Dworkin, death-panels, drug research etc

by Chris Bertram on September 3, 2009

Reading the current US debate on health care from the outside is pretty dispiriting. It is an example of what happens to rational debate in circumstances of inequality where vested interests and partisan pundits can distort discussion by throwing loads of noise, fear and disinformation into the conversation. Still, that’s no reason not to try to have a conversation about which principles ought to obtain, and I think for that it is hard to beat Ronald Dworkin’s paper “Justice in the Distribution of Heath Care”, McGill Law Journal, 38 (1993), pp. 883-98 (though I’m looking at the reprint in Clayton and Williams eds The Ideal of Equality ).

Dworkin’s “central idea”:

… we should aim to make collective, social decisions about the quantity and distribution of health care so as to match, as closely as possible, the decisions that people in the community would make for themselves, one by one, in the appropriate circumstances, if they were looking from youth down the course of their lives and trying to decide what risks were worth running in return for not running other kinds of risks. (C&W, 209)

Dworkin invites us to imagine a thought experiment involving three changes to existing society:

(1) Society changes so as to implement whichever economic structures the reader thinks implement equal concern and respect. (Obviously, Dworkin thinks his own “equality of resources” conception does that best, but he doesn’t require us to buy into that ideal for the purposes of the present exercise.

(2) Assume everyone knows all the relevant technical information about the costs, prognoses, risks associated with the full range of medical procedures.

(3) Imagine that no-one knows anyone’s antecedent probability of contracting a particular illness, dying from a particular cause, and so forth.

Now imagine (against the background of 1, 2 and 3) a free-market in health care, and ask what people would choose, both individually and in the aggregate, and what the distribution of medical treatment would look like. Dworkin’s claim is that whatever such as society would choose in such (hypothetical) circumstances is just for that society.

So what would people choose?

Dworkin argues that they would band together in big insurance schemes (possible a single scheme) to realize economies of scale in the provision of some agreed basic package, but that this would be supplemented by a secondary market enabling people to purchase some additional medical services (cosmetic surgery etc.).

So what wouldn’t get covered in the basic package? In other worlds, what conditions would rational individuals not choose to buy insurance to secure treatment of? Here are Dworkin’s answers: (1) “almost no-one would purchase insurance that would provide life-sustaining equipment once he had fallen into a persistent vegetative state …. (212). (2) nor would anyone buy insurance to provide expensive treatment for themselves in late-stage Alzheimer’s (it would be better to spend the money in the here and now whilst you’re fit and healthy). (3) people would also prefer to spend their money on their vigorous and healthy younger selves rather than on keeping themselves alive, at enormous expense, for a few additional months of low-quality life. So people wouldn’t choose to spend thousands of dollars (or pounds) on insurance to buy expensive treatements to prolong the life of terminal cancer sufferers, or severe heart failure cases: people would rather spend the money on other things. And we can extend the thought to cover a lot of R&D too. It may be all very nice (stimulating, good for careers etc) for scientists and/or drug companies to devote billions to speculative research that might or might not issue in treatments extending the life of the terminally ill by a few month, but almost nobody faced with a choice between that investment of resources or spending the money on other stuff (education, culture, vacations, their kids) would squander their resources on such research.

So it turns out that the McMegans of this world are right about one thing: in a just society (not that they’d call it that) there would be less spent on expensive medical/drug research and development than a country like the US spends now. But that’s a good thing : against a background of fairness and equality, rational and fully informed people would look at the opportunity cost of such activity and say “no thanks!”

{ 93 comments }

1

zic 09.03.09 at 6:28 pm

Assume everyone knows all the relevant technical information about the costs, prognoses, risks associated with the full range of medical procedures.

There lies the black hole in the debate. There is too much price obfuscation of costs in particular; but of prognosis and risk, as well. (And I assume cost means all costs, from r&d through marketing, diagnostics, treatments, billing, dividends to shareholders, etc.)

Wouldn’t you just love to see Anthem’s spreadsheets on what to include/exclude in a policy this week? The negotiations between insurers and pharma that determine drug pricing? Insurers and hospitals about room pricing?

From what I can tell, we know very little about the mechanisms behind the cost of our health care system.

2

Henri Vieuxtemps 09.03.09 at 7:00 pm

When I was in my 20s, I felt that life after 50 probably isn’t worth living. To sacrifice anything at all in order to give, say, a future 60 year-old myself say 5 additional years would sound completely absurd. But now, a couple of decades later, it seems like quite a meaningful project. See what I mean? This is a flaw in his logic.

3

Sebastian 09.03.09 at 7:16 pm

Also most medical innovation comes in small increments. Would you trade millions of dollars for 2 months? Probably not. But what about 2 months this year, 1 month next year, 6 months the following year, none the year after that, 1 month the year after that?

They add up.

4

Playdoe 09.03.09 at 7:21 pm

Health care isn’t purely a rational subject, and any time pure rationality has driven health care there has been some pretty scary results (ie. eugenics). The fact is there are emotional and philosophical components that must be balanced against the technological and economic. Failure to do that misses the issue completely.

Say, given the choice between spending the last 2 years of your life with a constant yet mild irritation in your head versus spending the last 2 hours of your life in excrutiating pain…which would you pick? If you think there is a right/wrong answer to that question, you probably think think the same about health care.

5

Charlie 09.03.09 at 7:24 pm

2:

You could work with the same heuristic at any age and get similar answers, no?

But what about this: I have a secret hope that through the enormous effort of others, the problem of aging will be solved in my lifetime. From that point on (barring fatal trouser-related accidents and the like) death will be optional. I think I’m not alone in this secret hope. So what if you viewed expensive medical R&D as necessary to such an end (it all adds to the great knowledge pool) no matter how peripheral the declared intent of the researchers?

6

Drew Drytellar 09.03.09 at 7:25 pm

“in a just society… there would be less spent on expensive medical/drug research and development than a country like the US spends now.”

I believe Dworkin’s “just society” less would be spent on research and development to prolong the life of terminal cancer sufferers and the like. I don’t think it necessarily follows that less would be spent on research and development overall. Perhaps in this “society” more money is spent on r&d, it’s just allocated to “healthy and vigorous” young folk. I’m not particularly endorsing the justness of this hypothetical society (Henri, for one, makes a good point) but I don’t think it has the same implications for r&d you’re claiming.

7

mpowell 09.03.09 at 7:39 pm

I think I pretty much agree with Dworkin. It is one of the reasons I am surprised some people are opposed to top ups in government run systems. Sure, the rich will buy more, but people with similar incomes will also make different decisions and I don’t think it makes any sense to push the problem of income inequality into a health care system. Where I disagree is with his conclusion. It doesn’t seem that unrealistic to me to spend 20-25% of our income on health. As long as food/housing remains as cheap as it currently is, that is. So I don’t see to much reason to believe we’re wasting money because of misdirected research. (though not to say money isn’t being misdirected in some ways).

8

Aulus Gellius 09.03.09 at 7:41 pm

Related to Sebastian’s point at 3: to take it even further, I certainly wouldn’t think it was worth spending much on, say, Alzheimer’s prevention treatments which couldn’t be fully realized within my lifetime. So I don’t pay for such research. But then my children find themselves in the same situation, so they don’t pay for it either; and so on, generation after generation, when if one generation would just suck it up and pay, all future ones could receive the benefits.

(Of course, this problem should be just as real in a free-market system, I think. But it’s still a problem.

