July 17, 2009
Media Matters: Charting a misleading course on health care
Nothing sends media conservatives off the deep end quite like the issue of health care reform. This week was certainly no exception.
This Wednesday on his nationally syndicated radio show, Fox News' Glenn Beck blew up on a caller who dared to challenge his unyielding, misleading war against health care reform. After patronizing the angry caller for several minutes, Beck "los[t]" his "mind," screaming at the caller: "Get off my phone you little pinhead!" Since then, the disturbing exchange has been burning up YouTube and is currently ranked the #5 video overall with more than 350,000 views. MSNBC's David Shuster and Tamron Hall even highlighted the clip as an example of how conservative "anger" has "intensified." Capping things off, Beck's screaming fit spawned a hilarious YouTube user-generated remix titled: "Glenn Beck 'Get Off My Phone' Radio Freak Out (Twilight Vampire Metal Remix)."
Coverage of health care, though, has been anything but funny of late.
This week, the Drudge Report, Fox News Channel, Fox Business and CNBC's The Kudlow Report ran with a chart released by congressional Republicans that day - just one day after House Democrats introduced their health care reform bill -- that purported to show "the complex health care reform proposal by Democratic congressional leaders." The release from Rep. Kevin Brady (TX) about the chart, titled "BAFFLING FLOW CHART; Public Gets Peek at Complicated Bureaucracy in Democratic Health Care Plan," stated that the chart "depicts how the health care system would be organized at the national level if the Democrats' plan became law. These new levels of bureaucracy, agencies, organization and programs will all be put directly between the patient and their health care."
Fox News' Sean Hannity hosted Bill O'Reilly ambush-producer-extraordinaire Griff Jenkins, who described the chart as "Candyland," noting that "whatever it is, it's a lot of government between you and your doctor," while syndicated columnist Charles Krauthammer, also on Fox, touted the chart by saying it makes the health care bill "look like an absurd Rube Goldberg device."
The conservative media's promotion of the House Republican chart harkens back to the media attention devoted in 1994 to a similar misleading chart -- distributed by the office of then-Republican Sen. Arlen Specter -- that then-Senate Republican leader Bob Dole claimed illustrated "what the health care bureaucracy would look like under" President Clinton's health care reform plan.
It really was a textbook example of how the right-wing noise machine operates. Media Matters produced a chart of its own documenting the media's web of misinformation on the subject, illustrating the disturbingly common pattern of conservative spin making its way from a Republican politician's press release to the Drudge Report to Fox News and other outlets on the right. Additionally, I discussed the subject as a guest on MSNBC Live noting, in part, that the conservative movement has been using the media to attack health care reform efforts for more than 70 years.
Not to be left out in the world of insane health care claims, an editorial by the conservative Investor's Business Daily actually claimed that the House tri-committee health-care reform bill includes "a provision making individual private medical insurance illegal." The claim is false, of course, but that didn't stop Rush Limbaugh, the Media Research Center or a host of other media conservatives from advancing the delusional line of attack on reform.
Other Major Stories This Week:
Crazy uncle Pat goes after Sotomayor
Sonia Sotomayor's confirmation hearings took place this week, which provided one final opportunity for her conservative critics to dust off the same set of attacks they unsuccessfully employed shortly after her nomination was announced. It also provided MSNBC's Pat Buchanan with an opportunity to once again test how much vitriol and hatred the peacock-branded cable network is willing to broadcast under the label of "political analysis."
In the span of a few days, Buchanan declared Sotomayor to be a "militant liberal Latina" of limited intellect who had never written any law review articles and who harbored "a lifelong resolve to discriminate against white males." (White men are never prejudiced, in case you were wondering.) After again explaining how Sotomayor is nothing more than an "affirmative action" pick who had been "appointed because she's a Latina, and a Hispanic, and a woman," Buchanan said he didn't "understand" the idea of affirmative action for Hispanics, seeing as they had never suffered through slavery. "This has been a country built, basically, by white folks," he finally told MSNBC's Rachel Maddow, for which she roundly rebuked him. "You're playing with fire," she said during a heated exchange, adding, "[Y]ou're living in the 1950s."
Which brings us back to the question Media Matters' Jamison Foser posed just six short weeks ago: What would Pat Buchanan have to say to get himself fired from MSNBC?
And what, you might ask, of Sotomayor's testimony itself? Fox News' Glenn Beck was so anxious to deride the proceedings that he began criticizing the questioning of the nominee a day before questioning had actually begun. Seriously. Fox News, meanwhile, wasn't particularly intent on showing what the Democratic members had to say, explaining that they might skip one "here or there" because the large Democratic majority meant there were more Democrats on the committee than Republicans. At Fox News, elections just don't have consequences. And why would they care, what with the "all-stars" on the Republican side of the ledger "scuffing ... up" the witness, as Carl Cameron put it. But in the sake of fairness, not everyone at Fox agreed. Sen. Lindsey Graham's airing of sexist, anonymous gripes about Sotomayor were too much even for anchor Megyn Kelly to accept -- although they sounded perfectly acceptable to a host of other reporters at the "fair and balanced" network.
