As part of my critical thinking class, I cover the usual topics of credibility and experiments/studies. Since people often find critical thinking a dull subject, I regularly look for real-world examples that might be marginally interesting to students. As such, I was intrigued by John Bohannon’s detailed account of how he “fooled millions into thinking chocolate helps weight loss.”
Bohannon’s con provides an excellent cautionary tale for critical thinkers. First, he lays out in detail how easy it is to rig an experiment to get (apparently) significant results. As I point out to my students, a small experiment or study can generate results that seem significant, but really are not. This is why it is important to have an adequate sample size—as a starter. What is also needed is proper control, proper selection of the groups, and so on.
Second, he provides a clear example of a disgraceful stain on academic publishing, namely “pay to publish” journals that do not engage in legitimate peer review. While some bad science does slip through peer review, these journals apparently publish almost anything—provided that the fee is paid. Since the journals have reputable sounding names and most people do not know which journals are credible and which are not, it is rather easy to generate a credible seeming journal publication. This is why I cover the importance of checking sources in my class.
Third, he details how various news outlets published or posted the story without making even perfunctory efforts to check its credibility. Not surprisingly, I also cover the media in my class both from the standpoint of being a journalist and being a consumer of news. I stress the importance of confirming credibility before accepting claims—especially when doing so is one’s job.
While Bohannon’s con does provide clear evidence of problems in regards to corrupt journals, uncritical reporting and consumer credulity, the situation does raise some points worth considering. One is that while he might have “fooled millions” of people, he seems to have fooled relative few journalists (13 out of about 5,000 reporters who subscribe to the Newswise feed Bohannon used) and these seem to be more of the likes of the Huffington Post and Cosmopolitan as opposed to what might be regarded as more serious health news sources. While it is not known why the other reporters did not run the story, it is worth considering that some of them did look at it critically and rejected it. In any case, the fact that a small number of reporters fell for a dubious story is hardly shocking. It is, in fact, just what would be expected given the long history of journalism.
Another point of concern is the ethics of engaging in such a con. It is possible to argue that Bohannon acted ethically. One way to do this is to note that using deceit to expose a problem can be justified on utilitarian grounds. For example, it seems morally acceptable for a journalist or police officer to use deceit and go undercover to expose criminal activity. As such, Bohannon could contend that his con was effectively an undercover operation—he and his fellows pretended to be the bad guys to expose a problem and thus his deceit was morally justified by the fact that it exposed problems.
One obvious objection to this is that Bohannon’s deceit did not just expose corrupt journals and incautious reporters. It also misinformed the audience who read or saw the stories. To be fair, the harm would certainly be fairly minimal—at worst, people who believed the story would consume dark chocolate and this is not exactly a health hazard. However, intentionally spreading such misinformation seems morally problematic—especially since story retractions or corrections tend to get far less attention than the original story.
One way to counter this objection is to draw an analogy to the exposure of flaws by hackers. These hackers reveal vulnerabilities in software with the stated intent of forcing companies to address the vulnerabilities. Exposing such vulnerabilities can do some harm by informing the bad guys, but the usual argument is that this is outweighed by the good done when the vulnerability is fixed.
While this does have some appeal, there is the concern that the harm done might not outweigh the good done. In Bohannon’s case it could be argued that he has done more harm than good. After all, it is already well-established that the “pay to publish” journals are corrupt, that there are incautious journalists and credulous consumers. As such, Bohannon has not exposed anything new—he has merely added more misinformation to the pile.
It could be countered that although these problems are well known, it does help to continue to bring them to the attention of the public. Going back to the analogy of software vulnerabilities, it could be argued that if a vulnerability is exposed, but nothing is done to patch it, then the problem should be brought up until it is fixed, “for it is the doom of men that they forget.” Bohannon has certainly brought these problems into the spotlight and this might do more good than harm. If so, then this con would be morally acceptable—at least on utilitarian grounds.
The United States recently saw an outbreak of the measles (644 cases in 27 states) with the overwhelming majority of victims being people who had not been vaccinated. Critics of the anti-vaccination movement have pointed to this as clear proof that the movement is not only misinformed but also actually dangerous. Not surprisingly, those who take the anti-vaccination position are often derided as stupid. After all, there is no evidence that vaccines cause the harms that the anti-vaccination people refer to when justifying their position. For example, one common claim is that vaccines cause autism, but this seems to be clearly untrue. There is also the fact that vaccinations have been rather conclusively shown to prevent diseases (though not perfectly, of course).
It is, of course, tempting for those who disagree with the anti-vaccination people to dismiss them uniformly as stupid people who lack the brains to understand science. This, however, is a mistake. One reason it is a mistake is purely pragmatic: those who are pro-vaccination want the anti-vaccination people to change their minds and calling them stupid, mocking and insulting them will merely cause them to entrench. Another reason it is a mistake is that the anti-vaccination people are not, in general, stupid. There are, in fact, grounds for people to be skeptical or concerned about matters of health and science. To show this, I will briefly present some points of concern.
One point of rational concern is the fact that scientific research has been plagued with a disturbing amount of corruption, fraud and errors. For example, the percentage of scientific articles retracted for fraud is ten times what it was in 1975. Once lauded studies and theories, such as those driving the pushing of antioxidants and omega-3, have been shown to be riddled with inaccuracies. As such, it is hardly stupid to be concerned that scientific research might not be accurate. Somewhat ironically, the study that started the belief that vaccines cause autism is a paradigm example of bad science. However, it is not stupid to consider that the studies that show vaccines are safe might have flaws as well.
Another matter of concern is the influence of corporate lobbyists on matters relating to health. For example, the dietary guidelines and recommendations set forth by the United States Government should be set on the basis of the best science. However, the reality is that these matters are influenced quite strongly by industry lobbyists, such as the dairy industry. Given the influence of the corporate lobbyists, it is not foolish to think that the recommendations and guidelines given by the state might not be quite right.
