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March 13, 2006
Dedicated Ventilators?
Imagine that bird flu hits the United States, and you're a doctor at a hospital filled with 700 infected patients who all need ventilators to help them breathe. You have 100 ventilators. How do you allocate them? To the sickest? the youngest? the oldest? the most likely to live? the ones most likely to die without one?
The choices would be unthinkable, as Bernard Williams and Martha Nussbaum have suggested. We should be doing much more to avoid them, or at least make them less stark. But as this article from the NYT shows, we are instead doing very little:
Right now, there are 105,000 ventilators, and even during a regular flu season, about 100,000 are in use. In a worst-case human pandemic, according to the national preparedness plan issued by President Bush in November, the country would need as many as 742,500. To some experts, the ventilator shortage is the most glaring example of the country's lack of readiness for a pandemic.
Now aren't you happy that market forces got rid of all that "excess hospital capacity" in the 80s and 90s? According to one doctor from the Mayo Medical School, "Families are going to be told, 'We have to take your loved one off the ventilator even though, if we could keep him on it for a week, he might be fine.'"
Given various budgetary crises, we can't expect much help from government. Is there any creative solution? I'd like to suggest one: Let individuals buy ventilators to dedicate for themselves and their families (at nearby hospitals), in exchange for their donation of one ventilator for each one they dedicate. Here's some "figures"....
According to the article, ventilators cost about $30,000. According to Stephen Rose's Social Stratification in the United States, at least 160,000 families have yearly incomes above $300,000 per year, and another 150,000 have annual incomes above 1 million per year. (That book was written in 2000--certainly there are more in each category after the Bush tax cuts.) If only about half of these folks opt in, we can double the number of ventilators.
I think this proposal is win-win, especially because a) there is no way for a wealthy individual to "dedicate" a ventilator now and b) the relevant decisionmaking bodies are completely opposed to auctioning access off. Sure, some people wealthy enough to buy one ventilator (but not two) will complain. But they'd have been no better off in a system where there is no allocation according to ability to pay.
Now, is this an ideal solution? Of course not--this should obviously be addressed as a collective responsibility....just as much of Europe has Tamiflu for 25% of its population, and we have stockpiles for about 2% of ours. But in an age when government is constantly made out to be the "problem," not the solution, creative responses to public health threats are essential.
PS: Kudos to Richard Posner's Catastrophe for giving us a sense of how little we realize the benefits of advance planning for situations like this. And kudos to Clifford Geertz for balancing Posner's quantitative analysis with some humanistic insight on disaster.
PS: here's a fuller account of why Williams would believe the choices to be made "unthinkable," and reject any effort to "cut the Gordian knot" of the allocation problem via bioethical standards like QALYs:
One important misunderstanding can arise fairly naturally from Williams' two famous examples [in Utilitarianism: For and Against 97-99) of “Jim”, who is told by utilitarianism to murder one Amazon Indian to prevent twenty being murdered, and “George”, who is told by utilitarianism to take a job making weapons of mass destruction, since the balance-sheet of utilities shows that if George refuses, George and his family will suffer poverty and someone else—who will do more harm than George—will take the job anyway. It is easy to think that these stories are simply another round in the familiar game of rebutting utilitarianism by counter-examples, and hence that Williams' integrity objection boils down to the straightforward inference (1) utilitarianism tells Jim to do X and George to do Y, (2) but X and Y are wrong (perhaps because they violate integrity?), so (3) utilitarianism is false. But this cannot be Williams' argument, because in fact Williams denies (2). Not only does he not claim that utilitarianism tells both Jim and George to do the wrong things. He even suggests, albeit rather grudgingly, that utilitarianism tells Jim (at least) to do the right thing. (UFA: 117: “…if (as I suppose) the utilitarian is right in this case…”) Counter-examples, then, are not the point: “If the stories of George and Jim have a resonance, it is not the sound of a principle being dented by an intuition” (WME 211). The real point, he tells us, is not “just a question of the rightness or obviousness of these answers”; “It is also a question of what sort of considerations come into finding the answer” (UFA: 99). “Over all this, or round it, and certainly at the end of it, there should have been heard ‘what do you think?’, ‘does it seem like that to you?’, ‘what if anything do you want to do with the notion of integrity?’” (WME 211).Again, despite Williams' interest in the moral category of “the unthinkable” (UFA: 92-93; cp. MSH Essay 4), it is not Williams' claim that either Jim or George, if they are (in the familiar phrase) “men of integrity”, are bound to find it literally unthinkable to work in WMD or to shoot an Indian, or will regard these actions as the sort of things that come under the ban of some absolute prohibition that holds (in Anscombe's famous phrase) whatever the consequences: “this is a much stronger position than any involved, as I have defined the issues, in the denial of consequentialism… It is perfectly consistent, and it might be thought a mark of sense, to believe, while not being a consequentialist, that there was no type of action which satisfied [the conditions for counting as morally prohibited no matter what]” (UFA: 90).[22]
from the Stanford Encyclopedia of Philosophy.
