Patients ARE Consumers...Except When They Aren't

Do you shop the health care the way you shop for, say, a new mattress? Well, in the case of the unfortunate patient to the left, probably not. There are plenty of situations where medical care is an urgent case of life-and-death, not a consumer choice. But there are also many situations where our purchasing decisions are made with the same cognitive tools that we use to choose any other service or object.

Paul Krugman disagrees. In a column last week, Krugman resoundingly declared that patients are not consumers...that was even the headline if his point was in doubt. Let's look at his argument in a bit more detail:

Here’s my question: How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.

Certainly that vision of the medical experience as somehow removed from the normal way we buy is appealing: it's nice to think we will be taken care of without any consideration of our wealth or even our personal decision-making: just put yourself in the hands of your physician and all will be well.

But Krugman acknowledges, a few paragraphs later, that we're only having this conversation because of the current political moment, where people on both sides of the aisle are trying to figure out how we can afford our entitlement programs without bankrupting the country. So, at some point, money is going to come into the picture as a factor. And that's where the idea of talking about patients as consumers comes into play. The conservative theory is that bringing consumer-like behavior to health care (in other words, letting individuals try to go out and get the best value for their dollar) will slow the exploding health care costs that are hamstringing our economy. Referring to patients as consumers is not to minimize the emotional, human aspects of medical care, but to describe a certain rational, value-seeking behavior that conservatives hope to bring to the industry.

Krugman doesn't think patients can be wise consumers of health care. But he is dramatically oversimplifying. The trauma patient in the picture up top is not a consumer: he's not going to come back to consciousness to demand the ambulance drive him over to Memorial Hospital, where they charge 10% less for blood transfusions. But a patient with diabetes, dealing with a chronic condition, is going to make dozens, if not hundreds, of consumer-ish decisions about what drugs to take, what physicians to see, and which diet plans to attempt. If they were more personally responsible for those economic decisions, they would (in the aggregate) make better decisions about how to balance cost and care quality.

That's why it makes sense to move towards a system where the costs of catastrophic care (like traumatic injuries or heart attacks) are socialized to some degree, but to expect individuals (either on their own or through private insurance) to cover the costs of chronic care, physicals, and the like.

We want to believe there's a way to treat everyone "fairly", but what we really mean is that we don't want to hear tragic tales of system failure that make us sad for the victim and nervous for ourselves. We want to believe we and our loved ones and, perhaps, "the deserving" will always be cared for. And that we don't have to make tradeoffs between how good our care is and how much it costs. But we do. We can either wash our hands of the decision and ask the government to decide, for all except for the most wealthy, who gets what care, or we can embrace our role as consumers and make the best decisions we can for ourselves and our families.

Greed, Sex and Public Morality

Republicans, according to stereotype, are overly concerned with what other people do with their bodies, while Democrats are overly concerned with what other people do with their money. So it was interesting, and unexpected, to read an article encouraging a renewed aversion to greed in the latest issue of First Things magazine, which decidedly falls on the conservative side of the spectrum. It forced me to reconsider some basic assumptions I have made about wealth, capitalism, and morality.

The author of the piece, Edward Skidelsky, argues that our elites have lost the traditional, still-popular view that there is something wrong with being greedy, that it is an essentially disordered, wicked activity. This notion, which your average modern economist might dismiss as juvenile, has a rich heritage. As Skidelsky puts it:

Explanation of this point requires a brief excursus into Aquinas’ theory of acts and ends. An act, for Aquinas, has two ends: one “proximate,” which is what makes it the kind of act it is, the other “ultimate,” which is what the agent aims at in acting. If either end is bad, the act as a whole is bad. A good ultimate end cannot redeem a bad proximate end; thieving to help the poor is still thieving.

He goes on to say that most thinkers in western history, up until the Enlightenment, took it as a given that trying to accumulate more money or things than you needed is wrong, no matter if it leads to good things happening. But one of the views of the Enlightenment was the economic view of man, the belief that our wealth-building activities enhance human progress as a whole. Skidelsky notes:

This transformation of attitudes to wealth creation cleared the ground for the new science of political economy. Having been demoralized, so to speak, economic acts became open to analysis and assessment in terms of their effects, intended or otherwise. They could enter into a calculus. It now made sense to ask, for instance, whether it might not be more beneficial in the long run to let corn prices fluctuate freely, even in a famine, than to regulate them—a question that could not have been decently posed when the duty to feed the poor was regarded as absolute. Without this prior demoralization of economic activity, [Adam] Smith’s enterprise would have been unthinkable. Aquinas, for instance, would have regarded it as akin to an earnest discussion of the benefits of cutting up a hospital patient and distributing his organs among others.

