February 22nd, 2013

First, do no harm

Commenter “Jim Nicholas” had this to say on yesterday’s thread about Sarah Conly’s book Against Autonomy

Are we willing to or do we want to let persons suffer all of the consequences of their dumb mistakes or impulsive choices? Do we want a society in which there are no life-guards who attempt to rescue those who swim too far, in which there are no mountain rescue teams for those who do not realize their limits, in which there are no bankruptcy protections for those who tried and failed, in which we close the hospital doors to those whose heart attacks are caused by over-eating?

To the extent a society is willing to try to mitigate some of the consequences of bad decisions, that society pays a price for decisions of the individual. If so, is it unreasonable that society has some say about the decisions of individuals that are highly likely to be costly to society?

I am not sure that the balance between individual freedom and responsibility to others is an easy balance to achieve.

Conly’s book, and the ensuing discussion, was not so much about whether or not to let persons suffer the consequences of their dumb mistakes or impulsive choices. It was about Conly’s suggested remedy of preventing them from making those choices in the first place. That’s why it was called “Against Autonomy” rather than “Against the Consequences of Stupid Decisions.”

The proper analogy for the case of the swimmer who gets into trouble and must be rescued by a lifeguard is not to ban the rescue, but to ban ocean swimming in the first place. Rescuing the swimmer is done after the fact, but the person retains his/her autonomy to choose to swim in the ocean. Rescuing a swimmer is not compromising his/her autonomy at all, unless that swimmer is trying to commit suicide.

Naturally, the situation is not as clear and easy to conceptualize as that. There are difficult decisions to make, but they are more likely to be about financial consequences—such as, for example, whether society should pay for the increased health care costs of smokers. But that last question only really comes into play if we decide to foot the bill for other people’s health care in the first place—i.e. Medicaid, or universal non-private health care, or requiring that hospitals treat all comers regardless of ability to pay. That’s a different, although related, decision, because it’s a slippery slope from those decisions to one to limit personal autonomy and choice based on the costs of that decision to treat everyone regardless of financial ability.

I want to also call attention to one particular point that same commenter made, when he asked whether we should “close the hospital doors to those whose heart attacks are caused by over-eating.” My answer would quite obviously be “no,” but not only because I am somewhat of a libertarian. It’s also because the science is, as they say, “unsettled.” We have no idea whose heart attacks are caused by overweight and whose are not.

It is a fallacy to think that, because an overweight person has a heart attack, he/she has caused it through the mechanism of overeating. Plenty of overweight people are just fine, and plenty of thin people have heart attacks. At what point does it become clear that a particular overweight person’s overeating has caused a heart attack? And, to take it even further, since our understanding of the mechanisms by which some people end up overweight and others do not is primitive at best, at what point (and for whom) can we conclude that a particular person’s overweight is the result of a choice? All overweight people don’t even overeat as compared to many thin people, although some do.

I’m not saying these issues and their solutions are completely clear. But Mill’s harm principle is still a good basic guide:

[T]he only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or mental, is not a sufficient warrant.

I would add that mere financial harm to society at large or the public purse is not enough, unless the person’s act is criminal as well (for example: embezzlement, theft, fraud, which ordinarily also result in direct harm to another person or a company).

[NOTE: When I mention commenters' names, I always put the names in quotes, as I did here for "Jim Nicholas." This may seem silly, but I do it for two reasons: the first is that for almost all commenters, I don't actually know whether the names they use are their actual names or pseudonyms. The second is that, even if I did know that information, I wouldn't use a person's real name without getting that person's permission to do so.]

51 Responses to “First, do no harm”

  1. holmes Says:

    I have also noticed a trend in writing about these public policy topics, as the commenter “Jim Nicholas” did, in the use of the word, “We.” Anything that happens or is allowed to happen is a “We action” in America now. No, it is, I, you, and the government that you and I have consented to allow to govern.

    Like, “We spend way too much on healthcare.” No, the government spends a lot on healthcare. Individuals may spend a lot on healthcare too. But they are different concepts entirely. It’s the collective, “It takes a village…” language seeping into everything.

    I had a long argument with a liberal friend about the distinction in a government official questioning someone or urging someone to do something in their private capacity vs. a regular citizen doing the same. They really saw no distiinction (I’m thinking of the General who urged the crazy Koran burning pastor to relent.)

  2. Ann Althouse Says:

    I think putting quotes around commenters’ names is probably racist.

  3. Steve D Says:

    It seems simple enough to me. They don’t have the right to prevent me from swimming and I don’t have the right to demand that they rescue me.

