Saturday, 31 December 2011

A Short Thought on the Economics of Health Care

I've read arguments from those opposed to socialized medicine, who point out that as price for a good or service drops, demand rises, and at a price of zero, demand can be very high indeed.

I never really bought this argument, and I'm less convinced than ever, owing to my recent health issues. In June of this past year, I was diagnosed with colon cancer, and underwent surgery to have a tumour removed in July. I'm now nearing the end of about six months of chemotherapy "just to make sure". It's been interesting in its own way, and I do feel intellectually richer for having experienced it first hand (notwithstanding that what they call chemo-brain may have impaired my ability to learn as much as I might have hoped), but realistically, I'd really rather have learned all this stuff from a book. And it's true what they say about chemotherapy being a generally unpleasant ordeal, although the precise details vary greatly from patient to patient.

I only bring this up because it drove home to me just how ridiculous the idea of cost influencing demand for things like this is. You could lower my out-of-pocket expenses for this treatment to well below zero, offering to pay me to go through this, and it wouldn't increase my demand for the service one bit. Well, unless you offered to pay me an awful lot, and I mean a lot.

(I don't even want to bother addressing the patently obvious but morally obscene observation that as you raise the price, "demand" drops. That's just a bloodless way of saying that as you raise the price, people who can't pay for the treatment won't get it, regardless of how desperately they might need it. That's not really a drop in "demand" except in the technical sense used by economists, but unfortunately, expressing the idea in terms of demand curves allows us to import the unfounded inference that people who can't afford a treatment just don't really want it as badly as those who can afford it.)

Now, it is true that free health care does tend to encourage people to use more of it for non-essential purposes. People go to the doctor more for minor things that they might otherwise have stayed home and treated themselves. I'm not convinced this is necessarily a bad thing; while it certainly increases the work load and wait times on the front lines, it also may help to identify and perhaps prevent minor conditions from escalating into to something most serious and thus more costly to treat.

But let's suppose that overutilization of non-essential health care services is, on balance, a problem to be addressed. Yes, one way to reduce that utilization might be to raise prices, though I'm concerned that this might deter people from getting something looked at that might really need to be looked at. (It wasn't the price that deterred me, but I really wish I had got that colonoscopy five years earlier.) However, maybe it's not exactly the price that's the problem.

Or more accurately, maybe it's the whole economic paradigm that's the problem. When you pay for something, you're the customer. We have strongly ingrained attitudes about customer-seller relationships, as evidenced by trite sayings like "The customer is always right." But health care doesn't work that way, or rather, it shouldn't. A patient has a complaint, and concerns that need to be addressed, and of course there's the whole issue of informed consent and patient autonomy, but it's the expertise of the physician that is critical; the patient is not always right about what needs to be done.

I suspect that our habit of thinking in terms of serving customers may be responsible for a lot of inefficiencies in the medical system. We already know that antibiotics tend to be overprescribed, in part because physicians sometimes find it easier to write a prescription because that's what the customer expects, rather than to give advice about how to deal with a common cold virus (against which antibiotics are useless). I realize that may be more a matter of trying to make the patient feel better because they can go home with something tangible, but I wonder how much of it has to do with unconscious assumptions about the role of the customer leaking over into our expectations as patients.

So while it may be true that free health care leads to certain inefficiencies, raising prices to lower demand may not be the best way to address those inefficiencies. In fact, it might well make them worse, by reinforcing the idea of the patient as customer. When you're a paying customer, you're more likely to demand "value for your money", and just being told to go home and rest for a couple of days doesn't seem like good value (even if it is sound professional advice for your condition).

I'm not sure what the solution is, but part of it at least might be for all of us potential patients to remember that a doctor is an expert to whose judgment we should have considerable deference, and if the advice is to go home and sleep it off, then that's probably what's best for us. It's also necessary for some doctors to be more aware that a major part of their role is to advise and educate patients about their health, not merely to provide treatment.