9

Tom West 09.03.09 at 8:21 pm

mpowell in #3

It is one of the reasons I am surprised some people are opposed to top ups in government run systems

While there may be personal preferences on how much to spend on medical care that are ignored under a no-top-up system, this is weighed against the idea of equality of life itself and the fact that a two-tier system has difficulty in sustaining the bottom tier in the face of growing wealth where more and more people can afford top-ups.

It’s a trade-off of freedom against the idea of equality of life in the face of unequal wealth and the long-term security of the bottom tier. Others may weight the importance of these three items differently, of course.

10

Z 09.03.09 at 8:44 pm

nor would anyone buy insurance to provide expensive treatment for themselves in late-stage Alzheimer’s

Maybe not for themselves, but some might buy such an insurance for others. Like Henri Vieuxtemps, I used to think that at 80 and with already a 5 or 6 great grand-children, my great grand-father had lived a full life and could happily die in his sleep. 20 years later, I found myself hoping he could live a few more months, then a few more weeks. And I can sure imagine spending a good part of what I own in order to give my 9 month old son a few more months of life even if I knew he was terminally ill.

Perhaps Dworkin would contend people reasoning like this are not rational because they are blinded by kinship and family love; and I would tend to think he would be right in thinking so. But in that sense, not many human beings are rational beings as well.

11

mpowell 09.03.09 at 8:46 pm

Tom, what is this idea of ‘equality of life’ that you are talking about? Do you think there is a basic fundamental principle that leads immediately to denying expensive health care treatment for someone who has saved up for it? It seems to me that the argument has to be more subtle, since it is not obvious that any fundamental principles of equality that I would grant do the work that you are trying to do with this phrase. What do you have in mind here?

12

Tom Hurka 09.03.09 at 8:57 pm

Dworkin’s model assumes there are no issues of justice between age-groups, e.g. between the elderly and the young. There’s a single decision about medical expenditure that governs the care you get at all the ages you live.

And judging by Chris’s quotes (I haven’t gone back to Dworkin’s article), that decision gets made entirely by the young (“… looking from youth down the course of their lives …”). But as Henri says above, the young and the elderly have *very* different views about what’s worth preserving in life, or what’s worth spending medical resources to preserve or prevent.

If that’s so, however, and there are issues of justice between the young and the elderly, it hardly satisfies justice to let medical decisions be made entirely by the young, using values or (horrible phrase) conceptions of the good that the elderly don’t share.

This isn’t for a minute to argue against public health care, which is desirable on many, many grounds. It’s just to suggest that, once again, it’s not obvious that the Great American Dwork (cf. Private Eye circa 1978) has everything about justice properly worked out.

13

Chris 09.03.09 at 9:03 pm

So what would people choose?

Well, different people would choose different things, that seems fairly obvious.

Also, don’t you need a further condition (4): nobody knows in advance how rich they are going to be? Otherwise the rich people are going to systematically choose “You get as much as you, personally, can afford”, because it’s a great deal for them. But since they’re the rich ones, any system without them in it is underfunded. If you resolve societal disagreement by democracy (rather than the US’s near-plutocracy), the rich can be drafted into a more inclusive system, but then you have to do some serious work to demonstrate the justice of doing so.

In other worlds, what conditions would rational individuals not choose to buy insurance to secure treatment of?

Whoa, whoa, when did rational individuals enter this discussion? That’s an even bigger change to society. (See, e.g., Henri’s probably-not-entirely-ironic admission of time-inconsistent preferences.)

P.S. Dworkin’s hypothetical system doesn’t look all that hypothetical. Does he happen to be British?

14

Neel Krishnaswami 09.03.09 at 9:11 pm

You could work with the same heuristic at any age and get similar answers, no?

Yes. I think this poses a pretty severe challenge to anyone who has any humane degree of respect for both personal freedom and consequentialism — people have stable irrational preferences (here, we see hyperbolic discounting). So you respecting individual choice means you cannot embrace the best policy given the available means. Pure natural-rights theorists and pure utilitarians don’t have this problem, since they deny that respectively the consequences or the condition of liberty matter intrinsically, morally speaking. But unfortunately, those two positions are insane.

-*-*-*-

As an aside, Chris’s final gloss on the value of medical care/research is not empirically supported. Typically, people doing cost-benefit analysis on medical care price a quality-adjusted life year at around $50K. However, research suggests that the implicit price actually people put on a quality-adjusted life year is much higher — estimates vary a lot, but can get up towards half a million dollars a year (an order of magnitude higher than the figures typically used) . That high figure means that on purely utilitarian grounds, a drug that extends expected lifespan by two weeks and costs $10,000 is worth it.

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Henri Vieuxtemps 09.03.09 at 9:17 pm

@10: I don’t know if “issues of justice between the young and the elderly” is a good way to put it. This doesn’t seem to be a question of justice, necessarily; at least, not of justice alone. There are angles here that have nothing to do with justice.

16

JackFrost 09.03.09 at 9:24 pm

Responding to the statement:
“But as Henri says above, the young and the elderly have very different views about what’s worth preserving in life, or what’s worth spending medical resources to preserve or prevent.”

Probably true, *BUT* the issue is that by the time people change their mind on how precious they think their remaining years, they’re no longer in a position to fund the significant extra expense of those extra few months. Please note that significant research fails to find significant correlation between this kind of extreme medical intervention and both quality of life and length of life.

In many respects, many of the extreme costs of health care are made by these relatively irrational “becoming aware of my own mortality” decisions to postpone death at any and all cost. Our culture hides from the fact that we are indeed mortal and that we all, sooner or later will die.

17

Henri Vieuxtemps 09.03.09 at 9:37 pm

…I mean, sure, a 20 year-old may perceive it as injustice, just like a 10 year-old may feel that being forced to brush your teeth and go to bed at 9 is injustice. But I don’t think this is a serious complaint.

18

Tom West 09.03.09 at 9:40 pm

Equality of life: The base idea that at base, each life is equally worthy to society and thus society works equally hard (i.e. spends equal resources) to save each life.

The idea that wealth buys you a more comfortable life, but not more life itself.

From a practical point of view, it means that there is an active interest in the health of the health-care system by the most wealthy and powerful members of society. On an emotional level, the bonds between the richest and poorest are strengthened by the knowledge that all face mortality together equally well armed. At least in this one arena, the rich cannot wash their hands of the poor for their fate in inextricably bound with their fellow citizen’s.

Of course, that’s the ideal. Reality doesn’t quite match :-). But I do think there is a salutary effect on all of society knowing that in this, everyone’s interests are co-aligned.

Of course, against such benefits, one must weigh the loss of freedom and some loss of total expenditures. (I say some, because I suspect that in many cases (and especially in the long-term) excess expenditures often come at the cost of public resources.

19

Erin McD 09.03.09 at 9:57 pm

@7 Top-ups is a fascinating political turning point of the debate. On one hand they seem to offer a market-based balm against pure fear of being personally ignored in a scary future vision of big-brother healthcare, so in this sense they may make a government option more politically palatable in the *transition.* But the costs of making a transition palatable may be, as you acutely point out, more and more flight from the system that serves all which will likely (if present European welfare state research bears here) doom the system in the long run. Seems to create a sort of perverse self-fulfilling prophecy where initial skepticism about the program by the well-off make its adaptation less likely, and if top-up becomes the mechanism to facilitate its adaptation, then it makes the program’s long run success less likely.