It was perhaps Sen. Jefferson Beauregard Sessions III who led the most charmed life this week. Not only did Fox fawn over his line of questioning, the New York Times quoted his statement that there is "no place in the courtroom" for empathy without mentioning his support of Justice Samuel Alito, who spoke at length about his compassion for people involved in immigration and discrimination cases during his own confirmation hearings. Numerous media outlets also reported Sessions' statement that "I will not vote for -- and no senator should vote for -- an individual nominated by any president who believes it is acceptable for a judge to allow their personal background, gender prejudices, or sympathies to sway their decision in favor of, or against, parties before the court," without noting the crucial Alito context. Major broadcasts ignored conservative hypocrisy on empathy, too, although CNN's Kyra Phillips seemed to get it about right. But this pales in comparison to the fact that major newspapers failed to report on Sessions' alleged history of racial insensitivity in stories discussing his questioning of Sotomayor. Compare this to the endless discussion and distorted versions of Sotomayor's "wise Latina" comment, and you'll come away from the whole thing shaking your head.
Darth Cheney and the CIA controversy
As details continue to trickle out about Dick Cheney's reported role in keeping Congress in the dark about a CIA counterterrorism program, Liz Cheney, the former veep's daughter, took to the airwaves yet again to mount his defense.
MSNBC's Morning Joe hosted the younger, less scary Cheney to discuss recent reports that her father instructed the CIA not to disclose to Congress an intelligence program that CIA director Leon Panetta recently discontinued. Cheney repeatedly defended her father during the interview, and at one point stated, "[Dick Cheney] doesn't comment on classified programs, and obviously I'm not going to comment on classified programs on his behalf." Of course, the Morning Joe crew never asked her to explain what conversations she's had with Dick Cheney about CIA practices and policies during the Bush administration, or whether her father did in fact provide her with classified information that he reportedly withheld from Congress.
Then again, why would anyone ask such tough questions? After all, just last weekend Fox's Chris Wallace was asking whether he was "overly cynical" in thinking Democrats "just trot[ted] out" Dick Cheney because he's always a pretty good "whipping boy."
Friday, July 17, 2009
Thursday, July 16, 2009
To Sleep, Perchance to Analyze
NYTimes By DAVID POGUE
In the last nine years, I’ve reviewed nearly 1,000 products for The New York Times. Can you guess what every single one of them has had in common?
All of them were intended for use while you’re awake.
Today, the exception.
Studies show that about half of all Americans don’t get the recommended amount of sleep. ( For adults it’s seven to nine hours.) And as we stumble our way through each day, groggy and cranky, we pay a terrible price in our relationships, productivity and health.
Science has learned all kinds of things about sleep. We now know, for example, that during the night, we experience several cycles of different kinds of sleep. There’s REM (rapid eye-movement) sleep, which restores and refreshes our brains. There’s deep sleep, which restores and refreshes our muscles. There’s light sleep, which is better than nothing. And there are all those times we wake up but don’t even remember we slept.
Now, to find out why you feel so wretched in the morning, you could go to a sleep lab, pay thousands of dollars, and spend the night hooked up to wires and sensors. Or you could pay $400 and get yourself a Zeo alarm clock.
That’s expensive, sure, but this one does a few things your basic Wal-Mart special doesn’t do.
It comes with an elastic headband, which you’re supposed to wear to bed each night. In its center, resting against the skin of your forehead, there’s a little transmitter pod, something like a digital watch without the band. All night long, this thing measures your brainwaves and transmits them wirelessly to the clock on your nightstand.
When you wake, you put the headband back onto its charging shelf on the clock. The screen comes to life, showing you a very cool graph of your night.
You can walk through it using arrow keys. The clock, and the graph, indicate where you were at each five-minute interval: awake, in light sleep, in REM sleep or in deep sleep. You can also step through screens that display your sleep-cycle tallies in huge digital numbers: “2:54 REM,” “0:35 deep” and so on.
Everything is polished and easy to use, from the way the headband snaps magnetically onto its charging shelf to the way the alarms themselves (music or nature sounds) slowly grow louder the longer you ignore them. If you like, the alarm can try to wake you where you’re sleeping lightly, to prevent the grogginess that comes from being awakened from a deep sleep. (It will never wake you later than the time you’ve set; you specify how much earlier you’re willing to accept.)
And it’s truly amazing, if not a little creepy, to see all of this data about a part of your existence that you’ve known nothing about until now.
But as my wife said, “If I wake up and feel lousy, I don’t need a $400 gadget to tell me it’s because I didn’t sleep well.”
Ah, but that’s where the coaching comes in.
The Zeo stores your sleep records on a memory card. As often as you can, you’re supposed to pop it out and insert it into a U.S.B. card reader (also included) on your computer. At this point, you can go to MyZeo.com and upload your data to the Web.