I understand that's especially challenging when you have a big caseload, and it takes a lot of time to explain to a patient why, for example, antibiotics are useless for viral infections. As a lawyer, I've felt myself subject to the same sort of pressures to do something more than simply advise, but to do something. Very often, though, the best legal advice I can give someone is to how to resolve a dispute amicably so as to avoid the need to involve a lawyer at all. It's good advice, and well worth the hourly fee to someone who needs it, but it doesn't seem like what you'd expect to pay a lawyer to do for you. Even so, one serves one's clients better by giving them what they actually need, rather than just what they expect. This is true of all professionals, and it's something that patients/clients should respect as well.

Wednesday, 28 December 2011

On Respecting Beliefs

     I have a feeling that many of my blog posts will consist of me taking a common expression or turn of phrase, and complaining about how it propagates a bad habit of thought that needs to be corrected. In this post, I'm going to take issue with the idea that we need to respect people's beliefs.

     We absolutely do not. We need to respect people, not the beliefs they happen to hold. To be sure, respecting a person means respecting that they hold beliefs, and further we should presume that they have good reasons for holding those beliefs, but all of this is part of respecting the person, not the belief.

     Now, it may be that when we talk about respecting beliefs, that's really just a shorthand for respecting the person who holds them, in which case I've no complaint. But these kinds of shorthand expressions tend to gravitate to their literal meaning in our thinking, and so we fall into the habit of thinking that beliefs themselves should be respected, rather than the people who hold them.

     So what does it mean for a belief to be respected? In short, it means not to challenge it. Beliefs, if respected, become sacred, not to be criticized or disputed. While one need not adopt a belief in order to "respect" it, one cannot contradict it or even suggest it might conceivably be in error. At most, one can remain silent.

     Yet this is backwards. Beliefs have no interests, let alone any rights to respect or to be taken seriously, in and of themselves. Any obligation we may have with respect to beliefs stems from our obligation to those who hold them, or perhaps our own obligation to seek diligently after truth. To treat beliefs as independently deserving of respect or protection is actually to deny the rights and dignity of the belief holder.

    Consider: Jack believes that a power outlet has been disconnected, and is about to remove the faceplate and start rewiring it. You happen to know the outlet is live. Respecting Jack's belief by not contradicting it puts Jack himself at risk of serious injury or death.

    To be sure, that's a rather simple example. Few people invest a lot of their identity in a claim about whether or not an outlet is live, and most would rather be mildly embarrassed than electrocuted. It may appear to be different with deeply-held identity-defining beliefs, such as religious tenets. Yet these too, in some cases, expose the believer (or others) to serious dangers. Even when a false belief is essentially harmless, it remains false, and it is not especially respectful of a person to presume he'd rather believe a falsehood than a truth.

     Now, I'm not at all saying we should go around correcting every mistaken belief we encounter. Most people don't really like to be corrected, and respecting people also entails not subjecting them to needless annoyance. As well, we're as likely to be mistaken as they are, so we should always be prepared to consider that our perception that they're wrong might be based on incomplete or inaccurate knowledge itself; we should always be prepared to be corrected ourselves.

     What I AM saying is that we should discard the idea that disagreement is disrespect, and we should be willing to engage in respectful dialogue people with whom we disagree. By respectful dialogue, I mean that we must always remember that the authority to decide what the other person's opinions ought to be always lies with that other person. We can suggest alternative interpretations, we can point to new data, we can point out logical fallacies or apparent inconsistencies in their stated opinions, but we must not simply demand their agreement. We also must be open to their arguments and evidence, and do our very best to interpret it charitably and in good faith, not simply dismiss their positions out of hand. We should not take offense at honest, good faith disagreement, and we should not presume that they will, either.

    The end result is very similar, a lot of the time, to what we hope to achieve by "respecting people's beliefs". We "agree to disagree" (which is another phrase I just might take apart one of these posts, but I'm not sure whether I like it or hate it yet), and recognize that we each enjoy full responsibility for our own beliefs. But we do not subjugate the interests of human beings to the interests of their beliefs, true or false. So I think it is best to speak just of respecting people, and leave aside this nonsense of respecting their beliefs.

