Human Nature: Science, Technology, and Life.

The Abortion Coverage Dilemma

The argument being made by pro-choice groups is perfectly logical: If you standardize health insurance through federal subsidies and coverage requirements, people might lose benefits they used to enjoy in the private sector. But that's more than an argument against excluding abortion. It's an argument against health-care reform altogether. The left's argument against abortion exclusion is the right's argument against socialization.

More here.

Boob Jobs vs. HMOs

Eight months ago, I thought I saw a silver lining in this recession. Now it's looking more like scar tissue.

The silver lining, I thought, was that cosmetic surgery was taking a financial hit:

A breast implant company disclosed a decline in surgeries late last year; a laser eye-surgery firm has lowered its forecast based on a similar trend early this year. A professional breast augmenter frets that in January and February, business for some of his colleagues was off 30 percent to 40 percent. ... More effectively than any bioethicist, the recession is reminding people that cosmetic work isn't medicine. "While healthcare spending as a whole has traditionally moved independently of the economy—a safe haven—that really isn't the case with plastic surgery," a financial analyst tells the Times. In the new, sobered economy, the paper reports, some cosmetic doctors are diversifying into "reconstructive surgery for cancer patients and others that is covered by insurance." Insurance!

Say what you will about coverage-denying bean counters, but they do enforce the essential priority of urgent procedures over elective ones. In a health-care industry controlled by tight budgets and insurers, you might even see the cream of the med-school crop shift back to the kind of work that keeps people alive.

That was then. This is now: The Associated Press reports,

Johnson & Johnson said [Dec. 1] it would buy Mentor, a maker of cosmetic products and breast implants, for $1.07 billion, a move that would help the drug maker become a major player in cosmetic and reconstructive surgery. Analysts said Johnson & Johnson was paying "a giant premium" for Mentor, which makes MemoryGel breast implants, liposuction equipment and skin repair products. ... "It's a good space for J.& J. to get bigger in because it's a space with the least cost-control pricing pressures," as patients, rather than insurers or government health programs, generally pay for cosmetic surgery, said Erik Gordon, associate dean and head of biomedical industry programs at Stevens Institute of Technology.

In other words, the increasing power of insurance gatekeepers and cost controls, driven by the recession, might drive some companies out of health-oriented medicine and into cosmetic procedures. The inability of middle-class people to pay for boob jobs doesn't mean providers have to shift their focus to real medicine for the middle class. Maybe they'll shift their focus instead to boob jobs for the rich.

True, the rich are a smaller market than the middle class. But if the cost controls in real medicine are too tight, providers can make up in profit margins what they lose in volume. So, as we're revising our health-care system, let's try not to drive too many doctors and health companies out of real medicine. They might have something less important to do.

In Praise of Lethal Rationing

Good front-page article in today's New York Times on Britain's National Institute for Health and Clinical Excellence (NICE), which, among other things, decides whether a few more months of your life are worth the expense. The article begins with a guy named Bruce Hardy who needs a drug that might give him an extra half-year of life but would cost $54,000. NICE said no. The agency comes off as heartless. "Everybody should be allowed to have as much life as they can," Hardy's wife pleads. The article concludes: "Meanwhile, Mr. Hardy waits. In recent weeks his growing tumor has pressed on a nerve that governs his voice. He can barely speak and is increasingly out of breath."

Aw, hell. It'd be great if we could buy an extra half-year for everybody. But we can't. We have unmet needs everywhere. People die every day from being uninsured and unattended. They just don't make the front page.

There's a cruel bias built into our minds that makes you feel more for the person who's suffering in front of you than for people whose suffering appears only in statistical form. (I can't remember what the psychologists or economists call this bias. If you do, please share it with the class.) So now you know all about Bruce Hardy, and you probably regard the bureaucrats at NICE as cads for stiffing him. It's harder to remind yourself of all the health and added life that $54,000 could buy for others. For example: Where does the Gates Foundation send its medical dollars for maximum efficiency? Childhood vaccines.

As far as I can tell, NICE is doing good work. Its refusal to pay any amount for life-prolonging drugs has forced drug companies to cut prices. And by drawing a line against paying too much in some tragic cases, NICE preserves money for other cases where the money can do more good. If anything, NICE is a bit soft. For instance, the Times reports: "After consulting a citizens group, the institute decided that the nation should spend the same amount saving or improving the life of a 75-year-old smoker as it would a 5-year-old." If I ran NICE, the 5-year-old would take priority. And I'm irked to see that NICE is already backing off from its rejection of cases such as Hardy's. According to the Times, this comes after NICE was "flooded with anguished comments." I'm sorry, but anguish is everywhere. If patients like Hardy get funded at $9,000 per month, which other patients won't be funded? What about their anguish? Or does your anguish count only if you have the means and know-how to lobby the government?

Yes, everybody deserves as much life as possible. But that means the person in front of you can't take an undue share of limited public funds when others are in need.

Hospitals vs. Factories

Last week I promised to start using this blog to highlight and explain the day's top stories. Unfortunately, scanning wires, papers, magazines, journals, and Web sites for the best stories (make sure to bookmark the Human Nature home page so you'll get the list every day) has taken so much time that I haven't been able to make good on my promise. Sorting out how long these tasks take, and which of them I should spend my time on, will take at least a few weeks. Anyway, I've cleared some time this afternoon to talk about today's stories, so let's get to it.

One item worth noting is today's Wall Street Journal article [subscription required] on hospitals replacing factories. Reporter Conor Dougherty lays out the data:

Demand for health care tends to stay strong during recessions. Cash-strapped consumers are more likely to cut back on new appliances or cars than emergency-room visits. Indeed, while the number of manufacturing jobs nationwide fell by 48,000 in March and by 310,000 over the past 12 months, health-care employment rose by 23,000 last month and is up 363,000 jobs on the year ... Growth in health care is fueling local economies across the country, as medical facilities replace factories. In Duluth, Minn., 20% of the jobs are in health care, compared with 14% a decade ago. In the Canton, Ohio, area, which lost the maker of Hoover vacuum cleaners and dozens of other manufacturers, the health-care industry is expanding rapidly. A similar story is unfolding in Anderson, Ind., once a major producer of cars and car parts.

I haven't researched this topic enough to analyze all the factors. But one theme is already intriguing: An economy based on constructing and repairing objects is giving way to an economy based on repairing and maintaining the human body. Faced with recession, consumers are deciding that widgets are expendable, but people aren't.

Actually, that's not quite right. We haven't decided that the health of ­all people is so important. The manufacturing that used to happen here is migrating to the developing world. Likewise, its replacement by hospitals is happening here, not there. Yes, American and European medicine are often being outsourced to poorer countries. But the patients benefiting from this overseas treatment are still American and European. Just ask all those transplant tourists.

My bet is that the trends reflected in this article will dominate the economy of the next century. The biotechnology of human health will increasingly become the technology most highly valued by the measure that counts most: economic demand. To put it in moral terms: The most valued objects of maintenance and repair will be subjects.

That's the good news. The bad news is that because the mechanism behind this process is economic, and because wealth is unevenly distributed, billions of people will benefit little or not at all. Dougherty shows us, through interviews and stories, how easily supply and demand can shuffle workers not only from manufacturing to health care, but vice versa when nursing wages don't add up. That's why, in much of the world, the economy will continue to value objects more than subjects, no matter what morality says.