Now, I have accepted uncritically that the best way to improve the well-being of all is to allow individuals to pursue their own self-interest. And I don't see how you can renounce that principle without setting some group (whether the command-and-control planners of the Soviet Union or the divine-rights kings of old Europe or some body of clerics) as the arbiters of what is allowed and what is forbidden. But do we need to promote the idea of material success as a complete good? is there room for guilt about greed in a capitalistic society?

I struggled with these thoughts for a little while, but then was absorbed in another First Things article, I began another, this time "Religion, Reason and Same-Sex Marriage" by Matthew J Franck. In this piece, Franck expands on an earlier article where he argued that anti-gay marriage arguments are not based solely on irrational bias and have a place in the public debate. I have outlined my position on gay marriage on the blog in the past: namely, that we have gone so far away from the traditional sense of marriage already, and it makes so little sense for the state to license romantic companionship, that we ought to eliminate civil marriage entirely. Franck, as you might imagine, takes a different view:

Yet another danger may await us in the event that traditional views of sexual morality are overthrown and same-sex marriage is established. We see a sign of it in the driving of Catholic Charities out of adoption services in Massachusetts. The freedom to participate fully in civic life, to offer oneself to others in civil society, conscientiously on one’s own terms as a religious person professing one’s beliefs, may be jeopardized by this new dispensation.

Franck, along with many other observers, thinks the adoption of gay marriage and the host of cultural assumptions that go along with it will push Christians out of public life. This may be possible in the long term, though it is unlikely to happen any time soon in a majority-Christian nation.

So, to recap: we have two articles. One is about the ubiquity of greed in our society and of the need to curtail it, and one is a reaction to the legal advance of gay marriage. What do they have in common? In my view, both authors commit the fallacy of equating laws and government action with public morality as a whole. Look at this quote from Skidelsky:

Democratic states use economic incentives all the time to encourage motives and ways of life considered to be civilized. They limit hours of work, restrict or forbid Sunday trading, regulate where and how advertisers may operate. In a utilitarian political culture, such legislation is usually justified on grounds of economic efficiency or “health and safety,” but its unacknowledged motive is ethical. These states wish to erect safeguards against the powerful human tendency to rapacity.

If we acknowledged the legitimacy of such motives, we might think of many further ways in which the power of the state could be harnessed to discourage avarice. Of course, such proposals will encounter the objection of “paternalism,” but there is nothing inherently paternalistic about a citizen body collectively deciding to encourage certain forms of life and discourage others.

It's true that society's laws are an important benchmark of what is acceptable and what isn't, but they are far from the only ones. The culture of a society can be an equally powerful force in shaping behavior, and yet both Skidelsky and Franck are primarily concerned with whether the law advances or challenges their beliefs about the well-ordered life.

It is probably easier to change the laws to reflect the kind of society you want than to change the culture, but I would argue that a truly Christian response to the problems of materialistic greed and sexual amorality are to build up a virtuous alternative in Christian communities, prove the superiority of that way of life and then share it with others. This may be a libertarian point of view that borders on the naive, but the law that supports our beliefs on Monday may change to oppose them by Friday. (This is, in fact, what is happening with marriage laws.) If we can encourage a truly neutral state in matters of morality and culture (which I admit is a high challenge itself) than Christians should be confident that living out their beliefs will show others a better way. Public morality should be built (and renewed) from the ground up by moral individuals, not imposed from the top down by the state.

Building Authorial Brands

After a few years on the outside looking in at the publishing industry, I have to admit I am flummoxed: why does it seem so hard for authors to take advantage of the new technologies out there to build their careers? Why does the publishing industry view digital technology as a threat instead of an opportunity? And how come books are more like wine and less like whiskey?

