Excerpts From the New York Times Magazine Section (July 15, 2009):
Why We Must Ration Health Care
By Peter Singer
...The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?...
...If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades...
...When a Washington Post journalist asked Daniel Zemel, a Washington rabbi, what he thought about federal agencies putting a dollar value on human life, the rabbi cited a Jewish teaching explaining that if you put one human life on one side of a scale, and you put the rest of the world on the other side, the scale is balanced equally. Perhaps that is how those who resist health care rationing think. But we already put a dollar value on human life. If the Department of Transportation, for example, followed rabbinical teachings it would exhaust its entire budget on road safety. Fortunately the department sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million. Other government agencies do the same...
...multiplying what we would pay to reduce the risk of death by the reduction in risk lends an apparent mathematical precision to the outcome of the calculation — the supposed value of a human life — that our intuitive responses to the questions cannot support. Nevertheless this approach to setting a value on a human life is at least closer to what we really believe — and to what we should believe — than dramatic pronouncements about the infinite value of every human life, or the suggestion that we cannot distinguish between the value of a single human life and the value of a million human lives, or even of the rest of the world. Though such feel-good claims may have some symbolic value in particular circumstances, to take them seriously and apply them — for instance, by leaving it to chance whether we save one life or a billion — would be deeply unethical...
...the benefits may vary in ways that defy straightforward comparison. We need a common unit for measuring the goods achieved by health care. Since we are talking about comparing different goods, the choice of unit is not merely a scientific or economic question but an ethical one.
As a first take, we might say that the good achieved by health care is the number of lives saved. But that is too crude. The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved... It’s easy to say, “What if the teenager is a violent criminal and the 85-year-old is still working productively?” But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.
...How can we compare saving a person’s life with, say, making it possible for someone who was confined to bed to return to an active life? ...One common method is to describe medical conditions to people — let’s say being a quadriplegic — and tell them that they can choose between 10 years in that condition or some smaller number of years without it. If most would prefer, say, 10 years as a quadriplegic to 4 years of nondisabled life, but would choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life or 10 years with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life...restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.
This is the basis of the quality-adjusted life-year, or QALY...
Some will object that this discriminates against people with disabilities. If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics. That clashes with the idea that all human lives are of equal value. The problem, however, does not lie with the concept of the quality-adjusted life-year, but with the judgment that, if faced with 10 years as a quadriplegic, one would prefer a shorter lifespan without a disability. Disability advocates might argue that such judgments, made by people without disabilities, merely reflect the ignorance and prejudice of people without disabilities when they think about people with disabilities. We should, they will very reasonably say, ask quadriplegics themselves to evaluate life with quadriplegia. If we do that, and we find that quadriplegics would not give up even one year of life as a quadriplegic in order to have their disability cured, then the QALY method does not justify giving preference to procedures that extend the lives of people without disabilities over procedures that extend the lives of people with disabilities.
This method of preserving our belief that everyone has an equal right to life is, however, a double-edged sword. If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it. That implication, no doubt, would have been vigorously rejected by someone like Christopher Reeve, who, after being paralyzed in an accident, campaigned for more research into ways of overcoming spinal-cord injuries. Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition...
...The QALY approach does not even try to measure the benefits that health care brings in addition to the improvement in health itself. Emotionally, we feel that the fact that Jack Rosser is the father of a young child makes a difference to the importance of extending his life, but his parental status is irrelevant to a QALY assessment of the health care gains that Sutent would bring him. Whether decisions about allocating health care resources should take such personal circumstances into account isn’t easy to decide. Not to do so makes the standard inflexible, but taking personal factors into account increases the scope for subjective — and prejudiced — judgments...
Comment Below: I think this one speaks for itself, but I look forward to the inevitable comments.
I have two blog entries on the Singer essay:
http://notdeadyetnewscommentary.blogspot.com/2009/07/peter-singer-in-ny-times-disabled-lives.html
This entry includes additional comments on Singer and links to other bloggers writing about the essay:
http://notdeadyetnewscommentary.blogspot.com/2009/07/singer-plagiarizing-jerry-lewis-and.html
Posted by: Stephen Drake | July 21, 2009 at 10:45 AM
Dear Pete Singer, Your lack of sensitivity is your greatest disablity. It by far exceeds any physical or mental one. I take great pity on you. ~
Posted by: diora | July 21, 2009 at 01:13 PM
In my case, I've was labeled "disabled" without my permission, in fact I was trying to stop this NONSENSE. Yes, we are spending incountable amounts with NONSENSE. But NO, the government, in it's immense stupidity, would rather pay YOUR dollars ($85,000/yr) to institutionalize me, instead of finding a way to look at me. If we can stop and listen, instead of the horrid, ugly, evil voices that are heard by the media, the government, the employers, and insipid writers like this, we could ALL live in a productive way.