  4. sergey Says:

    Implicit assumption in Mill’s Harm principle is that the individual whose autonomy must be protected is sane. How it can be applied to individuals who are not sane and what degree of insanity justify restrictions on one’s autonomy? Say, a person with suicide mania, or severe depression, or paranoid delusion of gilt can be expected to commit suicide if not institutionalized with high degree of probability. Should society or families interfere? Or gambling mania of the type described by Dostoevsky (he himself was a compulsive gambler) – does it justify restriction of person ability to spend his own money?
    These are not easy questions, and I do not know would I try to stop a person who tries to commit suicide. Is such behavior a part of sacred autonomy or saving human life is more sacred?

  5. neo-neocon Says:

    sergey: well, there are libertarians who believe insane people should have complete autonomy, too.

    But most people believe that certain people can be legally declared to have diminished autonomy because of diminished capacity due to insanity or senility, but there must be complex legal proceedings to establish either. The only class of people who have diminished autonomy because of diminished capacity automatically, as a class (at least, all I can think of) is minors. And those people don’t really have diminished capacity, they have as-yet-undeveloped capacity, a capacity they attain on majority.

  6. Lizzy Says:

    Britain’s “Liverpool Care Pathway” has amply demonstrated what happens when bureaucrats take over health decisions for the individual patient from the patient and/or patient’s family. All sorts of non-patient related factors are included in the decision whether or not to kill an elderly patient, such as: Do we need that hospital bed? Is this patient annoying? Have we made our target # of LCP cases in order for our hospital to receive a bonus from NHS? And so on.
    http://tinyurl.com/dx2n2ra

    How can anyone see what’s happened with NHS and still believe that a government entity – any government entity – can make better personal decisions than the individual?
    But this isn’t about care at all, is it?

  7. Jim Nicholas Says:

    Sergey’s comment that ‘These are not easy questions’ is the point I am trying to make–that striking a balance between the costs of limiting individual freedom and the costs that an individual’s action can impose on society is not easy.

    As I see it, limiting individual freedom is a cost that, yes Holmes, we all bear. And absorbing the costs of individual errors, whatever the cause, does affect us all–unless, of course, one disagrees with John Donne that ‘No man is an island’.

    I am not proposing an answer to what that balance should be. However, I am skeptical of answers that seem so easy or categorical.

    Neo, ‘Jim Nicholas’ is Jim Nicholas. It is a personal unwillingness to write something I do not take responsibility for.

  8. Holmes Says:

    Jim,

    It’s a fair point. But I am skeptical of skepticism which defaults to limiting freedom.

  9. sergey Says:

    A topic when these considerations are especially complicated are crazy cults. At what point of craziness of belief religious freedom should be suppressed or restricted? You know, like “People’s Temple” by Jim Jones, or “David’s Branch” or, may be, Scientology? Leaders of apocalyptic sects often prepare their followers for collective suicide. Should we allow this to happen? Apocalyptic delusion is contagious, after all, that is why Catholic Church for ages discourage their parishioners to read the Book of Revelation. Inductive psychoses are especially often occur with this type of delusion. Preventing epidemic of psychosis is a quarantine measure of some kind, so it is done for the sake of society and is not covered by Harm principle. On the same grounds Chinese communist rulers suppressed Fai Lungun movement as harmful for moral sanity of population, and Ukrainian government suppresses White Brotherhood, a pseudo-Christian apocalyptic sect. I can not get rid of a thought that if Jim Jones was compulsory hospitalized in mental institution where he belonged some 900 people would be saved.

  10. DNW Says:

    “But that last question only really comes into play if we decide to foot the bill for other people’s health care in the first place.”

    Right into the centerfield bleachers.

  11. Mac Says:

    It was roughly 25 years ago, when the anti-smoking crusade was revving up, that I first encountered the idea that “society,” meaning of course the government, has the right to stop people from smoking because of the cost of treating smoking-related health problems. This view did not even rest on the assumption that those costs would be borne directly by “society”–the person making the argument was content with something much vaguer than that. I remember thinking at the time “Hmm, there’s a lot of potential for mischief in that line of thinking.” Well, here it comes.

  12. DirtyJobsGuy Says:

    In the 1980′s I worked with a lot of Soviet emigre engineers. They were at least nominal Jews who were pushed then allowed to emigrate. The first thing that happened prior to their exit visa issuance was that they got fired with the only jobs being in some out of the way Siberian location.

    More importantly, when they left they could only take about $100 in money with them. The argument was that the State had paid for all their education etc. so none of their efforts were their own properties. The more the indirect costs are assigned by the commutarians, the less freedom anyone has. This is also a strong case for the minimal provision of services by the government.

  13. Geoffrey Britain Says:

    ” Are we willing to or do we want to let persons suffer all of the consequences of their dumb mistakes or impulsive choices?

