This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
Notes -
This is a powerful objection because it feels like an unanswerable dilemma. It conjures the image of a cold, centralized bureaucracy, a "death panel," weighing a beloved grandmother's life against a line item in a budget. The implication is that any system forced to make such a choice is morally monstrous, and that your current system, for all its faults, avoids this grim calculus.
But this assumes the alternative to an explicit line is no line at all. In reality, the American system draws lines constantly. The line is your FICO score. It is the fine print of your employer’s chosen insurance plan. It is the difference between an in-network and out-of-network hospital. You don't get to avoid the decision about grandma’s chemo, you simply outsource it to an opaque web/distributed network of insurance adjusters, hospital billing departments, and personal bankruptcy lawyers. I presume that, at some point, someone with an MD will have opinions on the matter.
The interesting thing is that the dreaded explicit system is not a hypothetical construct from a dystopian novel. It is a real, functioning, and remarkably mundane bureaucracy in places like the United Kingdom. The NHS confronts the line-drawing problem head on, not with a panel of grim-faced commissars, but with a legion of actuaries and medical ethicists, and yes, actual medical doctors at an institution called NICE, the National Institute for Health and Care Excellence.
NICE's primary tool is something called the Quality-Adjusted Life Year, or QALY. It is a straightforward, if necessarily imperfect, metric. One year of perfect health is one QALY. A year lived with a condition that reduces your quality of life by half is half a QALY. NICE then calculates the cost of a given treatment per QALY gained. As a general rule, a treatment that costs between twenty and thirty thousand pounds per QALY is considered cost-effective.
I'll run the numbers on grandma, even if I already know the answer. A $300,000 treatment (roughly £240,000) for a 60% chance at two months (0.16 years) of very low-quality life (let's generously say 0.2 QALYs) results in a cost per QALY that is astronomically high. The answer from the system is a clear, predictable no. Conversely, a treatment with the same price tag for a teenager that offers a high chance of fifty more years of healthy life would be approved without a second thought. The system is explicitly utilitarian. It prioritizes maximizing the total amount of healthy life across the population. It can and will spend millions on a child, but it will counsel a family against a futile and painful intervention for a demented octogenarian. This isn't some big secret either. I have had such discussions with dozens of families, and not a single one has had a problem with it, or withdrawn their relative to go elsewhere, as they are at full liberty to do.
For those who find this calculus unsettling (I do not know why the standard approach to handling scarce resources unsettles anyone) the system provides an escape hatch. The existence of the NHS does not preclude private medicine. The wealthy, or anyone with good private insurance, can opt out of the public queue and pay for the treatment the state has denied. You can, in effect, disagree with the state’s valuation of a life year and substitute your own. The state provides a robust, free baseline for ninety-nine percent of situations, while allowing a private market for those who want more. A similar model exists in India, a country with far fewer resources than the United States (citation available on request) which manages to provide basic care for free while supporting a thriving private sector.
The American conversation on this topic often seems stuck in a state of arrested development, terrified by the philosophical specter of a problem that other Anglosphere nations have long since downgraded to a matter of accounting. The "death panel" is not a uniquely socialist horror. It is an inescapable feature of any system that deals with scarce resources, which is to say, any system in the real world. Not even the most charitably inclined soul will spend the entirety of their nation's GDP on the cancer treatment of even the most photogenic child. Their parents might empty their bank account and go into debt to do so, but that's simultaneously their right while also not entitling them to demand infinite resources from the rest of us. The Pope might claim that all lives are priceless, but you don't see him pawning off the Vatican's paintings or his Pope Mobile to do so.
I mean, it’s a news story every few years that the pope(or secular Italian government) offers to pay for medical treatment for some very sick baby thé NHS is pulling the plug on and the organs of the British state won’t let the parents take him to it.
I keep saying I've reached the point in my Motte career where I've discussed every topic under the sun. That's true for this one.
In this specific case, assuming it's the incident from a year or two back, the child was almost guaranteed to die regardless of where they were taken. The main objection of the doctors and the government against them being taken was both that transfer would be highly expensive, and that it wouldn't make a single jot of difference other than prolonging the anguish. If you know any paediatricians, you'll know that they're the kind of people who love kids and will move heaven and earth to help them. If they're saying it's a write off, I am highly inclined to believe them.
