Mortality, Money and Other People

The data might not be this clear-cut, but clearly the US is an outlier.

How much is your life, or your health, actually worth? I'm sure you'd put a pretty big number on it. If, for example, you needed to borrow $100,000 to cure a chronic, life-altering disease, I would bet you would do so. Where you place your personal cutoff point when health care is no longer worth the money will vary, but at some point almost everyone will decide that it is better to accept your mortality than to expend your family's wealth in pursuit of life-extending care.

But what if I re-phrased the question? What if I asked how much your life and your health should be worth to some third party who is obligated to pay for your care? It is much less likely you would say, "you know, the government/insurance company has wasted enough money on me, it's time to let go." No, if you are entitled to care from someone else, you will want as much of it as you can get.

I think the above chart (which, in updates to the blog posts where I originally saw this now point out, is a display of GOVERNMENT spending, and may have other inaccuracies) is showing what happens when that psychological truth is given free reign. In the other countries shown, there is an understanding that the government will impose limits on what will be paid for in the interest of fairness and frugality. In the US, by contrast, there are very few limits. This leads Matthew Yglesias to argue that the much-maligned death panels are actually just what we need. As he puts it:

The "death panels" charge was a potent one for a reason. But not only is this health care spending on the elderly the key issue in the federal budget, our disproportionate allocation of health care dollars to old people surely accounts for the remarkable lack of apparent cost effectiveness of the American health care system. When the patient is already over 80, the simple fact of the matter is that no amount of treatment is going to work miracles in terms of life expectancy or quality of life.

To clarify, again, Yglesias was writing when he thought the chart captured ALL healthcare spending in each country, but surely adding in non-government spending on elderly patients would not invalidate his general point. Namely, that the decisions other countries make about what care is economically justifiable, which we would call "death panels", are the only way to constrain the growth in healthcare spending when the government is footing the bill.

But the reason the death panel argument is so potent is that we in the US understand healthcare as an entitlement, full stop. Politicians have sold Medicare, Medicaid and now Obamacare as a guarantee of full care. Think about this statement by President Obama: "I'm running because I believe that in America no one should go bankrupt because they get sick." That is a pretty remarkable statement, when you stop and think about it, because healthcare is enormously expensive. And as a practical matter, he doesn't mean it: someone who opts for experimental procedures, who tries a costly drug to tread a disease for which it is not indicated, or even someone who chooses a doctor outside of their insurance plan can all still go bankrupt. What he really means is that no one who follows the rules and limits the government imposes on healthcare will go bankrupt because they get sick, but that's not what most people hear. And so when the government tries to impose or extend those limits, people get very angry. And, as has been noted extensively in political commentary, older people vote.

There isn't a happy ending to this story, because people don't like giving up something they think they've been promised. But the only way out of the healthcare mess we're in is to make people feel they're making a financial tradeoff when they consume healthcare. One simple suggestion: the government could give tax credits (or even cash awards) to seniors who are among the lowest consumers of Medicare. Eventually, we could seek to establish a lifetime dollar target for an individual's government health benefits. People who die under that number would pass on some percentage of the difference to their estates. Or, we could provide an annual grant to seniors to buy coverage, and they pocket the difference if they find a cheaper option. (This is essentially Paul Ryan's Medicare reform proposal.) 

None of these changes would be painless, and there is a large contingency that wants to maintain the status quo no matter the costs. But a system that pretends there are no limits on what we can afford to cover, and implies there are no limits on how much care it is even rational to get, encourages people to seek out the maximum amount of care instead of the care that makes sense for them, their families, and their finances.

I know, in writing this, that I might be thought cruel. In other words, that I'm saying we should let people die if they're poor. But I'm not: what I'm saying is by creating a system that encourages the view that you should do everything possible to stave off death, no matter the financial or personal toll, we've driven people to disbelieve in their own mortality and have outsized expectations for what medicine can do. In contrast, I would recommend this piece on how doctors die: people who truly understand medicine, health and the human body are much less inclined to seek end-of-life care.

There is dignity in accepting when our life has run its course. One of the under-discussed benefits of giving more control of our health decisions back to us is that we will more clearly make our own decisions about when to keep fighting and when to let go. With no death panels required.

