Williams on Equality Notes for September 9

Main points

Williams’s treatment of health care reflects a common sense belief that it is irrational to distribute health care for reasons other than ill health.

We talked about how Williams’s approach diverges from those you might find in economics. We also talked about some of the problems it faces.

Efficiency, incentives, and ideology

Two of the most significant points on which Williams and economists part ways concern efficiency and incentives.

As Rhett pointed out, economists define an efficient distribution of goods as one in which there is no way to make anyone’s share better without making anyone else’s worse. As Professor Brown showed, an efficient distribution of health care, in this sense, could fall short of treating need as a basis for care.

Roger and Rhett raised the question of incentives. How will it work if we just declare that health care is for curing illness? Should doctors work for free, to avoid tainting their care with something irrelevant and irrational like money? What about technological discoveries: should researchers and their funders ignore future benefits and concentrate solely on curing present illness? Do we expect the health care system to work on a disinterested concern for the “rational” distribution of health care rather than the interests of its members?

A way of rephrasing their question is: who or what is irrational in a society that does not allocate health care according to ill health? Daniel said “the health system.” Nozick will force us to ask whether there is such a thing.

We also kicked around Williams’s claims about false consciousness. It’s possible to have serious unmet needs but not appreciate this fact. It’s possible to be in this situation because of false beliefs. And it’s possible that those beliefs have social causes.

Sometimes, this gap between what people believe and what we think they need raises a question about what we think. Maybe they don’t really need it. Other times, it raises a question about using subjective utility functions as a measure of individual well-being. It isn’t easy to say much in general about when the one question rather than the other is raised.

Is health care a competitive good?

Max raised a tough point at the end. Williams distinguishes between goods that should be distributed according to need from those that should be distributed according to merit on a number of grounds. One of these grounds is that the latter, but not the former, are scarce, meaning there is competition for them. That’s why he said that, strictly speaking, we distribute opportunities for goods distributed according to merit rather than the goods themselves.

I can see his point if he’s assuming that a society has enough resources to meet needs that are finite. For instance, a society as wealthy as ours can easily provide enough for everyone to eat. Once everyone is fed, there’s little pressure to keep feeding them.

But health care probably isn’t like that, even for a wealthy society. The reason is that there will always be demand to do more to save life. As we approach death, we all want as much as possible to be done to prolong our lives, generally speaking. But unless we devote nearly every resource we have to health care, we’ll have limits somewhere. Where there are limits, there is competition for scarce goods.

Research priorities** Added September 10

Here’s the money quote from the article on drug resistant bacteria that I referred to.

In the past, large pharmaceutical companies were the primary sources of antibiotic research. But many of these companies have abandoned the field. “Eli Lilly and Company developed the first cephalosporins,” Moellering told me, referring to familiar drugs like Keflex. “They developed a huge number of important anti-microbial agents. They had incredible chemistry and incredible research facilities, and, unfortunately, they have completely pulled out of it now. After Squibb merged with Bristol-Myers, they closed their antibacterial program,” he said, as did Abbott, which developed key agents in the past treatment of gram-negative bacteria. A recent assessment of progress in the field, from U.C.L.A., concluded, “FDA approval of new antibacterial agents decreased by 56 per cent over the past 20 years (1998-2002 vs. 1983-1987),” noting that, in the researchers’ projection of future development only six of the five hundred and six drugs currently being developed were new antibacterial agents. Drug companies are looking for blockbuster therapies that must be taken daily for decades, drugs like Lipitor, for high cholesterol, or Zyprexa, for psychiatric disorders, used by millions of people and generating many billions of dollars each year. Antibiotics are used to treat infections, and are therefore prescribed only for days or weeks. (The exception is the use of antibiotics in livestock, which is both a profit-driver and a potential cause of antibiotic resistance.)†† Jerome Groopman, “Superbugs,” New Yorker, August 11, 2008.

Drug resistant bacteria are one of my big time fears. Brrr. So perhaps I exaggerate the significance of Groopman’s point.

I also recall being impressed by Marcia Angell’s “The Truth About Drug Companies.”‡New York Review of Books, July 15, 2004. Angell argues that the market does not drive genuine innovation in drugs. What does, according to her? Publicly funded research institutes and universities! (Though Angell and others worry that the latter are becoming profit seeking enterprises).

Generally speaking, we can engage in just-so stories about how market driven inequalities could lead to the best long term results. Or, if our politics are on the left, we could do the same by imagining ways to make a buck that skirt or harm the public interest.

Both kinds of thinking are valuable! That’s how we come up with research projects. But in the end, the answer has to be based on empirical study of the facts rather than speculation about how things could be. The two sources I have referred to here present part of the factual picture and speculate a bit about the best explanation for it. A more detailed study would be needed to settle the issue of whether the market influence on health care research is benign or malign on balance.

Gosh, that could be a senior thesis project!

This page was written by Michael Green for Freedom, Markets, and Well-Being, PPE 160, Fall 2008. It was posted September 9, 2008 and updated September 10, 2008.
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