Posted on 07/07/2004 12:07:50 PM PDT by neverdem
Edited on 07/07/2004 5:07:20 PM PDT by Admin Moderator. [history]
Arthur Caplan at the University of Pennsylvania is America's most famous bioethicist. He's unusually reasonable for that notoriously risk-averse breed. But lately he's been reverting to the rigid presumption of egalitarianism that infests most bioethical musings. Caplan is deeply concerned that in the future the rich will get better medicine and the poor worse—that more resources will allow people to obtain better quality products, an apparently unbearable situation when it comes to health care.
Caplan begins by decrying the development of "concierge medicine," in which groups of doctors contract with patients to give them 24/7 access for a fee. Patients who choose concierge medicine are, in effect, paying "bounties" so that they can get better service than other people. Caplan doesn't like this. But why? In free markets most goods and services are differentiated by quality and customers get what they pay for. The more one pays, the better one expects to be treated. But many bioethicists think that medicine is different—that "health care is a right." But this mentality leads them to the position that we only have a right to the health care the state chooses to give us—and that we ought to be, or at least will be, denied anything better.
Caplan writes: "From my point of view, health care ought to be a right for two reasons. If we are going to guarantee equality of opportunity to every American, then health is a key part of that equal opportunity. You have to have it in order to function in a market-based capitalist society. The other reason is it's a sign of communal solidarity. We care about one another. We're not going to let our kids who are mentally ill or our elderly just flounder around even if they can't, so to speak, earn it." But Caplan does think that some differentiation in health care can be, in principle, ethically acceptable, and that society merely ought to guarantee "access to a minimal package of health care."
But what's an acceptable minimum? In his column Caplan decries recent reform proposals for Tennessee's state Medicaid program. The reforms, known as TennCare, were launched with much ballyhoo 10 years ago. They involve the state government taking its allocation of federal dollars for Medicaid and using it to cover not only those residents who met Medicaid poverty guidelines, but also other poor residents lacking health insurance. As with most any open-ended government entitlement, TennCare is heading for bankruptcy. So the Tennessee legislature passed a reform earlier this year under which medical necessity would be defined as the least costly "adequate care," instead of the traditional standard of "most effective" care.
Although a bit vague, the concept of "adequate care" encompasses such things as requiring doctors to prescribe generic drugs whenever possible; limiting the number of prescriptions to no more than six per month without special permission; requiring co-payments from patients in order to cut down on frivolous visits; and an annual limit on the number of doctor visits. Instead of prescription medicines, TennCare patients will have to buy over-the-counter medications like Prilosec for controlling stomach acid and Allegra for allergies.
Tennessee's governor Philip Bredesen claims the reforms will save $2.5 billion for the state over the next four years. However, if the reforms are not adopted, then Tennessee will have to revert to traditional Medicaid programs. That would eliminate health care coverage for 260,000 of the 1.3 million residents currently on TennCare. On the face of it, it seems that the reforms are offering a minimal package of health care as a safety net for Tennessee's poorer residents, which is surely better for them than dropping them from the program entirely.
But Caplan isn't satisfied. He especially objects to the notion of "adequate care." "If a bureaucrat in the Tennessee department of health thinks a low-cost drug or treatment, or even no treatment at all, is 'adequate,' then that is what TennCare will provide," he complains.
Caplan isn't being completely consistent with his own judgments in the past. For example, in the early 1990s, Oregon adopted a plan to control Medicaid costs and extend coverage to more of the state's poor residents by imposing explicit rationing on medical care. The Oregon Health Plan uses a list of about 700 medical conditions, and the state will pay to treat the top 550 of those. So bureaucrats are making decisions about what is medically necessary for the poor in Oregon. For example, in 2000, Oregon refused to pay for an experimental lung and liver transplant for an 18-year-old suffering from cystic fibrosis.
Contra his current stance on TennCare, Caplan saw no problem with this. In a 1996 interview with the American Political Network he declared, "It was incredibly courageous what they did there. They took on the issue (of rationing) in a public way that was unprecedented and hasn't been duplicated since."
Caplan did add that Oregon's Health Plan has "a fatal flaw: the effort to think about rationing was confined to the poor." His implication seems to be that it's OK for bureaucrats to make medical care decisions, just so long as they are made for rich and poor alike. As Caplan told the Chicago Tribune in 1995, "The danger is, politically in this day and age, threadbare [insurance] will be considered enough. The poor will be asked to make sacrifices, and the rest of us can do whatever we want."
But he still hasn't come up with a convincing answer to the question: What's ethically wrong with people with means doing "whatever they want" with regard to their health care? They can already do whatever they want with their educations, jobs, housing, food, and so forth. So eager is Caplan to play class warfare by contrasting concierge care with adequate care that he actually misses the main lesson to be learned from TennCare—that any government-run national single payer system would inevitably run up against fiscal limits and impose rationing on everybody. Bureaucrats would then be making health care decisions for us all. But then at least we could share the "solidarity" of all having the same equally inadequate health care.
Ronald Bailey is Reason's science correspondent. His new book, Liberation Biology: A Moral and Scientific Defense of the Biotech Revolution will be published in early 2005.
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Ahem, this plan was given prominance for about 70 years. It failed in the U.S.S.R. Communism hasn't worked, won't work today and will NEVER work in the future. There is no incentive to be productive, when a minimalist existance is handed out to everyone, and people are prevented from realizing the full benefits of their own productivity.