    Do we want a society in which there are no life-guards who attempt to rescue those who swim too far, in which there are no mountain rescue teams for those who do not realize their limits, in which there are no bankruptcy protections for those who tried and failed, in which we close the hospital doors to those whose heart attacks are caused by over-eating?

    To the extent a society is willing to try to mitigate some of the consequences of bad decisions, that society pays a price for decisions of the individual. If so, is it unreasonable that society has some say about the decisions of individuals that are highly likely to be costly to society?

    I am not sure that the balance between individual freedom and responsibility to others is an easy balance to achieve.”

    Jim is confused and therein lies his uncertainty. Clarity and common sense are the antidotes. Societal insistence upon personal responsibility and accountability for one’s actions does not equate to a society without compassion.

    ‘Dumb’ mistakes are the mechanism whereby we learn, otherwise known as “the school of hard knocks”. The prevention and/or amelioration of dumb mistakes inevitably ensures a populace of immature adults. If the mistake is moronic enough, consequence is natures way of (hopefully) eliminating that stupidity from the gene pool.

    Life-guards, mountain rescue teams and bankruptcy protections are predicated upon the premise that the individual will not make that mistake again and desires rescue.

    The mechanism that ensures that mistakes that are costly to society are not committed by the same individuals again is the concept of; ‘give a man a fish and feed him for a day’ (the initial rescue) and then, insist that he learn how to fish or face the consequences of refusal. i.e. John Smith’s declaration; you don’t work, you don’t eat.

    “The first principle of freedom is the right to go to hell in your own handbasket.” R. Heinlein

    Lincoln had some insights into this issue as well;

    “You cannot build character and courage by taking away a man’s initiative and independence.
    You cannot escape the responsibility of tomorrow by evading it today.
    You cannot help men permanently by doing for them what they could and should do for themselves.
    You have to do your own growing no matter how tall your grandfather was.”

    Society figured out how to balance individual freedom and responsibility to others long ago. It’s trying to re-invent the wheel, while solemnly renouncing common sense, wherein the problem lies.

  14. parker Says:

    “‘Dumb’ mistakes are the mechanism whereby we learn, otherwise known as “the school of hard knocks”. The prevention and/or amelioration of dumb mistakes inevitably ensures a populace of immature adults. If the mistake is moronic enough, consequence is natures way of (hopefully) eliminating that stupidity from the gene pool.”

    I totally agree. But then people who think like this are typically called evil conservatives and social Darwinists. I have no problem with non-government forms of charity and support which are voluntary and self-financed. Government is financed by coercion. All government efforts to solve ‘problems’ eventually become an ever growing bureaucracy. Student loans, Fannie and Freddie, Social Security, Medicare, and now Obamacare will bring us to the tipping point.

  15. Holmes Says:

    As I mentioned in the other thread, Jim is talking about economic externalities- sort of. As is discussed above as well, sometimes the state takes on those externalities and then uses that as an excuse to control the underlying behavior. See: health care and smoking.

    But why is control always (and I mean always) the first solution? First, it’s always risky for the goverment to take a moral stance on anything (hello, food pyramid!) because it may not know as much as it thinks it knows. Secondly, let’s say something is a problem and is also within the province of proper government (recall that we have a Constitution that, in theory, is supposed to limit government power to a few defined areas. Try not to laugh), the first act is to control behavior. Period. And the mechanism by which it does that is to 1) proscribe the behavior followed by 2) sufficiently severe enforcement and consequences to punish that behavior.

    So, per Jim’s seat belt example, the costs of health care (somehow always the state’s responsibility?) are offered as an example of an externality. But the costs of the “click it or ticket” campaign are not included. Hours of a police officer sitting on a road with guaranteed pension at 55 and billboards and advertising, along with the costs of the judicial system for enforcing this, what was it again, externalized costs you were saying?

    I’m not arguing specifically against seat belt laws, but the cost-benefit is very much in question. There is something to be said for requiring seat belts in auto manufacturers (though incentivizing would be better) to give consumers at least the option of saving their or their kid’s lives.

    And the other externality of regulation besides the cost themselves? Freedom once again. It’s eroded. It changes our relationship to each other and to the state. As we make this “Well sheesh, it’s so tough to find the balance between freedom and regulation” argument on every single item, giving permission for it to continue, essentially, the area of freedom to operate diminishes.

    So the question becomes, how many of these little freedoms restrained does it take before we’re actually not free, even if we could justify each one on their own merits?

    Oh, I know, it’s a silly question. This is America, after all, and we have a flag and voting and we’re very rich. And we can continue to do anything we like to it and it will still be. I guess.