A third point of concern is the fact that the dietary and health guidelines and recommendations undo what seems to be relentless and unwarranted change. For example, the government has warned us of the dangers of cholesterol for decades, but this recommendation is being changed. It would, of course, be one thing if the changes were the result of steady improvements in knowledge. However, the recommendations often seem to lack a proper foundation. John P.A. Ioannidis, a professor of medicine and statistics at Stanford, has noted “Almost every single nutrient imaginable has peer reviewed publications associating it with almost any outcome. In this literature of epidemic proportions, how many results are correct?” Given such criticism from experts in the field, it hardly seems stupid of people to have doubts and concerns.
There is also the fact that people do suffer adverse drug reactions that can lead to serious medical issues and even death. While the reported numbers vary (one FDA page puts the number of deaths at 100,000 per year) this is certainly a matter of concern. In an interesting coincidence, I was thinking about this essay while watching the Daily Show on Hulu this morning and one of my “ad experiences” was for Januvia, a diabetes drug. As required by law, the ad mentioned all the side effects of the drug and these include some rather serious things, including death. Given that the FDA has approved drugs with dangerous side effects, it is hardly stupid to be concerned about the potential side effects from any medicine or vaccine.
Given the above points, it would certainly not be stupid to be concerned about vaccines. At this point, the reader might suspect that I am about to defend an anti-vaccine position. I will not—in fact, I am a pro-vaccination person. This might seem somewhat surprising given the points I just made. However, I can rationally reconcile these points with my position on vaccines.
The above points do show that there are rational grounds for taking a general critical and skeptical approach to matters of health, medicine and science. However, this general skepticism needs to be properly rational. That is, it should not be a rejection of science but rather the adoption of a critical approach to these matters in which one considers the best available evidence, assesses experts by the proper standards (those of a good argument from authority), and so on. Also, it is rather important to note that the general skepticism does not automatically justify accepting or rejecting specific claims. For example, the fact that there have been flawed studies does not prove that the specific studies about vaccines as flawed. As another example, the fact that lobbyists influence the dietary recommendations does not prove that vaccines are harmful drugs being pushed on Americans by greedy corporations. As a final example, the fact that some medicines have serious and dangerous side effects does not prove that the measles vaccine is dangerous or causes autism. Just as one should be rationally skeptical about pro-vaccination claims one should also be rationally skeptical about anti-vaccination claims.
To use an obvious analogy, it is rational to have a general skepticism about the honesty and goodness of people. After all, people do lie and there are bad people. However, this general skepticism does not automatically prove that a specific person is dishonest or evil—that is a matter that must be addressed on the individual level.
To use another analogy, it is rational to have a general concern about engineering. After all, there have been plenty of engineering disasters. However, this general concern does not warrant believing that a specific engineering project is defective or that engineering itself is defective. The specific project would need to be examined and engineering is, in general, the most rational approach to building stuff.
So, the people who are anti-vaccine are not, in general, stupid. However, they do seem to be making the mistake of not rationally considering the specific vaccines and the evidence for their safety and efficacy. It is quite rational to be concerned about medicine in general, just as it is rational to be concerned about the honesty of people in general. However, just as one should not infer that a friend is a liar because there are people who lie, one should not infer that a vaccine must be bad because there is bad science and bad medicine.
Convincing anti-vaccination people to accept vaccination is certainly challenging. One reason is that the issue has become politicized into a battle of values and identity. This is partially due to the fact that the anti-vaccine people have been mocked and attacked, thus leading them to entrench and double down. Another reason is that, as argued above, they do have well-founded concerns about the trustworthiness of the state, the accuracy of scientific studies, and the goodness of corporations. A third reason is that people tend to give more weight to the negative and also tend to weigh potential loss more than potential gain. As such, people would tend to give more weight to negative reasons against vaccines and fear the alleged dangers of vaccines more than they would value their benefits.
Given the importance of vaccinations, it is rather critical that the anti-vaccination movement be addressed. Calling people stupid, mocking them and attacking them are certainly not effective ways of convincing people that vaccines are generally safe and effective. A more rational and hopefully more effective approach is to address their legitimate concerns and consider their fears. After all, the goal should be the health of people and not scoring points.
Kaci Hickox, a nurse from my home state of Maine, returned to the United States after serving as a health care worker in the Ebola outbreak. Rather than being greeted as a hero, she was confined to an unheated tent with a box for a toilet and no shower. She did not have any symptoms and tested negative for Ebola. After threatening a lawsuit, she was released and allowed to return to Maine. After arriving home, she refused to be quarantined again. She did, however, state that she would be following the CDC protocols. Her situation puts a face on a general moral concern, namely the ethics of balancing rights with safety.
While past outbreaks of Ebola in Africa were met largely with indifference from the West (aside from those who went to render aid, of course), the current outbreak has infected the United States with a severe case of fear. Some folks in the media have fanned the flames of this fear knowing that it will attract viewers. Politicians have also contributed to the fear. Some have worked hard to make Ebola into a political game piece that will allow them to bash their opponents and score points by appeasing fears they have helped create. Because of this fear, most Americans have claimed they support a travel ban in regards to Ebola infected countries and some states have started imposing mandatory quarantines. While it is to be expected that politicians will often pander to the fears of the public, the ethics of the matter should be considered rationally.