Re: time horizons for distributing expenditures. Experimental and Behavioral economics has a whole series of findings that seem to bear here. One of the potential benefits to a single payer system that has the incentive to promote healthfulness (citizens vs customers) is that a collective system often promotes better long horizon rationality: the ability to overcome our own individual short time horizons in our decision making. It can thus incentivize small costs now at 30 (less smoking or drinking, losing weight) that have long term benefits that we will enjoy when we’re 60. Left to our own devices we as individuals might not choose to make those costs because we persistently discount how much we will actually enjoy them when 60 rolls around.

20

Chris Bertram 09.03.09 at 10:08 pm

I think the difference in young-old perspectives is best dealt with by beefing up the rationality and knowledge assumptions (indeed I thing this is implicit in D’s discussion). So, the perspective from which the spending decisions are taken isn’t exactly that of a young person but that of a idealized young person who is properly informed and vividly aware of what later outlooks will be like.

Chris @ #13: well if the content given to change (1) is sufficiently egalitarian, the issue doesn’t arise.

Neel at #14 – I’m not sure how to take the claim about implicit price. But if we are talking real money from an equal share of resources, then I think very high figures are implausible once people contemplate the opportunity cost.

Z @10 – if we’re starting with equality of resources, then the preferences of the people I care about are already given full weight. So I don’t think that we need consider the paternalistic option of making additional purchases (that they wouldn’t make themselves) on their behalf.

21

mpowell 09.03.09 at 10:34 pm

Tom, I think your view could make sense in a society truly committed to equality of outcomes. But if you are not willing to enforce equality of outcomes (wealthwise- and maybe you are!), I don’t think limiting healthcare expenditures is a consistent course of action to follow. The wealthy will already have increased access to resources that will enable them to enjoy a healthier life (and probably, statistically longer) if they wish. Direct healthcare expenditures do not really seem different in kind to me. In that vein, I am not sure even a society committed to equality of outcomes should limit health care expenditures. You can imagine all sorts of trade offs different individuals might want to make between exercise/time spend doing other activities/wealth invested in direct health care. Or to put it another way, even if one was that committed to equality, in most western societies, I’m not sure the impingement to freedom of choice limiting health care expense would imply would be justified with gross inequalities already present in so many other respects.

22

Tom West 09.03.09 at 11:06 pm

Letting reality intrude into my justification from no second tier, of course there isn’t going to be equality of outcomes.

Direct healthcare expenditures do not really seem different in kind to me.

Philosophically, I understand where you are coming from. However, from an social perspective, I think people feel a big difference between someone who has had a trainer to allow them to keep fit and healthy and the idea who can say, “Sorry, wait times don’t apply to me.” I’m far more concerned about how citizens view reality and how it influences their attitudes than I am about the reality itself.

I feel fairly strongly about the benefits of social cohesion, and my dislike for an official second tier is roughly on order to how I feel about legally allowing the wealthy to buy their way out of (heaven forbid) a draft. It might have some logical merits, but the cost to the attitude of the citizenry (both the wealthy as well as the poor) is too high.

Even if one was that committed to equality, in most western societies, I’m not sure the impingement to freedom of choice limiting health care expense would imply would be justified with gross inequalities already present in so many other respects.

A perfectly valid view. It’s all about how you weight the costs and benefits of the various policies. Frankly, I’m don’t really care about those who use a second tier outside of Canada, as long as we obtain the social benefits of at least the rough equality that we have now.

23

Neel Krishnaswami 09.03.09 at 11:19 pm

But if we are talking real money from an equal share of resources, then I think very high figures are implausible once people contemplate the opportunity cost.

I don’t agree, because even modest costs can quickly add up to very large figures when they are continued over time, and our intuition for those numbers is suspect. It’s easy to say “tens of thousands of dollars for a few months more is too much”, when in fact that’s actually quite a reasonable amount.

Concretely, let’s take kidney dialysis. It’s an expensive procedure, which can cost 70 thousand dollars per year. On the standard QALY pricing, this will normally be ruled an unjustifiable procedure. However, this works out to 200 dollars per day — which is the price of a no-frills hotel in New York City. I simply can’t imagine the Rawlsian veil of ignorance would lead us to believe that abstract conditions of justice rule out any medical procedure more expensive than a cheap hotel room!

Furthermore, the need for very expensive medical care is very concentrated. In the US, substantially less than 1% of the population needs care even this expensive in any given year (I don’t know the exact number, since the reported statistics stop at 1% granularity). So even though it’s a burden on society, it’s not an unbearable one. (It’s this very concentration of need that makes me skeptical of the reasonableness of the equal-share-of-resources principle.)

24

Jeff R. 09.03.09 at 11:32 pm

Once we’ve started to give our hypothetical young selves rationality beyond what they may actually possess, the decision of exactly how young they are starts looking more and more arbitrary, doesn’t it? One finds it difficult, other than by a wholly illegitimate results-based backwards reasoning, to privilege any age between 18 and -1 mo. over any other such age, getting one fairly radically different results…

25

Anthony 09.03.09 at 11:54 pm

The research issue is harder than Dworkin makes it out to be. Treatments which give a few months of additional pain-filled life to 70-year-old cancer patients might give 40 years of pain-free life to 30-year-old cancer patients. Research which finds such treatments may be essential steps to finding treatments which give years, instead of months, of life to older patients.

26

engels 09.04.09 at 12:04 am

So, the perspective from which the spending decisions are taken isn’t exactly that of a young person but that of a idealized young person who is properly informed and vividly aware of what later outlooks will be like.

Is it conceivable that I, at age 25, might by properly informed and vividly aware of how I will see things at age 55 and yet strongly disagree with my 55-year-old self (who might be likewise vividly aware of my outlook…) about how resources should be distributed over my life course? If so, is this evidence of irrationality? Or can a rational person still exhibit a kind of partiality towards the person he currently is over the person he was or is going to become? If so, then however informed and rational Dworkin’s insurance-buyers are the 55-year-me could appear to suffer from ‘taxation without representation’…

27

Neel Krishnaswami 09.04.09 at 12:26 am

Is it conceivable that I, at age 25, might by properly informed and vividly aware of how I will see things at age 55 and yet strongly disagree with my 55-year-old self (who might be likewise vividly aware of my outlook…) about how resources should be distributed over my life course? If so, is this evidence of irrationality?

It’s not just conceivable, as far as we can tell this is what people actually do — as a simple matter of fact, people do not discount the way that discount rates say we ought to. (Google for “hyperbolic discounting”.)

Whether this is evidence of irrationality or not depends on how much belief you have in the continuity of identity. Granting this assumption, it’s an irrational behavior, though it is a useful heuristic. If you know there is a fixed but unknown rate of delayed rewards not happening at all, then the Bayesian discounting behavior corresponds to hyperbolic discounting. What makes it irrational is that people apply this discounting behavior even when they know that the hazard rate is zero.

28

Salient 09.04.09 at 12:34 am

I’m pretty sure that in the VoI nobody knows how old they are or how old anybody else is. It is universally known to these constructs how many persons will be of what age at time t = 0 in the society; they can plan accordingly. They just don’t know which of those people they will be/become when the veil drops. So,

Or can a rational person still exhibit a kind of partiality towards the person he currently is over the person he was or is going to become?

No, a VoI-rational person is completely incapable of this partiality (I think).

29

engels 09.04.09 at 12:38 am

Neel, that’s interesting, but my question wasn’t whether it is conceivable for real people to do it but whether it is conceivable for the ‘idealised’ subjects with the rationality, knowledge, etc with which Chris endows them.