    By the way, Jim, I’m banning you from writing anymore comments. Think of all the time/costs associated with infrastructure and lost work time for others in responding to them. Ok, not banning, but I’m charging $10 per post. :)

  16. Jim Nicholas Says:

    Holmes, “But I am skeptical of skepticism which defaults to limiting freedom.”

    That too is a fair point. Although I confess that in trying to balance the costs, I am likely to push down on the side of individual freedom, I do not think that a default approach to a complex problem is wise–if ‘default’ means a preselected action without ever considering alternative solutions.

    Also skepticism, it seems to me, does not relieve one of the responsibility to make a decision when a decision is called for. But skepticism may cause one to consider more than a default position.

    Geoffrey Britain, I agree that “Societal insistence upon personal responsibility and accountability for one’s actions does not equate to a society without compassion.”

    As I understand it, compassionate societies insist upon personal responsibility and accountability for the very reason that they realize that compassion is not an unlimited commodity. For that reason they limit the freedom for more costly individual behaviors that would exhaust the ability to respond with compassion to less costly individual errors.

    It is true that “Society figured out how to balance individual freedom and responsibility to others long ago”. It is also true that long ago societies figured out how to balance individual freedom and to limit behavior that imposes costs the society is not willing to bear–recognizing that limiting freedom is itself a cost to the society as well as to the individual.

    Different societies have struck different balances. Also changing knowledge and circumstances face society with new balances to be struck. Not too long ago the benefits of seat belts or the dangers of smoking were unknown. And so we still face tough decisions.

  17. Holmes Says:

    “Different societies have struck different balances.”

    Well, outside of democratic societies, those balances aren’t really chosen. And until recently, we really did not have very many democratic societies.

  18. MorningSparrow Says:

    Probably the best/important things in life that I have learned were from mistakes so no, I really don’t need a USG bureaucrat guiding me through my independent life when they can’t even run their own life.

  19. Holmes Says:

    There’s a cost to compassion to, at least as it comes from government. We mention bankruptcy laws- the cost is access to credit, or making credit more expensive. These second phase costs are rarely counted and of course you look like a jerk for even mentioning them because it’s in response to a proposal for compassion. This is conservatives’ marketing dilemma in a nutshell.

  20. Lizzy Says:

    Completely agree with others that mistakes are important learning opportunities. What concerns me most is that these social engineers/control freaks like Conly & Sunstein have an expansive definition of “mistakes” that we must be protected from making. I’d wager they’re not making their case out of a concern for risks like rock climbing and base jumping. More likely that they want to protect us from “mistakes” like consuming 16+ oz. of soda, too much salt, and fast food. They’re already attempting to protect us from icky guns. And then they’ll move on to protecting us from the harmful effects of global warming by further dictating which goods and activities we must cease to reduce our carbon footprint (for our own good, of course).
    There will be no end to the “mistakes” they’ll need to save us from.

  21. Holmes Says:

    “There will be no end to the “mistakes” they’ll need to save us from”

    And that is the key.

  22. SGT Caz Says:

    The help that people get when they take risks and fail should be help that they get from family, community, and church, parochial institutions that know the character of the people in need well enough to tell the difference between a true tragedy and a fool who needs the discipline of a rough period in life brought on by poor calculation of cause and effect. This is a structural issue. The broader the level of society that regulation and assistance are put in, the worse the ability to gauge character and handle the situation with any comprehensive understanding. These should not be national or international issues. They should be local ones. The national and international perspectives are not supposed to serve the individual; they are supposed to serve the smaller units that define our identity.

    The broadening of our perspective into seeing problems and solutions in broad strokes that affect millions has massively screwed up the way we think in terms of social interest. The “we” Holmes talked about in the first comment should not be so large; we can’t possibly understand what’s actually going wrong, and we can’t possibly be empowered to do anything about it except by giving more authority to stupid bureaucracies.

    Screw up, I’ll just blame the internet. Stupid series of tubes.

  23. parker Says:

    “It is also true that long ago societies figured out how to balance individual freedom and to limit behavior that imposes costs the society is not willing to bear–recognizing that limiting freedom is itself a cost to the society as well as to the individual.”

    Ah, but those who indulge in “dumb mistakes and impulsive choices” know society, via government, will pick up the tab for the consequences of their behavior. We have been sending this message to them for 5 decades. We have shown them that society is willing to bear the costs even when government borrows 43 cents on every dollar it spends.

    I have 2 questions. Do you donate to local charities? Or do you believe government has the obligation to point a gun at you to force you to pay for the consequences of “dumb mistakes and impulsive choices”? Red or blue pill?

  24. parker Says:

    SGT Caz,

    Great comment!