How Much Control Do We Have Over Our Brains?

There is a significant trend in neuroscience, and maybe even more so among the commentators who use that science to justify their political or social beliefs, of denying that we are really responsible for our own behavior. The usual argument goes like this: when a person does X, their brain scans light up in a certain way. People with brain damage to that area don't do X, or do it differently. Therefore we don't really have control of ourselves, our decisions or beliefs are just a function of our anatomy. I have written critically about these Just-So Science Stories here. Other writers (ok, better writers), in a political context, have pointed out that some liberal social scientists have started using this same approach to define conservatism as a disease.


However, just because science can be manipulated to support certain dubious conclusions doesn't mean there isn't a lot of interesting work being done in understanding how the brain works. And one such finding has to do with how a parasite in our brains might be responsible for our positive reactions to the scents of certain wines and perfumes. As writer Patrick House puts it:

Why is it that the elite French perfumers (known as “noses”) and sommeliers (“upturned noses”) of the world spend so much of their time inhaling cat effluvia from expensive glass bottles? A guess: It may have to do with a mind-control parasite called Toxoplasma gondii. The tiny protozoan may be getting into our brains and tricking us into liking cats—not to mention certain perfumes and wines.

In a recent study, Czech scientists gave men and women towels scented with the urine of various animals—horses, lions, hyenas, cats, dogs—which they rated for “pleasantness.” Turns out, men who tested positive for Toxo found the smell of cat urine more pleasant than men without Toxo. For Toxo researchers like me, this was a shock but not entirely surprising. Why? Toxo does approximately the same thing to rats.

You'll have to read the article to get the full theory of why Toxo does what it does, but the implications are staggering: a single-celled organism might be altering way our brain processes information from our senses. Think of it: could we find a bacteria that lowers the speed at which our neurons fire, influencing how fast we remember or respond to stimuli? Could we find a parasite that alters our hearing our sight?

Or think of the commercial issues. Some perfume and wine companies would presumably do better if more people were infected by Toxo. Maybe Chanel will start working with animal adoption organizations to try to get cats into more homes, increasing their likely customer base.

If we begin to discover that some significant portion of the way we perceive the world is influenced by outside organisms, will we attempt to purge them all to standardize the way the human mind works? Will we search for those with favorable impacts and try to infect everyone with them? Could this be the next frontier in pharmaceutical development? Or is this a one-off, and our mental machinery is basically unaltered by microscopic invaders? I guess we just have to wait and see.

Why We Believe We Are Entitled to Health Care

I learned the Supreme Court voted to uphold Obamacare today while I was in a brainstorming session for a drug that will launch next year. I had the same thought I've had on other occasions when people define the "right" to health care: how can someone have a right to a product that has just been invented, or to a skill that certain individuals study for decades to acquire and perfect? Of course, if we want to be strict with our language, Obamacare doesn't give anyone a right to health care, it creates a new entitlement to health care.

I've always had a problem with the notion of a government entitlement. It implies, to my ears, that the State determines what people need to get by in life, and then sets out to give it to them. And that the people have to be vigilant in making sure that they get what's coming to them. I hear, in my head, a smart but whiny teenager, "If my sister is getting a new car, then I'm entitled to one, too!"

But leave aside my grumpy dislike of the word: should there be an entitlement to health care? And what would we include (and exclude) within that entitlement? A lot of people clearly believe there should be a very broad health care entitlement, including medicines like contraception that stretch that entitlement far beyond life-and-death issues. So, are we entitled to all pharmaceutical products? Even this one? Is every surgery part of that entitlement? Even this one? Suddenly it becomes hard to find the line.

I kept sitting in my meeting, thinking about these issues and (as it happens) eating a wonderful chipwich. My mind went to FDR's Four Freedoms, and specifically the Freedom from Want. That idea is largely defined as implying a right to adequate food, clothing and shelter, and sometimes to the right to a job that pays a living wage. It seems odd, first of all, that we would push for universal healthcare before we would push for universal access to those more basic elements of survival. But it also seems apparent, if we defined a food entitlement as broadly as we define the health care entitlement, that we would be enshrining universal access to chipwiches into law. Of course, people like me would love that, and I'm sure the chipwich people would love that (and clearly, the pharmaceutical industry was bullish on the notion of increasing their potential market with Obamacare), but that doesn't mean it makes economic or practical sense.

