope, or a couple of months as many self-administered opiates as you like (no maximum cutoff) whilst being well cared for by hospice nurses, is possibly not one that NICE should be answering for people, and is what the wingnuts fear about this kind of B/CA analysis. Which is why it isn’t one that NICE answers for people and isn’t covered by this kind of B/CA analysis.

(although for me, it’d be B all the damn way, and if I ran the world I’d be sorely tempted to cut down on aggregate misery *and* healthcare spending by making B the only funded option…)

@91: But then you really *would* be a one-man death panel. I would probably decide for myself the same way you would decide for yourself, but I’m not very comfortable with either of us deciding for others.

Even the false hope is a kind of psychological opiate. I like to think that I would refuse it myself, but I haven’t been put to that test, and even if I had, that doesn’t necessarily give me the right to refuse false hope to others. I do find people who sell false hope for a profit rather disgusting, but if other people find their “product” useful, maybe I shouldn’t come between them.

(Similar remarks apply to that even bigger false hope, the afterlife.)

@93, agreed – that’s why I dismissed it before even raising it. There are a lot of things that I Would Do If I Ran The World that I wouldn’t *actually* do in the unlikely event that I were to find myself in charge of the world.

@95: But then they’re things that you wouldn’t do if you ran the world, so isn’t it a little confusing to describe them as things that you would do if you ran the world? At least, it confused me.

@94: Good point. People who buy false hope aren’t exactly making an informed decision, are they?

What i want to know is, how does anyone in the “Star Trek” world pay for anything. They seem to have abandoned the idea of currency (no one could fit a wallet into those skinny uniforms anyway). I was struck by this idea while watching one of the franchise movies. Not unlike Dilbert’s garbage man or Hogwarts’ Hagrid, the groundskeeper is the “Wise Sage” of Starfleet Academy. But how did this happen? Do they pay the guy? If not, why hang out like some low-rent Mr. Chips? How much does Kirk Make? McCoy? Do they assign “life jobs” like “Futurama”? Is everything in their world rationed and assigned? If so, they all seem content, if not happy— just like Denmark.