Sunday, January 27, 2008

A bottle of whisky and a loaded revolver

"Don't treat the old and unhealthy," begins a Daily Telegraph article describing the contents of a survey conducted by Doctor magazine sparked a fierce row last night, with the British Medical Association and campaign groups describing the recommendations from family and hospital doctors as "out­rageous" and "disgraceful".

More interesting were proposals, by medical professionals, to withhold treatment from people who 'refused to take responsibility for their health'.

Gordon Brown promised this month that a new NHS constitution would set out people's "responsibilities" as well as their rights, a move interpreted as meaning restric­tions on patients who bring health problems on themselves. ... The survey found that medical professionals wanted to go much further in denying care to patients who do not look after their bodies.

Ninety-four per cent said that an alcoholic who refused to stop drinking should not be allowed a liver transplant, while one in five said taxpayers should not pay for "social abortions" and fertility treatment.

Paul Mason, a GP in Portland, Dorset, said there were good clinical reasons for denying surgery to some patients. "The issue is: how much responsibility do people take for their health?" he said.

"How much responsibility do people take for their health?" is a question, which asked hard enough, forces us to examine the merits of private versus universal health care cover. The Australian Financial Review described the problem inherent in charging an average premium to provide universal health care for everyone.

Imagine a perfect world of complete comprehensive, universal health insurance. No one would face any financial burden when they fell sick. Everyone would be able to utilise care of the highest quality both during treatment and recuperation. And all this without any waiting. This is a world where individuals’ health risks have been completely removed.

While nice to imagine, the simple fact is that the economics of health care does not (yet) permit this world. Governments may aim for perfect universal coverage, but reality falls short. Indeed, neither the government nor the market comes even close. As we will argue here, the way we have set up the health system actively works against improving the level of health insurance. This is because health insurance is governed by the forces of self selection.

Let’s start with the private market. Self selection drives away those with low health risk and makes insurance expensive for those more at risk. To see this, suppose that private insurers set a premium based on the average population health risk. Then those individuals and families who have a lower than average health risk would find the price of health insurance too high. But if some low risk families fail to buy private health insurance then the average risk faced by insurance companies increases and to remain profitable, premiums must rise. This in turn leads more low risk families to drop out. In a purely private market for health insurance either high risk families will pay more for insurance than low risk families or only those who face a high risk of medical care and hospitalisation will find it worthwhile to buy insurance.

The Telegraph story describes a situation where the relatively low risk working population of the the UK is balking at consumption of health resources by high-risk elderly and dysfunctional groups. People who are "too old", "too fat" -- that is to say the people on the high side of the risk curve -- ought to take more 'responsibility' for their health because otherwise they'll simply soak up the resources which other persons want. The problem in Britain is probably exacerbated by the fact that "the NHS is not funded by insurance, instead being funded from general taxation". Thus the burden falls on the people who pay the most taxes: people of working age.

But since social norms prevent a complete reliance on private health insurance system which would leave the too fat and the too old unable to afford any reasonable cover, some kind of hybrid eventually emerges in which there is provision for members of society who, for reasons of age or dysfunction, can't fend for themselves.

For those unable to pay for what they need or afford the health cover appropriate to their situations, rationing eventually rears its ugly head. And rationing, in health care, means somebody gets to play God. The Telegraph describes what the logical conclusion of rationing is.

Paul Mason, a GP in Portland, Dorset, said there were good clinical reasons for denying surgery to some patients. "The issue is: how much responsibility do people take for their health?" he said.

"If an alcoholic is going to drink themselves to death then that is really sad, but if he gets the liver transplant that is denied to someone else who could have got the chance of life then that is a tragedy." He said the case of George Best, who drank himself to death in 2005, three years after a liver transplant, had damaged the argument that drinkers deserved a second chance.

So maybe God, after all, is nothing that even socialism can abolish. Those unwilling to trust that there is meaning to universe can still hope there will be beds available at the NHS or compassion in the heart of a bureaucrat.


Blogger Triton'sPolarTiger said...

Wretchard said:

"For those unable to pay for what they need or afford the health cover appropriate to their situations, rationing eventually rears its ugly head. And rationing, in health care, means somebody gets to play God."

As much as I'm concerned about the impact of unchecked illegal immigration, unconfronted islamic facism, and income redistribution via "progressive" taxation, this business of socialized medicine just might be the greatest danger of them all.

We've all heard the phrase (in various iterations) "If you haven't got your health, you haven't got anything."

Introduce single-payer healthcare into the equation, and the government will have us by the stones in a way that even confiscatory progressive taxation couldn't touch.

Imagine how, just a few years from now, this new govt healthcare bureacracy, populated with leftist crusaders in much the same fashion as current govt bureaucracies, proceeds to deny health claims by persons in various govt-declared "unfit for coverage" groups as a matter of policy...