Now the real fun begins. This Web site lets you slice, dice and cross-compare your sleep data in a million ways.
It starts with a bar chart of your nightly sleep scores. This number (your ZQ, as the company cutely calls it) is a single convenient score that takes into account both the negatives (like disruptions) and the positives (REM and deep sleep). During the month I wore the Zeo, my average was about 70, which is typical for middle-agers like me.
My highest was 105. That was for a luscious 10-hour sleep after an all-nighter.
But you can go much deeper with your statistics. You can plot the quality of your sleep, or one type of sleep, over time, by week or month. Or plot these characteristics against each other, looking for cause and effect. See whether your bedtime affects how long you sleep, whether you get more deep sleep on weekends, whether caffeine in the afternoon affects the number of times you wake up in the night, and so on.
Weirdly, the Zeo system almost completely ignores exercise. There’s no way to report how much you exercised on a given day, to see if it affects your sleep. (Hint: It does. A lot.)
In any case, you get much more utility from all of this if you take the trouble to fill out the Sleep Journal online, where you’re interviewed about events of the previous night: “How sleepy were you when you went to bed?” “How much alcohol did you have within three hours of bedtime?” And so on. The analysis can take these factors into account.
The final benefit of all of this is the coaching. For six months, or longer if you’re willing to pay for it, Zeo’s busy little automated writer robots send you daily semi-personalized e-mail messages, filled with analysis and advice. “It looks like you held to a more consistent sleep schedule in this step than during your baseline,” an initial recording period, it might say. “Well done!”
So will spending $400 on the Zeo make you a better sleeper?
Well, no and yes.
First of all, the headband itself may make it harder for you to fall asleep at first; it has to be tight enough not to fall off during the night. (In my e-mail column next week, I’ll review a rival product, the SleepTracker, in the form of a watch. Sign up at nytimes.com/email.)
Here’s the part that may really bug you, though: the Zeo is soundly based on modern sleep science, and was developed with all kinds of experts. But its 7-Step Sleep Fitness Program, and all the coaching, basically boils down to a list of well-documented sleep tips that won’t come as a surprise to anyone.
You know: Don’t drink alcohol or caffeine before bed. Make your bedroom cool, dark and quiet. Don’t use your bed for anything but sleep and sex. Don’t watch TV, use the computer, do bills or fight in the hour before bed. Don’t sleep with your dog. And so on.
The real question is: if this information is so well known, why are half of us still exhausted all the time?
Simple: we know these rules, but we don’t follow them. They’re lifestyle changes. They’re a hassle. They’re low priority.
Just watching the Zeo track your sleep cycles doesn’t do anything to help you sleep better. Plotting your statistics on the Web doesn’t help, either.
But the funny thing is, you do wind up getting better sleep — because of what I call the Personal Trainer Phenomenon. People who hire a personal trainer at the gym wind up attending more workouts than people who are just members. Why? Because after spending that much money and effort, you take the whole thing much more seriously.
In the same way, the Zeo winds up focusing you so much on sleep that you wind up making some of the lifestyle changes that you could have made on your own, but didn’t. (“Otherwise,” a little voice in your head keeps arguing, “you’ve thrown away $400.”)
That’s the punch line: that in the end, the Zeo does make you a better sleeper. Not through sleep science — but through psychology.
In the last nine years, I’ve reviewed nearly 1,000 products for The New York Times. Can you guess what every single one of them has had in common?
All of them were intended for use while you’re awake.
Today, the exception.
Studies show that about half of all Americans don’t get the recommended amount of sleep. ( For adults it’s seven to nine hours.) And as we stumble our way through each day, groggy and cranky, we pay a terrible price in our relationships, productivity and health.
Science has learned all kinds of things about sleep. We now know, for example, that during the night, we experience several cycles of different kinds of sleep. There’s REM (rapid eye-movement) sleep, which restores and refreshes our brains. There’s deep sleep, which restores and refreshes our muscles. There’s light sleep, which is better than nothing. And there are all those times we wake up but don’t even remember we slept.
Now, to find out why you feel so wretched in the morning, you could go to a sleep lab, pay thousands of dollars, and spend the night hooked up to wires and sensors. Or you could pay $400 and get yourself a Zeo alarm clock.
That’s expensive, sure, but this one does a few things your basic Wal-Mart special doesn’t do.
It comes with an elastic headband, which you’re supposed to wear to bed each night. In its center, resting against the skin of your forehead, there’s a little transmitter pod, something like a digital watch without the band. All night long, this thing measures your brainwaves and transmits them wirelessly to the clock on your nightstand.
When you wake, you put the headband back onto its charging shelf on the clock. The screen comes to life, showing you a very cool graph of your night.
You can walk through it using arrow keys. The clock, and the graph, indicate where you were at each five-minute interval: awake, in light sleep, in REM sleep or in deep sleep. You can also step through screens that display your sleep-cycle tallies in huge digital numbers: “2:54 REM,” “0:35 deep” and so on.