This is stance is so ugly, it's like saying we don't have enough food to feed everyone. I think we all know that that is stupidity. We have enough food, we have enough jobs, we have enough air, but when we are allowed to give space in a "disability" website to read sad, pathetic "solutions" we are ALL HURTING FOREVER!!!
Shame on this writer, shame on the New York Times, shame on this website!
AGAIN, COULD SOMEONE IN THIS "ADVOCACY" WEBSITE GET OFF OF HIS/HER MENTAL DERRIERE AND COMMUNICATE WITH ME!!! (You have my e-mail address). MY SITUATION IS DESPERATE AND IMMEDIATE AND I NEED AN DISABLED ADVOCATE (not a government advocate), IF THIS WEBSITE IS NOT JUST MORE SMOKE AND MIRRORS PUBLISHED BY THE GOVERNMENT TO KILL ALL OF US!
Posted by: Ralph | July 21, 2009 at 07:15 PM
Some of us, an ostracized few because of, have been trying very hard for quite some time to bring a number of particularly related things to people's attention.. It's been very lonely..
The White House :: They must be held accountable.. They, at this point, are now *openly* allowing this to happen.. For example, where is Kareem Dale's *public* outrage at, denouncement of the Peter Singers of the World..?????
To this Keyboard, it comes as no accident that people with disabilities are being left conveniently warehoused where they can be, well, controlled just when *so many* are becoming so beautifully empowered, especially the last few years..
It is my not-so-Humble-O that it's time to hit this hard for the Segregation topic that the [White House's] institutional bias can't help but be called, the *exact* same way that other minorities have done in the past.. Am feeling pretty safe in saying that those committing that travesty against PWDs' civil rights will start paying "just a little beet more" attention then..
Warmest wishes from Talking Rock..
PS.. :waving: to Stephen.. MY HERO..! :))
Posted by: Cindy Sue Causey | July 21, 2009 at 08:24 PM
My elderly mother was put on life support for pneumonia in 1998, 2000 and 2002. She passed away peacefully in 2004, in her own bed, at the age of 94. If health care had been rationed for the elderly who were seriously ill, she would have died in 1998. She would have been robbed of 6 good years of her life. She was in fairly good health both physically and mentally at the end. How on earth can someone say an older person's life is not valuable, and health care for them should be rationed. That is totally inhumane, and a very sick way of thinking. Perhaps, people with such apathy for the elderly, will feel a bit differently when they become a senior citizen. Suddenly, an older persons life will be viewed as valuable, after all. And perhaps, it will be too late, and senior life will be cut short due to health care rationing.
Posted by: Donnie | July 21, 2009 at 11:38 PM
The problem is NOT TOO MANY PEOPLE IN NEED HEALTH CARE!
The real problems: Mismanagement and lack of health insurance!
People who are too poor to have an ongoing relationship with a "family doctor" line up in emergency rooms among people who had an accident. This is not good diagnostic care, has minimal follow up, so the same poor person arrives again in the emergency room for a treatable illness that should have been resolved up front.
Another problem is lack of communication among physicians and patients. Several doctors run almost identical tests in short succession. These could be spaced according to genuine medical need.
Lack of knowledge about good health maintenance and sound nutrition causes wide spread treatable conditions like obesity and lack of muscle strength. Consequence: An even greater need for medical intervention.
Then of course there is obvious warehousing of older or disabled human beings in residential settings. We need to build accessible apartments and/or houses where medically fragile people can reside. Combined with some household help and attendant care the cost is much cheaper than publicly subsidized residential facilities.
As a society we need to have the will to do what is necessary for ourselves and our peers!
