Seqram (seqram) wrote,

Cultural Changes and Risks

I seem to have a much greater capacity for being bored lately, and find myself trying to do all kinds of hard thinking to keep busy during boring tasks. And I sometimes come up with possibly interesting stuff. Unfortunately, I usually forget them when I get a chance to write them down. But I'm trying to buck that trend, and managed to scribble down some notes on some things I thought about yesterday (still just a small part of it, alas) and I hope I have been able to flesh it out into some sort of article. If I'm lucky, maybe I can do this more often.

There were stories in the press about the outburst of assent from the "Tea Party" faction during the recent Republican debates when asked whether someone who chose not to buy health insurance and later became catastrophically ill should simply be allowed to die. I'm not going to pass judgment on the viewpoint, or talk about agreeing or disagreeing with it, but it does need looking at to see what it entails.

As I understand it, the argument is mostly from personal responsibility: if you had the opportunity and chose not to prepare against this eventuality, then the state/society at large should not be saddled with rescuing you when your carelessness comes back to haunt you. This is a common theme throughout the current right wing's philosophy, in opposition to the feeling they have that today's governments are becoming too intrusive and "nanny state"-like, and that therefore the successful elements are being forced to subsidize the less successful, which reduces the incentive to be fiscally responsible since there'll always be someone to bail you out. So the idea is that successful people should be allowed to reap the full rewards of their hard work without having to bail out the less successful, and on the other side the less successful people should have to face the consequences of their lack of success.

There's a lot to discuss about this in general, and maybe we'll get there, but starting back where we started, with the issue of health care, let's see if this philosophy can really be put into practice. See, the problem is that whether they're "right" or "wrong," whether this is a good idea or a bad idea, putting it into practice will require a definite cultural shift, a change in the way our culture views things. Most hospitals (and the people to staff them) simply would not have the will just to wheel suffering people out back and let them die, even if it were legal to do so. Our culture puts a high value on human life (or at least it claims to), and standing by idly while someone dies is morally repugnant to us (it's even in the Bible, Leviticus 19:16, "Thou shalt not... stand against the blood of thy neighbour," (KJV) which is apparently interpreted by most Jewish and Christian sources to refer to standing idly by). That's just a fact of our current culture; one could argue for or against it as a moral standpoint, but either way it is currently favored by our society.

So even if laws are passed to support this suggestion that the uninsured who can't pay for their care be wheeled out back to die, it's very unlikely that most hospitals (and hospital-workers) will be able to find it in their hearts to do so. And so they'll keep treating indigent patients who show up on their doorstep, which means they'll have to pass on the costs to their paying customers in higher fees. And so we'll be in the same state that we are now, exactly the state the whole "personal responsibility" philosophy wants to avoid: the healthy and wealthy (i.e., hard-working) will be paying for the sick and the poor (i.e., lazy).

Hmm? Why are you looking at me like that? That the poor are lazy or irresponsible is a basic tenet of the "personal responsibility" philosophy, I didn't make that up. The whole point is that you're supposed to be able to reap the rewards—or consequences—of your actions, and the rest of us shouldn't have to shield you from those consequences, or take those rewards away from you. So in this case, being too poor to afford your health care is a consequence you are supposed to be responsible and face, so it follows that it must be due to your actions. (It is to be noted, however, that the actual case brought up in the debate was a hypothetical person who was rich enough to buy health insurance but chose not to, so the argument was trying to focus on someone who was in this situation by choice. However, it winds up being difficult or impossible to really draw the line—what if he could have afforded it only by giving up some of his lifestyle? Exactly how much luxury does one have to refuse to give up before it's his choice to be without insurance? If he could have afforded it only by living on the street, is it still his choice that he didn't?)

I have great disagreements with this viewpoint in general (it's essentially Social Darwinism: survival of the fittest), but I said I wasn't going to argue about right or wrong here. I have my opinion, but it isn't really at issue. It must be said, though, that this viewpoint does overlook the important role that random chance plays in people's success and failure. So if you prefer, you can read "lucky/unlucky" instead of "hardworking/lazy" above. But that lessens the strength of the personal responsibility argument. It's one thing to say that I have a right to the rewards of my hard work, but the rewards of my good luck weren't really earned, and maybe it is less unreasonable for society to demand a piece of them. On the other hand, the effects of chance on success and failure can't be denied even by the most ardent responsibility-fans. When people take risks and succeed, they are praised for the bravery of their choice to take the risks, and when they fail, the thinking is that they are paying the consequences of not being prudent enough to avoid too much risk. So even managing chance is considered to be a matter of choice.