Everything is polished and easy to use, from the way the headband snaps magnetically onto its charging shelf to the way the alarms themselves (music or nature sounds) slowly grow louder the longer you ignore them. If you like, the alarm can try to wake you where you’re sleeping lightly, to prevent the grogginess that comes from being awakened from a deep sleep. (It will never wake you later than the time you’ve set; you specify how much earlier you’re willing to accept.)
And it’s truly amazing, if not a little creepy, to see all of this data about a part of your existence that you’ve known nothing about until now.
But as my wife said, “If I wake up and feel lousy, I don’t need a $400 gadget to tell me it’s because I didn’t sleep well.”
Ah, but that’s where the coaching comes in.
The Zeo stores your sleep records on a memory card. As often as you can, you’re supposed to pop it out and insert it into a U.S.B. card reader (also included) on your computer. At this point, you can go to MyZeo.com and upload your data to the Web.
Now the real fun begins. This Web site lets you slice, dice and cross-compare your sleep data in a million ways.
It starts with a bar chart of your nightly sleep scores. This number (your ZQ, as the company cutely calls it) is a single convenient score that takes into account both the negatives (like disruptions) and the positives (REM and deep sleep). During the month I wore the Zeo, my average was about 70, which is typical for middle-agers like me.
My highest was 105. That was for a luscious 10-hour sleep after an all-nighter.
But you can go much deeper with your statistics. You can plot the quality of your sleep, or one type of sleep, over time, by week or month. Or plot these characteristics against each other, looking for cause and effect. See whether your bedtime affects how long you sleep, whether you get more deep sleep on weekends, whether caffeine in the afternoon affects the number of times you wake up in the night, and so on.
Weirdly, the Zeo system almost completely ignores exercise. There’s no way to report how much you exercised on a given day, to see if it affects your sleep. (Hint: It does. A lot.)
In any case, you get much more utility from all of this if you take the trouble to fill out the Sleep Journal online, where you’re interviewed about events of the previous night: “How sleepy were you when you went to bed?” “How much alcohol did you have within three hours of bedtime?” And so on. The analysis can take these factors into account.
The final benefit of all of this is the coaching. For six months, or longer if you’re willing to pay for it, Zeo’s busy little automated writer robots send you daily semi-personalized e-mail messages, filled with analysis and advice. “It looks like you held to a more consistent sleep schedule in this step than during your baseline,” an initial recording period, it might say. “Well done!”
So will spending $400 on the Zeo make you a better sleeper?
Well, no and yes.
First of all, the headband itself may make it harder for you to fall asleep at first; it has to be tight enough not to fall off during the night. (In my e-mail column next week, I’ll review a rival product, the SleepTracker, in the form of a watch. Sign up at nytimes.com/email.)
Here’s the part that may really bug you, though: the Zeo is soundly based on modern sleep science, and was developed with all kinds of experts. But its 7-Step Sleep Fitness Program, and all the coaching, basically boils down to a list of well-documented sleep tips that won’t come as a surprise to anyone.
You know: Don’t drink alcohol or caffeine before bed. Make your bedroom cool, dark and quiet. Don’t use your bed for anything but sleep and sex. Don’t watch TV, use the computer, do bills or fight in the hour before bed. Don’t sleep with your dog. And so on.
The real question is: if this information is so well known, why are half of us still exhausted all the time?
Simple: we know these rules, but we don’t follow them. They’re lifestyle changes. They’re a hassle. They’re low priority.
Just watching the Zeo track your sleep cycles doesn’t do anything to help you sleep better. Plotting your statistics on the Web doesn’t help, either.
But the funny thing is, you do wind up getting better sleep — because of what I call the Personal Trainer Phenomenon. People who hire a personal trainer at the gym wind up attending more workouts than people who are just members. Why? Because after spending that much money and effort, you take the whole thing much more seriously.
In the same way, the Zeo winds up focusing you so much on sleep that you wind up making some of the lifestyle changes that you could have made on your own, but didn’t. (“Otherwise,” a little voice in your head keeps arguing, “you’ve thrown away $400.”)
That’s the punch line: that in the end, the Zeo does make you a better sleeper. Not through sleep science — but through psychology.
‘No Excuses’ for Any Failure Obama Tells Fellow Blacks
NYTimes-SHERYL GAY STOLBERG
President Obama delivered a fiery sermon to black America on Thursday night, warning black parents that they must accept their own responsibilities by “putting away the Xbox and putting our kids to bed at a reasonable hour,” and telling black children that growing up poor is no reason to get bad grades.
“No one has written your destiny for you,” he said, directing his remarks to “all the other Barack Obamas out there” who might one day grow up to be president. “Your destiny is in your hands, and don’t you forget that. That’s what we have to teach all of our children! No excuses! No excuses!”
Mr. Obama spoke for 45 minutes to an audience of several thousand people, most of them black, , clad in tuxedos and ball gowns, who had gathered in a ballroom of the Hilton New York to celebrate the 100th anniversary of the National Association for the Advancement of Colored People, the nation’s largest civil rights organization.
