This is a slightly revised version of my Thanksgiving post from five years ago. I think it bears repeating:
After the philosopher Daniel Dennett was rushed to the hospital for lifesaving surgery to replace a damaged aorta, he had an epiphany:
I saw with greater clarity than ever before in my life that when I say “Thank goodness!” this is not merely a euphemism for “Thank God!” (We atheists don’t believe that there is any God to thank.) I really do mean thank goodness! There is a lot of goodness in this world, and more goodness every day, and this fantastic human-made fabric of excellence is genuinely responsible for the fact that I am alive today. It is a worthy recipient of the gratitude I feel today, and I want to celebrate that fact here and now.
To whom, then, do I owe a debt of gratitude? To the cardiologist who has kept me alive and ticking for years, and who swiftly and confidently rejected the original diagnosis of nothing worse than pneumonia. To the surgeons, neurologists, anesthesiologists, and the perfusionist, who kept my systems going for many hours under daunting circumstances. To the dozen or so physician assistants, and to nurses and physical therapists and x-ray technicians and a small army of phlebotomists so deft that you hardly know they are drawing your blood, and the people who brought the meals, kept my room clean, did the mountains of laundry generated by such a messy case, wheel-chaired me to x-ray, and so forth. These people came from Uganda, Kenya, Liberia, Haiti, the Philippines, Croatia, Russia, China, Korea, India—and the United States, of course—and I have never seen more impressive mutual respect, as they helped each other out and checked each other’s work. But for all their teamwork, this local gang could not have done their jobs without the huge background of contributions from others. I remember with gratitude my late friend and Tufts colleague, physicist Allan Cormack, who shared the Nobel Prize for his invention of the c-t scanner. Allan—you have posthumously saved yet another life, but who’s counting? The world is better for the work you did. Thank goodness. Then there is the whole system of medicine, both the science and the technology, without which the best-intentioned efforts of individuals would be roughly useless. So I am grateful to the editorial boards and referees, past and present, of Science, Nature, Journal of the American Medical Association, Lancet, and all the other institutions of science and medicine that keep churning out improvements, detecting and correcting flaws.
Indeed. And because the supply of thankfulness is not fixed, it will not depreciate the value of Professor Dennett’s sentiment to add a word of thanks not just for goodness but for greed—the greed that inspired generations of inventors and investors, laborers and capitalists, doctors and nurses, technicians and scientists to envision and perfect such a thing as an artificial aorta, to educate themselves in the healing professions, and to show up for work every day. For the most part, they did it to make a buck.
We can be thankful too for the system that channels all that potentially destructive greed into life-sustaining brilliance. But we might temper our gratitude just a bit with a moment of wistful regret for the lives lost because of unnecessary imperfections in that system. As a society, we spend far too little on basic research in health care, largely because breakthroughs are under-rewarded. For one thing, our reliance on third-party payers (with the attendant loss of control over our own health care choices) makes us willing to pay handsomely even for relatively ineffective treatments, which diminishes the incentive for innovators to make treatments more effective. (This compelling observation comes from a paper by the economists Kevin Murphy and Robert Topel.)
For the sake of future Daniel Dennetts, I hope our legislators have the goodness and wisdom to design policies that strengthen the incentive structure instead of weakening it still further. When they fail, as they probably will, there will be plenty of time for outrage. Meanwhile, things could be far far worse, and there’s much to be grateful for on this Thanksgiving day.
“For the most part, they did it to make a buck.” This is speculation. Maybe lots of people nurse (as opposed to doing something else) not to make a buck but because they want to help people. Of course they had to do something to make a buck, but why that particular thing?
“breakthroughs are under-rewarded” This is interesting. Unfortunately JSTOR is experiencing temporary problems, so I can’t see the paper you link to – although I suspect it will only be the abstract. Perhaps the flood of traffic from your link has swamped their system. Rewarding breakthroughs in general is a problem. Pharma companies invest heavily in R&D, but can only get money back if we impose a temporary monopoly through a patent. It means that anything un-patentable does not get researched, such as ways to get us to adopt a healthier life-style, naturally occurring substances or “talking therapies” for mental health problems. Also a huge amount of effort is put into supporting the patent rather than improving performance.
Funnily enough, just as our market innovations have gone through selection pressure and benefited us consumers by cumulative step by step improvements (with competition being the mechanism here), so too has this selection pressure occurred in the evolution of our views. There is perhaps one key difference, though, between saleable goods and beliefs. Due to competition, and the market punishing inefficiency, bad service, poor quality products, the present day tends to produce the highest quality of goods available rather than any time in the past. It’s not true in every sense, of course, but generally speaking a laptop, mobile phone, washing machine, car, movie player, data storage device, and so on should be better now than previous versions 10 or 20 years ago.
This doesn’t, however, seem to happen with the same rigour in belief and about God. Maybe it’s the subjection to chaotic non-linear feedback effects, or the vicissitudes of the human mind, or the complex nature of the socio-personal, or the lack of competing selection pressures on those beliefs – or more likely a combination of the four – but the present day state of affairs regarding theists and atheists doesn’t seem to produce the modern day equivalent of the market improvements seen in capitalism. When one thinks of the kinds of poorly thought out buffoonery from the so-called modern day spokespeople for atheism (Dawkins, Hitchens, Harris, Myers), and align that with the crackpot blockheadedness of the young earth creationism and Intelligent Design movements so prevalent in these times, one hardly sees the upper echelons of critical thinking and good argumentation going on.
“Maybe lots of people nurse (as opposed to doing something else) not to make a buck but because they want to help people.” Here in Portugal, nurses regularly strike for higher wages – and they make close to doctors and college entrance is subjected to numerus clausulus. I think greed plays a part of course – nobody changes diapers and gives baths merely for the hack of it.