Ok, let me start with the last one, first. I drink both wine and whiskey. (I'm surprised my wife doesn't come out of her dead sleep right now to shout, "and too much of both!") I have been enjoying wine since a trip to Italy in 2004. Whiskey is a more recent hobby, something I've only been trying for the last two years. And yet I feel much more comfortable picking out a bottle of unfamiliar whiskey than a wine I've never tried before. Why?

It's simply because whiskey operates under a few relatively simple rules that help me to categorize it and find what I like: it could be scotch or bourbon or rye. If I want a scotch, I could go for a single malt or a blend, and know exactly what I'm getting. There are a few simple descriptors that give me a good sense of what I'm getting. Wine, on the other hand, seems endlessly complex, and thus remains intimidating. Books are the same way: other than the broad categories like 'romance' or 'fantasy', what guide is there to help me try a new author on a whim? No, you have to do research: read reviews, ask friends, what have you. One would think modern technology would help with this, but not really. (I will say that Amazon's recommendations are a step in the right direction, but unless you buy a lot they seem wildly speculative.)

Let me offer one example relevant to my efforts as a struggling writer of science fiction. The magazine I spend the most time with is Asimov's, which I'd say has a 50% 'hit rate' for me: 50% of what they publish, I like. I consider that pretty good. And yet I have not bought a book on the basis of those stories, though many of the authors have books out, and many are published repeatedly so I have a good sample of their work. And that's mostly because the magazine makes no effort to encourage that behavior, and neither do the writers, other than putting a bio at the beginning of their stories. Why isn't Asimov's looking to actively promote some writers, and have a stake in their success? Why don't they seem much interested in promoting a specific "Asimov's Style" that would reliably please readers and build a more consistent brand experience? As it exists, the magazine (and all the others I've found in the fiction world) seem to exist as a checkpoint for writers looking to get along to a book contract, where they will start from scratch in building their audience.

There is an opportunity for writers, magazines and book publishers to form an alliance that would serve all parties. But each group should be looking to build a more reliable, recognizable brand that consumers can trust. If they do, the electronic world we are entering will offer rich opportunities and many satisfied (and paying) readers for all sides. If not, we'll continue to hear whining about the decline of publishing.

Reflections on the iPad

I'm writing this on my sad old desktop computer because I haven't found just the right blogging app on my iPad yet. But I'm sure I will, and then happily abandon this annoying large screen and convenient full-sized keyboard. No, I'll be able to peck out these ramblings from anywhere!

For the last two weeks or so, I have in fact been glued to my new iPad. In fact, I'll probably be reading on it as soon as I'm done here. So obviously I love the darn thing. But why? 90% of the time I use it, I'm within 30 feet of a computer. Typing is undoubtedly slower, although I do have a wireless keyboard I can use with it. The games are good, but I have more advanced games on my Wii and the desktop. It doesn't add any major capability that some other device in my life doesn't have.

But, unless I'm completely irrational (no comments, please), there must be something that has driven me to spend hours a day with the darn thing. So here are three bits of speculation on why the iPad has wormed its way so deeply into my life, and the psychological drivers that have made it so popular.

1) Casualness: Nothing about the iPad feels like work, even when I'm doing something like capturing notes. The ability to pick it up and put it down, to switch to some other task, to close its cover like a book, all give it a less formal feel than plunking away at a laptop. Its weight and size also allow me to take it more places, allowing me to spontaneously use it when I have a need (or a free moment).

2) Bite-sized-ness: Everything feels stripped down and simple, and that translates in part to making it feel like you're not making a big time commitment when you start using any particular application. I can waste hours on a game, but it is not some elaborate epic that requires my whole engagement for long stretches. The successful games offer relatively quick levels or challenges that are almost endlessly repeatable, so each "five minutes" leads into the next, and soon you've lost an hour.

3) Utilitarianism: The iPad is a newspaper, a web browser, a video game console, a camera, an video phone, a notepad, a GPS, a TV, and a bunch of other things besides. People, and men in particular, like feeling that they have s tool for every need. The iPad is an electronic Swiss Army knife.

I'm sure there are other reasons people fall for the iPad, but those are the three that are most important to me. It is a transformative technology that sits at the intersections of productivity and entertainment, of simplicity and power, and of phone and computer. As these devices continue to advance, we will see more and more people experiencing the virtues of having so much of your life always at hand.