Posted by: Elisabeth Ellenbogen | July 22, 2009 at 10:18 AM
All I have to say is-- These are not the articles we should be focusing on this national network for disability advocates. I am ashamed to call myself part of the disability community for taking part in complaining about such minor things as this mans piece of academic work. He is writing a black and white Cost Benefit Analysis where you have to make dicey calls in order to give yourself numerical values to work with. None of you obviously know anything about Economics if you are insecure enough to take offense to a piece of writing. Maybe instead of attacking everyone else-- we should look at his arguments as a way for us to become stronger. He makes a good debate don't you think? If there are so many people out there who are actively searching for cures for their disabilities- doesnt that give you the impression that they feel their lives are less good with the disability than it was without it? Maybe we should be talking to these people and giving them some disability pride workshops rather than pointing fingers at the man who merely pointed it out to us.
Posted by: Reality Check | July 22, 2009 at 11:06 AM
and how are they going to pay for all of this "healthcare for all? By forcing young people to pay in for health care they don't want to buy and don't need. Should't you have the right to only buy the insurance you need? This is just going to become like Social Seucrity. A big Ponzi scheme where they collect the money and the first ones in will get coverage and then it will start running out and they will have to go into borrowing to cover it and how much longer will the Chinese buy US treasuries?
Haha. You can't let the govt run anything!!!
Posted by: John Smith | July 23, 2009 at 02:32 AM
Peter Singer would have fit perfectly in Hitler's Germany. He and his utilitarian bioethicist colleagues are a pox on humanity.
From Dean Koontz: "Utilitarian bioetchics as portrayed in One Door Away From Heaven is unfortunately not a figment of my imagination, but a real threat to you and to everyone you love. This philosophy embodies the antihuman essence of fascism, expresses the contempt for individual freedom and for the disabled and the frail that has in the past marked every form of totalitarianism. One day our great universities will be required to redeem themselves from the shame of having honored and promulgated ethicists who would excuse and facilitate the killing of the disabled, the weak, and the elderly."
Mr. Koontz is a far more eloquent writer than myself. He is, by no means, an alarmist. 'Nuff said.
Posted by: Michael | July 26, 2009 at 02:42 AM
What we think about Health Care Reform
This recent New York Times article says "some form of health care rationing is both inescapable and desireable..."some will object that this discriminates against people with disabilities. If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends..."
Yes, read that again. I'm especially fond of ...."a year with quadriplegia is valued at only half as much as a year without it." If this is the "valuable" health care rationing which is "desirable" where will it end? I am appalled. After decades of hard-fought gains where disabled people have moved out of the shadows to make huge gains in employment, accessibility and power, we are being told that when it comes down to the basics of the value of life, the disabled person is less valuable and therefore will not be given the same level of beneifits a non-disabled person might be afforded.
Yet, people with disabilities are overwhelmingly backing President Obama's new health-care reform efforts. And surprisingly, those I have talked to are not exactly chasing down the details on the 1,000 page bill that was signed in the House of Representatives without so much as a thorough read-through.
Is ANY change a positive change? I don't think we can come even close to saying that. Health care change needs to be critically examined, and thoughtfully enacted. it needs to have the input of the entire community. I cannot even imagine a system which insitutes some kind of sliding scale that places a Third Reichian value on a human life. That's not the America I live in. God, I hope it never is.
-Nancy Cotterill,
Editor People On Wheels
Posted by: Nancy Cotterill | August 06, 2009 at 10:35 PM
I'm severely disabled but I'd sure like to come eye to eye with this **** and show him my worth!
Posted by: Sherrie F. Eugene, Oregon | August 07, 2009 at 12:33 AM
In this day and age, I cannot begin to relate to the ignorant and unrealistic rationale used here.
How do people come up with such ludicrous thoughts, perceptions and concepts?
I am all for freedom of thought, freedom of speech and expression of such - but geez! Sometimes it is better to keep your mouth closed!