Forgive me for going on, but I'm trying to make the argument that we have very muddle-headed thinking about what a health care entitlement should actually do, and what it should (or shouldn't) cover. I'm going to assume that my chipwich analogy has you convinced that we can't give all people access to everything that falls under the header of health care. But why isn't this instantly apparent to people?

Well, I'd like to offer two completely speculative suggestions. The first is that health care consumption is much more passive for most people than is their consumption of food, clothing, shelter and other basic necessities. If you need food, you go out and buy what you think is best and what you can afford. Even if you are on food stamps, the choice of food and the act of getting it is still in your hands. But taking charge of your health in a similar way is almost impossible. You very rarely even know what you need until someone else tells you: if you feel "bad", you go to a doctor who pronounces what you need, and then hands you a piece of paper which you docilely take to a pharmacist, who hands you a bottle of nondescript pills that you assume will do what everyone told you to do. And most of this is paid for by your insurance, so you don't even really know what it costs. Essentially, your health is already basically someone else's problem, so taking the step of saying it is the government's responsibility isn't really that dramatic.

The second possibility is that improving our health through popping pills or invasive surgery is evolutionarily novel. The psychologist Satoshi Kanazawa has developed the theory that intelligence evolved to deal with evolutionarily novel problems, the type of things we wouldn't have to deal with every day. As he puts it:

We know what to do when it comes to mating.  We know what to do when it comes to parenting and learning a language associated with other people. All these things our ancestors did already have ready-made solutions in our brain, but occasionally there are novel problems that required our ancestors to think and that’s how intelligence evolves. Some people who could think and reason and solve these evolutionary novel problems did better occasionally, so my contention is that intelligence evolved to deal with novel problems and as a result more intelligent people are more likely to recognize evolutionarily novel entities and situations.

So, you'd expect that, faced with the proliferation of new treatments, intelligent people would be more comfortable dealing with them and coming up with ways to make them more accessible. But he continues:

The key part of the equation is that intelligence leads individuals to seek novel solutions and as a result they become more likely to adopt novel preferences and values, so intelligence makes people do unnatural things.

I read this to imply that, in the face of evolutionarily novel situations, people are willing to try something different, but we aren't automatically going to pick the right or most workable solution to the problem we face. People generally know what to do to get food, clothing and shelter, but the novelty of accessing health solutions might make us willing to consider "unnatural" alternatives.

To go back to food analogies: we would never say that everyone has the right to prime rib and lobster every day, because we all intuitively understand we'd go broke. But the novelty of health care makes us blind to that simple truth. Of course, eventually economic reality will overwhelm our confusion and the good intentions that have led us to this point.

Apple Gets an FDA Letter

April 23, 2012

Mr. Tim Cook
CEO, Apple Inc
1 Infinite Loop
Cupertino, CA 95014

Mr. Cook:

As I hope you are aware, under USC Title 15, Chapter 48, Section 2101, Congress has expanded the FDA's regulatory powers to cover all businesses that a consumer could reasonably (or unreasonably) believe are in some way involved in the production or distribution of ingested substances. Obviously, a company named Apple is now well within our purview. (And, if I may be frank with you, the use of a business name that creates the expectation of nutritional value when none is provided may, in and of itself, be the violation of several key regulations.)

However, it is my purpose today to provide a warning about Apple's current non-compliant marketing practices, hereafter to be referred to as NCMPs, and an order to cease and desist all such practices immediately. As these issues may be unfamiliar to a businessman who has not had previous dealings, I would encourage you to discuss the contents of this letter (subject to the counsel of your internal legal department) with executives from any pharmaceutical company, who are more than familiar with these regulations and how to comply with them.

