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July 2012 posts

Is health or health care a public concern, a right, or a need?

Mark D. White

One of the topics that fascinates me, but which I never seem to have time to catch up on, is the moral/political status of health and health care. In most cases (other than particularly infectious or contagious diseases), I consider health and health care to be matters of personal choice and responsibility, but I'm eager to hear the arguments on the other side as well.

JLMETwo articles in the latest issue of The Journal of Law, Medicine & Ethics (40/2, Summer 2012), part of a symposium on pharmaceutical firms and the right to health, address this issue:

"Health as a Basic Human Need: Would This Be Enough?" by Thana Cristina de Campos

Although the value of health is universally agreed upon, its definition is not. Both the WHO and the UN define health in terms of well-being. They advocate a globally shared responsibility that all of us — states, international organizations, pharmaceutical corporations, civil society, and individuals — bear for the health (that is, the well-being) of the world's population. In this paper I argue that this current well-being conception of health is troublesome. Its problem resides precisely in the fact that the well-being conception of health, as an all-encompassing label, does not properly distinguish between the different realities of health and the different demands of justice, which arise in each case. In addressing responsibilities related to the right to health, we need to work with a more differentiated vocabulary, which can account for these different realities. A crucial distinction to bear in mind, for the purposes of moral deliberation and the crafting of political and legal institutions, is the difference between basic and non-basic health needs. This distinction is crucial because we have presumably more stringent obligations and rights in relation to human needs that are basic, as they justify stronger moral claims, than those grounded on non-basic human needs. It is important to keep this moral distinction in mind because many of the world's problems regarding the right to health relate to basic health needs. By conflating these needs with less essential ones, we risk confusing different types of moral claims and weakening the overall case for establishing duties regarding the right to health. There is, therefore, a practical need to reevaluate the current normative conception of health so that it distinguishes, within the broad scope of well-being, etween what is basic and what is not. My aim here is to shed light onto this distinction and to show the need for this differentiation. I do so, first, by providing, on the basis of David Miller's concept of basic needs, an account of basic health needs and, secondly, by mounting a defense of the basic needs approach to the right to health, arguing against James Griffin who opposes the basic needs approach.

"A Right to Health Care" by Pavlos Eleftheriadis

What does it mean to say that there is a right to health care? Health care is part of a cooperative project that organizes finite resources. How are these resources to be distributed? This essay discusses three rival theories. The first two, a utilitarian theory and an interst theory, are both instrumental, in that they collapse rights to good states of affairs. A third theory, offered by Thomas Pogge, locates the question within an institutional legal context and distinguishes between a right to health care that results in claimable duties and other dimensions of health policy that do not. Pogge's argument relies on a list of “basic needs,” which itself, however, relies on some kind of instrumental reasoning. The essay offers a reconstruction of Pogge's argument to bring it in line with a political conception of a right to health care. Health is a matter of equal liberty and equal citizenship, given our common human vulnerability. If we are to live as equal members in a political community, then our institutions need to create processes by which we are protected from the kinds of suffering that would make it impossible for us to live as equal members.

CoggonBut what I most look forward to reading is What Makes Health Public?: A Critical Evaluation of Moral, Legal, and Political Claims in Public Health by John Coggon, whom I had the pleasure of meeting and listening to at the "Regulating Bodies and Influencing Health" symposium in Rotterdam in June.

John Coggon argues that the important question for analysts in the fields of public health law and ethics is 'what makes health public?' He offers a conceptual and analytic scrutiny of the salient issues raised by this question, outlines the concepts entailed in, or denoted by, the term 'public health' and argues why and how normative analyses in public health are inquiries in political theory. The arguments expose and explain the political claims inherent in key works in public health ethics. Coggon then develops and defends a particular understanding of political liberalism, describing its implications for critical study of public health policies and practices. Covering important works from legal, moral, and political theory, public health, public health law and ethics, and bioethics, this is a foundational text for scholars, practitioners and policy bodies interested in freedoms, rights and responsibilities relating to health.

Which is "harder": social science or physical science?

Mark D. White

Yesterday, Kevin Drum at Mother Jones spoke up for social science following an editorial in Nature arguing against the NSF's proposed defunding of research in political science. Here's a bit of the op-ed:

Part of the blame must lie with the practice of labelling the social sciences as soft, which too readily translates as meaning woolly or soft-headed. Because they deal with systems that are highly complex, adaptive and not rigorously rule-bound, the social sciences are among the most difficult of disciplines, both methodologically and intellectually. They suffer because their findings do sometimes seem obvious. Yet, equally, the common-sense answer can prove to be false when subjected to scrutiny. There are countless examples of this, from economics to traffic planning. This is one reason that the social sciences probably unnerve some politicians, some of whom are used to making decisions based not on evidence but on intuition, wishful thinking and with an eye on the polls.