Even in the U.S.S.R., you had differing levels of existance. That is the human condition, no matter how hard leaders try to erase it, for they are the very ones who will make sure they have the best existance possible.
Some children are born without arms, so in the name of equal opportunity and communal solidarity we will chop off the arms of those children lucky enough to be born with two. (Of course, certain exemptions will be made for those with political pull.)
Now excuse me while I go back to work on the communal farm and sing The Internationale.
Indeed, health care should be offered to all equally. No one should be denied the same prices for health care based on race or creed or whether the individual is paying or is running it through their insurance company. Health care does not have to be socialized to accomplish those goals.
"The other reason is it's a sign of communal solidarity. We care about one another."
I agree - if we care for one another, we provide for one another. So get off your duff and volunteer, donate money to charities, etc. Don't expect the government to steal money from other people's pockets in order to make you feel more 'caring.'
Steak and lob for the masses!
</sarcasm for those that don't get it>
These academic armchair elitists just frost me. Most medical condtions in this country that are drving up the cost of health care are behaviorally related. This include cardiovascular and cerebrovascular disease, Type 2 diabetes, AIDS and lung cancer, and most people with kidney disease. Some the patients I see when they are given an "opportunity" to improve their health squander it. Jut in the past month, I can think of two patients who did not fill their greatly subsidized prescriptions (from patient assistance programs)beause they used the twenty bucks the meds would cost them to buy cigarettes.
Even if we provide Caplan's utopian "equal opportunity health" care to everyone via rationing, patients from lower socioeconomic groups have still higher mortality and morbidity rates, even in Great Britain (click here). I just wish we could send Dr Caplan to the UK for his medical care so he can experience what "equal opportunity health" is all about.
Yeah, its my right to be a fat, lazy, sponge, and live off the government tit. That's right, I'm just gonna quit trying right now. After all, I'm not rich so I must be in that other America Edwards is always talking about. Whatever. These intellectuals really need to get out and away from their comrads more often.
Furthermore, there is no such thing as a collective right - there are only individual rights.
A "right" is a moral principle defining and sanctioning man's freedom of action in a social context. A "right" means freedom from physical compulsion, coercion, for interference from other men.
I agree with you snopercod. I agree with your tag also. It won't be returned.
So let me understand this, in order to give everyone a good chance at a market based society we are first going to socialize health care. Tsk Tsk, not a very good arguement.
I believe people have the right to spend their earnings on anything they want, including health care. If they want to purchase a premium health care, that is also their right. No one has the right to expect equal outcome, people are not all equal. I do oppose people spending on everything but health care, and then throwing their health care concerns on society's altruism. What society provides for the penniless should be at the lowest level of health care. I'm sorry, thats how it works.
“Even people comfortable with the idea of fixing obvious brain defects become much prissier when it comes to mucking with brains to make them better than good,” he writes in the September issue of Scientific American. “Americans in particular believe that people should earn what they have. [But] Would it be bad if some innovation—say a brain chip implanted in the hippocampus—enabled a person to learn French in minutes or to read novels at a faster pace? Should we shun an implant that enhances brain development in newborns?”
To Caplan, brain engineering is no more unnatural than eyeglasses, artificial hips, plane rides, and vitamins. “It is the essence of humanness to try to improve the world and oneself.”
But does something get lost in the improving? “It’s probably one of the great worries we have,” Caplan responds in a phone interview. “If we eliminate the different and the unusual and the neurotic, will we wind up with less art and beauty and culture and zest in life? But I’m not sure that’s incompatible [with brain enhancement]. More to the point, you can still be neurotic and have a better memory and learn new languages faster.” It’s also unlikely that we’d end up the same if we had the option to improve our brains in different ways, Caplan says. “Not everyone is going to value the same things.”
“I’m going to predict a TV show for you,” says Caplan, who has a keen sense of the entertainment value in over-the-top prognostications. “The show will be called Liar Liar. It’s going to be on the air within seven years. On the show, which will be hosted by Jerry Springer’s son, couples will come on and make allegations of infidelity or embezzlement or stealing against one another, and then a scanning machine will be brought on and the head stuck inside it and the host will render the verdict about whether they’re telling the truth or not.”
Who’s Minding the Brain? By Susan Frith
As for me, I will have none of it! Iwaih to be free and remain human! ENDTHEMATRIX
Thanks for the links. When I think about NMR in organic chemistry three decades ago, and look MRI today, Wow!
Nah, not what I was thinking. I was trying to find out more about fMRI. That they are able to detect activity from deoxygenated blood is impressive. Do you know if they have to inject intravenously any contrast agent?
If I have to take what someone wants to give, I have no control. Personal freedom, the desire for it, is what makes most of us work hard.
We save for retirement because we don't want to HAVE to depend upon what someone will give. We work hard to have money so that we can take ourselves off to get another opinion, a different test, etc.
If I have no control over the important things, if I can't become more free, have more options, then what is the point?
I agree. And if no matter how hard you work, or shirk your duty, you'll always get the same pay, why work hard?
It's human nature.
You know, our system doesn't always reward as well as it should, when you excell. That's a mistake. The less government redistributes, the better.
Anyone who thinks that socialized medicine is the cure for what ails American medicine ought to spend some time in a country that has it.
Not for fMRI. Note that fMRI is for the most part still experimental, and clearly in its infancy.
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