Saturday, January 21, 2017

No Moral Trump Cards in Health Policy

Apparently some people think you can answer questions about health policy with their moral outrage alone. At least, that’s the impression I get from my Facebook feed. I see arguments every single day of the variety, “It’s just the right thing to do…” or “It’s just wrong to let someone go without healthcare” or (and this one is a paraphrase from memory, but it may be the exact language) “It’s called being a fucking decent human being!” These are bad arguments. They aren’t even arguments, really. These are simply assertions by the speaker (or writer or meme-sharer) that they hold the moral high ground and will make pronouncements thusly. (At the moment I’m talking about the potential repeal of the ACA, but I could be talking about any public flare-up over health policy.)

I’m sorry, but you simply cannot draw conclusions about health policy without being a little bit analytical. How much would it cost to save one quality-adjusted life-year (QALY, a standard unit of relative health)? Is this close to what most people objectively value a year of life? Is it an order of magnitude higher, thus rendering a strong verdict against the health policy in question? Is it an order of magnitude smaller, thus rendering a strong verdict in favor of said health policy? Based on our best evidence, might the health effects be *negative*, thus making the whole policy morally dubious? How are other values, like freedom of choice and property rights, to be weighted against a policy that forces you to purchase something? If the cost per life saved came out to something absurd, like a trillion dollars, would you still favor it (as a “moral trump card” argument would commit you to doing)? Is there massive uncertainty in even our best estimates of the benefits, thus making it impossible to justify the enormous expense of the law? To play a moral trump card is to dodge all these important questions.

People often use the following hypothetical: “If we can save the life of an uninsured man with no resources for a million dollars, aren’t we obligated as a society to do so?” This is the equivalent of making about 20 median households work an entire year for the sake of one person. (20 households x $50,000/year income per median household.) You can try to make this sound noble, but to my ear it sounds like we’re enslaving 20 households for a year for the benefit of a single person. I’m not trying to support any particular answer to the question posed by the hypothetical (mine is “No”). I’m simply pointing out that there is a trade-off of rights here, and it isn’t clear a priori whose rights should dominate. I think even the moral trumpists on my Facebook feed would balk at the idea of spending a billion dollars to save a life, or the idea of *literally* enslaving 20 people, conscripting them to work exclusively on the task of saving one man’s life. In fact I think they’d balk at the idea of enslaving even *one* person for significantly shorter than a year, even if they objectively valued the man’s life higher than the conscript’s freedom. If a slight re-framing of the hypothetical causes you to answer differently, then it’s no more than a superficial rhetorical trick.

You can continue to grandstand on some all-trumping moral principle, but if you're playing that game your opponents can simply grandstand on some other moral principle that you are neglecting (freedom of choice, property rights, etc.) and they would be on equal footing. There is no framework for discussing anything in this kind of exchange. However, if you engage a little bit with the concept of trade-offs, if you are a little bit empirical about your assessment of government policy, if you employ a little bit of numeracy and mathematical thinking to compare the relative values in conflict, you can have a reasonable conversation about the topic under contention. 

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