30

Neel Krishnaswami 09.04.09 at 12:54 am

Sorry, engels, I misunderstood. I think the answer to that question is “it depends”. Part of the assumption of perfect rationality in decision theory is having coherent preferences, so the kind of change in values you describe is technically irrational.

However, this setup assumes that preferences are an a priori given for each agent — if you want preferences to arise endogenously from experience, then that conception of rationality doesn’t work any more, and I don’t think anyone knows of a mathematically tractable replacement. (If you do, then please send me a reference!)

31

engels 09.04.09 at 1:04 am

Salient, but this isn’t the Veil of Ignorance — see Dworkin’s ‘central idea’ quoted in the post.

32

engels 09.04.09 at 1:33 am

Ok, to try to make things clearer, I’m really trying to probe what Chris (or Dworkin) means when he says that the subjects of the thought experiment are ‘idealised’ in terms of knowledge, rationality, vivid awareness of future outlooks, etc. Assuming that there is a difference in opinion on certain matters (as Henri and others plausibly suggest) between my 25-year-old self and my 55-year-old self, would the process of ‘idealisation’ obliterate these differences, such that the idealised 25-year-old would be in perfect agreement on these points with the idealised 55-year-old?

The information about decision theory is interesting but I’m not sure how much of that (if any) Chris or Dworkin intended to take on board…

33

Neel Krishnaswami 09.04.09 at 2:23 am

The trouble is that if you want to do cost-benefit analysis, you pretty much have to swallow nearly all the machinery of decision theory in order to avoid extremely silly paradoxes. (This is why Bayesians make economists look like sensitive, tolerant, pluralists at home with the ambiguity of experience.) So the sort of idealization they are advancing pretty much has no choice to destroy the kind of differences you and Henri are talking about. It’s obvious that this is a serious limitation of decision theory, but I don’t know of any better alternatives.

It just now occurs to me, though, that the sorts of problems that arise with aggregating changing preferences are similar to the problems that arise in voting systems (where we must aggregate differing preferences), so some of the same techniques applied to analyzing voting systems might apply.

34

engels 09.04.09 at 2:34 am

One more point. Neel suggests that real people would have different preferences on this point at different ages and that having such unstable preferences is irrational (from the point of view of decision theory, at least). So if the idealised subjects in Dworkin’s choice-situation are to be rational they must have preferences that will not change as they grow older. But simply knowing this to be true offers no way of determining the stable preferences that these idealised, rational 20-year-old subjects would have. Would these be closer to the ones that, as actual people, they have at 20, or 60, or some kind of average of the two, or something else altogether?

35

Patrick 09.04.09 at 2:51 am

I’m confused why he’s arguing for a health care “original position” that isn’t really a full original position. His argument would be stronger with a bit more Rawls.

36

Salient 09.04.09 at 2:56 am

Salient, but this isn’t the Veil of Ignorance—see Dworkin’s ‘central idea’ quoted in the post.

Argh, I fail at reading. I finessed my reading, assuming that Dworkin was describing a VoI scenario and was in that “central idea” passage proceeding to explain the most likely mentality of a VoI participant, in the same way that Rawls goes on to argue a VoI participant would adopt the mentality “I should presuppose I am likely to occupy the worst-off role in this society.”

Now I don’t know what to think. I had assumed Dworkin was describing the mentality of a 55-year-old who is remembering what it was like to be 25 imagining what it’s like to be 55, with that remembrance tempered by experience.

I guess it would be simpler and more sensible to assume the hypothetical person is quite old and looking back on life with an understanding of consequences that a youthful person does not have. One is more temperate about mortality, probably, when older.

But what would a sage older person do to gain intuition about appropriate health care spending? Perhaps a sage older person would indeed devalue themselves — oh, what’s a month more of life, if at the expense of these kids getting on. Perhaps likewise a sage older person would highly value the ((lovably) intemperate) opining of the youth, would hold their valuations in high esteem. It’s their world to inherit, after all.

(I am basing this analysis, for no particular reason, on the final lines of Kazuo Ishiguro’s book An Artist of the Floating World.)

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alex 09.04.09 at 6:52 am

Wisdom in the face of death – that’s what we need. Now all we need to do is figure out how to get it…

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Chris Bertram 09.04.09 at 6:57 am

I agree that the issue of perspective needs to be better thought out than in Dworkin’s original. What we really need is some kind of guardian angel counterpart self, capable of impartially evaluating the worth of each time segment. Whether D uses the term VoI or not though, he clearly has one in respect of some aspects of the choice situation. So, for example, the denial of knowledge of individuals’ antecedent probabilities of death or illness.

39

Chris Bertram 09.04.09 at 7:08 am

Neel, on kidney dialysis above ….

I think the answer to this one is clear if one reads the paper against the background of Dworkin’s analysis of insurance in What is Equality, Part 2: Equality of Resources. Since most people don’t suffer from kidney disease, a person in ignorance of their own antecedent probabilities (and with the insurance company also denied this k) would be able to buy insurance for the case where they turned out to need it at age N (where N is quite low) very cheaply. On the other side of things, since most men in their eighties suffer from prostate cancer (thought they tend to die of other things first!) insurance to buy expensive treatments to address it would approach the cost of the treatments themselves and so the decision to buy would be much more marginal.

(Actually, PC is an interesting case, and suggests a stronger VoI than Dworkin is letting on, requiring ignorance of one’s own sex, or ignorance that women don’t have prostate glands …)

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JoB 09.04.09 at 7:37 am

Chris, Salient,

The “central idea” is definitely Rawlsian (maybe independently discovered, don’t know) but it’s less weak if, as salient suggests, you eliminate age knowledge from the participants. That would deal a.o. with Henri’s objection.

The strength of the VoI (although not strong enough) depends on the radicality of assumptions on knowledge of self.

41

Chris Bertram 09.04.09 at 7:40 am

Notice, by the way (if you haven’t already) a further feature of the Dworkin scheme. If, over the course of a lifetime, you have taken your equal share of resources and turned it into a lot of money, nothing prevents your older self from then spending that money on the full cost expensive short-term life extension. What you can’t do it to make a claim against the social scheme that they should pay for such extension, and the reason you can’t is that it would have been irrational for your rational younger self to have paid the premium.

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dsquared 09.04.09 at 7:59 am

Few points:

1. the high end estimates of subjective value of a QALY come from revealed-preference job risk studies. I am not a fan of this literature because it’s very dependent on strict distributional assumptions and perceptions of tail risk (basically, what is the hourly wage premium per additional 1 fatality/100k worker years), and I think it’s just picking up all the known issues about subjective estimation of tails.

2. $70k kidney dialysis seems expensive; I think the NHS gets it done for £15k in a hospital setting or £20k at home (£30k is the level at which NICE tends to regard a treatment as not cost effective). Historically, the QALY concept was first brought in for renal dialysis IIRC, and cynics would probably suggest that the value threshold has pretty consistently been set at a little bit more than the cost of a year’s dialysis ever since. Here’s (the first side of) a debate in the BMJ over Neel’s general point.

3. On research, I think I share the concerns of Sebastian, Charlie and Aulus above, I think this argument works a lot better for treatments than for research. Nobody sits down in the lab and thinks “right, time to start work on a drug that will extend life by an average of two weeks for people who are bedridden, semiconcious and in severe pain”. They try to find a drug that will cure cancer (or whatever), mess around a bit, tweak the molecules, etc and then find out that it works a little bit, but doesn’t really help a great deal, isn’t much of an improvement on existing drugs and costs a hell of a lot to make, and go “ah well, back to the lab, might as well put this thing on the market for the small number of people it can actually help, maybe we learned a few things that will help next time”.