Saturday, 24 December 2011

War on WHAT?

     There's something beautiful about the traditional Christmas story. In the dark and cold of winter, a pregnant woman and her husband of humble means find themselves  with no place to stay but the stable of a crowded inn. So that is where the baby is born, and despite the modest surroundings and cruel, cold world outside, it is a time of sublime joy and love and warmth and togetherness.
     It's never mattered to me much that the baby was or wasn't of special divine nature; the birth of any baby is miraculous enough to warrant celebration, and for passing shepherds and wise men from afar to arrive bearing gifts seems fitting in any event. The central point of it all, for me, was to share that joy when we need it most, the deepest darkest night of the year, and especially so here in the frigid North.
     So this nonsense about a "war on Christmas" disturbs me. I understand feeling threatened when government-sponsored religious displays are banned, but the war-rhetoric is never constructive. The wars on terror, crime, drugs, poverty, AIDS and anything else you'd care to name are badly misnamed, and the war paradigm leads us to adopt inappropriate and ineffective tactics. How much more so, then, to rush into war-thinking over whether or not we say "Happy Holidays" instead of "Merry Christmas"?
     I appreciate how seductively attractive war is. We don't admit it in polite company, but the fact is we like war. General Sherman is said to have remarked at the Battle of Fredericksburg that it's a good thing war is so terrible, else we'd love it too much. There's no doubt lots of people, even pacifists, are fascinated with weapons and warfare, and enjoy playing war games or watching war movies. But besides that attraction, war seems to give us license to ease our moral constraints, and feel righteous about doing so. So much more so when we feel we are the victims, that the other side has started this war against us, as in the War on Terror and, it seems, the War on Christmas.
     But what can possibly be more destructive to the spirit of Christmas than embracing the imagery of war, even in its supposed defense? How is it Christ-like, let alone Christmassy, to reject warm holiday wishes because they don't affirm your particular religious beliefs? 
     There is no orchestrated campaign to eradicate Christmas. There's just a rule being enforced that you can't spend public funds on promoting a particular religion. That shouldn't be a problem for Christmas; if anything, it's more of an opportunity to stay true to its mythic origins, when there was no room at the inn, and the sharing of warmth and joy took place in the humble, makeshift surrounding of a stable. 
     Merry Christmas! 

Thursday, 22 December 2011

Culture of Fear

     I'm disappointed in the way we've been moving towards a culture of fear over the last decade or so. Franklin Roosevelt was quite right in saying it's the only thing we have to fear, and as Frank Herbert wrote in "Dune", it is the mind-killer.
     The terrorist attacks of September 11, 2001 were the most obvious trigger for the current descent into fear-driven politics, and I need not go on at any length about how spectacularly terrifying those events were. Much has already been written about how fear drove us as a society to engage in a whole lot of silly and self-destructive behaviour. Fortunately, we managed to avoid the consequence that was the chief objective of the architects of the plan, which was for a U.S. overreaction to spur a global jihad against it, though it was touch and go for a while. (In fact, I suspect that this particular attack may have unwittingly prevented the global jihad it was meant to incite; imagine if the invasion of Iraq had proceeded without the windfall of international sympathy and support received by the second Bush Administration following the attacks.)
    But we certainly have harmed ourselves in innumerable ways owing to our disproportionate and largely unthinking fear of further attacks. We endure ridiculously intrusive and inconvenient security screening at airports, and thousands of people are further inconvenienced by their mistaken inclusion on no-fly lists, little of which has any actual positive effect on making us materially safer, though the whole process does seem to show that we're especially cowardly and weak if we're afraid of what a grandmother might do to us with a set of nail clippers. This is especially silly when one considers that it's actually been heroic and unarmed passengers who have foiled most airborne terror attempts since 9/11, starting with United Flight 93 on that very day.
     Just as silly, and far more shameful, has been the move towards what are euphemistically called "enhanced interrogation techniques", more properly called torture. We've known for centuries that torture is generally not very good for getting useful intelligence out of people who will say absolutely anything to get it to just stop, please stop. Yet the desire to get tough and take off the gloves is overwhelming when you're afraid. That's natural, of course. But those who advocate the use of torture are really telling us that torture (or the threat thereof) would work on them, too. (They might not work on particularly determined subjects, and when we're dealing with people who are happy to blow themselves up, it might not be appropriate to assume a lack of resolve on the part of our opponents.)
     Here in Canada, our Conservative Government is happy to exploit the culture of fear through its omnibus crime bill. Despite the fact that crime rates have been consistently dropping for years, they made much political hay about their promise to "stand up for victims and get tough on crime". Never mind that the policies they're about to implement will be disastrously expensive and very probably lead to rising crime rates (unless that's their cunning plan -- "See?! Crime rates are rising! We need to get even tougher!"). The psychology is virtually the same as that behind the torture advocacy: Maybe if we can make criminals/terrorists more afraid of us than we are of them, we'll at least be the least afraid people in a world of fear.