While Ebola is scary, the basic “formula” for sorting out the matter is rather simple. It is an approach that I use for all situations in which rights (or liberties) are in conflict with safety. The basic idea is this. The first step is sorting out the level of risk. This includes determining the probability that the harm will occur as well as the severity of the harm (both in quantity and quality). In the case of Ebola, the probability that someone will get it in the United States is extremely low. As the actual experts have pointed out, infection requires direct contact with bodily fluids while a person is infectious. Even then, the infection rate seems relatively low, at least in the United States. In terms of the harm, Ebola can be fatal. However, timely treatment in a well-equipped facility has been shown to be very effective. In terms of the things that are likely to harm or kill an American in the United States, Ebola is near the bottom of the list. As such, a rational assessment of the threat is that it is a small one in the United States.
The second step is determining key facts about the proposals to create safety. One obvious concern is the effectiveness of the proposed method. As an example, the 21-day mandatory quarantine would be effective at containing Ebola. If someone shows no symptoms during that time, then she is almost certainly Ebola free and can be released. If a person shows symptoms, then she can be treated immediately. An alternative, namely tracking and monitoring people rather than locking them up would also be fairly effective—it has worked so far. However, there are the worries that this method could fail—bureaucratic failures might happen or people might refuse to cooperate. A second concern is the cost of the method in terms of both practical costs and other consequences. In the case of the 21-day quarantine, there are the obvious economic and psychological costs to the person being quarantined. After all, most people will not be able to work from quarantine and the person will be isolated from others. There is also the cost of the quarantine itself. In terms of other consequences, it has been argued that imposing this quarantine will discourage volunteers from going to help out and this will be worse for the United States. This is because it is best for the rest of the world if Ebola is stopped in Africa and this will require volunteers from around the world. In the case of the tracking and monitoring approach, there would be a cost—but far less than a mandatory quarantine.
From a practical standpoint, assessing a proposed method of safety is a utilitarian calculation: does the risk warrant the cost of the method? To use some non-Ebola examples, every aircraft could be made as safe as Air-Force One, every car could be made as safe as a NASCAR vehicle, and all guns could be taken away to prevent gun accidents and homicides. However, we have decided that the cost of such safety would be too high and hence we are willing to allow some number of people to die. In the case of Ebola, the calculation is a question of considering the risk presented against the effectiveness and cost of the proposed method. Since I am not a medical expert, I am reluctant to make a definite claim. However, the medical experts do seem to hold that the quarantine approach is not warranted in the case of people who lack symptoms and test negative.
The third concern is the moral concern. Sorting out the moral aspect involves weighing the practical concerns (risk, effectiveness and cost) against the right (or liberty) in question. Some also include the legal aspects of the matter here as well, although law and morality are distinct (except, obviously, for those who are legalists and regard the law as determining morality). Since I am not a lawyer, I will leave the legal aspects to experts in that area and focus on the ethics of the matter.
When working through the moral aspect of the matter, the challenge is determining whether or not the practical concerns morally justify restricting or even eliminating rights (or liberties) in the name of safety. This should, obviously enough, be based on consistent principles in regards to balancing safety and rights. Unfortunately, people tend to be wildly inconsistent in this matter. In the case of Ebola, some people have expressed the “better safe than sorry” view and have elected to impose or support mandatory quarantines at the expense of the rights and liberties of those being quarantined. In the case of gun rights, these are often taken as trumping concerns about safety. The same holds true of the “right” or liberty to operate automobiles: tens of thousands of people die each year on the roads, yet any proposal to deny people this right would be rejected. In general, people assess these matters based on feelings, prejudices, biases, ideology and other non-rational factors—this explains the lack of consistency. So, people are wiling to impose on basic rights for little or no gain to safety, while also being content to refuse even modest infringements in matters that result in great harm. However, there are also legitimate grounds for differences: people can, after due consideration, assess the weight of rights against safety very differently.
Turning back to Ebola, the main moral question is whether or not the safety gained by imposing the quarantine (or travel ban) would justify denying people their rights. In the case of someone who is infectious, the answer would seem to be “yes.” After all, the harm done to the person (being quarantined) is greatly exceeded by the harm that would be inflicted on others by his putting them at risk of infection. In the case of people who are showing no symptoms, who test negative and who are relatively low risk (no known specific exposure to infection), then a mandatory quarantine would not be justified. Naturally, some would argue that “it is better to be safe than sorry” and hence the mandatory quarantine should be imposed. However, if it was justified in the case of Ebola, it would also be justified in other cases in which imposing on rights has even a slight chance of preventing harm. This would seem to justify taking away private vehicles and guns: these kill more people than Ebola. It might also justify imposing mandatory diets and exercise on people to protect them from harm. After all, poor health habits are major causes of health issues and premature deaths. To be consistent, if imposing a mandatory quarantine is warranted on the grounds that rights can be set aside even when the risk is incredibly slight, then this same principle must be applied across the board. This seems rather unreasonable and hence the mandatory quarantine of people who are not infectious is also unreasonable and not morally acceptable.
In science fiction stories, movies and games automated medical services are quite common. Some take the form of autodocs—essentially an autonomous robotic pod that treats the patient within its confines. Medbots, as distinct from the autodoc, are robots that do not enclose the patient, but do their work in a way similar to a traditional doctor or medic. There are also non-robotic options using remote-controlled machines—this would be an advanced form of telemedicine in which the patient can actually be treated remotely. Naturally, robots can be built that can be switched from robotic (autonomous) to remote controlled mode. For example, a medbot might gather data about the patient and then a human doctor might take control to diagnose and treat the patient.
