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Sunday, July 19, 2009

Peter Singer and Health Care Reform

For the past few days Peter Singer's article "Why We Must Ration Health Care" published by the New York Times has been listed in the top ten most popular articles read on the NYT homepage. Singer is a "name scholar", sure to prompt a strong if not violent reaction from readers. I was once one of these people as Singer's writings could make me furious within paragraphs. I am no longer angered by Singer though his work and its influence on Obama's plans for health care reform worry me greatly. I am worried because significant changes in our health care system are inevitable and needed. The changes that are ahead of us will change the lives of the elderly, disabled, chronically sick, terminally ill, and those people with serious health problems such as cancer and a multitude of other conditions. What do these populations share in common? They are expensive and their lives are not valued. This is a social and economic problem. Scholars and activists have no neat ready solutions for the social problems we are confronted with today with regard to health care. No tidy sound bites make the national news. No nuanced debate is taking place that appeals to a general audience. In this void we have people like Singer who are described as bioethicists but are in fact ill tempered polemicists pushing a particular viewpoint. Thus when I read Singer's aforementioned article it struck me as more of the same polemics with a particular focus on QALY--quality adjusted life year.

For those unfamiliar with the health care industry, lacking any experience with disability or illness, and who don't have a clue as to what ableism is Singer's position is seductive. The health care system in America is hopelessly flawed--agreed. Rationing in health care already exists--agreed. Too many people suffer or die--agreed. Medical care is shockingly expensive--agreed. We need to maximize the "bang for our buck" as Obama puts it--agreed (sort of). All these statements are put in terms we can all directly relate to--starkly economic words. What is not discussed is the down side to a strictly economic discussion. For instance, Singer correctly points out economists have used QALY for 30 years to compare the cost effectiveness of medical procedures in this country and abroad. Singer argues that QALY "tells us what brings about the greatest health benefit, irrespective of where that benefit falls". Singer is half correct. QALY indicates the greatest economic benefit but significant problems arise when we start to think about the value of human life. Singer loves to use disability as an example in his work. He discusses a "hypothetical assumption that a year with quadraplegia is valued at only half as much as a year without". How he comes up with this hypothetical figure I do not know. What I do know is that people who are quadriplegics would strongly disagree about the value of their life post injury has to them. I also know, as do doctors, nurses, insurance companies, nurses, social workers, nursing homes, and many others that living a life as a quadriplegic or a paraplegic for that matter is expensive. Some of the problems encountered by paralyzed people are directly related to their physical condition (the vast majority have well established solutions) but the real issues are less medical and economic than they are social. No price tag can be placed on the social problems encountered by people with a disability. In contrast, it sure is easy to inflame the public when one writes about how much a wheelchair costs or the lifetime economic impact disability has on one's life. What is lost is the social reasons why life with a disability is so expensive and why stigma is still attached to disability. No one wants to think about why 66% of people with a disability are unemployed and likely without health insurance. The result is we as a culture consider some people to be costly--those populations I have already mentioned like the disabled. If we want to maximize health care benefits do you think any money will be spent on the elderly, terminally ill, or disabled people? The skeptic in me wants to scream "not a chance". A more likely scenario is we will spend as much as we value a given life. Thus if you are sick, disabled or elderly you are screwed. These people, humans one and all, are screwed because their lives are not valued and from an economic viewpoint not worthy of saving. These people are losers and remind me of Susan Sontag's seminal work Illness as a Metphor. Illness, Sontag wrote, was the "nightside of life". Singer does not think about the "nightside of life", he wants to divert our attention away from this sort of discussion. What Singer proposes via ideas like using QALY is nothing more than a giant smokescreen. He wants to hide the human element of health care and place a dollar amount on human life. Perhaps this should make me angrier than it does.

