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Thursday, January 19, 2006

Should People be "Totaled Out"?

Robert Frank says using cost-benefit analysis does not make one a moral monster:

Economic Scene Weighing the True Costs and Benefits in a Matter of Life and Death, by Robert Frank, Economic Scene, NY Times: Do the poor deserve life support?" asks the economist Steven E. Landsburg in an article ... in Slate this month (www.slate.com/id/2133518/?nav=fo). The subtitle says: "A woman who couldn't pay her bills is unplugged from her ventilator and dies. Is this wrong?" Mr. Landsburg invokes "economic considerations" to suggest that the answer is "no." Many commentators have attacked his argument as morally preposterous. Well, yes. But it is also economically preposterous. ...[H]ere are some details of the case...:

The patient was Tirhas Habtegiris, a 27-year-old legal immigrant being kept alive by a ventilator as she lay dying of cancer last month in the Baylor Regional Medical Center in Plano, Tex. Physicians offered no prospect for her recovery. She was hoping, however, to hang on until her East African mother could reach her bedside. Ms. Habtegiris had little money and no health insurance. On Dec. 1, hospital authorities notified her brother that unless another hospital could be found to treat his sister, Baylor would be forced to discontinue care after 10 days. But ... the family was unable to find a willing hospital. True to its word, Baylor disconnected her ventilator on Dec. 12, invoking a law signed in 1999 by George W. Bush, then governor of Texas. ...

Unlike the comatose Terri Schiavo, Ms. Habtegiris was fully conscious and responsive when she was disconnected, according to her brother. She wanted to continue breathing. Her brother and several other family members have described the agonizing spectacle of her death by suffocation over the next 16 minutes. Her mother never got there. ...

In Baylor's defense, Mr. Landsburg argues that Ms. Habtegiris's treatment would have failed the economist's basic cost-benefit test... The cost of care is relatively easy to calculate, but measuring its benefit is more difficult, and it is here that Mr. Landsburg stumbles. In general, ... the benefit of an action as what its beneficiaries would be willing to pay to see it taken. To place a rough upper bound on the benefit ..., Mr. Landsburg asks us to imagine that before her illness, she had been given a choice between free ventilator insurance and $75 in cash (his ... estimate of the cost of providing ... such insurance). He assumes, plausibly, that she would have chosen the cash. The implication, he believes, is that the benefit of extending Ms. Habtegiris's care must be less than its cost.

He is mistaken for multiple reasons. For one thing, he ignores the economically compelling reasons for having social safety nets... [C]atastrophe is only one unlucky break away. One might lose one's job and be unable to afford health insurance, for example, or be stranded by a mountain blizzard and unable to afford a helicopter rescue. With such prospects in mind, most people favor collectively financed rescue efforts. That a poor person would not, or could not, buy private insurance against such contingencies is entirely beside the point.

Even more troubling, Mr. Landsburg completely ignores moral emotions like sympathy and empathy. As economists since Adam Smith have recognized, economic judgments are often tempered by these emotions. ... Had the opportunity presented itself, many would have eagerly contributed to Ms. Habtegiris's care. But organizing an endless series of individual private fund-raisers for such cases is impractical. So, we empower government to step in when the need arises.

Mr. Landsburg's argument finesses the important distinction between a "statistical life" and an "identified life." The concepts were introduced by the economist Thomas C. Schelling, who observed the apparent paradox that communities often spend millions of dollars to save the life of a known victim - someone trapped in a mine, for example - yet are often unwilling to spend even $200,000 on a highway guardrail that would save an average of one life each year. This disparity is not economically irrational, Mr. Schelling insisted, because the community values what it is buying so differently in the two cases. It is one thing to risk one's own life in an unlikely automobile accident, but quite another to abandon a known victim in distress.

By offering a transparently unsound economic argument in defense of the Habtegiris decision, Mr. Landsburg unwittingly empowers those who wrongly insist that costs and benefits have no legitimate role in policy decisions about health and safety. Reducing the small risks we face every day is expensive. The same money could be spent instead on other pressing needs. We cannot think intelligently about these decisions without weighing the relevant costs and benefits. But using cost-benefit analysis does not make one a moral monster. In the wealthiest nation on earth, a genuine cost-benefit test would never dictate unplugging a fully conscious, responsive patient from life support against her objections. Mr. Landsburg's argument to the contrary is wrongheaded, not just morally, but also economically.

    Posted by on Thursday, January 19, 2006 at 12:29 AM in Economics, Health Care | Permalink  TrackBack (0)  Comments (16)

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