4. Technically on insurance (I almost feel like writing a short textbook “Elements Of Actuarial Science For Utilitarian Moral Philosophers”, because it’s really easy to get unstuck), Chris says:

“since most men in their eighties suffer from prostate cancer (thought they tend to die of other things first!) insurance to buy expensive treatments to address it would approach the cost of the treatments themselves

which actually gets it right but then gets the wrong answer – because so many men die of other things first, insurance against the cost of expensive prostate cancer treatments would not necessarily be that expensive, as the patients who pay their premiums then die of something else are pure underwriting profit for the insurer; the fact that comparatively few men get prostate cancer at a young age also means that there are a lot of years of investment return to take into account, so a 20-year old man paying a single upfront premium for prostate treatment in his 80s would not necessarily be quoted such a big number as a premium.

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Kenny Easwaran 09.04.09 at 8:53 am

Neel – on hyperbolic discounting, doesn’t that mean that we discount the near future too much, but the distant future not enough? After all, the alternative is supposed to be exponential discounting, which means that stuff going on in my 50s should get just as littler consideration in me now thinking about me at age 40 as stuff in my 40s gets in thinking about me now – while hyperbolic discounting says it should get half as much consideration, which is surely much more than stuff in my 40s gets compared to me now.

Also, I want to agree with dsquared and others about research. Surely an academic philosopher should realize that the how much one ought to spend on research and how much one would be willing to pay for the immediate products of the research can be quite different from one another.

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Chris Bertram 09.04.09 at 8:56 am

_4. Technically on insurance (I almost feel like writing a short textbook “Elements Of Actuarial Science For Utilitarian Moral Philosophers”, because it’s really easy to get unstuck), Chris says:_

Thanks! I wish you would.

Maybe a different example of something we’re all likely to get would have worked better?

45

Chris Bertram 09.04.09 at 8:58 am

_Also, I want to agree with dsquared and others about research. Surely an academic philosopher should realize that the how much one ought to spend on research and how much one would be willing to pay for the immediate products of the research can be quite different from one another._

Yes, I think you are right about this.

46

Z 09.04.09 at 9:15 am

Chris,

Maybe I misunderstand, and I think it is clear that I haven’t read Dworkin’s work, but let me restate my remark. Rational beings might very well choose not to buy something for themselves and yet choose to buy it for someone else, even if that other person does not want it. Right now, I would not buy an insurance giving myself a few more months of pain-ridden crippled life, nor would my wife, for herself. However, it is conceivable to me that I would buy it for her, even though I would know fairly certainly that it would be against her will, and that her own preferences were given due weight. By the same logic, a rational person might try to rescue someone who has just jumped from a bridge.

Quitting hypotheticals, I am quite sure that my great grand-father wanted to die for the last 10 years, and I am certain he wanted to die for the last 3 or 4. But I wanted him to live, and I think I would have been willing to pay for extending his life beyond his will

Specifically, the sentence “So people wouldn’t choose to spend thousands of dollars (or pounds) on insurance to buy expensive treatements to prolong the life of terminal cancer sufferers, or severe heart failure cases: people would rather spend the money on other things” seems to me to be reasonable for oneself, but completely false (more precisely inhuman, in the literal sense) when the terminal cancer sufferers might be your child. Now maybe Dworkin assumes that we are pure individuals in his setting, and that children do not exist. In general, I think this is not a bad way to treat some abstract political questions but I am not sure health care is one of them.

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James Wimberley 09.04.09 at 9:21 am

On research, it’s also important to remember quite how random it is. Some of the research done by Big Pharma eg on cancer drugs is inherently incremental, but what about the basic research funded by governments and charities like Wellcome? Sequencing the genome and cataloguing all the receptors may lead to incremental treatments, they may lead to cures, we don’t know. (I have a primitive go at the distinction here, advt.) The best strategy is probably just to throw money at promising ideas. Luckily, this is roughly what is happening.

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Chris Bertram 09.04.09 at 9:59 am

Z: What we’re interested in here is (a) how much health care we should provide and (b) its distribution. We’re tackling that problem in a way that tries to take equal account of the rational interests of each individual, with each person (or at least their fully-informed and rational counterpart) being authoritative about what those interests are. I don’t see why we should allow third-party views about how they should live their lives into this picture at all.

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dsquared 09.04.09 at 10:14 am

Maybe a different example of something we’re all likely to get would have worked better?

Yes there must be something … I’d guess that it would be pretty difficult for a 20-year old women to buy insurance against the costs associated with pregnancy (particularly since by offering to buy it, she’s sending a signal about her intentions).

(in general this is usually the case; the mistakes that moral philosophers make in writing about insurance are rarely such as to make an important philosophical difference and just mean that they tend to construct bad examples (which in turn are actually only ever confusing to insurance obsessives like me). I once thought I’d caught Gerry Cohen out in something important over whether something he had said was consistent with the existence of an actuarially solvent retirement system but on reflection decided I probably hadn’t).

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dsquared 09.04.09 at 10:30 am

Rational beings might very well choose not to buy something for themselves and yet choose to buy it for someone else, even if that other person does not want it.

I think it would be entirely understandable to do this and even laudable, but quite odd to insist that in doing so one was being rational in anything other than the economists’ tautological sense in which anything you want to do is the rational thing for you to do because you wanted to do it.

(I’m also, through no fault of yours, reminded of Emo Phillips’ joke “I asked my wife wanted she wanted for her birthday and she said ‘oh surprise me, just get something expensive that I don’t really need’, so I bought her a course of chemotherapy”)

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Sam C 09.04.09 at 11:07 am

‘I almost feel like writing a short textbook “Elements Of Actuarial Science For Utilitarian Moral Philosophers”’ – another potential buyer for this here…

52

James Kroeger 09.04.09 at 11:41 am

Chris – 13 :

But since they’re the rich ones, any system without them in it is underfunded. If you resolve societal disagreement by democracy (rather than the US’s near-plutocracy), the rich can be drafted into a more inclusive system, but then you have to do some serious work to demonstrate the justice of doing so.

Some of the serious work you are referring to may already have been done. In The Progressive Income Tax: Theoretical Foundations, I point out that even a steeply progressive/graduated income tax does not actually deprive wealthy households of any of their purchasing power. How can such a claim be made? It’s because that particular method of tax collection obtains money from taxpayers in a way that always preserves every citizen’s purchasing power.

Those who pay the highest tax rates still end up with the highest disposable incomes in the land, which is all they need to make their claim on the scarcest goods/services produced by the economy. In market economies, it is an absolute certainty that a steeply progressive tax, which cuts across all income groups, will lead to price reductions. In fact, the price of all luxury goods/services will drop to a level that heavily-taxed rich people would be able to afford.

So if the rich are not actually not penalized by heavy taxation (in terms of lost purchasing power), how can we say that it is not just to obtain the money needed to finance a health care system that takes care of the needs of the less-privileged classes?