He was one part politician and one part black preacher as he spoke in lilting cadences, his voice quiet at times, thundering at others, in unusually personal terms. At one point, when his audience shouted back at him, repeating his words, he threw back his head and laughed, saying, “I’ve got an amen corner back there.”
Mr. Obama spoke directly about his own upbringing, crediting his mother (who was white) with setting him straight, and departing from his prepared text to talk about how his life might have turned out had she not. “When I drive through Harlem and I drive through the South Side of Chicago and I see young men on the corners,” he said, “I say there but for the grace of God go I.”
It was an unusual moment for a president who has sought to transcend race and has only reluctantly embraced his unique place in history. Six months into his presidency, Mr. Obama has seemed more comfortable embracing his identity as the first black American president overseas than at home, as was the case during his trip to Ghana last week, when he declared, “I have the blood of Africa within me.”
At home, though, Mr. Obama has largely avoided talking about himself in racial terms. As a candidate, he jumped into the issue of race relations when his campaign was threatened by the controversial remarks of his former pastor, the Rev. Jeremiah A. Wright Jr., and delivered a pointed speech to black fathers on Father’s Day in 2008.
But the White House was low-key in preparations for the N.A.A.C.P. event. When a reporter tried to cast the speech as Mr. Obama’s first to the black community, the press secretary, Robert Gibbs, demurred, saying, “I think the first speech to black America and the first speech to white America, the first speech to America was the Inaugural Address.”
But there was no mistaking Thursday night that Mr. Obama was speaking directly to black America. In part, it was a policy speech.
Mr. Obama told his audience what it wanted to hear on housing, the criminal justice system, education, health care, and jobs — all issues central to the N.A.A.C.P.’s agenda.
Even as he urged blacks to take responsibility for themselves, he spoke of the societal ills — high unemployment, the housing and energy crisis — that have created the conditions for black joblessness. And he said the legacy of the Jim Crow era is still felt, albeit in different ways today.
“Make no mistake: the pain of discrimination is still felt in America,” Mr. Obama said, by African-American women who are paid less for the same work as white men, by Latinos “made to feel unwelcome,” by Muslim Americans “viewed with suspicion” and by “our gay brothers and sisters, still taunted, still attacked, still denied their rights.”
Mr. Obama paid particular attention to education, declaring that more than 50 years after the Supreme Court’s landmark segregation case, Brown v. Board of Education, “the dream of a world-class education is still being deferred all across this country” as African-American students lag behind white classmates in reading and math.
The organization’s president, Benjamin T. Jealous, said afterward that the address “was the most forthright speech on the racial disparities still plaguing our nation” Mr. Obama has given since moving into the White House.
But as much as a policy speech, it was a personal one. Details of the address were closely held, partly because Mr. Obama was still working on it through the afternoon.
Aides said he intended to make the case for personal responsibility — a frequent theme of his presidency — in the context of the civil rights movement and how it has shaped his own life. But he also wanted to send a message to black parents, and especially to black children.
“They might think they’ve got a pretty jump shot or a pretty good flow,” Mr. Obama said, “but our kids can’t all aspire to be LeBron or Lil Wayne. I want them aspiring to be scientists and engineers, doctors and teachers, not just ballers and rappers. I want them aspiring to be a Supreme Court justice. I want them aspiring to be president of the United States of America.”
President Obama delivered a fiery sermon to black America on Thursday night, warning black parents that they must accept their own responsibilities by “putting away the Xbox and putting our kids to bed at a reasonable hour,” and telling black children that growing up poor is no reason to get bad grades.
“No one has written your destiny for you,” he said, directing his remarks to “all the other Barack Obamas out there” who might one day grow up to be president. “Your destiny is in your hands, and don’t you forget that. That’s what we have to teach all of our children! No excuses! No excuses!”
Mr. Obama spoke for 45 minutes to an audience of several thousand people, most of them black, , clad in tuxedos and ball gowns, who had gathered in a ballroom of the Hilton New York to celebrate the 100th anniversary of the National Association for the Advancement of Colored People, the nation’s largest civil rights organization.
He was one part politician and one part black preacher as he spoke in lilting cadences, his voice quiet at times, thundering at others, in unusually personal terms. At one point, when his audience shouted back at him, repeating his words, he threw back his head and laughed, saying, “I’ve got an amen corner back there.”
Mr. Obama spoke directly about his own upbringing, crediting his mother (who was white) with setting him straight, and departing from his prepared text to talk about how his life might have turned out had she not. “When I drive through Harlem and I drive through the South Side of Chicago and I see young men on the corners,” he said, “I say there but for the grace of God go I.”
It was an unusual moment for a president who has sought to transcend race and has only reluctantly embraced his unique place in history. Six months into his presidency, Mr. Obama has seemed more comfortable embracing his identity as the first black American president overseas than at home, as was the case during his trip to Ghana last week, when he declared, “I have the blood of Africa within me.”