    Sincerely,
    Parker

  25. southpaw Says:

    “for example, whether society should pay for the increased health care costs of smokers. But that last question only really comes into play if we decide to foot the bill for other people’s health care in the first place—i.e. Medicaid, or universal non-private health care, or requiring that hospitals treat all comers regardless of ability to pay”
    The decision for society to pay or absorb the cost of the bill in the first place is central to the argument. Once that is established, whether by government fiat or democratic means, control of individual behavior can always be justified in terms of financial cost, and forever links together individuals to a collective. The “balance” may be voted on and made law, but it then becomes and an establshied precedent for subsequent “balances” to usurp freedom. There is no end to the justification for infringing on individual liberties, if financial cost is the basis for which measures public need against individual liberty — socialism is the natural outcome.
    In any case, we are supposed to be a different experiment — founded on the ideas that life, liberty, and the pursuit of happiness are inalienable rights to all individuals, and not matters to be arbitrated by a politbureau or academy of professors; and least of all by the people who call themselves social scientists. When science becomes politicized, it is no longer science.
    My decision not to smoke is unrelated to another person’s decsion to smoke, as long as it’s understood that the smoker accepts responsibiity for their behavior. This is a simple solution; it only becomes complicated when we make it so by claiming we as a society are obligated to take responsibility for the smoker when he cannot take care of himself. It may be a nice thing to do, but it does not make it my responsibility, and forcing me to accept it does not necessarily constitute a balance of for the public good – it simply transfers responsibility to from one individual to many.
    Relegating public policy to social “science” and social engineering is the road to serfdom. People make mistakes as the good professor points, out, and so do social scientists who are people too. Again, I am invoking the not so distant past and eugenics, which was once extremely popular social science in the US, and worst of all, accepted as scientific fact. I will go kicking and screaming to the gas chamber, whether or not a social scientist decides that it’s in everyone’s best interest to send me there.

  26. Jim Nicholas Says:

    Holmes,
    I would have acceded to your ban except for wanting to respond to Parker’s question. Not knowing where else to send you imposed fine, I will send it to Neoneocon, our gracious host.

    Parker,
    You ask “Do you donate to local charities?” When I first began getting an allowance at age 5, I put two of my seven cents into the Sunday School envelop. While I was working my way through college, medical school, internship, and residency, I was much less generous. When I began earning, from my army days through the next 54 years, I have given at least 10% of my income–approximately half to the church and half to secular charities, primarily local but some distant.

    I answer your question only to establish a foundation (of not dodging you) for asking what possible relevance your question has to the statement I made in the previous thread–that it seemed to me to be often difficult to apply Mill’s harm theory, to know where the harm fell and how to deal with that uncertainty.

    In the absence of a clear rationale for your question, it seems to me to be a bit impertinent.

  27. Rainbo Says:

    What if we could reverse all the smoking bans in restaurants, work places, airplanes, and bring back the Marlboro Man and Virgina Slims, the cigarette for women, on television?

  28. Roy Lofquist Says:

    Most of the arguments about society’s costs for healthcare are specious.

    “The last two years of life are the most expensive for healthcare”. Picturing granny here? Wrong. Age at death doesn’t matter. The last two years are the most expensive.

    “Lifestyle caused illnesses are more expensive.” Wrong again. We’re all going to meet The Reaper. If it happens sooner society actually saves money because of Social Security.

    There are lots of silver tongued bastards out there reaching for your wallet and your freedom. Should be open season if there were any justice.

  29. Don Carlos Says:

    Jim Nicholas:
    As doc to doc, how do you feel about a doc’s individual ethical duty to serve a patient in need, versus “society’s” (more correctly, government’s) mandating that you do so?

  30. J.J. formerly Jimmy J. Says:

    The U.S. has become hooked on the idea that some individuals can do harm to themselves through stupid or risky behavior that ends up costing society as a whole. Where does that come from? I aver that it’s our overactive legal system, which is always looking for a reason to blame someone and recover damages. For instance, everywhere you go in society today there are warnings, prohibitions, and safety measures. Why? Because when or if someone is hurt the lawyers will be there to sue for damages.

    Twenty years ago when my wife and I were roaming around the Alps we were amazed by the lack of warning signs, prohibitions, and safety measures in places where people could easily fall to their death if they didn’t use good judgment. I learned that the Swiss, Austrians, and Italians expected everyone to use good judgment. If you fell in one of those places it was an unfortunate accident not a cause for damages. I also learned that if you did a big climb (and there are plenty of big climbs in the Alps) and required rescue, you would receive a bill for your rescue. That factor led to the establishment of a rescue insurance industry. Those attempting big climbs in very hazardous conditions could buy insurance against the cost of a possible rescue. It struck me as an eminently sensible system. It had the affect of forcing climbers to use good sense and restraint in their climbing or at least be ready to foot a rescue bill through their own resources or from insurance.

