Thursday, July 16, 2009

Health Care for the Generic Person

Peter Singer, who's famous-or infamous-for most candidly promoting the thought that a rat and a boy and a dog are equals (although the precise quote "A rat is a pig is a dog is a boy" was made by Ingrid Newkirk, a co-founder of PETA), has an essay in today's New York Times explaining "Why We Must Ration Health Care":

Well, first let's look at the "we." It's not you nor I with our choices to purchase, or not, health insurance, nor our doctors with their advice on the efficacy of treatments who must ration health care, but rather bureaucrats in a governmental agency such as Britain's NICE (National Institute for Health and Clinical Excellence) who will do the rationing. Singer notes, with jaundice, these are the bureaucrats conservatives label "soulless," but in his exposition they come across merely as bloodless... straightforward actuaries.

Singer, himself, is a straightforward utilitarian philosopher, who is a professor of bioethics at Princeton University and also laureate professor at the University of Melbourne, Australia. He was the subject of a fairly sympathetic review by Mark Oppenheimer in the Christian Century (July 2002) that you can read here:

As a utilitarian, Oppenheimer says, Singer sees "the moral task is to create utility--to increase the amount of happiness in the world, or at least decrease the amount of pain." Of course, these are excellent goals shared by religious people, but one that runs contrary to "monotheistic traditions" that hold "suffering can be redemptive; that people can be called to unexpected and unusual tasks, that a lone human life can have inviolable worth; and that there is something greater than humankind that deserves to be worshipped"...and perhaps honored by the building of cathedrals, by scriptual study, and by contemplation, items Oppenheimer categorizes as "a part of godliness," a trait Singer denies.

Indeed, Singer is well beyond the religious..and not so religious... mainstream because along with promoting respect and good treatment for animals and generosity in charitable giving, he also believes "it's OK to kill babies," and he does mean babies not fetuses. It's OK because, Oppenheimer points out, Singer is a "preference utilitarian" who believes in "allowing people to satisfy as many of their preferences as possible." Babies are incapable of having preferences beyond basic instincts to feed, sleep, and extricate (one might say to live) and so they are subordinate to their parents' preference to live without them...a condition that may continue up to three years of age: "a grey area," Singer told Oppenheimer.

This is the shocking aspect of Singer's world view. However, Oppenheimer also points out that many of Singer's views are accepted generally: for example, killing one of a set of Siamese twins to insure life for the second. And many would accept keeping brain-damaged infants alive only long enough to harvest their organs to save other lives.

Fewer agree with Singer that an animal may have a greater claim to life than a person..."that an intelligent adult ape has more conscious interests than a newborn" and should, perhaps be rescued from a fire before the infant, especially if the infant is retarded. The existence of preferences is the grounds for not taking a life and does not apply to infants and perhaps not to the severely retarded. The fetus's and infant's dearth of preferences is easily outweighed in Singer's philosophy, Oppenheimer points out, by preferences of the parents to kill. Apparently, the ingrained capacity of the infant to develop preferences in the future is of no account.

Oppenheimer points out that Singer might also argue that parents who thus deny themselves a child could later produce another and that parents who do not want the burden of raising a brain-damaged child might then be able to contribute thousands of dollars to UNICEF to save other children.

So this is the Singer who writes in the Times that "we must ration health care." Singer's tone in the Times' essay denies his more radical views. He sounds less like a college professor and philosopher than a business manager. He can think of no other way to apportion health care except by government rationing or by price as we (mostly) do now--although one might suggest charity, prudence (purchasing insurance), or reforming the insurance marketplace to allow individuals to buy the insurance...and only the insurance...that they need (i.e. eliminating requirements to include procedures such as stomach stapling, breast implantation, and sex changes that most people do not want and that drive up costs unreasonably).

With his proposals Singer attempts to set a price on human life--or to outline how to do so. It's important to realize he's speaking of generic people. In these terms, "the death of a teenager is a greater tragedy than the death of an 85-year-old. He asks rhetorically, "What if the teenager is a violent criminal and the 85-year-0ld is still working productively?" Well, no dice, seniors: "Decisions about the allocation of healthcare resources should be kept separate from judgements about the moral character or social value of individuals."

Singer also disses those with disabilities. He hypothesizes that a life as a quadriplegic is half as good as a non-disabled life, so it might be more beneficial to save the lives of two non-disabled than to restore the life of a single quadriplegic. If you don't think so, if you think the life of the quadriplegic is equal to that of the able-bodied, Singer asks why bother treating the quadriplegic at all? It's all in the numbers.

Now, Singer does, at the end of his 10 (printed) pages, qualify his support for government care: either people or physicians should be able to get out of Medicare for All should they choose not to participate. Unfortunately, Democrats in the House disagree with him here. Singer also believes people should be able to buy supplemental care to have an option for unrationed care (one I suspect he would use for his family). Does Obama government care allow this? Perhaps for the moment.

And I can't help but remember (because he frequently reminds us) that Obama is also infamous for regretting that the grandmother who raised him worried about the cost of her healthcare deductibles as she lay dying, despite her well-positioned and well off grandson (which opens up the moral, if not ethical, question of family support and care).

And also, I think, utilitarians may find it easy to be fickle. Singer has admitted to believing one might "need to lie for a good outcome." Utilitarians profess to seek lives that are free and valuable, but they value statistical averages and government edict rather than real people and free choices. And they are single minded in the way that I find many libertarians single minded, allowing them to sound logical when in reality they ignore the greater picture. For example, Singer ignores the destruction of incentive to produce new treatments and new pharmaceuticals that destroying profit from them will cause. He ignores a physician's inherent desire to practice his profession to the best of his (or her) own ability freed from bureaucratic restraint. And he ignores grown ups' desire to be free of government interference in personal life choices. And by ignoring "godliness" and human uniqueness, he removes most of the reasons we would choose to have a long life after all.


  1. I think long and hard about health care. My DH is on medicare and it has worked out. I am not qualified, so I pay dearly for a major medical policy. I want health care reform, but I don't want it in the same style as the Brits and the Canadians have it. I think we need to start a reform on lawsuits. I think the Brits have a good system...if you lose, you pay...for both sides. Hugs, Dotti Dots

  2. I really agree on tort reform, Dotti. We're trading legions of doctors for legions of lawyers. But the trial lawyer lobby is huge, and Democrats have no interest in curbing a group comprised of its largest campaign contributors...although one wonders how successful trial lawyers might be suing a government public plan.