...As Washington Post columnist Charles Lane wrote in a recent article that called for the NSF not to fund any social science: “The 'larger' the social or political issue, the more difficult it is to illuminate definitively through the methods of 'hard science'.”

In part, this just restates the fact that political science is difficult. To conclude that hard problems are better solved by not studying them is ludicrous. Should we slash the physics budget if the problems of dark-matter and dark-energy are not solved? Lane's statement falls for the very myth it wants to attack: that political science is ruled, like physics, by precise, unique, universal rules.

And here's some of what Mr. Drum added to it:

The public commonly thinks of disciplines like physics and chemistry as hard because they rely so heavily on difficult mathematics. In fact, that's exactly what makes them easy. It's what Eugene Wigner famously called the "unreasonable effectiveness" of math in the natural sciences: the fact that, for reasons we don't understand, the natural world really does seem to operate according to strict mathematical laws. Those laws may be hard to figure out, but they aren't impossible. ...

Hari Seldon notwithstanding, the social sciences have no such luck. Human communities don't obey simple mathematical laws, though they sometimes come tantalizingly close in certain narrow ways — close enough, anyway, to provide the intermittent reinforcement necessary to keep social scientists thinking that the real answer is just around the next corner. And once in a while it is. But most of the time it's not. It's decades of hard work away. Because, unlike, physics, the social sciences are hard.

Bonus points for the Foundation mention!

(I don't have much to add; I made a similar point in this post, comparing the complexity of marcoeconomic forecasting models to meteorological weather-forecasting models.)

Decision-making is not math: A lesson in the subjectivity of value

Mark D. White

Last month, The Economist published an article (based on research published in Journal of Marketing) on consumers' irrationality when compared discounts and added content:

Consumers often struggle to realise, for example, that a 50% increase in quantity is the same as a 33% discount in price. They overwhelmingly assume the former is better value. In an experiment, the researchers sold 73% more hand lotion when it was offered in a bonus pack than when it carried an equivalent discount (even after all other effects, such as a desire to stockpile, were controlled for).

In a recent issue, the magazine printed a letter by Rory Sutherland of Ogilvy & Mather UK, succinctly and humorously pointing out the problem with attributing irrationality to such consumers:

You mentioned research which revealed that shoppers often prefer “50% extra free” to a notionally more generous 30% reduction in price, and you cited this as evidence of irrationality or poor mathematical ability on the part of consumers. I think you may be wrong and consumers may be right.

There is, as the advertising sage Jeremy Bullmore observed, a significant difference between a bonus and a bribe. A price tells you much more about a product than merely what it costs. A price cut may be sensibly perceived as a mark of mild desperation on the part of the seller and it is not unreasonable to infer from a price cut that a product is an inferior good. Charging the full price but adding something extra does not convey the same desperation. In any case this whole debate is silly.

If people value 50% extra free more highly than 33% off, then that is an end of the matter. Since all value is subjective, what you are doing by offering the former is simply creating more perceived value at a lower cost. Whether or not the resulting behaviour conforms to some autistic neoclassical idea of rationality is irrelevant.

If the sole purpose of life was to be rational, we would have banned golf years ago.

Mr. Sutherland said it better than I ever could--and I've tried, in many places and many contexts, including previous posts (such as here), book chapters, and my forthcoming book, The Manipulation of Choice: Ethics and Libertarian Paternalism. Economists--of both mainstream and behavioral varieties--all too often see irrationalities where none exist because they insist on interpreting choice through the lens of their narrow understand of decision-makers and the overly simplistic choices they assume on consumers' parts.

The factors that consumers take into consideration when make choices are much more complicated than economists recognize--as Mr. Sutherland points out. And while behavioral economists are making headway in identifying some of these factors, they still don't account for qualitative ones like principles and ideals. Nor do they consider the complex and subjective interests of consumers (and all decision-makers), choosing instead to assume simple unitary goals like wealth-maximization. Until they take these common influences on choice into account, they will see irrationalities wherever they look--which reflects more on the shortcoming of their models than on the decision-makers themselves.

Compassion—It’s Not Just for Sundays

Jonathan B. Wight

The human mind and heart has the capacity for compassion, which produces important ramifications for cooperation. These are the results of experiments by David DeSteno and others discussed in today's NY Times, "Compassion Made Easy."