What puzzles me the most about Singer is why the NYT loves to publish his work. I suppose his name helps sell papers and fills a void. The void I refer to is how do we fix the health care system and make it accessible and affordable to all Americans? I wish I had an answer to this question and I bet if I did I would be a very rich and powerful man. Sadly, I have no faith the American government, Obama included, is going to provide the people of our nation with an efficient solution. If you have not noticed the government does not exactly operate all that efficiently. As a New Yorker this thought strikes me ever time I listen to the news about what is going on in Albany or visit the department of motor vehicles. My snide comments do not mean I am opposed to health care reform, or worse yet, I will use that dirt word that sends terror into the heart of my fellow Americans--nationalized medicine. To me health care reform comes down to choosing between the lesser of two evils or maybe even a hyrid system: Our choices as I see them are maintaining the current system and "trusting" the corporate structure that dictates how we access health care. This is untenable in my estimation. Alternatively, we can place our trust in the American government and look toward other countries that already operate health care systems such as those in Britain and Canada. This too is untenable. A possible solution lies between these extremes and given Obama's penchant for compromise this seems more likely. The real key is who will Obama listen to and seek council with. Obviously, Singer has the attention of the general public and the Obama administration. This causes me great concern in large part because I think Obama has distanced himself from disability rights groups and disability issues since he was elected. I thus wonder in his haste to foster change will Obama be like Singer and ignore the human element of health care thereby avoiding thinking about Sontag's nightside of life.


The Goldfish said...

I wrote about this yesterday and I suggest you read my post to clear up much of what Singer gets wrong about how this stuff works in practice. QALYs are used in the UK by the government body which makes decisions about the medical treatments should be made available on the National Health Service. But QALYs are used to assess the cost effectiveness of treatments not people and I think, in general, they work pretty well.

kitkat said...

QALY's are used to assess cost effectiveness?

QALY'S assess quality of life, and fixing broken people. If you can't be fixed, how cost effective can wasting money on you be? If you already have quadriplegia and develop breast cancer, how effective will QALY assess your treatment to be? Can't fix your quadriplegia, why waste money on your breast cancer?

In the NHS: Can't change your age of 65 years old, already becoming a drain on the socialized system, no mastectomy for you.

Nonsense. There is judgement on human worth built into the entire notion of cost effective treatment.

What on earth do you think Obama means about rationing health care and the chronically ill? Ask his health czar.

william Peace said...

QALY has utilitarian value. QALY also places a monetary value on medical care and human life. The NHS in Britain for instance places a monetary value on "futile" treatment for people with cancer. If you are terminally ill there is a limit, a dollar amount, as to how much your life is worth. Applying this logic to people with a disability will devastate the population and will be socially sanctioned. Why not just kill all people with a spinal cord injury? This will save lots of money and as Singer points out people who have a spinal cord injury are half as valuable as someone that can walk.

The Goldfish said...

Again, recommend you read my post. I live in Britain, I know how this works. You've taken on Singer's misinformation.

william Peace said...

Goldfish, I read your post and respectfully disagree. I suspect we have a cultural difference here in the way we perceive QALY. I will confess though I am not a fan of the NHS having lived in London for a while. I do agree Singer gets things wrong in his article, many things actually. I also find his arguments misleading--purposely so in some instances. Polemic, ugh! To me, we need to consider humanism in medical care first and foremost. That is not the case today, in Britain or the United States. Thanks for your comments which make me think.

lyrogersle said...

Why are we allowing any shades of gray to genocide?

The Goldfish said...

Thanks William and apologies for the brevity of my last half-awake comment which, on seeing it again, sounded rather ill-tempered!

william Peace said...

Goldfish, No apology needed. We are on the same side and I know your blog well.
Lyro, Genocide is not yet taking place (here I exclude the abortion of children that would have Down Syndrome). But genocide has taken place in the past, the Nazi's being the classic example. In this country we had the Eugenics Movement that still makes me shudder. It never ceases to shock me that Supreme Court justice Oliver Wendell Homes who is revered once wrote "three generations of imbeciles are enough in Buck v. Bell circe 1924.

Kathy said...

You are worried that Obama will leave out the "human element." He had to fight insurance companies to get his mother care, i dont think he will forget the human element. On the other hand, will congressmen remember the "human element" when the medical lobby is writing them campaign checks.