Posted by: NC disability advocate | August 07, 2009 at 12:03 PM
Jesus was the first example God sent to save
everyone 'by becoming one of them'. Ignorant
individuals who cannot see the advantages of
what can be gained has the blind leading the
blind indeed. One who has been in the trial
and tribulation involved with being disabled
has so much of an advantage to better human
potential. Perhaps it is the opposite, and
we should deny care to those who have never
had any adversities. We'd all benefit from a more compassionate society and all happier
people who appreciate their good fortune! :)
Posted by: Patricia Banks BMsc | August 07, 2009 at 06:04 PM
Under Singer's Schema, do we value the life of a quadriplegic veteran higher than we would a quadriplegic high school dropout or college professor? In Singer's world, who draws the line, and where is it drawn? I have had a disability my entire life, and a more significant physical disability for the last 32 years (two thirds of my life). In the first 16 years, I was not what Singer would define as a contributing member of society, although I had the potential to become a contributing member of society. Since my injury at 16, I have graduated from high school, obtained a University degree, married, bought a house (and countlerss other consumer goods) and become a taxpayer. By nearly any definition, a "contributing member of society." Yet under the guise of Utilitarian Bioethics, I am defined as a "non-contributing member of society" merely because I have a disability. Health care rationing is already happenning in the United States by pricing it beyond the means of a significant percentage of the population; even those with health care are often unable to obtain necessary pieces of assistive technology, because insurers hold that a device is "not medically necessary," or is a "luxury." I am presently attempting to purchase (through my insurance provider), a wheelchair that would not only improve my overall health, but make it safer to perform many activities of daily living
Posted by: Kendall Corbett | August 07, 2009 at 06:31 PM
When the organized disabilities community....and that includes the organization that runs this website, refuses to take seriously committed activists like myself who are taking on both the feds and Congress right now, along with one of the Mayors of the biggest cities in the country right now, what can you expect? It's time for us to fight like hell, not say "thanks for the breadcrumbs" which the Democrats are going to give us and in fact already have. For those of you fed up with the "compromise" and "diplomacy" of Washington based groups who are really no better than those they criticize (I have worked in DC for more than a decade and the Beltway mentality is like poison) then please get in touch. I need to build a grassroots coalition ready to go kick some ass. And we have the perfect opportunity to do it.
For those who do not see my name and address below on this link, check out my website, soon to be moved to a self hosted site for maximum flexibiity and real webcount, but its getting attention, as is my plan for economic development, jobs, healthcare and housing.
The White House doesn't intimidate me. I kicked their asses when I was 27. This one is easy, it's just that the disabilities community is so downtrodden it doesn't know how to play power politics and does things like calling a meeting with a junior white house staffer "historic" which is BS.
The White House website isn't even 508 compliant. Trust me, they just walked into a gunfight with a knife. And I've got (figuratively speaking of course) an army of machine guns.
Posted by: Marguerite Arnold | August 07, 2009 at 08:15 PM
this article is discusting shame on the writer, shame on the new york times for posting this discusting article. this article should not have been posted.
Posted by: lauren | August 07, 2009 at 08:48 PM
As Dr. Singer explains and justifies this process, " Some will object that this discriminates against people with disabilities. If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics" does he also feel the mentally ill or genetically unbalanced are not deserving of life?
Peter Singer, one of the most controversial figures in our nation, is equating a value on any life. It could be said Singer, a man with no faith in a higher power, could possibly be considered a eugenicist. I recall a regime in Germany that was tried for war crimes against humanity for these very same action's he is calling for and advoacating.
It's obvious that heir singer, does not believe in god at all. When a society is allowed to make judgments that life is not worth living, it shows that the society calling for these practices is doomed to fail and is in decline. Rome and NAZI germany, both states engrained in facist thought failed. Perhaps, singer should be considered a real war criminal and by thought guilty of war crimes against humanity?
Where is justice singer?
Posted by: Philip Kirschner | August 08, 2009 at 12:50 PM
What do you mean, we have to ration health care, Mr. Singer?
We already are rationing health care.
Those who can afford it get it.
Those who can't don't.
If that's not rationing, I don't know what is!
30,000 people a year die prematurely because they are overtreated for their generous dollars.
20,000 more die because they suffer from treatable but neglected conditions as a result of no health insurance!
That's 50,000 every year.
Almost Vietnam every year.
We have rationed health care such that there is overtreatment and undertreatment.
Posted by: E.I. Burns | August 08, 2009 at 04:32 PM
Marguerite - where have you (or I) been?? And why do the JFA folks, Marca Bristo's, of the "disability community" not have your info out in front? I just spent too much time reading your stuff and am thrilled to find another p/w/d who is not being sucked in by the lies of this administration. If you need my "gun" lemeno.
Ric
Posted by: Ric Edwards | August 08, 2009 at 04:33 PM
Aw Ric, the never-ending story and growth of that long pointy finger is getting so repetitiously old already! We may be persons with disabilities here but WE are NOT stupid! Exactly who is it that YOU and Marguerite think you are kidding to insult others with shoddy attempts at trying to only stroke your own selves here anyway?
Posted by: Sherrie F. Eugene, Oregon | August 08, 2009 at 09:54 PM