Interestingly, there are environmental triggers and positive externalities to this practice. The environmental triggers for feeling compassion could be simple things that bring two people randomly together. Once compassion is triggered, it spreads to third parties. This is reminiscent of the oxytocin findings by Paul Zak, who has a theoretical model to explain the results.

If you are not doing active work on becoming compassionate in your life, as encouraged by virtually all major religions and psychological groups such as AA, you may be missing a key element for creating a fulfilled life. Adam Smith's superior prudence likewise presupposes "the best head joined to the best heart."

The Demise of Noblesse Oblige

Jonathan B. Wight

Noblesse oblige means literally, "Whoever claims to be noble must conduct himself nobly."

David Brooks laments the passing of a Protestant-leader age in which the elites understood that virtue went with the territory:

The best of the WASP elites had a stewardship mentality, that they were temporary caretakers of institutions that would span generations. They cruelly ostracized people who did not live up to their codes of gentlemanly conduct and scrupulosity. They were insular and struggled with intimacy, but they did believe in restraint, reticence and service.

Today's elite is more talented and open but lacks a self-conscious leadership code. The language of meritocracy (how to succeed) has eclipsed the language of morality (how to be virtuous). Wall Street firms, for example, now hire on the basis of youth and brains, not experience and character. Most of their problems can be traced to this.

If you read the e-mails from the Libor scandal you get the same sensation you get from reading the e-mails in so many recent scandals: these people are brats; they have no sense that they are guardians for an institution the world depends on; they have no consciousness of their larger social role.

Think no further than the difference between President George H.W. Bush and scion George W. Bush—one a war hero who dutifully sacrificed through many ranks of faithful service, the other….

Krugman was drinking from the same well today.

Frank Knight on Foolish Beliefs and Vending Machines

Jonathan B. Wight

Interesting perspectives from Frank Knight, fifty years ago*:

Of the many "fool" beliefs about "capitalism" current in the public mind, none is intellectually more false or socially more costly than the idea that the employee is "working for" a capitalist or property-owner, or "management," or any "boss," any more than the latter is working for him—or that either is true. Exchange and its benefits are mutual, and in a free-market system nobody works for any one but himself, except as he chooses to do so, on charitable grounds [emphasis added].

Lovely! It's refreshing to view ourselves in control of our destinies, not victims of circumstances. But of course, this sanguine view is based on living in a country with an impartial legal system and competitive labor markets. Much of world's population lives in rural areas where often a monopsony (buyer monopoly) exists. Agricultural workers may be tied to the land by generational debts. Trying to leave for a better opportunity could land you in jail. Knight cautions us to have a realistic view:

However, these self-evident generalizations by no means prove that under realistic conditions complete laisser-faire is socially ideal. That, it is equally a primary task of economic teaching to make clear, against the folly or prejudice of those who oppose governmental action on principle."

Finally, this quote on the alleged impersonal nature of exchange:

In fact, the concept of perfect economic rationality is finally mechanistic, and the perfect market could be approximated only if exchanges were made through vending machines, without personal contact (emphasis added, p. 274).

And since most transactions involve people conversing, exchanging information, and bonding, some other mechanism beside perfect economic rationality may be present to make it all work.

*"Methodology in Economics: Part II," Southern Economic Journal, Vol. 27, No. 4 (Apr., 1961): 273-282.

[Thanks to David Levy at George Mason University for unearthing this article.]

Industrial Policy and the God Particle

Jonathan B. Wight

The European Organization for Nuclear Research (CERN) has come up with a doozie. They announced this week that they might have discovered the fundamental building block of the universe, the Higgs Boson or the "God particle."

This is exciting on many levels and leads researchers into areas that could fundamentally change our world. But the news is also deeply disappointing from the view of America's hegemony in science.

Nobel prize winner Steven Weinberg unravels the sorry state of America's nuclear collider project in The New York Times, "The Crisis of Big Science":

In the early 1980s the US began plans for the Superconducting Super Collider, or SSC, which would accelerate protons to 20 TeV, three times the maximum energy that will be available at the CERN Large Hadron Collider. After a decade of work, the design was completed, a site was selected in Texas, land bought, and construction begun on a tunnel and on magnets to steer the protons.

Then in 1992 the House of Representatives canceled funding for the SSC. Funding was restored by a House–Senate conference committee, but the next year the same happened again, and this time the House would not go along with the recommendation of the conference committee. After the expenditure of almost two billion dollars and thousands of man-years, the SSC was dead.

