Benjamin Studebaker

An interesting topic arose in one of my seminars today–given a scarce amount of health resources, how do we determine whom we provide care to and whom we do not? Forget for a moment the distribution of wealth, what about the distribution of health? I would like to give my answer to that question today.

Often when we talk about healthcare in philosophy, years are used as a substitute for the welfare comparisons made when we examine justice in other contexts. Many of the same guiding principles again see play, including prioritarianism, sufficientarianism, and utilitarianism. Reading the linked post will provide a background to those concepts if the reader has not encountered them previously. When trying to illustrate these principles, we usually look at two potential people in differing health scenarios and use said principles to determine which individual should be saved given conditions of scarcity. So, for instance:

A prioritarian might argue that we should prioritise the welfare of the worst off. Carl dies the earliest in this scenario; he is the worst off. Therefore, the prioritarian saves Carl.

The sufficientarian might argue that everyone deserves to live at least a minimum number of years. If that minimum were set above 20, the sufficientarian would help Carl. If it were set below 20, the sufficientarian would be indifferent.

The utilitarian might argue that because more years of life are saved when Paul is saved, the total aggregate health of the population rises more if Paul is saved, and consequently saves Paul.

There are no healthcare egalitarians, because a true egalitarian would not only seek to help those dying early, he would seek to kill those living extraordinarily long. After all, doing especially well is as detrimental to the equality value as doing especially poorly is.

I do however think that there is a problem with applying the same theoretical framework used to evaluate welfare states over to healthcare, namely that it makes a false equivalency between longevity and well-being. How are years not equivalent to welfare?

1. Two people can live for the same length of time but derive different amounts of welfare from said time–length of life does not indicate quality of life.
2. The welfare measurement takes into account all effects on welfare socially; the year measurement only looks at how long the specific person receiving the care lives.

Often the first objection is simplified away for practical reasons. We cannot know when we are deciding who should be treated what sort of life the specific individual will live and whether that individual will find that time fruitful. Then again, we also cannot know for certain how long said individual will live in the first place either, so the entire premise of the measurement–comparing the number of additional years added–is somewhat preposterous. When we decide who to treat and who not to treat, we typically do not know how long the individuals will live or to what degree the added time will be enjoyed, though actuaries can guess and generalise about the former.

This brings us to the second objection–this entire discussion is too focused on the welfare of the healthcare recipient. We do not provide healthcare only for the purpose of benefiting the recipients. The welfare gain for the recipient is actually relatively trivial. If you live an additional 10 years, you are not the only one who benefits. Assuming that you are a productive person employed to good purpose, those 10 years of work provide society with tax money and with whatever benefits your employment provides. If you are a doctor, 10 years might allow you to save many additional lives. If you are a scientist, it might allow you to make additional helpful discoveries, and so on down the line. Perhaps instead of basing our decision on what the recipient gets out of the healthcare, we should examine instead what the rest of society, the people paying for the healthcare in the first place, are likely to get.

Conceive of the entire socio-economic organism as a giant happiness machine. Each citizen is a part of this machine and performs a function augmenting this machine’s output. The state is the operator of this machine, and the writings of the various political theorists and philosophers represent the instruction manual that nobody ever reads. The various individuals in society, the parts of the machine, will eventually wear out and need to be replaced. You can forestall replacing them for a time however by performing basic maintenance–providing healthcare. However, you have conditions of scarcity and cannot maintain all the parts. You must choose some to maintain at the expense of others. It would be senseless to choose to maintain parts simply because they were newer or because you could get more years of functionality our of some parts than others with the same amount of maintenance. That would oversimplify the question. What you’d really be concerned with are these factors:

1. How essential is this part to the efficient functioning of the machine? What is this part’s happiness output?
2. How replaceable is this part? Are there other parts being made like this one?

When we decide to whom we should provide healthcare, we should not reflexively choose the youngest people or those who will live the longest with the care, we should choose those that are the most helpful and beneficial to the rest of us, those of us who are paying the healthcare cost. The right utility equation is one that measures the collective social result, not merely the result for the individuals. The utility provided by adding years to a person’s life comes not nearly so much in the years and pleasures themselves as in the wider social benefit for all. If you’ll allow me to indulge in a pop culture example to illustrate the point:

Here we have two individuals, one of which does an exceptional amount of good, Spock, and the other of which does comparatively much less, the red shirt. Both are in need of medical care from a doctor–let’s call the doctor “McCoy”. McCoy, unfortunately, is only one man, and he only has time to save one of the two patients. McCoy can add five times as many years to the red shirt’s life as he can to Spock’s, but, nonetheless, Spock is a very morally gifted individual and does ten times the good to wider society each year as that done by the red shirt. As a result, McCoy has good reason to save Spock. It is important to note, however, that this has nothing to do with the utility Spock derives from living the additional year. As any viewer of Star Trek knows, Spock is incapable of emotion and will not enjoy his added year at all to speak of. For the sake of argument, let’s say that this particular red shirt is a hedonist with a love of life–that still does not countervail the far more important fact that Spock will do lots of good to other people outside himself with his added time, even if he does not enjoy a second of it, than our red shirt will.

When we look at healthcare, we need to look not at the individual recipients, but at wider society, to see what the potential is that these recipients will use their added time to help others. After all, what was that one line about the needs of the many?