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Phil 09.04.09 at 11:56 am

Dworkin’s central idea confuses me. “if they were looking from youth down the course of their lives and trying to decide what risks were worth running”: what level of knowledge is assumed here? The implication seems to be that everyone in this thought-experiment is angelically transported back to the vantage-point of youth at the point of death – otherwise how could they ‘look down the course of their lives’? But if they could do that, how could they make any assessment of what risks had been worth running? Each person will find one or two risks particularly salient, after all. Or is Dworkin arguing that rationality would come out of the aggregation? Can we produce a collective policy out of a compendium of “if I’d only known”s?

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anon 09.04.09 at 12:02 pm

One extra thing that private payers get – beyond the actual healthcare – is the private room, bedside telephone, wi-fi connection and nice croissants. Staying in the private ward of an NHS hospital is like the Ritz compared to the public wards downstairs (rows of beds, mixed gender, no privacy etc). A not-insignificant motivation among Brits with private insurance (at least, those I know) is to get the Ritz treatment rather than to jump the queue. Of course, this may create perverse incentives for the hospital to keep the general wards grotty so those who can afford it will pay to move upstairs. But it also gives another reason why it would be politically impossible to force everyone to use the same NHS facilities.

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Chris Bertram 09.04.09 at 1:01 pm

Phil #53

Contra any modifications/interpretations that I may have suggested (sensible or otherwise) it seems that Dworkin’s actual view on the perspective of choice is revealed in his third footnote to the paper:

bq. Some paternalistic interference with individual decisions about healthcare insurance, particularly those people make early in their lives, might be necessary out of fairness to people who might make imprudent insurance decisions when young. And some constraints and requirements might be necessary in the interests of justice toward later generations.

So it looks like he is thinking of the actual decisions young people would make in contemplation of their future, with those decisions subject to review by wiser older heads. (Of course there’s no reason why we can’t take his hypothetical insurance heuristic and modify it ….)

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Phil 09.04.09 at 1:22 pm

I prefer my version, if only because the objection to giving the job (even hypothetically) to actual young people is so obvious. “Some paternalistic interference” – how much is ‘some’, and grounded in what, eh? (I realise I should probably just read the whole thing.)

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engels 09.04.09 at 2:01 pm

Dworkin’s idea is to inquire as to what health insurance people would themselves choose (in ideal circumstances) to protect themselves against the event of illness. You can’t purchase insurance retrospectively so it has to be young people making the choice (for their unknown future) not old people doing so (looking back over their known past). And the point of doing this is to be able to hold people responsible for their own choices, so it has to be people themselves doing the choosing (even if subject to various cognitive ‘improvements’) I think, not some paternalistic angels deciding on their behalf. At least that is how I understand his approach from other contexts. (I haven’t read this paper).

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engels 09.04.09 at 2:06 pm

Sorry, the second sentence is a bit unclear. There’s no reason why an elderly person can’t purchase insurance to cover his remaining years but he is not in a position to negotiate cover for events that have already occurred.

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Chris Bertram 09.04.09 at 2:23 pm

_And the point of doing this is to be able to hold people responsible for their own choices, so it has to be people themselves doing the choosing_

Well yes, but since the whole exercise is one of counterfactual abstraction, and hypothetical people can’t be held responsible for anything (alternatively, real people can’t be held responsible for the choices they _would_ make under unrealistic conditions), this comes out a bit weird. (Cf btw Dworkin’s own initial commentary on Rawls in TRS ch. 6.)

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CALPhilosophyisBest 09.04.09 at 2:33 pm

Why wouldn’t the Dworkin argument support extensive R & D? After all, its the R & D that leads (eventually, hopefully) to long term cures; small gains often lead to large discoveries. What could be said is that the R & D market would be regulated so that resources aren’t put into 1 month extension research. But even this regulation I think is controversial, even if one is in agreement with Dworkin’s argument. How does one measure the importance and value of one extra month of life? Is it really true that “almost nobody” in a just society would allow for a huge amount of resources used just to live? An extra chance to say “I love you” to family friends? An extra chance to finish an artistic project? An extra chance one has to see something beautiful they have never seen?

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James Kroeger 09.04.09 at 2:39 pm

“Sorry, wait times don’t apply to me.”

I feel fairly strongly about the benefits of social cohesion, and my dislike for an official second tier is roughly on order to how I feel about legally allowing the wealthy to buy their way out of (heaven forbid) a draft.

How about an approach that grants every individual an equal right to whatever scarce health resources may be available, but which also allows those individuals to trade their “place in line” (position in the queue) to wealthier individuals for the right price?

Go ahead and grant every citizen a “first come, first serve” right to ALL scarce health services (include even favorable positions on the patient lists of the ‘best doctors’). Make it possible for the Keepers of the Lists to create a market that gives those with high positions on a list (shorter waiting times) the opportunity to trade their places in line with those who are lower on the list for some kind of mutually agreed upon compensation. It could be done in a number of ways. Something a bit more dignified than Ebay comes to mind.

If I’m rather poor and have only a week to wait for my knee replacement surgery, I might be willing to trade my position in line with a very wealthy citizen who might otherwise have to wait for 6 months. What this would end up doing is eliminate the single greatest concern of wealthy Americans re: ‘socialized medicine.’ They would be able to use their wealth to still get the best doctors and best ‘quality’ of health care, if they are willing to pay the market price, and I’m willing to bet that they would.

At the same time, every poor citizen would still have an “equal right” to the best quality medical care available. If prompt treatment is what a poor individual wants, then that is what she is going to get. But if she chooses the option of waiting, instead, at least she will be compensated for her longer wait. She might also be willing to ‘settle for’ treatment by an intern instead of by an established physician who has a great reputation.

My prediction is that we would still end up with basically the same result that we have today, i.e., that the wealthiest citizens will still obtain the the best medical care on the planet, and they will still be paying a premium for the privilege. They may have to pay more for the privilege than they do now, but they would not have to ‘do without.’ The big difference, of course, is that those who are poor can get compensated directly for accepting poorer quality medical care, instead of simply being relegated by fate to the status of the “underprivileged.”

This approach would seem to morally superior to any other approach, would it not? Of course, the ultimate solution in the long run is to simply stop underfunding the health care industry.

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James Kroeger 09.04.09 at 2:44 pm

BTW, it was Tom West at (22) who said:

Sorry, wait times don’t apply to me.” I’m far more concerned about how citizens view reality and how it influences their attitudes than I am about the reality itself.

I feel fairly strongly about the benefits of social cohesion, and my dislike for an official second tier is roughly on order to how I feel about legally allowing the wealthy to buy their way out of (heaven forbid) a draft.

…above.

63

Phil 09.04.09 at 2:50 pm

engels – no ‘paternalistic angels’ in my (mis)reading of Dworkin; my point was precisely that I would care far more about minimising the risk of my early death (or other bad health outcome) than anything not affecting me. Which becomes interesting if you take into account all the other people looking at their own life-courses.

But I’m not sure I understand what Dworkin’s trying to do here. Is he saying the system should provide what people really want, not just what they’re able to demand? In which case, isn’t there a rather obvious disjuncture (even in these ideal circumstances) between want and actuarially predictable need?

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Henri Vieuxtemps 09.04.09 at 2:55 pm

61 But if she chooses the option of waiting, instead, at least she will be compensated for her longer wait. She might also be willing to ‘settle for’ treatment by an intern instead of by an established physician who has a great reputation.

What if she is desperate enough to sell her kidney?

65

Neel Krishnaswami 09.04.09 at 4:07 pm

Kenny: you’re right, and I screwed up. Hyperbolic discounting does overweight the future (since it’s 1/t rather than d^-t), so I need to rethink all of my comments.