    If people are looking at paying for their mistakes whether it be reckless driving, death defying mountaineering, smoking, illegal drug use, or even a poor diet, it tends, I believe, to focus the mind a bit more on making good choices.

    As an airline pilot, I had to take a physical every six months and two simulator check rides a year. We used to refer to these days as “You bet your job” days. It did focus my mind on trying to maintain good health and constantly working to maintain my skill as a pilot.

    Unfortunately, there will always be a percentage of the population who can’t get their act together. What about them? We call it a safety net, but over the past thirty years the net has gotten a lot bigger and seems to hold ever more people. IMO, the lawyerly mentality (and most of our legislators are lawyers) that someone has to pay for failures has become a mantra that has seeped deep into our souls.

    I believe there is a social contract, but itis worthless if not entered into willingly. We do owe every person the opportunity to better themselves. But they owe it to society to make that effort. Pproviding help to those unable to pull themselves up because of health or other legitimate reasons is best done through private charity, family, religious groups, and individuals; not government which is too big and too impersonal to provide the right amount and type of help.

  31. rickl Says:

    J.J. formerly Jimmy J.:

    The safety net has morphed into a security blanket.

  32. peter horne Says:

    ” whether society should pay for the increased health care costs of smokers”
    You’d have to prove an increase in health care costs. Firstly smokers pay a lot of tax on tobacco and secondly they are less likely to reach old age, which is when most health care is needed.

  33. Armchair pessimist Says:

    Actually, smoking should be mandatory because (I’ve read) smokers die early and relatively cheaply. See? You have to think like a rational bureaucrat!

    On coercion: Remember the book burning in Don Quixote? The village priest and barber have a bonfire of his books. On the local level it’s the action of good neighbors. Practiced nationally it’s thought control.

  34. ErisGuy Says:

    Are we willing to or do we want to let persons suffer all of the consequences of their dumb mistakes or impulsive choices?

    No. But helping people recover from poor choices or bad luck is the responsibility of charities, not government.

  35. Mrs Whatsit Says:

    “The last two years of life are the most expensive for healthcare”. Speciousness aside, I’ve never understood the point of this argument. It seems obvious that most people are sicker and more in need of medical care in the period just before they die than they were previously. This is most likely WHY THEY DIED.

    I don’t understand why this is raised as some kind of telling argument about health care costs. Is it a suggestion that, when someone dies at the end of a long medical battle against some illness, all the care invested in buying them more time or trying to save them was wasted? In that case, we should withhold care from anyone who is very sick on the theory that medical resources shouldn’t be squandered on those who are very sick and thus likely to die soon. So then why have medical care at all? I can’t imagine that this is really what people who cite this statistic mean to imply, nor can I figure out what else they think it means. Help, anyone?

  36. IGotBupkis, Legally Defined Cyberbully in All 57 States and some Canadian provinces Says:

    I will call attention to the words of our LAST truly GREAT president, who actually understood what GOVERNMENT is for:

    Grover Cleveland, from his wiki entry:

    In 1887, Cleveland issued his most well-known veto, that of the Texas Seed Bill.[95] After a drought had ruined crops in several Texas counties, Congress appropriated $10,000 to purchase seed grain for farmers there.[95] Cleveland vetoed the expenditure. In his veto message, he espoused a theory of limited government:

    I can find no warrant for such an appropriation in the Constitution, and I do not believe that the power and duty of the general government ought to be extended to the relief of individual suffering which is in no manner properly related to the public service or benefit. A prevalent tendency to disregard the limited mission of this power and duty should, I think, be steadfastly resisted, to the end that the lesson should be constantly enforced that, though the people support the government, the government should not support the people. The friendliness and charity of our countrymen can always be relied upon to relieve their fellow-citizens in misfortune. This has been repeatedly and quite lately demonstrated. Federal aid in such cases encourages the expectation of paternal care on the part of the government and weakens the sturdiness of our national character, while it prevents the indulgence among our people of that kindly sentiment and conduct which strengthens the bonds of a common brotherhood.

    —-

    Cleveland also offered the following somewhat related observation in his 3rd SOTU:

    “When we consider that the theory of our institutions guarantees to every citizen the full enjoyment of all the fruits of his industry and enterprise, with only such deduction as may be his share toward the careful and economical maintenance of the Government which protects him, it is plain that the exaction of more than this is indefensible extortion and a culpable betrayal of American fairness and justice … The public Treasury, which should only exist as a conduit conveying the people’s tribute to its legitimate objects of expenditure, becomes a hoarding place for money needlessly withdrawn from trade and the people’s use, thus crippling our national energies, suspending our country’s development, preventing investment in productive enterprise, threatening financial disturbance, and inviting schemes of public plunder.”