One thing that killed the SSC was an undeserved reputation for over-spending. There was even nonsense in the press about spending on potted plants for the corridors of the administration building. Projected costs did increase, but the main reason was that, year by year, Congress never supplied sufficient funds to keep to the planned rate of spending. This stretched out the time and hence the cost to complete the project. Even so, the SSC met all technical challenges, and could have been completed for about what has been spent on the LHC, and completed a decade earlier.

Spending for the SSC had become a target for a new class of congressmen elected in 1992. They were eager to show that they could cut what they saw as Texas pork, and they didn't feel that much was at stake. The cold war was over, and discoveries at the SSC were not going to produce anything of immediate practical importance. Physicists can point to technological spin-offs from high-energy physics, ranging from synchotron radiation to the World Wide Web. For promoting invention, big science in this sense is the technological equivalent of war, and it doesn't kill anyone. But spin-offs can't be promised in advance….

Before the Texas site was chosen, a senator told me that at that time there were a hundred senators in favor of the SSC, but that once the site was chosen the number would drop to two. He wasn't far wrong. We saw several members of Congress change their stand on the SSC after their states were eliminated as possible sites.

Industrial policy, we know, can be a really bad idea because government never has enough information to pick winners. But we also know that failing to run in the race will guarantee you will lose. Government has no information about the technology spill-overs and potential economic from research into pure science. In fact, no one does. But the excitement this week coming out of Switzerland shows that government investments can have generational effects on human capital. The Chinese are going into outer space and the Koreans are going into stem cells, areas that require them to develop their human capital. The spill-overs generated from Airbus and Embraer and CERN will be interesting PhD dissertations one day.

Why Rules Are Not Enough

Jonathan B. Wight

In case you missed it, a Florida lifeguard was fired for saving a drowning swimmer. Huh?

Turns out, the swimmer was in an unguarded part of the beach, and the lifeguard left his own station to help with the rescue. It's a good rule to mind your own business and especially to not cause unintended harm by acts of intended benevolence.

[What if other swimmers in the protected area needed help? (Turns out other lifeguards had covered for him.) What if by saving the drowning man, the lifeguard creates a moral hazard and hence other swimmers start taking risks in unguarded parts of the beach, confident that lifeguards will come to rescue them? All valid arguments, but weak ones.]

Rules are made to be broken, and this was one such case.

Tommy Lopez, the young lifeguard, had more common sense than the beach contractor that fired him.

"I'm not going to put my job over helping someone. I'm going to do what I felt was right, and I did," Lopez said. Four other lifeguards resigned in support of Lopez, saying they would have done the same thing. Moral sentiments and virtue ethics to the rescue of wooden rules.

Belatedly, the contractor rescinded the firing and offered Lopez his job back. So far, he's refused. Would you want to work for this company that doesn't know the difference between basic right and wrong in these circumstances? Would you trust someone who hired you back only under public duress?

(I guess it worked for Teresa Sullivan and Helen Dragas…)

Happy 4th of July, 2012!

Jonathan B. Wight

Fireworks last night along the James River, with Richmond city skyline in background and 17th century Shockoe Bottom market in foreground. Photo taken from Church Hill where Patrick Henry reportedly* incited the wavering patriots to fight in 1775 with these words:

Gentlemen may cry, Peace, Peace – but there is no peace. The war is actually begun! The next gale that sweeps from the north will bring to our ears the clash of resounding arms! Our brethren are already in the field! Why stand we here idle? What is it that gentlemen wish? What would they have? Is life so dear, or peace so sweet, as to be purchased at the price of chains and slavery? Forbid it, Almighty God! I know not what course others may take; but as for me, give me liberty or give me death!" (March 23, 1775, at St. John's Church).

Edward Carrington was so moved by the speech he had his heirs bury him outside the window to St. John's Church where he heard the words.

* The speech was not written down but recreated 40 years later through the memories of spectators. Henry's oratory skills were such that people were mesmerized at the moment, making recreation difficult. One account says:

Ear-witnesses to Henry's hypnotic orations remarked that while they always seemed to be convincing in the moment, they had a difficult time remembering exactly what he had said immediately afterwards: according to Thomas Jefferson, "Although it was difficult, when [Henry] had spoken, to tell what he had said, yet, while speaking, it always seemed directly to the point. When he had spoken in opposition to my opinion, had produced a great effect, and I myself had been highly delighted and moved, I have asked myself, when he ceased, 'What the devil has he said?' and could never answer the inquiry."

Yet in this speech delegates remembered and left the chamber crying "Liberty or death!"

As we know, most revolutionary founders lost either their lives or their fortunes in the endeavor to liberate us from the empire's yoke. For a good account, see Woody Holton's, Forced Founders: Indians, Debtors, Slaves, and the Making of the American Revolution in Virginia (1999).