Follow Up on the Impact of Church Buildings

Earlier this week, I wrote on the difficulty the Catholic Church has in both spreading the Gospel and maintaining its aging, underutilized buildings. I contend that this is a major problem for the Church in the 21st Century. It needs to adapt to new circumstances, not continue to operate under the assumption that its buildings are the central gathering places of its communities.

Well, count on Walter Russell Mead, my favorite blogger, to point out a useful and instructive contrast:

Historically, the Pentecostal churches in the United States as elsewhere are strongly rooted among the poor. In the favelas of Brazil, the “informal settlements” of South Africa and in the squalid slums surrounding emerging megacities like Nairobi and Lagos, as well as in America’s inner cities, Pentecostal churches, many in storefronts, are often the most active, the fastest growing, and the most connected to the aspirations and the needs of the communities they serve.

Mead is making a larger point that populations afflicted by multi-generational poverty need more than government-subsidized welfare, they need faith (or something equally as powerful and motivational) to change the essence of their lives. In passing, he mentions the effectiveness of Pentecostal churches in accomplishing this mission, noting that they often set themselves up in humble storefronts.

But think about the flexibility and persuasive power that approach entails. First, a Pentecostal church can spring up wherever there is demand, because it will not wait for a formal building to be constructed. It could be sandwiched between the corner deli and the laundromat, but it is there and can have a presence. Second, this church will have low overhead, allowing it to spend the donations it gets towards good works and outreach, not maintenance and utilities. Finally, the humble surroundings likely resonate better with the community and the times than an elaborate structure. The ostentation of a Catholic church, meant to inspire and attract, can seem quite out of touch.

No one knows where the faithful will live in a decade or a century. Mobile populations call for churches that go where the believers (and the needy) are.

A Brief Bit of Self-Promotion

I'm proud to announce the first step has been taken on a path that will undoubtedly have me joining the ranks of the Bard himself as a colossus of English letters. That step comes courtesy of Necon E-Books, which has seen fit to publish one of my (very) short stories as a winner of their March flash fiction contest, and will also include it in their end-of-year anthology.

If you have a second, definitely go check them out. My story took its inspiration from the idea that some of the large computing networks we are creating are for shockingly trivial, and even anti-social, activities. Readers of this blog may also enjoy another story featured: "HEALTH CARE 2016", by Jan Kozlowski. It offers a humorous yet vivid take on where our desire to cut costs in the health system could take us.

Enjoy, and any feedback on the piece is welcome in the comment section.

How Churches Kill the Church

This is my church, St. Agnes. I love it. If I move away from Brooklyn, it will be one of the things I miss most. However, I also know that it is an albatross around the neck of the Church, that is the Roman Catholic faith to which it is such a beautiful monument.

This past week was the kickoff of the annual appeal that the Diocese of Brooklyn conducts to raise funds. After the homily, the lights went down and we saw a video outlining all the good things the diocese will do with our money if we give it to them. Then, after the video was concluded, our priest reminded us that the majority of what we give will come back to the parish and go towards maintaining the building.

In that moment, it occurred to me why the Catholic Church feels so weak and passive: parish priests have been turned into caretakers for massive, under-peopled buildings like St. Agnes. Their minds are full of the latest contractor's estimates, fundraising plans, worries about the state of the roof, and heating bills. This seems to leave remarkably little time for instruction and evangelization. Heck, we're lucky they still have the time and energy to say mass.

And what about the parishioners? Their plight is summed up by the annual appeal: asked to sit back and watch as folks from a diocesan office provide things like 'immigration services' that they will never see. Told to send money, to fix a building built to hold the thousands of immigrants who built the neighborhood, but now hosts only the few families who have hung on, and the chance newcomer who keeps the faith. Their priest doesn't ask much of them, may not even know them (although, I will say, my parish priest is making a real effort to change that), but constantly reminds them that more funds are needed.It starts to feel a lot more transactional than inspirational, and the faithful become slowly discouraged, and even more drift away.

The Church must either renew or wither, and if the buildings it constructed in earlier days are now holding it back, they should not fear letting them go. After all, Jesus himself said, "If your eye betrays you, pluck it out." It would be painful to see the great built heritage of Catholicism pass away, but the Church is greater than the sum of its churches.