Posted by Frank Pasquale at March 13, 2006 10:00 PM
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Comments
I think you're being overly flippant about adding a 100% tax to ventilators. Why not just raise taxes across the board, rather than taxing health care?
Posted by: Adam at March 13, 2006 11:24 PM
You let the old people die first, then the sickest, then the youngest. It seems pretty simple to me.
Posted by: John at March 13, 2006 11:27 PM
John,
There's a nearly infinite number of things to tax. For example, we could tax blog postings, and use the money to buy ventilators. Then some folks could buy ventilators who could not if we tax them at 100%. That would seem superior to letting the old people die because they can afford one ventilator, but not two.
Posted by: Adam at March 14, 2006 09:42 AM
Adam, that's a very good point re taxing only health care...I actually try to address it in my piece on stem cell research...pages 117-188 of this pdf:
http://law.shu.edu/faculty/fulltime_faculty/pasquafa/pasquale_stem_cell.pdf
Posted by: Frank at March 14, 2006 09:48 AM
Please don't just cite your own papers as a response to what reads to be devastating criticisms of your blog post. Your post looks like it makes an enormous error: you tax ventilators exclusively, rather than spreading the tax in a more efficient way. If you have a response, give it. But to just link to your paper is lame. Who would bother to read your long-ish paper on this subject if your 3-paragraph summary has such a huge and obvious hole?
Posted by: Puzzled at March 14, 2006 10:14 AM
Puzzled--well, this is a blog, not a tutorial or lecture. If I were really serious about making the point, I'd direct people to Daniel Callahan's books on the topic, the extensive literature on rationing, etc. But anyway, here's the core quote:
Individuals, too, are obliged to rethink the ways they invest (directly and indirectly) in the projects of negative immortality [i.e., the indefinite evasion of death]. One strategy would be to match whatever one spends on extra-ordinary medical technologies with donations to assure that poorer people get access to ordinary medical technologies. Since the distinction between the ordinary and the extraordinary is difficult to apply in practice, a more reliable heuristic would be comparative evaluation of insurance payments. In other words, a person genuine-ly concerned about the potential of new technologies to advance inequality of life chances would try to match whatever they spent above the average on health insurance with donations to insure those without coverage.
One might object: why scrutinize health care expenditures so carefully? Even if we follow liberal theorists and accept a public duty to assure that all persons meet a certain baseline of care, why should our contribution to this goal be tied to our own health expenditures? Shouldn’t people match, say, what they spend on entertain-ment, with expenditures for the poor?
These difficult questions challenge the heuristics proposed above. Nevertheless, health care is an area in which we need to be concerned, not only with assuring everyone a certain baseline of care, but also with assuring that levels of care in general do not diverge too far from a norm. As “boutique” medical practices become more common, already existing medical resources are being allocated away from those who cannot afford them in order to provide “deluxe” care for the wealthy.