At home, though, Mr. Obama has largely avoided talking about himself in racial terms. As a candidate, he jumped into the issue of race relations when his campaign was threatened by the controversial remarks of his former pastor, the Rev. Jeremiah A. Wright Jr., and delivered a pointed speech to black fathers on Father’s Day in 2008.
But the White House was low-key in preparations for the N.A.A.C.P. event. When a reporter tried to cast the speech as Mr. Obama’s first to the black community, the press secretary, Robert Gibbs, demurred, saying, “I think the first speech to black America and the first speech to white America, the first speech to America was the Inaugural Address.”
But there was no mistaking Thursday night that Mr. Obama was speaking directly to black America. In part, it was a policy speech.
Mr. Obama told his audience what it wanted to hear on housing, the criminal justice system, education, health care, and jobs — all issues central to the N.A.A.C.P.’s agenda.
Even as he urged blacks to take responsibility for themselves, he spoke of the societal ills — high unemployment, the housing and energy crisis — that have created the conditions for black joblessness. And he said the legacy of the Jim Crow era is still felt, albeit in different ways today.
“Make no mistake: the pain of discrimination is still felt in America,” Mr. Obama said, by African-American women who are paid less for the same work as white men, by Latinos “made to feel unwelcome,” by Muslim Americans “viewed with suspicion” and by “our gay brothers and sisters, still taunted, still attacked, still denied their rights.”
Mr. Obama paid particular attention to education, declaring that more than 50 years after the Supreme Court’s landmark segregation case, Brown v. Board of Education, “the dream of a world-class education is still being deferred all across this country” as African-American students lag behind white classmates in reading and math.
The organization’s president, Benjamin T. Jealous, said afterward that the address “was the most forthright speech on the racial disparities still plaguing our nation” Mr. Obama has given since moving into the White House.
But as much as a policy speech, it was a personal one. Details of the address were closely held, partly because Mr. Obama was still working on it through the afternoon.
Aides said he intended to make the case for personal responsibility — a frequent theme of his presidency — in the context of the civil rights movement and how it has shaped his own life. But he also wanted to send a message to black parents, and especially to black children.
“They might think they’ve got a pretty jump shot or a pretty good flow,” Mr. Obama said, “but our kids can’t all aspire to be LeBron or Lil Wayne. I want them aspiring to be scientists and engineers, doctors and teachers, not just ballers and rappers. I want them aspiring to be a Supreme Court justice. I want them aspiring to be president of the United States of America.”
Ginsburg Defends Sotomayor
Ginsburg Calls ‘Wise Latina’ Flap Ridiculous
By Debra Cassens Weiss
Justice Ruth Bader Ginsburg thinks it’s ridiculous for critics to make a big deal about the “wise Latina” comment by Sonia Sotomayor, the federal appeals judge nominated to join Ginsburg as a second female justice on the U.S. Supreme Court.
In a New York Times interview, Ginsburg delved into the controversy over a 2001 appearance by Sotomayor in which she said, “I would hope that a wise Latina woman with the richness of her experiences would more often than not reach a better conclusion than a white male who hasn’t lived that life.”
Interviewer: “Did you think that all the attention to the criticism of Sotomayor as being ‘bullying’ or not as smart is sex-inflected? Does that have to do with the rarity of a woman in her position, and the particular challenges?"
Ginsburg: “I can’t say that it was just that she was a woman. There are some people in Congress who would criticize severely anyone President Obama nominated. They’ll seize on any handle. One is that she’s a woman, another is that she made the remark about Latina women. And I thought it was ridiculous for them to make a big deal out of that. Think of how many times you’ve said something that you didn’t get out quite right, and you would edit your statement if you could. I’m sure she meant no more than what I mean when I say: Yes, women bring a different life experience to the table. All of our differences make the conference better. That I’m a woman, that’s part of it, that I’m Jewish, that’s part of it, that I grew up in Brooklyn, N.Y., and I went to summer camp in the Adirondacks, all these things are part of me.
“Once Justice O’Connor was questioning counsel at oral argument. I thought she was done, so I asked a question, and Sandra said: Just a minute, I’m not finished. So I apologized to her and she said, It’s OK, Ruth. The guys do it to each other all the time, they step on each other’s questions. And then there appeared an item in USA Today, and the headline was something like ‘Rude Ruth Interrupts Sandra.' ”
Interviewer: “It seemed to me that male judges do much more abrasive things all the time, and it goes unremarked.”
Ginsburg: “Yes, the notion that Sonia is an aggressive questioner—what else is new? Has anybody watched Scalia or Breyer up on the bench?”
Interviewer: “She’ll fit right in?”
Ginsburg: “She’ll hold her own.”
Ginsburg also responded to a question about Sotomayor’s claim that she is a product of affirmative action. Ginsburg said she has benefited too, becoming the first tenured woman at Columbia law school because of affirmative-action pressure from the Nixon administration. She added that it’s important for feminists to work with men: “If you’re going to change things, you have to be with the people who hold the levers,” she told the interviewer.