Like: obese... smokers... owners of "dangerous animals" like large dogs (i.e. pitbulls), people who have lousy teeth and the attendant health issues that result because of a lifetime of avoiding dentistry, people who own... (Wait for it)... GUNS!

And you thought the social experimentation power of the current US tax code was great...

The possibilites for social engineering and outright social control at the hands of our "betters" are endless once a single-payer govt healthcare system is in place...

"We're sorry, sir, but the regulations state quite clearly that hunters are not covered for injuries sustained while in the field if they use any weapon other than a compound bow, sit in a deer stand without proper fall protection harnesses, utilize a deer stand higher than "X" feet off the ground, etc... NEXT!!!"

1/27/2008 05:38:00 AM  
Blogger Marcus Aurelius said...

A guy who I knew whose father was a union guy and a result voted D complained how the govt was getting down so hard on his smoking habit.

I told him straight out, if you want others to pay for your medical treatment from smoking expect those paying to get owly about the smoking.

There was a time when routine medical care did not require major expenses, think back to the idea of doctors making house calls.

As is often pointed out, two areas of medical endeavor the prices are getting cheaper and it is those areas with the least government interference and insurance does not pay for.

The govt is involved in education and medical care and what is happening to costs in both fields?

Triton is correct. What scares me even more is incomplete (or incorrect) knowledge may lead these bureaucrats to make really poor decisions. In a way, will they not be like the doctor at the train depot viewing patients and pointing a direction for the patient?

1/27/2008 05:49:00 AM  
Blogger Triton'sPolarTiger said...

"We're sorry, sir, but the regulations state quite clearly that in chosing to have a second child, your family's carbon footprint will increase beyond the allowable impact threshold. You cannot have the baby at any national healthcare facility, as such an act will make the government complicit in harming the environment, which is clearly illegal. Oh, and sir, in the event that complications arise with the mother while delivering, treatment at any government healthcare facility will not be posible, for the same reasons cited moments ago, etc... NEXT!!!"

1/27/2008 05:49:00 AM  
Blogger Triton'sPolarTiger said...

"Oh my, sir, I can't say that I've seen a leg with double digit compound fractures before. Let's get you headed back right awa... uuh... Oh. It says here that you're an avid base jumper. Hmmm.... NEXT!!!"

1/27/2008 06:38:00 AM  
Blogger Triton'sPolarTiger said...

"Ah, sir, on your pre-qualification questionnaire, you indicated that you're a sheep farmer, and that the sheep are managed in part by a collection of border collies; is that right? It also notes that you are the owner of and responsible for the care of the dogs. Well, unfortunately, your skin tests have indicated you are highly allergic to dogs, which you have in abundance. You'll have to take some responsibility for your own health before we can treat you legally; no more than three working dogs are allowed on a farm within the size guidelines under which yours falls. Get rid of seven of the dogs, then come back.

Oh, and sir, by the way... you've also tested positive for wool sensitivity...

1/27/2008 07:03:00 AM  
Blogger Triton'sPolarTiger said...

"Ma'am, I'm sorry, but the regulations are clear. You've elected to remove your older children from government schools, hence we are to assume that your toddler will also be home-schooled. There is a limited supply of whooping cough vaccine, and it must be reserved for those children at greatest risk of exposure. If you want to have your toddler vaccinated, then return your older children to public school. If, after one calendar year, they are still in public schools, we will then be free to offer the vaccine. NEXT!!!"

1/27/2008 07:10:00 AM  
Blogger Triton'sPolarTiger said...

"Good afternoon, dearie! Pregnant, are we? Third time in the last 18 months! My, aren't we a busy teenager! Well, not to worry, sweetheart, your secret is safe with us - Right to Privacy, and all that - we'll have you right as rain in no time, no need to worry about missing your Sweet Sixteen party. Can't have that now, can we! Oh, and while we're at it, let's get that little wart taken care of...

1/27/2008 07:16:00 AM  
Blogger Unknown said...

My Canadian sister-in-law's mother came home one day from her market trip, fell and hurt her hips. She was rushed to the hospital in severe pain. The doctor gave her morphine to ease her pain. Then the good doctor told the family that the patient was in coma (he induced that, btw) and it would take at most five days of morphine to ease her over (to the other side, of course). The woman was 92, she was in perfect health until she fell. She went to market herself. She and her 96 years old husband took care of each other.

It only takes one fall ...

The family refused the good advice, and was told to take the patient home. Now the patient is suffering from excruciating hip pain, but otherwise safe at home with her husband.

1/27/2008 09:54:00 AM  
Blogger NahnCee said...

The family refused the good advice, and was told to take the patient home. Now the patient is suffering from excruciating hip pain, but otherwise safe at home with her husband.