66

Mark T 09.04.09 at 4:58 pm

You keep lamenting present conditions of inequality and posit a “background of fairness and equality” but there is no plausible scenario in which, during the life of anyone now alive, every person in the USA will achieve “equality” in respect of either the means to pay for health care or the need for health care. Inequality among human beings in their ability to produce value and in their need for medical care is inherent and no corrective exists for the foreseeable future. You may not like the degree of it from one place to another or one time period to another. But it is academic in the extreme to proffer a rationale for decision that is premised on fundamental facts that are never going to come into existence. It’s an “if pigs could fly” argument.

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engels 09.04.09 at 5:12 pm

The “central idea” is definitely Rawlsian (maybe independently discovered, don’t know) but it’s less weak if, as salient suggests, you eliminate age knowledge from the participants. That would deal a.o. with Henri’s objection.

I’m not sure this is very helpfull. Firstly, I think it would be better to address Dworkin on his own terms, and to think about the reasons for choices of assumptions, rather than just importing facts about ‘how we did it in the Original Position’ (which is not to say that the OP can’t be useful as a point of comparison.) Secondly, I doubt that any insurer would be willing tquote lifetime health cover if you couldn’t say whether you were 18 or 78. Thirdly, what does ‘eliminat[ing] age knowledge’ amount to here? The claim is that as a 25-year-old I have different values than I shall have when I am 55. Eliminating my knowledge of my age doesn’t change those values, so how does it solve the problem?

(Chris, perhaps I shouldn’t have mentioned ‘responsibility’ but in your words the aim is to treat people as authoritative over their own interests.)

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br 09.04.09 at 5:53 pm

Not sure if anyone has mentioned this but Alex Tabarrok takes McBertie to task over at Marginal Revolution:
http://www.marginalrevolution.com/marginalrevolution/2009/09/the-fatal-conceit.html

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Chris Bertram 09.04.09 at 6:02 pm

Yes, thanks for that. Luis Enrique in the comments there reads me correctly, unlike Tabarrok who is true to his usual form.

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engels 09.04.09 at 6:13 pm

Tabarrok seems to be deeply worried about the possibility of Ronald Dworkin (or maybe its Chris) seizing power in the US as Philosopher-King-President-for-Life.

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Chris Bertram 09.04.09 at 6:22 pm

Depressing, though that he seizes on my (somewhat inept) reference to the terminally ill rather than the sentence which preceded it which makes my meaning clear:

bq. people would also prefer to spend their money on their vigorous and healthy younger selves rather than on keeping themselves alive, _at enormous expense_ , for _a few additional months_ of _low-quality life_ .

One quickly gets a sense of which bloggers are genuinely interested in having a conversation and which are point-scoring hacks.

72

Tom West 09.04.09 at 8:14 pm

James Kroeger #61

Your place-switching suggestion is fascinating and I’m still thinking about what its effect would be on social cohesion.

Of course, the ultimate solution in the long run is to simply stop underfunding the health care industry.

Unfortunately, free of any constraints, there’s essentially an infinite demand for health-care. So, one way or another, we’re rationing, be it by personal wealth, insurance companies, or government fiat.

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James Kroeger 09.04.09 at 10:09 pm

Henri – 64:

But if she chooses the option of waiting, instead, at least she will be compensated for her longer wait. She might also be willing to ‘settle for’ treatment by an intern instead of by an established physician who has a great reputation. What if she is desperate enough to sell her kidney?

Emergency services are already [generally] rationed according to triage considerations. But if an otherwise healthy person needs money and someone in great need of a kidney is willing and able to part with a great deal of money, then it would seem that the needs of each party would be optimally satisfied.

To ensure wise decisions, precautions could be followed, such a not allowing minors to put their organs on the market. Of course, an extraordinary effort should be made to ensure that organ sellers are fully informed about the actual risks involved. We don’t want anyone victimized as a consequence of our efforts to produce moral outcomes.

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James Kroeger 09.04.09 at 10:36 pm

Your place-switching suggestion is fascinating and I’m still thinking about what its effect would be on social cohesion.

One would think that social cohesion would be optimized if all underprivileged individuals enjoy the same right to “society’s compassion” that wealthy people possess. And no powerful, authoritative institution is ‘forcing’ anyone to act against her own will. I can’t imagine a less divisive state of affairs.

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Tom West 09.05.09 at 2:33 am

Sadly, human’s aren’t necessarily the most rational of all creatures. The appearance of equality is usually more important that actual equality, and even transactions freely entered into can result in great unhappiness and increased distrust between citizens.

[An example of the last: Consider a prolonged black-out. A man goes into a shop in desperate need of batteries and to his relief finds some. Then he notices that the price has quintupled. In all likelihood, he's going to be furious at the merchant for profiteering even if the batteries are worth this higher price to him, and *even if there would have been no batteries available if the price had remained stable.*]

Thus, while I think your suggestion should be welfare-maximizing, I’m not completely convinced that it wouldn’t produce some of the ill-effects of a two tier system. I still like the idea, though.

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Phil 09.05.09 at 9:07 am

Tom, there’s a real world example of your ‘battery’ story. During the petrol blockades a few years ago, when most petrol stations with fuel had long queues, one station owner installed new pumps and forgot (or ‘forgot’) to put in the actual price per litre, which at the time was 50p or so. So the pumps displayed – and charged – a price of 99.9, which he insisted that people paid; they did, after all, need the petrol. After the shortage was over, he was boycotted and went out of business.

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engels 09.05.09 at 9:38 pm

One more point addressed to the claims various people are making about Rawls’ Veil of Ignorance, which I do think possibly confuse things a little. The issue we have been concerned about can be put in Rawlsian jargon as the young and the elderly having different ‘conceptions of the good’. This problem could not arise to begin with behind the Veil of Ignorance because Rawls’ contractors are assumed to be ignorant of their conceptions of the good. Based on the excerpts Chris has posted, though, I see no reason to think that Dworkin meant to impose such a condition, as the only constraint of this kind mentioned in the post is that the subjects’ will not know their likelihood of contracting different illnesses.

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Salient 09.07.09 at 12:10 am

Luis Enrique in the comments there reads me correctly, unlike Tabarrok who is true to his usual form.

His comments thread is largely overtaken by people advocating for the right to legally buy other people’s organs, and is capped off by the bitter comment, “You’d almost think the vast majority of people didn’t earn their ‘unequal resources’ by working, saving, and caring for their family.” Oh, but there’s also, “That’s fine, but do they achieve better outcomes? And please don’t come back at me with life expectancy stats.”

I hope you washed your hands after leaving a comment there.

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c.l. ball 09.07.09 at 4:26 pm

Dworkin’s arguments are sensible; they are also irrelevant. First, In the US few people want “basic” coverage; they want comprehensive coverage, and that is expensive. Second, the medical dilemmas are not about whether to put stents in an 90-year old late-stage Alzhemeir’s patient but whether to treat pneumonia in a 75-year old early-stage Alzheimer’s sufferer. This topic isn’t even being debated but the same medicine for the latter patient would also help an otherwise spry 75-year old survive pneumonia, and live happily after. But the Alzheimer’s patient who survives pneumonia could go on to 85, while requiring ever-more medical care as he ages. That is what is breaking the bank, and that fiscal concern is driving Democratic plans because covering the uninsured while the costs for the elderly rise makes the legislation too expensive.