Topic A: Promotion of product feature "Siri" included with Apple iPhone 4s

Our regulators have been deeply disturbed by numerous NCMPs associated with your introduction of "Siri". First, our scientific advisors challenge the often-repeated notion that this application represents "artificial intelligence" in any meaningful way. The literature on AI is well-established, and establishing that a device demonstrates it requires, at minimum, that it pass a Turing Test.  As there is no evidence Siri has done so, you are hereby not allowed to use this phrasing, or any similar phrasing, in promotional messages. Additionally, it is an NCMP to refer to Siri as a "personal assistant", as this implies human characteristics and abilities that it cannot possess. (You may use the word "assist" to describe the applications MOA.) To avoid any possible confusion, all television advertisements depicting human users easily and naturally interacting with Siri are deemed not compliant and must be removed from all media immediately. Finally, there is a lack of fair balance in your Siri-related communications. To avoid future NCMPs, you must include the rate at which Siri misinterprets commands given to it, and any possible safety risks associated with such errors.

Topic B: Promotion of "The New iPad"

First, we find the naming of the iPad problematic, and ask you to find a more suitable name within 90 days to avoid the product being withdrawn from the market and the levying of significant financial penalties. As you should realize, there is a high risk of confusion between the iPad and the iPod, which is a completely distinct product with a different indication. Without being too prescriptive, we would suggest that a name like "TouchTablet" would be more clear, and thus in the best interests of users. Additionally, it is a significant NCMP to use the neologism "Resolutionary" to promote the product. The obvious intent is to imply that this is a revolutionary product, when most experts believe that a sharper screen and better cameras represent, at best, an incremental improvement over previous models

Topic C: The Apple Store

An audit of your retail locations has unearthed a number of violations that must be addressed immediately. First, it seems you have been offering free setup of your products for some time, which is an obvious NCMP. Any incentive to purchase a product other than offering certain permitted discounts is a violation of regulations. Second, you are henceforth no longer permitted to call your technical support area a "Genius Bar" unless you can document that the average IQ of your support staff is over 135.

We find that these are the most severe regulatory violations, although we would strongly suggest you establish a registry to help investigators determine whether, as some initial studies indicate, your iPhone products are in fact addictive.

The attached 274 page form should help you get started in your reply to this letter. We look forward to working with you to clear up these violations, and ensure, for the good of the consumer, that your future marketing efforts are conducted in a more thoughtful and balanced way.

Sincerely,

Dan Reed
High Inquisitor for Ridiculously Regulated Products


Editor's Note: I have fortunately never received an FDA letter myself, and I'm sure they're a bit more nuanced than my parody. But all of these theoretical violations on Apple's part do parallel the type of rules that pharmaceutical companies have to comply with when they want to talk about their products. So here's my question for my readers: do you think strictly limiting communications in this way actually helps consumers? Or, as I believe, do these rules actually makes it harder to communicate clearly about how health products can help people?

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.

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.

"I Like Paper": What's Holding Back Healthcare

So I was in the hospital, accompanying my wife for an emergency appointment that ended with the all-clear being sounded. As we were sitting in the triage room at Beth Israel, my wife's doctor, a woman that I would place at between 35 and 40, was inputting some information into the in-room computer system. She stopped, momentarily stymied by some piece of data the program was prompting her to collect. Turning to us, she said, "I hate this thing. I like paper. Don't you like paper?"

We all had a good laugh at that, but a day later that phrase is still running through my head: "I like paper." That sums up a huge problem with our healthcare system in three simple words. Having spent about thirty minutes watching this particular physician work, and seeing her whip out her Blackberry at one point, I can vouch that she was intelligent and reasonably comfortable with technology. Yet she would prefer paper, and by her own account, avoids the computer system as often as possible.

Now, maybe that bit of data the computer wanted to collect was meaningless in the situation. Maybe, in that instance, collecting the information in a paper chart would have been both quicker and more customized to the issue at hand. But one of the great things about computers is that they enable a level of standardization otherwise impossible. Perhaps my wife's next doctor will need that particular data point as part of making a care decision, or at least want to know it was collected to rule out some possibility he's considering. By computerizing medical records, we make it much more likely the right information is going to be collected and made accessible when needed.

As Walter Russell Mead notes yet again in a recent blog post, one of the areas where we have the most to gain economically is healthcare, where there are still great efficiencies to be found. But that can't happen as long as otherwise talented and intelligent professionals resist tools that, once a part of their daily lives, will enable those improvements. Progress on digitizing medical data continues, but it will be resisted until leaders in the field figure out better ways to have physicians embrace these technologies instead of fighting them.