One of the main and morally commendable reasons to create medical robots and telemedicine capabilities is to provide treatment to people in areas that do not have enough human medical professionals. For example, a medical specialist who lives in the United States could diagnose and treat patients in a remote part of the world using a suitable machine. With such machines, a patient could (in theory) have access to any medical professional in the world and this would certainly change medicine. True medical robots would obviously change medicine—after all, a medical robot would never get tired and such robots could, in theory, be sent all over the world to provide medical care. There is, of course, the usual concern about the impact of technology on jobs—if a robot can replace medical personnel and do so in a way that increases profits, that will certainly happen. While robots would certainly excel at programmable surgery and similar tasks, it will certainly be quite some time before robots are advanced enough to replace human medical professionals on a large scale
Another excellent reason to create medical robots and telemedicine capabilities has been made clear by the Ebola outbreak: medical personnel, paramedics and body handlers can be infected. While protective gear and protocols do exist, the gear is cumbersome, flawed and hot and people often fail to properly follow the protocols. While many people are moral heroes and put themselves at risk to treat the ill and bury the dead, there are no doubt people who are deterred by the very real possibility of a horrible death. Medical robots and telemedicine seem ideal for handling such cases.
First, human diseases cannot infect machines: a robot cannot get Ebola. So, a doctor using telemedicine to treat Ebola patients would be at not risk. This lack of risk would presumably increase the number of people willing to treat such diseases and also lower the impact of such diseases on medical professionals. That is, far fewer would die trying to treat people.
Second, while a machine can be contaminated, decontaminating a properly designed medical robot or telemedicine machine would be much easier than disinfecting a human being. After all, a sealed machine could be completely hosed down by another machine without concerns about it being poisoned, etc. While numerous patients might be exposed to a machine, machines do not go home—so a contaminated machine would not spread a disease like an infected or contaminated human would.
Third, medical machines could be sent, even air-dropped, into remote and isolated areas that lack doctors yet are often the starting points of diseases. This would allow a rapid response that would help the people there and also help stop a disease before it makes its way into heavily populated areas. While some doctors and medical professionals are willing to be dropped into isolated areas, there are no doubt many more who would be willing to remotely operate a medical machine that has been dropped into a remote area suffering from a deadly disease.
There are, of course, some concerns about the medical machines, be they medbots, autodocs or telemedicine devices.
One is that such medical machines might be so expensive that it would be cost prohibitive to use them in situations in which they would be ideal (namely in isolated or impoverished areas). While politicians and pundits often talk about human life being priceless, human life is rather often given a price and one that is quite low. So, the challenge would be to develop medical machines that are effective yet inexpensive enough that they would be deployed where they would be needed.
Another is that there might be a psychological impact on the patient. When patients who have been treated by medical personal in hazard suits speak about their experiences, they often remark on the lack of human contact. If a machine is treating the patient, even one remotely operated by a person, there will be a lack of human contact. But, the harm done to the patient would presumably be outweighed by the vastly lowered risk of the disease spreading. Also, machines could be designed to provide more in the way of human interaction—for example, a telemedicine machine could have a screen that allows the patient to see the doctor’s face and talk to her.
A third concern is that such machines could malfunction or be intentionally interfered with. For example, someone might “hack” into a telemedicine device as an act of terrorism. While it might be wondered why someone would do this, it seems to be a general rule that if someone can do something evil, then someone will do something evil. As such, these devices would need to be safeguarded. While no device will be perfect, it would certainly be wise to consider possible problems ahead of time—although the usual process is to have something horrible occur and then fix it. Or at least talk about fixing it.
In sum, the recent Ebola outbreak has shown the importance of developing effective medical machines that can enable treatment while taking medical and other personnel out of harm’s way.
There are about three million Americans and about 170 million people around the world infected with Hepatitis C. In the recent past, the cost of treatment could be up to $300,000 in extreme cases. A new drug, Sovaldi, would reduce that cost to about $84,000. On the face of it, that seems like a great deal. However, the company manufacturing the drug has generated some outrage. The reason is simple: the company, Gilead, plans to charge $1,000 per pill.
While $1,000 for a pill might seem exorbitant, Gilead has made the reasonable point that they have the right to recover the cost of developing the medicine. This is certainly correct—the expense of developing a product can be legitimately passed on to the customers.
In the case of Sovalidi, Gilead “developed” it by buying the company that developed it for $11 billion. While this is a certainly a large sum of money, if 150,000 people are treated at the asking price of $1,000 per pill, the company will have recovered what it spent to buy the company that developed it. This is a not uncommon practice in areas with high initial development costs. For example, new technology initially comes at a premium price and then the price drops as a company recovers its development costs.
When asked if Gilead would reduce the cost once it recovered its money, the vice president of the company said, “”That’s very unlikely that we would do that. I appreciate the thought.” One way to justify this is by contending that the cost of producing the pill warrants keeping the price high. After all, the cost of production is clearly a legitimate factor in calculating a fair price for a product.
However, the drug is most likely fairly cheap to produce. According to Andrew Hill, who is in the Department of Pharmacology and Therapeutics at the University of Liverpool, the cost per treatment would be $150-250 per person. If this is correct, the company would be making truly massive profits off a drug that is rather cheap to produce. On the face of it, such a mark-up would seem to be unfair.
It might be contended that the free-market will sort this out. However, there are two major concerns here. The first is that Gilead’s ownership of the drug rather limits the competitive force of the market. Until another company produces a competing drug, Gilead has an effective monopoly. Competing companies would need to spend considerable sums to develop a competing drug and they would have to avoid infringing on the ownership rights of Gilead. Whether this is seen as wrong or not depends on how one looks at the matter. On the one hand, there is the view that a company has the right to its government enforced monopoly and can use this to charge any amount it deems fit until competition forces it to reduce prices. On the other hand, there is the view that it is wrong for a company to use the coercive power of the state (the state ensures that the drug cannot be copied and sold by others) to exploit the very citizens that the state is supposed to protect from exploitation. The second is that the treatment is not a luxury item for the patients but a necessity—without it they risk severe illness and death. As such, the customers are coerced by their condition and this is being exploited by Gilead. If Gilead were selling $84,000 watches or cars, people could elect to buy them or not—so Gilead would need to make the product match the price. In the case of medicine, Gilead can set its price and give people a choice between buying and dying.