Found what might be a version
http://www.nber.org/papers/w11405.pdf
There is almost no discussion about third party payments in the paper I found – only one line at the end of the conclusion. I was hoping for a bit more on that. From my initial read, the authors suggest the value we get from increased longevity is huge. But then again, so is healthcare spending. US spending is something close to $3.8 trillion / yr. According to the paper, increased longevity between 1970 and 2000 added $3.2 trillion / year. If you compare it say UK system, spending is way lower, but longevity is higher by just over 1 year. That extra year is worth quite a lot according to the paper. Longevity is not all down to medical treatments – probably most of the gains in the early part of last century were due to sanitation and nutrition. What is clear is that the money spent on basic medical research is really quite small.
“Maybe lots of people nurse (as opposed to doing something else) not to make a buck but because they want to help people.”
I’m struck by why you believe these two things, helping people and making a buck, are mutually exclusive. In fact, helping others and improving other people’s lives is the best way to make a buck. The richest people in America have gotten that way by improving vast numbers of people’s lives.
“Of course they had to do something to make a buck, but why that particular thing?”
Because they are largely high paying jobs and are in demand always.
“If you compare it say UK system, spending is way lower, but longevity is higher by just over 1 year.”
This accounting has been debunked. In particular, car accidents, homicides, and other fatal injuries tell nothing about the quality and effectiveness of health care. You’ll note that national life expectancy in the US without fatal injuries is HIGHER than any other nation, including the UK (1.2 years higher in the US than in the UK).
The biggest problem in healthcare is its ever-increasing complexity. Third-payer is not why most people have little control over healthcare matters – the problem lies with information issues.
There is a huge information assymetry between patient and treatment provider. For the vast majority of diagnostic and treatment measures, it is far too costly for a patient (both in terms of time as well as in money) to obtain the sort of information he would require to make an efficient decision. This applies in particular to diagnostics.
Example: You have some kind of abdominal pain. You go to the doctor. The doctor says: It could be nothing, or it could be what Sigourney Weaver had in Alien 3.
When you show up at the doctor with unspecific symptoms, the doctor has a very wide range of medically defensible measures he could take.
He could wait and see (cheap) or he could run two dozen blood tests, take an ultrasound and a CT to exclude everything from appendicitis to ulcers to alien infestation. Unfortunately, under the prevailing fee-for-service model the doctor gets paid more the more he does, whether it is cost-efficient or not.
Let’s say he takes the middle road and wants to do 5 blood tests for 400 dollars. And you say what? “I don’t think that’s cost-efficient, I think we can make do with 3”? How would you know? Do you want to consult a second doctor (who is subject to the same incentives)? Tell the doctor you’ll be back in half an hour because you’ll have to research it on the internet first?
If you wish to rationalize healthcare you have to structure incentives appropriately. For the treatment provider, not for the patient.
In the majority of cases, due to the information assymetry between patient and treatment provider, the patient will not be able to make cost-efficient diagnostic and treatment choices without incurring unreasonable costs to bridge the information gap.
The current fee-for-service model ensures that the medical sector becomes ever more inefficient, because doctors are incentivized to use new and expensive diagnostic and treatment measures regardless of considerations of cost-efficiency, while the patient is mostly not in any position to challenge the doctor on his proposals.
#6. I did not say the effect was entirely due to healthcare- as I think this sentence makes clear: “Longevity is not all down to medical treatments”. I merely cited facts. Spending is lower. Longevity is higher.
Taking your linked article point by point. They say that longevity correlates strongly with wealth. From $20,000 to $40,000 the line is pretty much flat. Change in wealth has almost no effect on longevity. This initial point is clearly totally wrong when comparing developed economies.
Next point. “If you really want to measure health outcomes, the best way to do it is at the point of medical intervention. If you have a heart attack, how long do you live in the U.S. vs. another country? If you’re diagnosed with breast cancer?” Bollocks. That is not the best way to measure outcomes at all. If you fail to diagnose a disease it simply doesn’t get counted in that system. And it ignores prevention. For example, USA has aggressive monitoring for prostate cancer. This means that these cancers are diagnosed earlier. This means that even if there were no better treatment, people would live longer post diagnosis in the USA. The system proposed is dreadful way to measure outcomes.
Violent deaths have little to do with healthcare, but do reflect the wider society. I said that healthcare was not the whole explanation. It is indisputable that the way things are done in America generally leads to lower life expectancies, regardless of the higher healthcare spending.
Next, America does not have one healthcare system but three. This does not affect the data in any way at all. Whatever system(s) USA has is what it has. He says “To my knowledge, no one has attempted to segregate U.S. life-expectancy figures by insurance status.” This is irrelevant to whether USA has longer life expectancies, and would be cherry picking, as illustrated here ” if we compared the life expectancy of Americans on private insurance with that of centrally-planned Europeans, I’d bet that the U.S. would come out on top. And if that’s true, the argument that socialized medicine leads to longer life evaporates.” No it wouldn’t. It would demonstrate that if you cherry pick the people with the best outcomes then you can say it is better.
#7.”because doctors are incentivized to use new and expensive diagnostic and treatment measures regardless of considerations of cost-efficiency, while the patient is mostly not in any position to challenge the doctor on his proposals.” Indeed, but even if the patient believed the diagnostics were inefficient, when he is placed in the position of “needing” them, it is in his interests to accept them, so will probably not challenge the doctor. It is only when asked to pay for possible future expenditure that he could make the challenge, not knowing whether he will need the services or not.