     I want to argue that that's a dismal and fruitless approach. For one thing, the more afraid we are, the more powerful the use of terror becomes, not only by our enemies but also by the governments that are supposed to be protecting us. After all, the more we fear being accused of terrorism, or being beaten or pepper sprayed, the more we'll strive not to make waves or trouble for those in power, even if our complaints are legitimate. That's simply not a recipe for a healthy society (although it may not be that those who crave power are really interested in a healthy society). The cure for fear is not simply more fear.

     The answer I'd like to propose is this: Don't be afraid. Or more precisely, don't let your fear cloud your judgment or make you act foolishly. It's natural to be afraid, but courage is a matter of controlling fear so that one can remain rational and make good choices.
     Easier said, than done, perhaps. Aristotle said that courage was a matter of knowing what properly to be afraid of. I'm not sure I agree with that completely. Sure, there are times when the instinctive fight-or-flight response is useful, but by and large, I don't think that the problems that face us today are ones for which being afraid (and therefore reacting in a fear-driven mode) is appropriate. Being afraid of crime should not make us vote for foolish policies, and being afraid of terrorists should not make us waste resources on pointless security theatre; however afraid we are, we should still strive to act rationally about these sorts of threats.
    It occurs to me that one of the ways to overcome fear is, in a way, through more fear. Consider terrorist attacks, for example. The idea of being blown up or burnt to cinders by a terrorist attack is frightening, to be sure. But is it worse to die that way than, say, being blown up or burnt in an industrial accident, or a car crash, which is a far more likely threat. Or is it worse than dying of cancer or stroke or some other terminal disease? Because hey, I don't want this to come as too much of a shock, but you are going to die some day, and chances are it's not going to be entirely pleasant. No need to dwell on it, of course, but we really should get over the idea that if we're safe from terrorists, then we'll live out long and happy lives free from pain and suffering. If you accept and even embrace the inevitability of your own (quite probably painful) death, then the people who try to use your fear of death to control you suddenly lose a lot of their power.
    And really, that's the only power they have, relative to us. It's not as if terrorists or other criminals have access to huge armies, after all; that's why they resort to using things that are readily available to just about everyone. I drive a car; If I chose to, I could use it to cause a helluva lot more death, pain and property damage than the shoebomber was ever able to inflict. We decent folk are potentially every bit as scary as any terrorist; it's just that we have properly developed moral instincts that prevent us from engaging in such stupid and pointless mayhem.
    That isn't the case when our governments attempt to intimidate us. The state does have access to more force than we do, as well as the power to enact laws. Yet the basic principle still applies: they cannot use fear against us unless we let them. Indeed, as important as it is not to fear terrorists and criminals, it is even more essential that we not fear our government. Perhaps the best way to combat that is to remember that our governments, at least in democratic countries, belong to us and are accountable to us. That means we need to continually assert our authority as citizens, not only by voting in large numbers (another reason why I'm worried by declining voter turnout) but by engaging in vigorous public discourse wherever the opportunity arises, including (I hope) in the comments sections of blogs like this one.