Ginsburg told the interviewer that she is “doubtful” about academic studies finding a difference in the way male and female judges of similar ideologies vote in some cases. But she appeared to waffle when the interviewer asked what the U.S. Supreme Court would be like if three or four women were justices.
Asked if the results might be different in discrimination cases, Ginsburg gave this answer: “I think for the most part, yes. I would suspect that, because the women will relate to their own experiences.”
Ginsburg also touched on Roe v. Wade in the interview, saying she believes the right to abortion will one day be rooted in the constitutional right to sex equality. If she were a lawyer, rather than a justice, reproductive choice would be on her legal agenda, she said.
In another part of the interview, Ginsburg reveals the truth behind a newspaper account that told of her taking a long time to rise from the bench. “They worried, was I frail?” Ginsburg said. “To be truthful I had kicked off my shoes, and I couldn’t find my right shoe; it traveled way underneath.”
By Debra Cassens Weiss
Justice Ruth Bader Ginsburg thinks it’s ridiculous for critics to make a big deal about the “wise Latina” comment by Sonia Sotomayor, the federal appeals judge nominated to join Ginsburg as a second female justice on the U.S. Supreme Court.
In a New York Times interview, Ginsburg delved into the controversy over a 2001 appearance by Sotomayor in which she said, “I would hope that a wise Latina woman with the richness of her experiences would more often than not reach a better conclusion than a white male who hasn’t lived that life.”
Interviewer: “Did you think that all the attention to the criticism of Sotomayor as being ‘bullying’ or not as smart is sex-inflected? Does that have to do with the rarity of a woman in her position, and the particular challenges?"
Ginsburg: “I can’t say that it was just that she was a woman. There are some people in Congress who would criticize severely anyone President Obama nominated. They’ll seize on any handle. One is that she’s a woman, another is that she made the remark about Latina women. And I thought it was ridiculous for them to make a big deal out of that. Think of how many times you’ve said something that you didn’t get out quite right, and you would edit your statement if you could. I’m sure she meant no more than what I mean when I say: Yes, women bring a different life experience to the table. All of our differences make the conference better. That I’m a woman, that’s part of it, that I’m Jewish, that’s part of it, that I grew up in Brooklyn, N.Y., and I went to summer camp in the Adirondacks, all these things are part of me.
“Once Justice O’Connor was questioning counsel at oral argument. I thought she was done, so I asked a question, and Sandra said: Just a minute, I’m not finished. So I apologized to her and she said, It’s OK, Ruth. The guys do it to each other all the time, they step on each other’s questions. And then there appeared an item in USA Today, and the headline was something like ‘Rude Ruth Interrupts Sandra.' ”
Interviewer: “It seemed to me that male judges do much more abrasive things all the time, and it goes unremarked.”
Ginsburg: “Yes, the notion that Sonia is an aggressive questioner—what else is new? Has anybody watched Scalia or Breyer up on the bench?”
Interviewer: “She’ll fit right in?”
Ginsburg: “She’ll hold her own.”
Ginsburg also responded to a question about Sotomayor’s claim that she is a product of affirmative action. Ginsburg said she has benefited too, becoming the first tenured woman at Columbia law school because of affirmative-action pressure from the Nixon administration. She added that it’s important for feminists to work with men: “If you’re going to change things, you have to be with the people who hold the levers,” she told the interviewer.
Ginsburg told the interviewer that she is “doubtful” about academic studies finding a difference in the way male and female judges of similar ideologies vote in some cases. But she appeared to waffle when the interviewer asked what the U.S. Supreme Court would be like if three or four women were justices.
Asked if the results might be different in discrimination cases, Ginsburg gave this answer: “I think for the most part, yes. I would suspect that, because the women will relate to their own experiences.”
Ginsburg also touched on Roe v. Wade in the interview, saying she believes the right to abortion will one day be rooted in the constitutional right to sex equality. If she were a lawyer, rather than a justice, reproductive choice would be on her legal agenda, she said.
In another part of the interview, Ginsburg reveals the truth behind a newspaper account that told of her taking a long time to rise from the bench. “They worried, was I frail?” Ginsburg said. “To be truthful I had kicked off my shoes, and I couldn’t find my right shoe; it traveled way underneath.”
NICHOLAS D. KRISTOF Chemicals and Our Health
NYTimes
However careful you are about your health, your body is almost certainly home to troubling chemicals called phthalates. These are ubiquitous in modern life, found in plastic bottles, cosmetics, some toys, hair conditioners, and fragrances — and many scientists have linked them to everything from sexual deformities in babies to obesity and diabetes.
The problem is that phthalates suppress male hormones and sometimes mimic female hormones. As I’ve written before, chemicals called endocrine disruptors are believed to explain the proliferation of “intersex fish” — male fish that produce eggs — as well as sexual deformities in animals and humans. Phthalates (pronounced THAL-ates) are among the most common endocrine disruptors, and among the most difficult to avoid. They’re even in tap water, and levels soar in certain plastic water bottles.