Interestingly, Gilead does plan to offer lower prices in countries such as India, Pakistan, Egypt and China. While the price is not set, the estimate is that “It’ll be from the high hundreds to low thousands for these types of markets.” This rather obviously indicates that Gilead could sell the pills for less in the United States. This lower cost could be seen in at least two ways. One is that Gilead is being nice by offering people in these other countries a price break. Another is that Gilead knows that it will simply not be able to sell the pills for $1,000 each in such countries and are settling for taking what they can get. That is, some profit is better than none.
If Gilead is giving patients in these countries a real break—that is, selling the product with a very narrow profit margin, then the company would seem to be acting in a laudable way by providing an important treatment while only making large profits. However, given the estimated cost of providing the treatment ($150-250) the company would be making very large profits by selling the treatments for the high hundreds to low thousands. The company would also be making what might be regarded as obscene profits in countries like the United States where the pills would sell for $1,000 each.
Given that Gilead would recover its costs quickly and the actual cost of providing treatment is relatively low, what remains to be determined is what would warrant charging such a high price for a essential treatment.
Alton presents a standard reason for this: “Those who are bold and go out and innovate like this and take the risk — there needs to be more of a reward on that. Otherwise, it would be very difficult for people to make that investment.”
Alton’s basic point is reasonable. Developing new medicines is a risky business since most drugs never actually make it to being a sellable product. As such, this increases what companies must spend to actually develop a product they can sell.
One point of concern is the degree of risk that Gilead took when it bought the company that developed the drug. If that company took risks and developed the drug, then that company certainly earned the right to recover the cost of the risks it took. However, it is not clear that Gilead was bold, innovative and risk taking by buying that company.
Another point of concern is determining the cost and value of risk. That is, sorting out how risk taking legitimately contributes to a higher price. Oversimplifying things a bit, it would seem fair to consider the cost of legitimate attempts to develop drugs that failed as part of the legitimate operating expenses of a company and thus these can justly passed on to the consumer. However, as noted above, Gilead will recover the cost of buying the developer of the drug quickly and hence will lose the justification that it must charge a high price in compensation for its risk. Even if it is granted that risk taking warrants charging high prices, this should not warrant the high prices when the cost of the risk has been recovered. At that point a new justification would be needed for the high price. In the case of the medicine, the cost of providing the treatment would not warrant the high price. Also as noted above, the market is effectively not free since the state ensures that Gilead has a monopoly on the medicine it bought and the patients are coerced by their illness. If the patients tried to produce the medicine on their own by copying the pills, the state would send police to arrest them and they would face severe legal action.
It could be replied that $84,000 is a bargain compared to the current cost and this justifies the high price. To use an analogy, if one surgeon charges $300,000 to do a procedure and I will provide the same results for $84,000 then that seems like a good deal. However, if it only costs me $250 to treat the person, that would hardly seem to be a fair price. It would be a better price—but better is not the same as fair.
I freely admit that I have not settled the matter of what is a fair price. However, it does seem clear that $1,000 per pill is not a fair price.
On the face of it, the idea seems reasonable enough: if a person has health insurance, then she is less likely to use the emergency room. To expand on this a bit, what seems sensible is that a person with health insurance will be more likely to use primary care and thus less likely to need to use the emergency room. It also seems to make sense that a person with insurance would get more preventative care and thus be less likely to need a trip to the emergency room.
Intuitively, reducing emergency room visits would be a good thing. One reason is that emergency room care is rather expensive and reducing it would save money—which is good for patients and also good for those who have to pay the bills for the uninsured. Another reason is that the emergency room should be for emergencies—reducing the number of visits can help free up resources and lower waiting times.
As such, extending insurance coverage to everyone should be a good thing: it would reduce emergency room visits and this is good. However, it turns out that extending insurance might actually increase emergency room visits. In what seems to be an excellent study, insurance coverage actually results in more emergency room visits.
One obvious explanation is that people who are insured would be more likely to use medical services for the same reason that insured motorists are likely to use the service of mechanics: they are more likely to be able to pay the bills for repairs.
On the face of it, this would not be so bad. After all, if people can afford to go to the emergency room and be treated because they have insurance, that is certainly better than having people suffer simply because they lack insurance or the money to pay for care. However, what is most interesting about the study is that the expansion of Medicaid coverage resulted in an increase in emergency room visits for treatments that would have been more suitable in a primary care environment. That is, people decided to go to the emergency room for non-emergencies. The increase in emergency use was significant—about 40%. The study was large enough that this is statistically significant.
Given that Obamacare aims to both expand Medicaid and ensure that everyone is insured, it is certainly worth being concerned about the impact of these changes on the emergency room situation. Especially since one key claim has been that these changes would reduce costs by reducing emergency room visits.
One possibility is that the results from the Medicaid study will hold true across the country and will also apply to the insurance expansion. If so, there would be a significant increase in emergency room visits and this would certainly not results in a reduction of health care costs—especially if people go to the expensive emergency room rather than the less costly primary care options. Given the size and nature of the study, this concern is certainly legitimate in regards to the Medicaid expansion.
The general insurance expansion might not result in significantly more non-necessary emergency room visits. The reason is that private insurance companies often try to deter emergency room visits by imposing higher payments for patients. In contrast, Medicaid does not impose this higher cost. Thus, those with private insurance will tend to have a financial incentive to avoid the emergency room while those on Medicaid will not. While it would be wrong to impose a draconian penalty for going to the emergency room, one obvious solution is to impose a financial penalty for emergency room visits—preferably tied to using the emergency room for services that can be provided by primary care facilities. This can be quite reasonable, given that emergency room treatment is more expensive than comparable primary care treatment. In my own case, I know that the emergency room costs me more than visiting my primary care doctor—which gives me yet another good reason to avoid the emergency room.