What Are Cell Phones Doing to Us?

The big study that got a lot of media attention this week was one that showed extended cell phone use causes changes in brain activity, presumably due to the proximity of its electromagnetic field. Here's the key bit:

"Dr. Nora Volkow, director of the National Institute on Drug Abuse (part of the National Institutes of Health), reports Tuesday in the Journal of the American Medical Association (JAMA) that a cell phone's electromagnetic field can cause changes in brain activity. Specifically, she and her team found that the regions nearest to the antenna of closely held mobile devices showed higher rates of energy (or glucose) consumption."

Glucose consumption essentially means that that part of the body is working harder, and using more energy. Is that because we are stimulating the cells in such a way as they could become cancerous? Or is the brain just more active in the area near a signal? No one knows, although those who believe wireless signals cause cancer will not wait for definitive proof to validate their fears.

I highlight the study not because I think we're all about to grow iPhone shaped tumors in our brains, but because it shows how unclear we still are about how the changes we make to our environment impact the human body. When someone wants to build a dam, they have to do detailed studies and show exactly how that the development will impact the river. But if someone wants to sell us transmitting devices that we'll hold up to our ear or keep next to our reproductive organs all day, they go ahead and we figure out later if it is a problem. I think we ask too much in the case of the dam, and too little in the case of the cell phone.

And maybe we should be a bit more humble about pursuing advances in genetic engineering, bio-enhancements, and brain-computer interfaces when we can't even figure out if our phones are doing something nasty to our brains.

The Future of Spray-On Skin

In my last post, I wrote about how an increasing number of complexities in modern society may constrain our collective ability to innovate. Whether it is the existing infrastructure that supports older technologies over newer ones, or a litigious society that exposes those doing something new and unproven to enormous financial risk, we are putting our inventors and entrepreneurs in an ever-tighter straight jacket.

Well, I found an interesting test case for the theory: spray-on skin. What's that? It sounds like some ridiculous thing I just made up? Well, then watch this video and doubt no more, my skeptical friend. For those of you who would rather not see images of severe burns, let me explain: scientists have figured out how to harvest skin cells from the remaining healthy skin on a burn victim, put them in a solution, and apply that mixture through a spray gun to encourage rapid skin growth. They have successfully demonstrated that this works in a number of cases, and it takes a fraction of the time that traditional skin grafts do.

On the surface, this seems like an easy innovation to adopt. It is easier, faster, clinically superior and (once it gets up to scale) probably cheaper than the existing options. Yet I see a number of obstacles to spray-on skin coming to a hospital near you:

1) The procedure uses stem cells, which have the taint of controversy, even though in this case the cells are harvested from the patient's skin, not embryos.
2) The gun will be a capital expense for hospitals, whereas skin grafts don't require any new capital equipment.
3) Surgeons are compensated based on set reimbursement rates for different types of procedures. Spraying on skin would need a code, which can take years. And when it gets one, it may pay physicians much less than the compensation for a skin graft procedure.
4) Skin grafts are big business (check out KCI if you don't believe me) and they are likely to vigorously oppose any disruptive new technologies in their space.

Now, all of these obstacles are surmountable, but it won't be easy. Which is why I view the spray-on skin as a test case of sorts: if it can run the gauntlet and get widespread adoption in the next few years, I will have to revise my earlier opinion and admit that our society, as imperfect as it is, still has room to identify and advance radical, life-improving innovations.

Healer, Heal Thy Guidelines!

I found my way over to an interesting blog written by one Joseph Paduda on Managed Care. A number of his posts were interesting, but I was most captivated by this one on the limits of guidelines. This is a topic, as a healthcare marketer, that always catches my attention, because health guidelines cause an essential challenge: namely, that the guidelines can only be improved upon if physicians ignore them.

What I had always assumed, and what Paduda calls into question, is that guidelines are based on the best science of the day. He puts it as follows:

A recent study may well give you pause - the key finding is rather alarming - many guidelines are NOT based on solid research, but on work that is kindly described as rather more superficial.