From my own, liberatarianish position, I would have preferred the family got to try nonetheless. But there is no clear cut answer, and it was a decision made in good faith.
It seems very likely that everything you’re saying is true but thé limited NHS budget wasn’t getting stuck with the bill(thé Italian government and the pope were gonna take care of it). What this actually looks like is petty bureaucrats being thin skinned self important control freaks- again, thé NHS wasn’t being forced to treat them, wasn’t being asked to pay to treat them, was merely being asked not to prevent seeking treatment in a foreign hospital.
Charlie Gard and other related cases had nothing to do with resource allocation.
English law (and this isn't an English weirdness - for example it is the same as the Florida law the courts applied in the Terri Schiavo case) is that once there is a legitimate dispute about whether a patient with no capacity to consent should be treated or not, the courts get to determine the best interests of the patient rather than automatically deferring to the next of kin. I am not a legal historian, but my understanding is that the law ended up in this state in order to stop parents who are Jehovah's Witnesses declining blood transfusions on behalf of their kids - the whole point is the parents' religious beliefs are not imputed to the child, so the Catholic parents' belief that they should prolong life for religious reasons is irrelevant. From a secular perspective, it is not in the child's best interests to keep a moribund child alive in horrible pain in order to attempt treatments with a negligible chance of success.
This isn't a libertarian rule, but it is a perfectly reasonable one. Gard-type cases (resources available to pay for the Hail Mary treatment but the current treating doctors object sufficiently on avoidable-suffering grounds to go to court over it) are rare compared to Jehovah's Witnesses etc, so the rule is life-preserving relative to "go with the parents". And "always try to preserve life" gives the wrong answer in a large fraction of the normal run of cases where resource allocation is an issue.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
I think you've put it perfectly here. I wasn't intending to use it as a counterpoint, instead I was just interested in how they might respond. I think a QALY-based calculation is a transparent and reasonable approach, at the very least moreso than the convoluted mess we have now, but I find a lot of people will, as you say, find the calculus unsettling.
I find this particularly interesting. I suppose there are significant UK/US cultural differences in this regard, because I cannot imagine such a thing going well over here (My doctor friends told me once about Daughter from California Syndrome. I don't suppose you have an equivalent over there?).
Sadly, we do. It is a human universal, including back in India. On the contrary, the fact that there's no financial incentivefor us to "do everything" means that it's easier to say no, though I have sufficient respect for my American brethren to assume they usually manage something in the end.
More options
Context Copy link
More options
Context Copy link
You know, the American edge of this kinda stuff runs into a few issues. One is our legitimate exceptionalism, we are the superpower, we don't usually need to make compromises. That's not a completely terrible approach and for long enough that most of the people alive in the country have only experienced that....it worked.
It limits our facility with actually going through this process however.
Part of it is that people know that something can be shaved off without impairing patient care. This is probably right but nobody knows (or agrees) what it is.
Then you have American specific attributes - we are pussies when it comes to pain for instance, we are more willing to seek and use care, we are too independent, and so on.
Low societal temperament to say "yeah let some mee-maws go down if it saves a few hundred million dollars."
But yes you are right that this conversation is happening just less transparently, and at the same time if you came over here I think you'd be shocked at how much we through at things.
Is it good that we'll code a clearly dead kid for 90 minutes? Is it good that we will give homeless crack cocaine Fred the standard of care 12 times a month when he presents with psychiatric issues caused by his recreational polypharmacy?
I don't know.
I am however at times horrified and at times proud.
Better men than me have tried to grapple with cost-disease in the American healthcare system. From my perspective, it is a 'good' problem to have, if only because it proves you guys have so much fucking money that you can piss away such large sums of it without causing the system to go up in flames. Everyone gripes and kvetches, nobody seems happy, but happiness is a tall ask when lives and money are on the line.
For all the flaws of the system, it is clearly adequate, in the sense that the majority of the country is unwilling to set the rest of it on fire in a bid to fix it. I don't mean to damn with faint praise, it's not like medical systems elsewhere don't have their flaws. The "good/quick/cheap, pick two" problem has never been solved anywhere that I know of. America is like a whale, so huge that even the most aggressive cancer doesn't amount to more than a pimple.
Usually (and especially here) my angst is generated by people's frustration with physician salaries, as it's an easy target for frustration but is A (but not the) load bearing feature of the U.S. health system and angry people don't care.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link