There is also some reason to think that people use emergency rooms rather than primary care because they do not know their options. That is, if more people were better educated about their medical options, they would chose primary care options over the emergency room when they did not need the emergency room services. Given that going to the emergency room is generally stressful and typically involves a long wait (especially for non-emergencies) people are likely to elect for primary care when they know they have that option. This is not to say education will be a cure-all, but it is likely to help reduce unnecessary emergency room visits. Which is certainly a worthwhile objective.
On October 7, 2013 Health and Human Services Secretary Kathleen Sebelius was the guest on the Daily Show. Given that Jon Stewart is often regarded as a liberal mouthpiece, most folks probably expected that this would be a mutual admiration sort of interview. However, things certainly turned out rather differently as Stewart did what “real” journalists rarely do: he raised an important concern and refused to allow the person to shift the issue.
The question raised was one that certainly should be answered, namely the question of why large businesses were granted a delay in their implementation of Obamacare while individuals did not receive the same delay. While there should certainly be a fair and rational answer to this question, Sebelius went into verbal acrobatics to avoid answering it. This tactic is known as the smokescreen/red herring in philosophy:
A Red Herring is a fallacy in which an irrelevant topic is presented in order to divert attention from the original issue. The basic idea is to “win” an argument by leading attention away from the argument and to another topic. A common variation on this is the smokescreen: it functions like a red herring, but the attempt at diversion involves piling on complexities on the original issue until it is lost in the verbal smoke. This sort of “reasoning” has the following form:
1. Topic A is under discussion.
2. Topic B is introduced under the guise of being relevant to topic A (when topic B is actually not relevant to topic A).
3. Topic A is abandoned.
This sort of “reasoning” is fallacious because merely changing the topic of discussion hardly counts as an argument against a claim.
In the case of Sebelius, her attempts to switch to other issues and to pile on other matters did not answer Stewart’s reasonable question. In general, people use this tactic in response to a question when they either 1) have no answer to the question or 2) have a problematic or bad answer to the question. In the case of Sebelius, I would suspect that the second option holds: she almost certainly has an answer, but it almost certainly is not a good one.
Stewart seems to have drawn this sort of conclusion regarding Sebelius’ maneuvering:
“I still don’t understand why individuals have to sign up and businesses don’t, because if the businesses — if she’s saying, ‘well, they get a delay because that doesn’t matter anyway because they already give health care,’ then you think to yourself, ‘fuck it, then why do they have to sign up at all. And then I think to myself, ‘well, maybe she’s just lying to me.’”
In terms of why this question matters, one obvious point of concern is the matter of fairness. If large businesses get a year delay, then fairness would seem to require that the same courtesy be extended to individuals.
It might be countered that there is a relevant difference between large businesses and individuals that warrants the difference in treatment. If so, Sebelius should have simply presented this difference or differences and that would have quickly settled the matter. For example, it might be the case that a large business would need more time to implement the change on such a large scale, while an individual just has to implement it for herself. But, Sebelius provided no such relevant difference and spent her time trying throw out red herrings and blow smoke. This suggests that she was either ignorant of a relevant difference or was aware that the difference did not actually justify the difference in treatment. That is, there is no legitimate relevant difference. Given her position, the explanation based on her ignorance seems unlikely, so the reasonable conclusion is that she knew the answer, but believes that it would make things look worse than engaging in evasion. Of course, it is also possible that such evasion are just a matter of how politicians operate—like the famous scorpion being carried across the river, they cannot deviate from their nature. In any case, Sebelius’ behavior creates the impression that something is wrong here and creating this impression is, I am sure, not what she intended in her interview.
Interestingly, while this difference between businesses and individuals is a legitimate point of criticism, the Republicans seem to have little interest in engaging Obamacare in depth on points where it actually generates legitimate concerns. While the Republicans have noted that they want to defund or delay Obamacare, they seem to be unable to avoid hyperbole and other excesses of defective rhetoric. I suspect that this occurs for a variety of reasons. One possibility is that they are also like that scorpion: they simply cannot bring themselves to engage the matter of Obamacare in a rational way—instead, they have to sting away with crazy rhetoric and a government shutdown. Another possibility is that they believe that engaging in the actual issues will be bad for them in some manner. A third possibility, which is more specific than the second, is that they believe that their target audience is best played to by such rhetoric and behavior and that they would be ill served politically by engaging on actual issues in a rational manner. As a final possibility, they might not actually care about Obamacare as such—rather, they are simply out to oppose Obama and Obamacare happens to be the point of contention. To use an analogy, they are like Meletus in the Apology—they are not concerned with what they claim to be concerned about, they are just out to get their man.
Once again, the United States government has been shut down. As is to be expected, the politicians and pundits are engaging in the blame game. A key Republican talking point is that Obama and the Democrats are to blame because they would not compromise on the matter of Obamacare. If, say the Tea Party Republicans, Obama had been willing to defund or delay Obamacare, then they would not have been forced to do what they did.
The obvious counter to this is that Obamacare became a law via the proper constitutional process and hence this is no longer a compromise situation. It should also be noted that the proposed compromise is a rather odd one. It is as if the Republicans in question are saying: “here is our compromise: we get our way on Obamacare and, in return, we will not shut down the government.” That hardly seems like a reasonable compromise. To use an analogy, it would be like being in a bus heading to an event that was voted on by the people on the bus. Then some folks say that they do not like where the bus is going and one of them grabs the wheel. He then says “here is my compromise: we go where I want to go, or I’ll drive us into a tree.” That is hardly a compromise. Or even sane.