Published in the Archives of Internal Medicine, the research found "More than half of the current recommendations of the IDSA (Infectious Diseases Society of America) are based on level III evidence [expert opinion] only." [emphasis added]

Paduda goes on to note that many guidelines are based on good science, but encourages people to be vigilant in asking about the basis of guidelines they come across.

And while that may be good advice for the healthcare professional, or even a well-informed lay person, most patients aren't going to be able to debate the merits of particular guidelines with their doctor, or, more importantly, their insurer.

This bothers me immensely, because care decisions are going to be further centralized in the coming years (probably whether or not Obamacare is repealed, by the way), and the centralizers are going to lean on guidelines to cut costs and standardize care. This seems highly likely to slow the adoption of medical innovation. So never mind that slavish conformity to guidelines limits the opportunities for smart individual physicians to come up with better approaches to care, many of those guidelines may not be worth the glossy medical journal paper they're printed on. Not comforting.

Lazy or Sick?

As a thought experiment, imagine that we discovered a virus that inhibited certain higher brain functions. Most subjects infected with this virus would exhibit a greater tendency towards short-temperedness, and would be seen as 'difficult' or 'moody' by others. A few, though, become criminally anti-social. When a treatment for this virus is developed, many formerly hardened criminals become model citizens, exhibiting none of the destructive tendencies that had seemed so hard-wired.

How would this change the way we viewed criminals? (And, for that matter, the cranky uncle who drives everyone nuts at Thanksgiving?) My hypothetical above does not claim that the criminals and the cranky were powerless to resist these urges, just that it was harder for them than for the non-infected. I would contend that society would be split between those who felt those with the virus had been dealt a bad hand, but their behavior was still their fault, and those who would argue people cannot be held really responsible for behavior driven to a large extent by an outside influence.

I bring this up because of a brief article in New Scientist that outlines the link between a mouse virus and Chronic Fatigue Syndrome (CFS). The science is clearly at an early stage, and previous attempts to link CFS to a virus have not borne out. But here is the key finding:

Shyh-Ching Lo of the Food and Drug Administration in Bethesda, Maryland, and colleagues found that blood samples from 32 of 37 people with chronic fatigue syndrome contained "polytropic" murine leukaemia virus-related fragments, compared with only three of 44 healthy blood donors.

Now, having done some work in this topic, I can say that many physicians, especially older male physicians, put CFS in a bucket of "women's conditions", along with related syndromes like Fybromyalgia and Restless Leg Syndrome. They tend to believe that the women in their care have underlying psychological problems that are manifesting themselves in these syndromes. That some anti-depressants have proven helpful in alleviating several of these syndromes reinforces their view. To say these physicians are dismissive of these problems and these patients is an understatement.

Patients would widely embrace the identification of a 'real' cause, and would undoubtedly demand a level of care and support for their condition far beyond what they receive today. But notice that not every CFS patient has the virus, and not everyone with the virus has CFS. That implies either that the virus may contribute to the syndrome without fully causing it, or that the reaction to infection might vary enough that a significant number of the infected aren't noticeably sick. (And would this be so surprising? After all, people react very differently to infection by the same cold viruses.) But if, for example, 25% of the people infected with this mouse virus are not noticeably fatigued, and another 50% are fatigued or lethargic to a degree, but are still able to function, many people are going to dismiss the 25% who are most affected as lazy, as milking their diagnosis. And it will be hard to prove the truth either way.

As the science of health continues its amazing advance, we're going to learn more and more about the environmental influences (viruses, bacteria, chemicals, etc.) that impact human performance. If pre-natal pollution exposure lowers IQ, should the less intelligent from dirtier environments be compensated, or get preferential treatment at schools? If certain gut flora lead to obesity, do we give them health coverage for bariatric surgery? With each new learning or theory, we move farther from the notion that people should be held accountable for their choices, and closer to a world where every personal failure is attributed to an outside force. It may be hard work to preserve the notion that we are masters of our own lives.

Declining Opportunities for "Earned Success"?

I am quite intrigued by Arthur Brooks' arguments about "earned success", which I have seen in several places but which are summarized nicely here. To briefly summarize, Brooks suggests that it is not ultimately income that correlates with happiness, but the feeling that our success (which yes, is often reflected in earnings) is the result of our drive, and that we have contributed in some way to improving humanity's condition. Whether that is by solving a scientific problem, making something useful for someone else, or creating beauty doesn't matter.

