Weighing the True Costs and Benefits in a Matter of Life and Death

Robert Frank--Ben Bernanke' coauthor on their Principles of Economics book--has a nice response to one of the pieces of immoral toxic swill that periodically emerge from Slate:

Weighing the True Costs and Benefits in a Matter of Life and Death - New York Times : Slate this month.... The subtitle says: "A woman who couldn't pay her bills is unplugged from her ventilator and dies. Is this wrong?"... the answer is "no."...

[T]his argument as morally preposterous. Well, yes. But it is also economically preposterous... some details.... 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.... 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, which says that an action should be taken only if its benefit exceeds its cost. The cost of care is relatively easy to calculate, but measuring its benefit is more difficult, and it is here that Mr. Landsburg stumbles.... He is mistaken for multiple reasons... he ignores the economically compelling reasons for having social safety nets in the first place... 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.... [L]arge numbers of people benefit when a patient in imminent mortal danger receives treatment. 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"... introduced by the economist Thomas C. Schelling.... 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.

Comments

[Abhijit]

Landsberg posts nonsense like this all the time. After the fall of Baghdad, he posted an article in Slate saying that the looting was a good thing because it meant that people could get back what the regime had taken from them Absent in this bizarre statement was the possibility that the people who did the theft are totally unrelated to those who had suffered, that lots of things were stolen from places like the national museum, and finally that theft undermines society and creates a climate of lawlessness.

[Tyrone Slothrop]

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.

This is an awful use of the passive tense.

[Tyrone Slothrop]

That first sentence should have been in quotes, or italicized, or something.

[healthcarethinktank]

Not to miss the point, but it would be very unusual to put a terminal cancer patient on a "vent."

However, once she put on the vent, taking her off while she was conscious was an act of incredible cruelity.

[Roger Albin]

It wouldn't be unusual to put a 27 year old previously healthy woman on a ventilator, even with advanced and incurable cancer. There are multiple reasonable ways this could happen. Nor is it "an act of incredible cruelty" to remove ventilatory support from a conscious individual. If the individual is terminally ill, is competent, consents, and can be provided with appropriate palliative care, its quite standard. This happens all the time in patients with advanced Motor Neuron Disease (ALS; Lou Gehrig's Disease).

[joe o]

Landsberg needs to be fired.

[dearieme]

Note too the entirely bogus use of "forced"; no bayonets in the back, I'll bet. Mind you, I'm hard put to see the utility of economics here: it does seem to come down to a matter of sensibilities.
Oops, sorry: there is one role for economics - wouldn't it be fair to ask who was going to end up paying for extending the poor soul's life?

[David Lloyd-Jones]

What am I missing here?

This looks like a clear case of premeditated murder to me.

[David Lloyd-Jones]

What am I missing here?

This looks like a clear case of premeditated murder to me.

[Jean-Philippe Stijns]

"Unlike the comatose Terri Schiavo, Ms. Habtegiris was fully conscious and responsive when she was disconnected, according to her brother."

Yeah, and where is all the conservative uproar about taking away sacred life??? That's right, this poor lady was from East Africa... You can't make up sh*t like this.

[Gideon S]

I'm with David, I can't see how this isn't murder. I lived in Oregon for some time and I'm all for physician assisted suicide when the person is both terminally ill and wants to die. But someone who didn't want to be taken off the respirator? That's fucked up.

[anne]

There are tragedies that are terribly difficult to follow, and I try to protect myself by knowing little at times so I know vaguely of this tragedy; but, I wonder whether this could have happened elsewhere, and if so where, and I wonder, without really wanting to know, why more has not been made of this.

[anne]

I am so saddened.

[yesh]

Fully concious. 27 years old. 16 minutes to suffocate. All because she was to poor to buy hospital air in America.

From Lady Liberty's pedestal:

"The New Colossus"

Not like the brazen giant of Greek fame,
With conquering limbs astride from land to land;
Here at our sea-washed, sunset gates shall stand
A mighty woman with a torch, whose flame
Is the imprisoned lightning, and her name
Mother of Exiles. From her beacon-hand
Glows world-wide welcome; her mild eyes command
The air-bridged harbor that twin cities frame.
"Keep ancient lands, your storied pomp!" cries she
With silent lips. "Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!"

[scribo]

"Unlike the comatose Terri Schiavo, Ms. Habtegiris was fully conscious and responsive when she was disconnected"

Terri Schiavo was not comatose, as most people know.

[liberal]

Keith wrote, "Frank makes a fundamental error: The level of coverage of social safety nets cannot vary by income."

Where did he state that?

[NinjaPlease]

I find it difficult to understand that a person who was conscious, did not want to die, was pulled off of a ventilator for lack of insurance.

Lack of insurance is the reason a black kid, 16 years old I think, was denied entry to a hospital after being robbed and, I think he was either stabbed or shot in New York a few years ago. I understand the ensuing lawsuit and public uproar either got the super corporate hospital heavily fined and closed, or all of the staff involved fired and barred from medicine.

If I was that brother, I would have entered that hospital and killed whomever came to remove the ventilator claiming "self defense." I would have been justified.

When no moral argument can be constructed it is funny to see an economic one, after all, math is hard, so you can't argue with numbers.

