Human Nature: Science, Technology, and Life.

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.

Longevity Risk

You think the economy is bad? I have worse news: We're living longer.

Well, that's not exactly news. Steady increases in life expectancy have been a regular topic here at Human Nature. Now they're relevant for an awkward reason: The longer you live, the longer you have to stretch out your retirement savings. And right about now, your savings probably aren't looking like they're up to the job.

As the latest Reuters report notes, over the last four decades, U.S. life expectancy has climbed from 70.8 to 77.8 years. By 2015, it's on track to hit 79.2 years. Meanwhile, unlike other industrialized democracies, the United States has replaced pensions with 401(k) plans. So your retirement-income pie can suddenly shrink—as, for example, it's doing right now—and, at the same time, the longevity you've gained from all this lovely industrialization requires you to carve that pie into more and more annual pieces.

Financial planners have even coined a term for this paradox: longevity risk. The Reuters story features an 84-year-old retired nurse who now worries "about outliving her savings." A financial advice executive tells the wire service, "Probably half our clients are retired and yes, we have a lot of very worried, concerned clients. Their leading concerns are, No. 1, that they're going to run out of money."

So, the good news, in a way, has become bad news. And that's not the worst of it. The worst of it is that a lot of these old people who now expect to outlive their savings might decide to kill themselves before they run out of money. I wonder what the financial planners will call that.

(P.S. If you're on the main HN blog page and are looking for a link to add your own comment, just click the headline of the relevant item, and you'll get a page that has a "discuss" link.)

The Audacity of Health

Housekeeping note: If you haven't bookmarked the Human Nature home page, I recommend it. It always has the best and freshest news from around the Web in easy-to-click format. Everything I discuss here, plus the stuff I can't get to, is posted there first. So are links to all the latest Human Nature essays and blog items. If you don't have it bookmarked, and the Slate URL is too hard to remember, just type humannature.us.com.

Here's one story you'll find there and in this morning's news batch: U.S. surgeons have begun the long process of repairing a 15-year-old Filipino girl, Jingle Luis, whose feet are so clubbed that they've twisted upside down and backward. The AP story explains:

Jingle's case is more severe than those usually seen by doctors in industrialized countries. "Generally speaking, with modern technology, it doesn't get to this point," said Dr. Terry Amaral, a pediatric orthopedic surgeon who performed the surgery. ... Clubfoot is a relatively common deformity, occurring in about one in 1,000 births. Children are usually treated in infancy with casts or braces that gradually bring the feet into correct alignment. The condition becomes harder to treat if it is not corrected early on.

It sounds like Jingle wasn't treated as a baby because the Philippines lacked the necessary technology. But that's not what happened. Read further:

Amaral said Jingle's case was complicated by the fact that her clubfoot was associated with spina bifida. ... He said doctors who saw Jingle as a baby thought that her spina bifida would shorten her life span and prevent her from walking, so they did not treat the clubfoot. "They felt it wasn't worth managing because of the life expectancy, so they decided to leave it alone," Amaral said.

This is a major factor in treatment decisions around the world. Often, the problem isn't that doctors in less-developed countries can't fix you. It's that resources are limited and that in this context, life-expectancy projections come into play.

In Jingle's case, doctors misjudged the severity of her spina bifida. If she'd been born in the U.S., it's likely that her doctors would have recognized that the defect wasn't so bad. But it's also likely that they would have calculated her prospects differently altogether. That's because life expectancies differ significantly between rich and poor countries, and life expectancies for infants with significant health problems differ even more. Life expectancy isn't a purely biological calculation. It's a socioeconomic calculation.

The interplay of economic progress, life expectancy, and treatment decisions doesn't end in childhood, or with the case of one disabled girl. In fact, it's going to be one of the most powerful forces driving the world in this century and beyond. Thanks to economic and technological progress, life expectancies are rising around the world. Some of this is due to reductions in child mortality. But a lot of it, if not most, is due to increases in the length of old age. As we conquer diseases and improve public health, people in India, China, and elsewhere can expect to live many years longer. That, in turn, is transforming calculations about which conditions are worth treating. If the average woman in Shanghai is probably going to make it to 75 instead of 65, a disease that strikes her at 60 and would take five years to kill her becomes, in utilitarian terms, a disease worth treating.

What's happening, in short, is an increase not just in our technological ability, but in our moral expectations. It's a wonderful thing. But it's going to be incredibly expensive.