I agree with the notion, but I find it mildly depressing, because I believe that the future will offer fewer professional opportunities for earned success. Most of the people I know (and admittedly, New Yorkers and other northeast urbanites/suburbanites are an unrepresentative sample) do not feel their jobs are contributing towards anything bigger, at least not in any way they can observe.

And the future seems likely to create more of the same. Most of the jobs created in the western world are based on various types of information manipulation: packaging facts and ideas for consumption. It may be lucrative, it may even be challenging, but it quite often feels detached and utterly meaningless to the people in these positions. Our corporations, our systems of production and distribution, are so large that few people really have a view of how their contribution fits in. In other words, they feel they are part of a machine and not in control of their own success. This is even happening in healthcare, where doctors and nurses frequently complain that they spend much more time doing administrative tasks and less tending to patients.

This is not cause for despair, exactly. There will always be jobs in research, in the arts, and in engineering that offer what corporate positions increasingly do not: a sense that your effort makes an impact. And for the rest of us, we may have to find earned success in our families or our avocations as we are denied it in the working world.

Thinking Honestly About Healthcare

I am amazed (and more than a little dismayed) that after years of debate about government intervention in the healthcare system, that there is still almost no rational conversation about the need to make tradeoffs to ensure better coverage for more people. Basically, the assumption on the right is that we already pay a lot of money to cover seniors and the poor, and we can't afford to massively expand government to increase benefits further. The liberal response is that it is a moral imperative that everyone have healthcare, and besides it will be more efficient than the system we have now. (For a nice summary of these arguments, read this Ross Douthat post and the responses below.)

But all of these arguments fail to account for the rapid pace of healthcare innovation. Or if they do account for them, it is with the assumption that everyone is entitled to the latest medical breakthroughs as soon as the FDA approves them. And I suppose, if you view 'health' as a right without any context, that makes sense. But that view, barring an amazing breakthrough that radically lowers treatment costs for chronic diseases, leads directly to national bankruptcy. The costs of new therapies, and the prevalence of heart disease, diabetes, cancer, Alzheimer's, and other conditions, will combine to swamp us.

Let's just talk about death for a second. (Sorry for the downer.) There are about 43,000 automotive deaths a year. A recent study (which I will for this argument accept uncritically) projected that there are about 45,000 deaths a year associated with lack of insurance. Now, lets hypothesize that automotive engineering advances, and new cars on the market dramatically reduce accident deaths. Putting people in the riskiest vehicles into these new cars could dramatically cut into that mortality rate. Would that be a moral imperative? Is there a right to these new safer cars? I think most would argue that the cars are a blessing, but would expect them to gradually replace older cars over time, and would accept the inevitable loss of life in the interim as an unavoidably tragedy, part of the cost of slow, uneven human advancement.

A lot of people, I'm sure, would say this is a ridiculous argument. But the cost of health insurance, annually, is priced somewhere between $5000 and $7000 per adult. That's somewhat more than my annual payments on a (very safe!) Honda Element. And don't expect those costs to go anywhere but up in the future. Most of the drugs being developed aren't easy-to-mass-produce chemical compounds, but more exotic and costly treatments like biologics, which are now used to treat everything from cancer to arthritis to psoriasis. The cost of a year on Enbrel therapy, for example, is about $12,000. These drugs aren't just more expensive to develop, they're more expensive to produce, so even the eventual generic versions will be expensive compared to the drugs we're used to.

So here's my point: I'm in favor of expanding healthcare assistance for those who can't afford their own insurance, but it should acknowledge the reality that some of the newest drugs may be too expensive to pay for in these plans. If I were to sketch the rough outline of such a plan, it would cover generic drugs, basic preventative care, and some sort of catastrophic coverage with a high deductible that would protect against life-threatening problems. (Over time, I would apply this model, with some variations, to existing government healthcare programs.) Will some people have sub-optimal outcomes on this plan? Absolutely. But the idea that we can afford to give everyone access to the latest healthcare innovations is a puppydogs-and-ice cream fantasy we can't afford to indulge in.