And I'll bet Canada doesn't have any sort of right-to-die or overt physican-assisted suicide program, does it?

I wonder what would happen if it was put to these English bureaucrats and pipsqueak doctors that if they want to withhold medical care from the unfit, that they REALLY need to have in place a right-to-die program with a space for their own individual name to be typed in as being responsible if a sick person chooses that option.

1/27/2008 10:55:00 AM  
Blogger Zenster said...

Triton: The possibilites for social engineering and outright social control at the hands of our "betters" are endless

Big government has already demonstrated such unbelievable incompetence that letting them get a hand on your life-support plug is sheer suicide. With the immigration debacle, we've already had a stunning demonstration of our politicians' craven conflict of interest. It would be orders of magnitude more foolish to place our very lives in their hands.

Marcus Aurelius: incomplete (or incorrect) knowledge may lead these bureaucrats to make really poor decisions.

Right now, your statement is more the rule than the exception. Unlike poor medical decisions at least poor legal decisions can be reversed. Death cannot.

1/27/2008 11:24:00 AM  
Blogger Zenster said...

One simple solution: Mandate that every politician who approves of this measure must receive all of their medical treatment at these government facilities without any access to private services.

It's long past tea for these socialist nimrods to share in the joy of their own handiwork.

1/27/2008 11:32:00 AM  
Blogger geoffb said...

Single payer health care is a way to turn us into a "water empire". In the USSR it was the "Single Employer" system that did it.

Catastrophic insurance should be had by all with subsidies for those too poor to afford it. HSAs to cover the regular medical expenses also with an assist for the poor which would also translate into a leg up on retirement for the poor also.

1/27/2008 11:34:00 AM  
Blogger JacksonvillePat said...

A very good book about the modern American Health care crisis is by Arnold Kling "Crisis of Abundance: Rethinking How We Pay for Health Care" Professor Kling makes a very good point that the American expectations of health care are mutually exclusive:

1. A desire for the highest quality of health care (regardless of cost).
2. Universal access to the highest quality of health care (regardless of cost)
3. Insulation from paying for universal access to the highest quality of health care (regardless of cost)

Health care as a limited valuable resource and is thus subject to the rules of economics.

Universal access of the highest quality of health care requires increasing the cost for consumers. If cost is contained some form of rationing is required (rationing services or rationing who receives services).

Perhaps the best solution is an honest assessment of priorities and application of realistic economic principles. Professor Kling, who is an economist, offers what seem to be honest and realistic (but not sugar- coated) solutions.

1/27/2008 11:37:00 AM  
Blogger Mad Fiddler said...

This comment has been removed by the author.

1/27/2008 06:48:00 PM  
Blogger Mad Fiddler said...

Some of the most persistent memories from my childhood come from reading LIFE magazine in the waiting room of my violin teacher's studio in downtown Oxnard, while she finished up with the student ahead of me.

One article, from circa spring of 1961, addressed the issues raised by the new technology of Kidney Dialysis. The machines were atrociously expensive and the manufacturing know-how limited, so that a given community served by a handful of hospitals might only be able to afford a single dialysis machine.

This in turn meant that only a handful of patients suffering from kidney failure could be kept alive. To keep a single person alive required being hooked up for several hours at a stretch, after which the machine and all of its tubing and receptacles --- i.e., anything that had any contact whatsoever with the patient's fluids --- had to be carefully sterilized. Today we are accustomed to seeing entire single-use surgery kits consisting of five scalpels, ten pair of clamps, gauze pads, teflon dressings, swabs, intubation supplies, assorted needles & thread, handy-wipes, face masks, and playing cards, all sterile and thoughtfully laid out in order of anticipated use, in a sterile blister pack. 1961 predates all those conveniences. A trained technician might need say, half an hour of careful work to remove the used tubing and blood-processing parts then clean and or replace them. They didn't have AIDS then, but there have always been blood-born diseases.

Life Magazine's stark black & white photographs showed groups of citizens drawn from different communities, sitting at table deliberating over the list of patient candidates for Dialysis. Each community with one of the new dialysis machines was expected to create such a representative committee, formed of firefighters, school teachers, housewives, clerks, shop owners, carpenters, etc. These people in their turn shouldered the burden of deciding who would live and who would die because ***SOMEONE HAD TO DO IT.***

I only appreciate now that the decision was not left to some faceless bureaucrat.

It seems to me that in the intervening years our culture has utterly lost the ability to confront such decisions. Our politicians AND our voters, consistently avoid taking responsibility for making any decision that could be characterized as rationing, as though the concept of rationing is, ipso facto, evil.

This seems particularly weird considering that the ENTIRE IDEA of socialism is from the start a RATIONING of resources, re-distributing wealth taken from those who are rich to those who are not.