    Note that last term: Public Plunder

    That’s what much of this crap is all about.

    We now pay out more than FIFTY PERCENT of our life’s work to the government at all levels. FIFTY PERCENT. Each and every one of us.

    As Robert Heinlein noted many decades ago: it is interesting that our schools fail to mention that the taxes which started the American revolution, which, at its heart, was a tax revolt, were, all totaled, substantially less than FIVE PERCENT.

    The Founders would be in open revolt by now.

  37. SteveH Says:

    “”We now pay out more than FIFTY PERCENT of our life’s work to the government at all levels. FIFTY PERCENT. Each and every one of us.”"
    igotbupkis

    Which leads to a common sense observation. Slavery would have obviously been ok if the slaves were only required to be slaves on odd number days.

  38. neo-neocon Says:

    peter horne: I don’t have to cite the figures, because health insurance companies have done the work for me, and I trust them to know which group of their customers is going to incur higher health care costs on average. It’s smokers, who have higher premiums across the board.

    They may indeed die earlier, but they get sick earlier, so the age at death is not necessarily relevant. The amount of time a person is ill over his/her lifetime is more relevant, and the type of illness the person has and how expensive it is to treat and care for.

  39. RigelDog Says:

    All overweight people don’t even overeat as compared to many thin people, although some do. >>>

    More to the point, WHY do overweight people overeat? I think for many (most?) it’s because they are actually still hungry. In my case, if I eat starch and sugar, I am chronically hungry. If I eat lower-carb, I can eat all I want until I am full—and then I stop eating, and it turns out that’s the right amount of food to maintain a good healthy weight. That’s the way it should work, non?

  40. neo-neocon Says:

    RigelDog: depends what you mean by “should.” Depends what our bodies evolved for.

    There is a certain amount of evidence that our bodies have evolved in response to the situation in which food was relatively difficult to come by, and that as a result we were selected (by evolution) for those who were able to eat more than they needed for the moment, in order to store some fat for times of famine or scarcity. So that eating more than needed for the next few hours would be an advantage, and putting on some weight (as opposed to being very thin) would be an advantage, too.

    Whether or not that’s the case, my point is that optimal health in order to live to be 100 was not necessarily what evolution was driving at. Survival in order to have offspring and raise them was much more likely to have been the biological goal.

    And by the way, I’ve written about low carb diets before. Some people do well on them, some don’t.

    For me, not only do they make me ill, but I don’t lose weight on them.

  41. RigelDog Says:

    Neo, I well remember your posts on low-carb, which is why I said “many (most?) people,” and not all people. The research I’ve read suggests that about 60% of us have the so-called “thrifty gene” that evolved to encourage us to gorge on high-carb food when we found it. But this triggers a lot of insulin. One of insulin’s main purposes is to convert this carb overload directly to fat. Around the middle. Insulin also causes excess hunger.
    When I said that we “should” be able to eat until we are full and not gain weight, what I meant was that this is what a healthy metabolism will do. For me and those like me, the only way my metabolism functions with this efficient feedback is if I do not eat much starch or sugar.
    You and I don’t disagree, I just wanted to chime in with what I think is an overlooked point about being overweight—for some reason, it’s seldom contemplated that actually being hungry is a big part of it.

  42. Don Carlos Says:

    Mrs. Whatsit:
    You have put your finger right on a most demagogic claim, onr that Hillary and her sidekick Ezekiel Emanuel have in the past trotted out: If it didn’t work (patient died) you should not have done it.

  43. Don Carlos Says:

    ‘one’, not ‘onr’.

  44. Jim Nicholas Says:

    Don Carlos asks “As doc to doc, how do you feel about a doc’s individual ethical duty to serve a patient in need, versus “society’s” (more correctly, government’s) mandating that you do so?”

    (Oh, dear me. Another $10 fine levied on me by Holmes for submitting another post!)

    I like to think that my own sense of duty was more stringent than any regulations imposed upon me by state or federal regulations. For example, I had very little problem of patients not paying my fees except for patients I acquired during my rotations through night and weekend emergency room duty, who often had no regular doc and were unable to pay. I admitted them without consideration of whether they could pay, even if at times rebuked by the hospital administration, who knew the hospital also would not be paid.

    Most of my colleagues did the same–I was not special. A few in one way or another shunned what I considered their ethical duty, and I confess I was glad when later on state (not federal) legislation prevented that behavior. In other words, I approved of the law that mandated that that small group of docs do what the rest of us did out of duty.

