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Death Panels, Revisited

Friday, December 7, 2012

When it comes to doling out medical care, especially life-preserving care, we all begin to get a little squeamish. No one wants to be the one who says no. We don’t even want to acknowledge that it is happening.

I saw a play the other day in which the playwright tries to induce the audience to consider a deep problem of health care and medical insurance. A brave undertaking, I concede, but unfortunately with a poor result.

The story revolved around an insurance company’s refusal to pay for a liver transplant for one of its clients, on the argument that she had concealed one of those famous “pre-existing conditions,” namely alcoholism. The scene was Thanksgiving Day at the home of the company’s CEO, and the characters included his two sons, one a doctor and chief medical officer of the company (and also an alcoholic) and the other the firm’s general counsel. Dad is a bully — in fact, he is a cartoonish monster — who has browbeaten the doctor son into denying the woman’s request. Others in the family are browbeaten, too, just because that’s what Dad does.

There’s a lot of squabbling, during which the audience is shown that the good guys are the ones who demonstrate the most sympathy for animals, the downtrodden, and in particular the woman needing a liver, while the bad guys employ purely utilitarian arguments in support of gun owning, meat eating, and the company’s decision. It’s Correct Feeling versus No Feeling, with the suggestion that somehow Correct Feeling could, if permitted to prevail, solve the whole problem.

It seems almost accidental when the lawyer, arguing with his fiancée, notes that if the woman gets the available liver, someone else won’t. The point is passed over quickly, as though it were just another bit of dialogue instead of the key to the entire matter. He is not allowed to go on to say that if there were enough livers, hospital operating rooms, staff, skilled surgeons, recovery facilities, and medications, everyone who needs a transplant could have one tomorrow. But there aren’t. Hence choices have to be made, by someone on some basis.

The problem with Sarah Palin’s widely repeated and criticized remark about “death panels” a while back wasn’t that it was absolutely untrue but that it embodied her sublime ignorance of economics. And her ignorance is that of most people.

Economics exists precisely because there is not enough desirable stuff to meet the human population’s aggregate demand for goods. When there isn’t enough of x to give everyone who wants some x as much x as he wants, some method of allocation is required. It may be a simple method, such as “Any person p gets as much x as he can grab and hold.” That’s an oldie and is still considered quite a goodie by a great many successful and potential grabbers the world over. Or it may be more complex, such as “Any person p gets as much x as he can pay for in the market.” This is widely believed to be a more civilized procedure, although there are those who argue that it merely moves the grabbing back one stage to the exchange medium.

The simple fact is that we already have death panels. The choices have to be made, and they are made somehow, somewhere.

There are still more-formal methods, such as having a government divide up the pile of x fairly (or, for that matter, unfairly but sternly enforced) or letting portions of x serve as rewards for desired behavior. And so on. However it is done, some number of persons p are going to get less x than they would like. This is why we all learn long division in school.

Getting back to the play, and to Sarah Palin, the simple fact is that we already have death panels. The choices have to be made, and they are made somehow, somewhere. When it comes to doling out medical care, especially life-preserving care, however, we all begin to get a little squeamish. No one wants to be the one who says no. (No one, that is, but that beastly CEO Dad.) We don’t even want to acknowledge that it is happening. We shut our eyes, put our fingers in our ears, and pretend to be living in Big Rock Candy Mountain.

So far the trick of hiding ourselves from reality has been accomplished mainly by pushing the decision into some dark office inside an insurance company, where horrible people like CEOs and lawyers abound, or, in the case of transplants, to the United Network for Organ Sharing (UNOS). It is UNOS, in case you are curious, that develops and applies “policies that make the best use of the limited supply of organs and give all patients a fair chance at receiving the organ they need, regardless of age, sex, ethnicity, religion, lifestyle, or financial/social status.”

A “fair chance,” you see. But what could be more unfair, we and the author of the play cry out, than denying a lifesaving transplant? And had the play gone another way, we would cry out against the unfairness of giving a liver to an alcoholic rather than to the cute little girl with a kitten who was next on the list and who may die before another organ becomes available.

Relying on our collective delicacy of feeling to guide the hard choices means falling back on the grabber method. What the grabbers and their proxies reach for is not the actual x in question, though, but the commodity that has become our chief medium of exchange in this age of too much information: our attention. And what gets our attention is not economics or public policy — boring! — but sound bites like Palin’s or heart-tugging anecdotes like the play I just saw. Neither is a contribution.

Robert McHenry is former editor of Encyclopædia Britannica and is a contributing writer to American.com. He is the author of How to Know.

FURTHER READING: McHenry also writes “Reflections of a Casual Fan,” “On the Origins of Bunk,” and “‘Despair, Destitution, and Undiluted Evil.’” Norman J. Ornstein says “‘Death Panels’ Are Real — Brought on by Budget Pressure.” David Shaywitz discusses “End-of-Life Medical Advice: Devaluing Patients in the Name of Greater Good?

Image by Darren Wamboldt / Bergman Group

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