Monday, 19 December 2011

An Atheist of Faith

     It's unfortunate, I think, that we so often use the word "faith" as a synonym for "belief". The two are very different things.  Belief is a matter of taking a position on the truth value of a statement, whereas faith is a matter of acting as if something is true, without necessarily believing that it is.
     In large part, it was law school that brought me to an understanding of faith, as distinct from belief. As they drill into us, "Nobody cares what you think." That's most commonly heard when preparing for a moot, when many students fall into the speech habit of saying, "I think that..." which generally speaking just isn't good rhetorical technique (though in some cases it can be very effective), but in fact it really does go to the core of legal ethics.
     Consider representing a defendant in a criminal case. You might well believe your client to be guilty. Heck, you might believe this so strongly that you'd say you know he's guilty. But nobody cares what you think (or what you think you know); your job is to give your client the best representation possible, to ensure the integrity of the legal process. You need to put aside what you think, and present to the court the best evidence and argument (subject to the proviso that you must do so with scrupulous honesty) for your client's case, and have faith that the judge (and jury, if any) will come to the proper conclusions on their own. 
     Now, you may not actually believe that the prosecutor will present enough evidence to convict your guilty client, and you may not believe that the judge and jury are actually smart enough to reach an appropriate verdict and sentence, but that is not your call to make. You are not the one charged with the responsibility of deciding your client's guilt or innocence, and your own prejudices could easily undermine the whole process if you attempt to preempt the court's judgment with your own. In order for the system to work, you must do your job, and leave it to the prosecutor, the bench and the jury to do theirs. So you must make your arguments with the available evidence as if you believe your client to be innocent, whether you do or not, and as if you believe your counterparts in the process are competent, whether you believe it or not. In short, you must act in good faith, regardless of what you believe.

     Contrast this notion of faith with religion's emphasis on belief. Many religious people go well beyond claiming to believe that God exists; they claim to know so. It is as if the fervency of belief is a measure of piety; the more certain one feels, the fewer doubts one harbours, the greater the devotion. 
     As a philosopher sharing in Descartes' radical skepticism, I find this concern with belief to be baffling. How can we puny, fallible mortal sinners possibly lay any claim to infallible certainty about any fact? It seems to me obvious that we are all capable of error, and indeed all churches seem to try to point that out: there may be a God, but we are not it. So the focus on certainty of belief itself strikes me as fundamentally impious right from the start.
    Yet faith is something else entirely, and does not demand that we overcome our human epistemological limits. All we must do demonstrate faith is to act as if we accept a proposition as true. We are free to doubt that it is true, and indeed I think that people of honest intellect are morally obliged to acknowledge doubts.

    That is why I don't object to describing myself as an atheist of faith, when I bother to describe my (lack of) belief at all. (I have also occasionally referred to myself as a Zen Catholic. A koan: What happens when you give up religion for Lent?) I have infinite faith in God's goodness, and none in His existence. This means that while I don't actually believe God exists, and more frighteningly, while I have no evidence whatsoever to suggest that if He does exist He's not an evil spiteful monster, I simply have to act as if I believe that a truly omniscient and omnibenevolent God will have perfect knowledge of my reasons and motives, and will not condemn me to the unspeakably nasty afterlife many religions threaten sinners and unbelievers with.
     These threats, by the way, lead to a curious paradox: many of those who believe (or who profess to believe) do so in bad faith: they do not trust God to be perfectly just and merciful, and thinking they err on the side of caution (consider Pascal's Wager), they go along with whatever their church, synagogue, temple, mosque or religious leader commands, perhaps expecting the "I was just following orders!" defense to be a complete answer. Me, I doubt, but I do so in good faith and with a clear conscience. At least, as clear as the conscience of one who knows himself to be fallible can be.