And risk is really what a lot of this is about, especially since we're talking about health care insurance. Insurance is entirely a matter of risk assessment itself: the insurance company "gambles" that you will wind up paying more in premiums than they will have to pay in benefits, and computes their premiums from the statistics so that the odds are in its favor. Insurance customers pay into the "bet", generally in full knowledge that the odds are against them coming out ahead, because the consequences of not betting and losing are potentially so severe. So you're sort of betting against your own health—and generally not very upset that you're likely to lose. In the case discussed in the debate, the man was healthy and successful and "bet" that he wasn't going to become sick, by not purchasing insurance. If he had won that bet, he would have saved more money by not paying insurance premiums than he would have paid out covering his own health care out-of-pocket. And indeed the odds were in his favor (if they weren't, insurance companies couldn't make a living. Though actually the situation is complicated by the fact that health insurance companies pay less for health care—a lot less—than private individuals do. As the spouse of a doctor, I know this from experience.) So it wasn't a bad bet when he made it, necessarily. As it happened, though, he lost the bet, as some people are bound to do.

This brings up a key point about using this sort of standard risk-analysis when it comes to health care. Statistics are all about long-term. In some sense, "probability" only means that in the course of many repetitions, a given event will happen a certain fraction of the time. For any one iteration, it either happens or it doesn't. This kind of risk-analysis works by computing the expected value, which is sort of summing over all the possible outcomes. More probable outcomes are weighted more heavily, and less probable ones less so. Or considered another way, maybe we imagine a million iterations of the scenario, and add up all the costs and benefits of each one, and then divide by a million to find the average (expected) cost/benefit. And this works great, for things that statistics are good for. Individual situations fluctuate randomly, but the fluctuations cancel out in the long term, and we can predict what we would expect them to cancel out to. But the kicker is, there is NO "long-term" when gambling with life. At least, not to the person who's living that life. Working out the expected cost is all well and good when considering the aggregate of many cases; I can tell someone playing the stock market, "OK, so you lost money on that trade. But this stock is mostly going up, and the trading company has a good track record, so other trades will wind up making up for it and on the whole you'll come out ahead." But you can't tell someone who's dying because he can't afford his health care, "OK, so you lost on this life. But the odds are in your favor; as you live many lives, you'll come out ahead on the whole." You only have one life to gamble with! "Long term" works when there are multiple trials, and for the insurance company there are: each client is a trial. But for the individual customer, one of the things he's betting is his own life, and you only get one of those.

I actually got to this line of thinking starting from someplace slightly different, with the (stupid) debate about vaccinations and (stupid) people refusing to vaccinate their children because of various (disproved) articles and studies linking it to certain health issues, or at least the slightly more real possibility of contracting the disease from the vaccination. So I'm imagining this from the point of view of someone getting a vaccination or other treatment like this... let's say for the sake of calculation that this is some horrible fatal disease, and you have a 1 in a million chance of contracting it from the vaccination, but if unvaccinated you have a 1 in a thousand chance of contracting it somewhere along the line (which is actually pretty bad, for a fatal disease). The vaccination is assumed to be 100% effective, so if you do get the vaccine, you're immune. So it seems like a pretty straightforward deal from a statistics standpoint: you're trading a 10⁻³ probability of Something Bad for a 10⁻⁶ probability. And yet people might still agonize over it. After all, taking the vaccine is deliberately exposing yourself to the disease. If you didn't take it, maybe you would never be exposed at all. Or to put it another way, consider the point of view of someone who "lost" the bet, and is dying of the disease after having contracted it from the vaccine. "If only I hadn't taken the vaccine," he might be thinking. "Then I'd only have a 1 in a thousand chance of being in this situation."

It's interesting to ponder the state of mind and logic involved here. In some sense it feels like an issue of prior and posterior probabilities. On the one hand, we have the probabilities of contracting the disease from taking the vaccine or not taking it, given that you don't have the disease already (which is not much of a given), which are 1 in a million and 1 in a thousand, respectively. On the other hand, which the sufferer above is seeing, we have the probabilities of contracting the disease from taking or not taking the vaccine given that you have already contracted it from the vaccine. Those probabilities are still 1 in a thousand for not taking the vaccine, versus 1 in 1 for taking it, since that's what's already happened. Am I messing around with causality and time here? Yes. The thinking here is not entirely clear and logical, but that's not entirely unexpected. You somehow think that "if I had known I would get it from the vaccine, I wouldn't have taken it," which is true I suppose, but is it really a comfort to be told, "But you didn't know, and what you did was the right thing to do given the information you had"? Maybe. But in some ways it's like being told, "The odds were in your favor to do what you did. In the long run, in all your other lives, this will balance out." Once again, the problem is that you don't have any other lives/trials to go around betting.

Now, I don't mean to say that it's wrong to be applying statistics to health-care, especially if you're a government or an insurer or some other entity dealing with aggregates. But it means that you're going to wind up with cases that tug at our emotions because they wind up with individuals losing, and losing big, and we can't be comforted by the long term, once again, because of the value we place on human life, or because of empathy. A system that succeeds for almost everyone and fails for some looks great, and probably is the way to go, but we can't help putting ourselves in the shoes of the ones it fails and realizing that they are simply out of luck, and all the "long run" in the world is not going to help them, personally. (Well, at least we should, or think we should, be putting ourselves in their shoes. Some people's personal amount of empathy is more or less than others, and it might depend on who these "losers" are to some people.) You can't win everywhere.

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