    An addendum, not quite on the topic of your question:
    As you know the quality of medical education before the 1910 Flexnor report was chaotic and patients themselves had little way of evaluating physicians. To deal with this problem, the states set up licensing boards, which I think was a good thing–and probably still is. In any case, as a licensed physician I had agreed to abide by the standards of licensure–in as much as I was a licensed physician, I was a creation of the state. The truth is that the state invoked those standards and revoked licenses too seldom rather than too often.

    I say all of this with a good deal of humility. I retired 19 years ago. As long as I practiced, the relationship was between me and my patient. My patient could terminate it at time and I could terminate it with a responsible notice. I am not sure it is even possible to practice today as I did. I have the impression that today most docs must be group or hospital employees to survive financially, and so they become subject to all of the mandates of their employer, which in turn is subject to governmental mandates I have never experienced. They are not even able to reduce their fee according to the patient’s ability to pay. And so I truly do not know how I might or whether I might have to reconcile my sense of duty with what I am mandated to do.

    My best wishes to you, especially if you are still in practice.

  45. Jim Nicholas Says:

    meant to type “terminate it at any time”

  46. Don Carlos Says:

    In reply to Jim Nicholas-
    I was the cofounder of s small single-specialty group practice, based largely on referrals, including from a “public” hospital. It was our founding philosophy to treat all who needed it, regardless of ability to pay, or source of payment. We did just fine.

    I will suggest that your support of “the law that mandated that that small group of docs do what the rest of us did out of duty” was a first step onto the slippery slope. In order to rectify a “small group” you supported government moral authority over us all. Which perhaps led incrementally to where we are today, with young docs taking salaried jobs with non-doc employers out of fear for their personal security.

    Over 90% of docs were opposed to Medicare pre-enactment, but once enacted, almost all took on Medicare patients.

    I am also retired….

  47. J.J. formerly Jimmy J. Says:

    In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay.

    IMO, this was the beginning of real financial problems for our health care system. It was well intentioned, but the unintended consequences have been vast. It has resulted in cost shifting that defies rational expanation.

    For those who want to understand how the costs of medical care keep rising beyond inflation or any other rational explanation, I recommend this: (It’s long, but well worth the time.)
    http://tinyurl.com/b8clrft

  48. Jim Nicholas Says:

    In reply to Don Carlos @ 10:43
    You may well be right about the slippery slope. It is a problem to know what to do about those whose own ethical standards are inadequate. I think the profession has a duty to protect patents. Patients have very little basis for judging their medical care, especially prior to treatment. Unfortunately, the medical profession itself has often been too slow in disciplining its members.

    Quite apart from the cost and size of government, my main problem with medicare was its intrusion into the doctor-patient relationship. In my attempt to minimize the intrusion, I never accepted assignment from medicare–nor did I ever from private insurance companies. Medicare and insurance companies paid my patients and my patients paid me.

    At first insurance companies paid the patient when the only documentation was my fee statement. Then they began requiring that the diagnosis be on the fee statement, and so the slippery slope began. Eventually I was talking with the managed care docs to justify treatments and the claim forms were too complicated for the patients to complete unassisted by my office personnel. And so even though I prevailed in my wish to be paid directly only by my patient, it seemed a hollow victory.

    Did your group find a better solution?

  49. Don Carlos Says:

    Jim-
    Only a partial solution. We took Medicaid, which does not pay the patient, only the ‘provider’ (a word which I hate only slightly less than ‘caregiver’). And we hired front office staff to evaluate all uninsured patients, referring those who seemed eligible for formal Medicaid evaluation. Those who remained uninsured we treated pro bono.

    In the mid 1990s our 5 doc group provided a larger dollar number of free care than did a 200 bed Catholic hospital (non-profit, needless to say), based on its annual report. That hosp. stopped reporting that number thereafter.

    The problem with slippery slopes is that one realizes too late that one is already sliding.
    I was a hothead in my younger days about crappy docs, since they reflect on the entire group of us, but never got any support. There seems a perpetual general willingness to play turtle and just draw one’s head in.

  50. Jim Nicholas Says:

    Don Carlos,

    Yours was a very generous group, one to be admired.

    Jim

  51. parker Says:

    JN,

    I was away for 3 days to be with my newest grandchild, and only just now revisited this thread. You will probably not see this post, but I wanted to reply to you even if it is a vain attempt to communicate.

    “In the absence of a clear rationale for your question, it seems to me to be a bit impertinent.”

    From my POV it is very pertinent. Those wearing the liberal badge are least likely to donate directly to local charities. They tend to believe government should redistribute and decide who is worthy of charity. That was the essence of my questions. Do you decide or does the government decide.

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.
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