It could be argued that Obama and the Democrats should have done a better job in the past in terms of getting Republican buy-in on Obamacare. Or that the fact that the Republicans are a majority in the house shows that Americans want to be rid of Obamacare. These are not unreasonable points. However, they do not justify shutting down the government.
While I believe that Obamacare is chock full of problems and will have a variety of unpleasant consequences, I also believe in the importance of following the constitution. That is, I believe in the process of law. Obamacare went through that process and properly became a law. As such, there do not seem to be any grounds for claiming that it should be stopped because it is somehow an improperly passed law.
There have been claims that Obamacare is unconstitutional. There are some merits to these claims, but the matter was properly settled by the Supreme Court. Presumably the matter could be reconsidered at a later date, but the constitutional process has been properly followed. As such, the rhetorical points that Obamacare is unconstitutional lack merit. However, even if there was new and most excellent legal argument for this claim, this would not warrant shutting down the government to block the law. It would warrant having the Supreme Court consider the argument. That is proper procedure—that is how a system of government should operate. Using the threat of a shutdown against a law is certainly not how things should be done. That is essentially attempting to “govern” by threats, coercion and blackmail.
To use an analogy, imagine a night baseball game in which one side is losing. That side has argued every call repeatedly and used all the rules of the game to try to not lose. But it is still losing. So the coach of the losing team says that his team will turn out the lights, take all the balls, rip up the bases, and throw away the bats unless the other team “compromises” and gives them all the points they want. That would obviously be absurd. Likewise for the Tea Party Republican shut down.
A possible approach to warranting the shutdown is based on the idea of popular democracy. Some have argued that Obamacare is unpopular with most Americans. While this seems true, it also is true that most Americans do not seem to have enough of an understanding of Obamacare to have a rational opinion and much of the alleged dislike seems to stem from how the questions are asked. Interestingly, many people seem to really like things like the fact that people cannot be denied coverage because of pre-existing conditions and that children can stay on their parents’ insurance until they are 26.
Since this is supposed to be something of a democracy, considering the will of the people (however confused and ill-informed the people might be) seems reasonable. However, this would need to be a consistent principle. That is, if the Tea Party Republicans say that they are warranted in shutting down the government because a majority of Americans are opposed to Obamacare, then they would need to accept that the same principle applies in the case of other laws as well. So, if most Americans believe that X should be a law or that X should not be a law, then that is what must be done—and if it is not done, the government must be shut down. Given the overwhelming support for certain gun control laws that congress refused to pass, if this principle is accepted then these laws must pass—or the government must be shut down.
However, the Tea Party Republicans are clearly not operating on a principle here, unless it is the principle of “we’ll shut down the government if we don’t get what we want”—but that is hardly a reasonable or democratic principle.
Another plausible approach to countering this is to argue that a shutdown can be justified on the grounds that a legitimately passed, Supreme Court tested law is so bad that action must be taken. While this could not be warranted on constitutional grounds, it could be justified on moral grounds, most likely utilitarian grounds. The idea would be that the consequences of allowing the law to go into effect would be so dire that the consequences of shutting down the government are offset by the achievement of a greater good. Or, rather, the prevention of a greater bad.
Interestingly, this could be seen as a variation on civil disobedience. But, rather than have citizens breaking an unjust law to get arrested, there are lawmakers breaking the government—or at least the parts that don’t pay their salary.
Since I find Thoreau’s arguments in favor of such civil disobedience appealing, I have considerable sympathy for lawmakers deciding to serve the state with their consciences. However, what needs to be shown is that the law is so unjust that it warrants such a serious act of civil disobedience.
Ted Cruz and other Tea Party Republicans have made various dire claims about Obamacare—it will result in people being fired, it will cause employers to cut hours so that workers become part-time workers, and so on. Cruz even brought out a comparison to the Nazis, which did not go over well with the Republican senator John McCain. Interestingly, Cruz and others have attributed backwards causation powers to Obamacare: the stock talking points well before Obamacare went into effect included claims that Americans were already suffering under Obamacare—despite the fact that it was not in effect.
When pressed on the damage that Obamacare will do, the Tea Party Republicans tend to be rather vague—they throw out claims about how it will come between a patient and her doctor and so on. However, they never got around to presenting an obective coherent, supported case regarding the likely harms of Obamacare. This is hardly surprising. As a general rule, if someone busts out a Nazi analogy, then this is a fairly reliable sign that they have nothing substantial to say. This is, I think, unfortunate and unnecessary: Obamacare no doubt has plenty of problems and if it is as bad as the Tea Party Republicans claim, they should have been able to present a clear list without having to resort to rhetoric, scare tactic, hyperbole and Nazi analogies. So, I ask for such a clear case for the harms of Obamacare.
As a final point, Obama has made the reasonable point that he has been asking the Republicans for their input and their alternative plan for health care for quite some time. Some Republicans have advocated the emergency room, which I wrote about earlier, but their main offering seems to be purely negative: get rid of Obamacare. In terms of a positive alternative, they seem to have nothing. But, I am a fair person and merely ask for at least an outline of their alternative plan.
Ted Cruz undertook an almost marathon talking session against Obamacare. Not surprisingly, he does not have any need of Obamacare. As a senator, he already has access to government funded healthcare. However, he also does not need this coverage as, apparently, he falls under his wife’s Goldman Sachs’ coverage. Interestingly, while one of the anti-Obamacare talking points is that the cost of providing insurance will destroy business, the top executives at Goldman Sachs have their $40,500+ family premiums paid for by the company. As a point of comparison, the median household income in the United States is $50,000.