Meanwhile, doctors and Insurance companies deal with such matters all the time. Doctors at least have a rational basis of experience, for example, observing that only about ten percent of patients given CPR after cardiac arrest are ever able to recover enough to leave the hospital alive. Insurance companies desensitize themselves from nagging ethical worries by concentrating on their fiduciary responsibility to investors to maximize profitability over all other considerations.

1/27/2008 06:58:00 PM  
Blogger Storm-Rider said...

Don't forget, Auschwitz was preceded by the ideas of Eugenics; and that was basically a modification of the German socialist universal healthcare system whereby the old and disabled were "taken care of." Others quickly followed.

1/27/2008 08:27:00 PM  
Blogger jj mollo said...

Mad Fiddler has got it right. Think of it as triage. In battle no one ever doubts the wisdom of triage. Facilities, supplies and personnel are fixed in the short run. You must set priorities somehow. The most obvious way is to treat first those who stand to benefit most. Those who will die anyway are given painkillers if they are dying too loudly. The same for those who will get better anyway. Treat first the ones who will die if you don't, but will live if you do. From that starting point, the hypothetical situations can get very emotionally distressing. Should you treat a 20 something NCO before you treat a 50 something Colonel? Should you treat an unlikeable American before an admired Iraqi? Nothing but nasty choices, but somebody has to make them without hesitation. And somebody will. (Remember the panic rules. Nearest first, top down, left to right, and flip a coin if that fails to clarify the choice.) Fairness will always be questioned. Usually the choices don't matter, but sometimes they do.

Unfortunately, the long run is no different than the short run and civilian life is no different than battle. Resources will always be finite. The casualties come in faster than we can treat them. Moreover, we have a seemingly infinite number of ways to expend our resources. In modern medicine, it seems, we always have one more thing that we could be doing. And today, as we speak, somebody is making that godlike Decision of whether to exercise the next option or let the patient go. It is being done. The decisions are being made. If we did away with all medical insurance, the patient and the family would be making the Decision, or would find themselves defeated by the need to raise money. If we have The Best Possible Medical System with complete coverage and a single payer system, somebody will still have to decide how to allocate resources. They can disguise it however they want, they can pass the buck or send out pink slips, but some poor bastard is always going to get the pointy end of the stick.

This is simple economics, and it doesn't matter whether you have private or socialized medicine. You try to design a system that gives you the biggest bang for the buck. It's not a complete zero/sum game, but there is never enough to go around. So you have to devise mechanisms for making things more fair, like the committee of citizens that Fiddler described.

1/27/2008 08:28:00 PM  
Blogger geoffb said...

"1. A desire for the highest quality of health care (regardless of cost).
2. Universal access to the highest quality of health care (regardless of cost)
3. Insulation from paying for universal access to the highest quality of health care (regardless of cost)

It seems that you can have 2 out of 3.

High Quality plus Universal Access equals extremely high cost.

High Quality plus Insulation from cost equals the health care plan for dictators themselves. Access only for the elite.

Universal access plus Insulation from cost equals lousy health care for all.

What is best is an individual decision and having each individual make the decisions will result in the most satisfactory solution or I should say solutions as each will have struck a different balance between the competing desires.

1/27/2008 09:45:00 PM  
Blogger ledger said...

If I were a doctor in the UK who wished to avoid doing a lot of work I would most certainly tow the line:

“If you drink or are obese than I don’t have to medically treat you.”

Bingo, case load dramatically reduced.

1/28/2008 12:40:00 AM  
Blogger Cato Renasci said...

Given that medical care will always be a (relatively) scare resource -- at least at the level requiring the most sophisticated, time-consuming, and resource intensive treatments, it WILL be rationed one way or another.

The only question is how will the resources be allocated and who will do the allocating.

In a private system, where price largely allocates the resources (but through charitable contributions and the actions of individual doctors that is often mitigated to some degree, and where some communities will decide to provide a minimum standard of care through publicly funded hospitals), those who place the highest value on the resouce and can pay will bet the resouce, assuming the caregivers agree.

In a government-run system, it will be bureaucrats who allocate the resouces, so the basis will not be ability to pay, but, ultimately, a judgment about one's relative political influence. That makes the citizen even more dependent upon the government, currying favor with bureaucrats, and avoiding expressing any belief or taking any action that might be counter to current bureaucratic and political initiatives.

Is there anyone who things the latter is not more corruptive of liberty than the former?

1/28/2008 04:56:00 AM  
Blogger Unknown said...

"People who are "too old", ..... that is to say the people on the high side of the risk curve -- ought to take more 'responsibility' for their health .."

How does someone "too old" take more responsibility for their condition. A Nobel Prize in medicine awaits the first answer.

1/28/2008 08:05:00 AM  
Blogger Fat Man said...

"How much responsibility do people take for their health?"

The irony is so deep.

1/29/2008 09:43:00 PM  

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