Third, Dworkin’s future-looking youth is not likely to say “if I’m 80 and spry but macular degeneration might blind me, I wouldn’t want the $2,000 biweekly shots to slow it.” He would not want to go blind and so would want to spend more at a later stage.

80

JackFrost 09.07.09 at 4:40 pm

c.l. ball etc: I think you are missing the point:
if *YOUR* younger selves would not pay for the treatment that your older selves now need, where the do you think the money for your treatment comes from?
Money just doesn’t magically grow on trees just because you now need it, you know.

Dworkin’s argument is to try to figure out what level of treatment will be paid. If you were given full knowledge of the various odds of contracting the various diseases/conditions and their costs, what level of insurance would you pay for?

What level of payments would you make vs what money would you keep for your present self for other priorities?

And the catch is that, while making this decision, you are given *NO INFORMATION* as to whether you specifically are going to require any of those expensive treatments. All you know is that the odds of you specifically needing it are relatively low.

Sure, we all want infinite amount of care and no expenses spared for our *OWN* treatments, but very few are willing to fund that for everyone else out of our own pocket. And at the same time, few of us will ever have the funds to be able to cover some of the serious possibilities of our later life on our own. So, some level of collective payment (aka insurance model, whether public or private) is needed.

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geo 09.07.09 at 5:38 pm

Money just doesn’t magically grow on trees … you know

Oh come on, Jack. That is so pre-Era of Great Financial Innovations.

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engels 09.07.09 at 6:49 pm

if YOUR younger selves would not pay for the treatment that your older selves now need, where the do you think the money for your treatment comes from?

Possible short answer: from taxes that you (and other people) were forced to pay when you were younger, even though you wouldn’t have agreed to them at the time.

83

engels 09.07.09 at 8:16 pm

‘Wouldn’t have agreed to’ is a bit strong: ‘wouldn’t have chosen’ might be better.

Fwiw I think that this is a very interesting problem with Dworkin’s approach but its practical consequences can be exaggerated. Notwithstanding differences in outlook between the young and old there must surely be a lot of overlap between earlier and later preference-sets among people who are sincere, rational and properly informed, and I would guess that these would be broadly supportive of the kinds of proposals outlined in the post.

84

Henri Vieuxtemps 09.07.09 at 8:40 pm

“if I’m 80 and spry but macular degeneration might blind me, I wouldn’t want the $2,000 biweekly shots to slow it.”

But does it really have to be so expensive? These $2,000 biweekly shots: who priced them? Get rid of the profits, marketing, and duplications; weaken patent protection; educate enough doctors and bring their incomes in line with other professionals – and what you’ll get is probably more like $200 biweekly shots. Or maybe even $20 shots. The whole thing is, I suspect, a bit overhyped and overglamorized.

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Chris 09.07.09 at 11:27 pm

@78: You’d almost think the vast majority of people didn’t earn their ‘unequal resources’ by working, saving, and caring for their family.

They don’t, of course – being in the right place at the right time (starting with the right uterus at the right time, the most important decision you’ll ever make) has far more influence. (It is, of course, really easy to make the fundamental attribution error about yourself and assume you earned every bit of success you enjoy, whether or not this is in fact the case, which it generally isn’t.) One hopes this point wasn’t lost on the person who posted it, but considering the atmosphere at MR, who knows.

As for the larger discussion… rational actor theories and human societies don’t mix. Isn’t Dworkin dooming his discussion to lead to, at best, a thought experiment with no bearing on reality, and at worst and probably more likely, to be mis-generalized to situations where his premises are thoroughly inapplicable? (Even if the question can be resolved at all in the toy universe, which is far from clear.)

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Mario Diana 09.12.09 at 11:59 am

Who is the “we” in Dworkin’s central idea (quoted above)? I realize that he’s using something along the lines of Rawls’ Original Position to decide how to allocate health care resources, but that just points out what troubles me about Rawls.

Practically speaking, Dworkin’s central idea amounts to a small band of enlightened elites intuiting what the rest of us “want” (if we only knew it) and deciding what we’re going to live with. That’s the “we” — those anointed with the “gift” of being able to discern the General Will of Le Peuple, a la Rousseau, and the political connections to implement their vision.

What we need in this country is not one-size-fits-all collectivist decision making. That’s what people against further government involvement in health care are against. What we need is a greater variety — more choices — in health care and health insurance products. That will require less government involvement in what is presently one of the most heavily regulated industries in the U.S.

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engels 09.12.09 at 4:16 pm

Who is the “we” in Dworkin’s central idea (quoted above)? [...] a small band of enlightened elites … That’s the “we”—those anointed with the “gift” of being able to discern the General Will of Le Peuple, a la Rousseau, and the political connections to implement their vision.

Er, no. ‘We’ simply means American citizens. (And that’s perfectly clear from the post and the article.)

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engels 09.12.09 at 5:08 pm

Okay, I think some people are missing the point of this. Like it or not, Americans do live in a state therefore they have to make a collective choice about how health care is to be allocated. Deciding to leave it to the market is a decision like any other. In effect it is a decision that any individual’s access to health care will reflect two factors: the choices she makes and how wealthy she is.

Dworkin thinks it is right for people’s access to health care to reflect their own choices. What he thinks is wrong is for it to reflect how wealthy they are. His thought experiment is an attempt to see how the market mechanism would allocate health care in a society where everybody started out in life with equal wealth in the absence of government interference. It is not intended to over-ride people’s choices–quite the reverse–but to negate the influence that unequal wealth has in the existing market for health care.

It’s fine to criticise Dworkin’s reasoning but claiming that you don’t want the government making collective decisions or to be involved at all, unless you are an anarchist, isn’t serious. The American government maintains the highly unequal distribution of wealth that gives some Americans access to expensive speculative treatments and leaves others to die of easily treatable diseases.

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engels 09.12.09 at 5:41 pm

And Mario I’m guessing that you are okay with this kind of government involvement…

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Mario Diana 09.13.09 at 12:09 am

Mr. Engels, I’m no anarchist, and I’m quite serious. I’m taking what I understand to be the classical liberal position: namely, that society is nothing more than cooperation among individuals, and that government should be nothing more than a monopolization of force, administered under the rule of law, to preserve the conditions necessary for that cooperation. The conditions are that people have an orderly means of defending themselves against force and fraud. I expect you will most strongly disagree with my next statement, but I’m taking the position that this is the only moral government. Moreover, I am unable to comprehend — though I have come across it in innumerable books and articles, and college lectures — what exactly is “collective” decision making.

As to what the U.S. government is maintaining now, that is not close to a market — not in health care.

As to the video you posted, respectfully, I am at a complete loss as to what is your point.

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Substance McGravitas 09.13.09 at 12:14 am

I expect you will most strongly disagree with my next statement, but I’m taking the position that this is the only moral government.

Moral government has never existed and will never exist. Okey-doke.

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Salient 09.13.09 at 3:35 am

I’m taking what I understand to be the classical liberal position: namely, that society is nothing more than cooperation among individuals, and that government should be nothing more than a monopolization of force, administered under the rule of law, to preserve the conditions necessary for that cooperation.

I believe that’s more aptly called the classical *libertarian* position.

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Chris Bertram 09.13.09 at 6:53 am

_Moreover, I am unable to comprehend—though I have come across it in innumerable books and articles, and college lectures—what exactly is “collective” decision making._

So you are out with your friends, trying to decide which restaurant/bar etc to go to, but you are “unable to comprehend” how you could all come to a decision?

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