Naturally, to attack Cruz’s claims by pointing out his health care situation would be a mere ad homimem. However, his situation does serve to illustrate the incredible health care gap between the wealthy pundits and politicians attacking Obamacare and average Americans. It is certainly a thing of beauty to see a man with incredible coverage provided for by his wife’s employer rail against a law that would require almost many employers to provide lesser coverage to their employees.
It also illustrates an interesting inconsistency, namely that he seems to hold to the position that his wife should receive health care benefits from her employer but that the same is not true for other Americans. Of course, it is consistent with the view that the wealthy should be treated differently from everyone else.
It might, however, be objected that Cruz is right. After all, Goldman Sachs is incredibly profitable and can easily afford such premiums as part of the very generous (some might say excessive) compensation packages they offer to their “top talent.” Lesser businesses, those run by and employing the little people, cannot afford to provide even the minimum health care benefits required by Obamacare and, apparently, the employees do not deserve such coverage. As such, health care benefits from employers are for the wealthy but not for the little people.
While this approach has some merit when it comes to small businesses, the obvious counter is that the smaller businesses are exempt from this requirement. However, the potential economic impact of Obamacare is worth considering. As is the potential economic damage of the threatened government shut down.
It has been claimed that the cost of implementing Obamacare will cause businesses to fire people and to cut employee hours so that they are not full time employees. Presumably this will not impact the wealthy—Cruz did not seem worried that Goldman Sachs would fire his wife or cut her hours so they would not need to provide healthcare benefits.
While cost is a point of concern, there is the obvious question of whether businesses actually need to fire people and reduce hours or not as a rational response to Obamacare. That is, would the increased cost be so onerous that the firing and cutting would be a matter of survival? Or would it merely be a matter of slightly less profits? After all, some businesses obviously believe they can afford to provide extremely generous health care benefits to some people, so perhaps those affected can afford to provide lesser benefits to their workers.
This does, of course, raise some interesting questions about what benefits employees should receive and what constitutes economic necessity. However, these matters go beyond the scope of this essay. However, I will note that I do agree that health care should not be linked to employment and that I do agree that it should not be the responsibility of businesses to provide health care coverage. Unfortunately, the structure of health care benefits in the United States is such that having businesses as the provider is the main viable option. The other is, of course, having it provided by the state. Unless, of course, health care could be reformed to the point where average individuals could afford quality health care on their average incomes.
Oddly enough, Cruz and others have spoken of all the terrible damage that Obamacare has done and is doing. While this might be merely a slip of tenses, Obamacare cannot be doing any damage yet—it has not gone into effect. As such, it is an error to speak of the damage it has done—at least until it starts doing damage.
Cruz also made use of hyperbole and a rhetorical analogy by trotting out the absurd comparison of Obamacare to the Nazis. In the past, I have advocated a bi-partisan ban on this (Democrats use it, too) and I still support this proposal. As a general rule, only things that are comparable in badness to the Nazis should be compared to the Nazis. Even if Obamacare does all the awful things that certain Republicans claim it will do, it will obviously fall far short of starting a world war and engaging in genocide. Making the Nazi comparsion seems to show that a person has nothing substantial to say or that he has an impaired grasp of reality.
While Obamacare will certainly have problems, Cruz and his fellows have not offered any alternative plan of any substance. For the most part they make vague claims about market reforms and some even advance the absurd idea that people can just rely on the emergency room. While it is fair to be critical of a law when one does not have an alternative, the Republicans need to offer something other than threats to shut down the government. This makes these Republicans seem rather crazy.
As Obamacare marches onward, its opponents are still endeavoring to stop its advance and send it packing. Of course, the opponents need to provide an alternative system. Interestingly, certain Republicans such as Rick Perry and Jim DeMint have claimed that uninsured Americans are better off relying on the emergency room for treatment. While the battle over Obamacare is largely ideological, the viability of using the emergency room would seem to be an objective matter.
On the positive side, anyone can go to the emergency room and hospitals cannot refuse to treat people with legitimate medical needs—even people who lack insurance or cannot pay.
However, there are numerous problems with the uninsured (or even the insured) relying on the emergency room. The first is the matter of cost. The emergency room is generally more expensive than the non-emergency options. It is certainly more expensive that routine preventative care that can keep a person out of the emergency room. The high costs are problematic because of the burden on the uninsured (medical bills is a leading cause of bankruptcy in America) and also because when the uninsured cannot pay, the cost is passed on to the rest of us (most often in the form of higher health insurance premiums). Thus, relying on the emergency room to treat the uninsured places a heavy burden on everyone and is actually a form of highly inefficient socialism in which those with insurance pay for needlessly expensive treatment for the uninsured. From a purely economic standpoint, if we are going to have medical socialism, we should at least go with the more economically efficient version.
The second is the matter of preventative medicine and ongoing treatments, such as routine checkups and dialysis. The emergency room hardly seems to be set for these medical matters, although people who are unable to avail themselves of them stand a significant chance of ending up in the emergency room, thus taking us back to the first problem. As such, the emergency room option does not seem to be a viable alternative to Obamacare. This is not to say that Obamacare is the only option or even a good option—just that it is better than the emergency-room-for-the-uninsured option.
The third is the matter of compassion. While hospitals cannot deny people necessary medical care, such care is certainly not charity: either the patient must pay or the cost is passed on to the rest of us. As such, relying on the emergency room as a matter of social policy is essentially saying to people that they can get treatment, provided that it is an emergency and that either the patient can pay or the cost can be passed on to everyone else. It is generally agreed that we should collectively protect each other from terrorism, foreign enemies, and our own criminals. This same concern should also extend to protecting each other from disease and injury. After all, whether Sally is dead because of cancer, a criminal’s bullet or a terrorist’s bomb, she is still dead. So, if we can have a huge collective defense against these other threats, we surely can have a developed collective defense against medical threats—one that is better than the emergency room.