[JRossi]

At Kaiser I saw some crazy stuff but not this bad. What would happen is that a burned-out or lazy or power-hungry MD would become an administrative doc. I heard it was nice: meetings with coffee and doughnuts, time off for lunch, a much reduced clinical schedule. After "smoking too much administration" he or she would start thinking like the business types and then come back and talk to us front-line docs about how we needed to offer less care and create efficiencies so as to save money. We couldn't see the big picture, you understand. And Kaiser is one of the more compassionate medical groups. It is a very dangerous thing to have your doctor think of himself mainly as a businessman.

[anne]

JRossi :)

I am told this could not have happened in most states. Why the Texas law was not immediately challenged on several levels on the case puzzles my "legal eagle" sister.

[anne]

JRossi

Notice as well that the United Nations malaria chief is warning drug makers to stop selling several formulations of a strong new malaria drug to avoid the development of resistant strains. This is most important and interesting.

[anne]

http://www.nytimes.com/2006/01/20/health/20malaria.ready.html?ex=1295413200&en=26e92d251aeca291&ei=5090&partner=rssuserland&emc=rss

January 20, 2006

Drug Makers Get a Warning From the U.N. Malaria Chief
By DONALD G. McNEIL Jr.

Warning that misuse of the most promising new malaria drug could create an incurable strain of the disease, the new chief of the World Health Organization's malaria program demanded yesterday that 18 pharmaceutical companies stop selling some forms of the drug.

After several of the companies refused the demand, the official, Dr. Arata Kochi, made an unusually strong threat for an official of the health organization, saying he would publicly name the companies still selling the drugs three months from now and, if they persisted, would try to disrupt sales of their other medicines.

The new drug, artemisinin, a derivative of sweet wormwood isolated by Chinese scientists, is the most powerful new weapon in the antimalaria arsenal. Health agencies consider it the best hope for controlling the disease, one of the world's leading killers, which takes more than a million lives each year, mostly those of young children.

But these agencies say artemisinin should be used only in a cocktail with other malaria drugs, usually including a slower-acting one that lingers longer in the blood.

Combination therapy, which is routine with AIDS and tuberculosis drugs, not only attacks a disease more effectively, but slows the emergence of microbes resistant to drugs.

But at least 18 companies from Belgium, China, France, Ghana, India, Kenya, Switzerland and Vietnam make the drug as a pill that can be taken by itself, in what doctors call monotherapy, and sell it cheaply in Africa, Asia and Latin America. People with fevers often buy drugs at small shops without a prescription or a test to make sure that their fever is caused by malaria.

That is a recipe for disaster, Dr. Kochi said.

"We can't afford to lose artemisinin," he said. "If we do, it will be at least 10 years before a drug that good is discovered. Basically, we're dead." ...

[anne]

This is a stunning social ethics-economics problem, and there will be others in this line.

[JRossi]

Thank you, Anne. Drug-impervious malaria would kill many, perhaps tens of millions. Let's hope it doesn't develop and spread.

[anne]

http://www.calvorn.com/gallery/photo.php?photo=4777&u=16714|3|...

Scarlet Tanager Eating an Insect
New York City--Central Park, Andrew Hasswell Green Bench.

Thanks, JRossi :)

[anne]

Malaria is a prime epidemic disease that can be terrifying in regions above the Tropic of Capricorn. Countries like Singapore and Malaysia owe development to decisively stopping malaria, but elsewhere the disease can be poorly controlled. The development of water centered urban aras above the Tropic of Capricorn sets the populations at risk, with infants at special risk. African development loses so much to malaria.

[anne]

http://www.nytimes.com/2005/12/13/health/13mosq.html?ex=1292130000&en=38fba7118e7cd139&ei=5090&partner=rssuserland&emc=rss

December 13, 2005

Beating Malaria Means Understanding Mosquitoes
By NICHOLAS BAKALAR

In Africa, 20 percent of the children get 80 percent of the bites from malarial mosquitoes, and an understanding of this could be central to controlling the deadly disease.

Researchers have developed a mathematical model that describes the complex relationship between the proportion of people who are infected with Plasmodium falciparum, the parasite that causes malaria, and the rate at which people are bitten by the mosquitoes that carry it.

Some people are bitten more than others because they live where mosquitoes are more common or because the mosquitoes, for various reasons, find them more attractive.

Those who are bitten most often play a role in malarial transmission similar to that played by the most sexually active in the transmission of sexually transmitted diseases: they are the ones who spread the disease. The people who are bitten most become infected and stay infected.

Then the heavy biting continues, so large numbers of mosquitoes acquire the parasite from their blood and can transmit it to others. So, the total burden of disease is influenced by a small minority of people.

A paper on the work appeared in the Nov. 24 issue of Nature.

Identifying the 20 percent of the population that is most often bitten is hard, said David Smith, an epidemiologist at the Centers for Disease Control and Prevention and the lead author. "No one knows how to do this," Dr. Smith said, "so right now the goal is to protect everyone. However, the gains from targeting may be so large that it is worthwhile. I think this should become a very active area of research."

Accounting for these factors requires a mathematical model that describes the way transmission occurs and who is likely to be infected. Using such a model, health officials can direct prevention efforts more accurately by concentrating on those most likely to carry the parasite....

[tim keller]

Disconnecting a respirator dependent patient against his or her will and allowing them to suffocate as Baylor Hospital did with a medically indigent, terminally ill East African woman is premeditated murder with malice. It is among the cruelest, more remorseless ways to end any life imaginable. The medical perpetrators deserve criminal prosecution and termination of any future medical role in patient care.