Regenerative medicine threatens to further inure the comparatively wealthy to the claims of the poorest by rendering their lives qualitatively different. Most other expenditures (such as those on entertainment) are methods of dealing with (or distracting oneself from) a common human fate of mortality. The new technologies of negative immortality are methods of escaping this fate, and thus may erode the bonds of empathy upon which the moral psychology of distributive justice is premised [unless they also help finance health care for the disadvantaged.]
Posted by: Frank at March 14, 2006 10:21 AM
Sadly, I think you just proved my point. Your response is not a response. The commenters above are telling you that we can achieve the exact same health outcomes in multiple ways: we can raise the money by taxing health care, we can raise it by taxing income, and so on. That is important because taxation has enormous efficiency implications, and we want to tax in ways that minimize those problems.
Your response doesn't speak to this issue. It seems instead to imagine that we are arguing about outcomes (how much health care to the poor, how much to the wealthy, and so on) when instead the criticisms here are about method. Why tax only one item (very very inefficient, most likely) when we can fund the same end result by taxing more strategically?
ps. Blogs aren't lectures, true; but that's no excuse for sloppy thinking. Besides, it's likely that more people read this blog than read your scholarship (or Dan's, or mine.) So we should strive to get things right.
Posted by: Puzzled at March 14, 2006 10:34 AM
Puzzled, your points are certainly economically sophisticated, but politically naive. The NYT article made it clear that this is not a priority for the government right now. In the face of government lethargy, creative private solutions are necessary. Would you be comforted if this were just done by an association of hospitals, via contracts, rather than being thought of as a "tax"? I know that's a dirty word to many...so just think of it as a contract between the hospitals and the people who buy the ventilators.
Posted by: Frank at March 14, 2006 10:54 AM
one last thought--i assume you'd defend my right to sell my house for, say, $100,000, with the requirement that the buyer also donate $100,000 to Oxfam. I don't see how this is different.
Posted by: Frank at March 14, 2006 10:57 AM
One more response, then I will let you have the last word. But your switch to contracts does not really help you. In a world with multiple suppliers of ventilator technology, anyone who in essence doubles the price of their ventilator will see sales disappear. Every potential purchaser will go buy from the supplier who is offering ventilators at the normal, lower price. Indeed, that is why taxation has to be done at the governmental level. If not, the "tax" just looks like a price increase, and competitors undercut it.
I do not mean here to beat you up, by the way. This is a great topic and a worthwhile discussion in which to engage. I do mean, however, to push you to do even better in your posts. As I say, blogs are not an excuse to drop the ball; here, you ought to be bringing sophisticated analysis to bear, albeit in engaging prose and with oh-so-pretty pictures.
Posted by: Puzzled at March 14, 2006 11:04 AM
You're free to sell your house as you like. (Although, I'll humbly suggest that you might sell it for $200,000, and donate to Oxfam yourself, perhaps getting a substantial tax benefit.)
When you suggest imposing taxes, then I am no longer free to invest my money as I see fit, and that, and further inefficiencies should be considered more carefully than what you personally choose to do.
Posted by: Adam at March 14, 2006 10:30 PM
Here is a creative solution.
This project is being worked on. The Pandemic Ventilator Project ( http://www.panvent.blogspot.com/ ) has already produced a workable prototype that can be made from readily available parts in an emergency. A second more sophisticated design that can meet the acquisition guidelines of the AARC (American Association of Respiratory Care) http://www.aarc.org/resources/vent_guidelines.pdf. is currently being developed.
This is not the first time homebuilt ventilators have been required to save lives in an epidemic. Look here to see examples of home built ventilators made in the 1940s and 50s to combat the polio epidemic.
http://www.ncl.ac.uk/nsa/vent.htm
The Pandemic Ventilator Project
http://www.panvent.blogspot.com/
Posted by: Dreamer at January 26, 2008 02:27 PM