They probably are not harmful to us adults, but it is another story for children. In girls, some research suggests that phthalates may cause early onset puberty. Most vulnerable of all, it seems, are male fetuses in the first trimester of pregnancy, just as they are differentiating their sex. At that stage, scholars believe, phthalates may “feminize” these boys.
“Commonly used phthalates may undervirilize humans,” concluded a study by the University of Rochester. The study, which was small, based its conclusion, in part, on measurements of “anogenital distance” — the distance between the anus and the genitals, which is typically twice as long for males as for females. Some scholars believe that shrinkage of this distance reflects “feminization” of male anatomy.
The researchers found that pregnant women with higher levels of phthalates delivered babies with a shorter anogenital distance. It’s possible this won’t cause any complications. But baby boys with shorter anogenital distance were more likely to have undescended testicles and less penile volume, and phthalates have been linked in humans to problems with sperm count and sperm quality.
In China, researchers found that female rats given phthalates gave birth to males with a penis deformity called hypospadias (in which the urethra exits the side or base of the penis, not the tip). Many other animal studies around the world have found similar results.
Some endocrinologists refer to the “phthalate syndrome,” including hypospadias and undescended testicles.
“Accumulating human epidemiological data point to a relationship between adverse fetal development and phthalate exposure,” concluded an article this spring in the journal Trends in Endocrinology and Metabolism. Just last month, the Endocrine Society — composed of thousands of doctors in the field — issued a powerful warning that endocrine disruptors including phthalates are “a significant concern to public health.”
One of the conundrums for scientists and journalists alike is how to call prudent attention to murky and uncertain risks, without sensationalizing dangers that may not exist? Increasingly, endocrinologists are concluding that the mounting evidence is enough to raise alarms.
Indeed, there has also been a flurry of scientific articles questioning whether endocrine disruptors are tied to obesity, autism and allergies, although the evidence there is less firm than with genital abnormalities and depressed sperm count.
The American Chemistry Council argues that phthalates are not a problem, that they do not migrate out of products easily and that they quickly break down in the body. The chemical industry has noted an apparently reassuring study in the Journal of Urology finding that hypospadias does not seem to be increasing in New York State (although different studies showed increases both in the United States and in Denmark).
James Yager, a professor of toxicology at the Johns Hopkins Bloomberg School of Public Health, agrees that there are huge uncertainties but says that pregnant women and children should be cautious. “When my wife was pregnant, we worried about drinking or smoking,” Professor Yager said. Now, he said, he would be more focused on exposure to chemicals such as phthalates in baby bottles.
Dr. Theo Colborn, the founder of the Endocrine Disruption Exchange, goes further. She tells researchers working with her to toss out plastic water bottles and use stainless steel instead. “I don’t have plastic food containers in my house,” she added. “I use glass.”
Certain phthalates have been banned from new toys sold in the United States, but kids continue to be exposed to these chemicals from the moment they are conceived. Dr. Ted Schettler of the Science and Environmental Health Network says that the way regulators examine risks — studying the impact of one chemical at a time — is bankrupt, for we’re exposed to a cocktail of them daily. Regulation is so pathetic that there’s not even disclosure when products contain phthalates.
If terrorists were putting phthalates in our drinking water, we would be galvanized to defend ourselves and to spend billions of dollars to ensure our safety. But the risks are just as serious if we’re poisoning ourselves, and it’s time for the Obama administration and Congress to show leadership in this area.
However careful you are about your health, your body is almost certainly home to troubling chemicals called phthalates. These are ubiquitous in modern life, found in plastic bottles, cosmetics, some toys, hair conditioners, and fragrances — and many scientists have linked them to everything from sexual deformities in babies to obesity and diabetes.
The problem is that phthalates suppress male hormones and sometimes mimic female hormones. As I’ve written before, chemicals called endocrine disruptors are believed to explain the proliferation of “intersex fish” — male fish that produce eggs — as well as sexual deformities in animals and humans. Phthalates (pronounced THAL-ates) are among the most common endocrine disruptors, and among the most difficult to avoid. They’re even in tap water, and levels soar in certain plastic water bottles.
They probably are not harmful to us adults, but it is another story for children. In girls, some research suggests that phthalates may cause early onset puberty. Most vulnerable of all, it seems, are male fetuses in the first trimester of pregnancy, just as they are differentiating their sex. At that stage, scholars believe, phthalates may “feminize” these boys.
“Commonly used phthalates may undervirilize humans,” concluded a study by the University of Rochester. The study, which was small, based its conclusion, in part, on measurements of “anogenital distance” — the distance between the anus and the genitals, which is typically twice as long for males as for females. Some scholars believe that shrinkage of this distance reflects “feminization” of male anatomy.
The researchers found that pregnant women with higher levels of phthalates delivered babies with a shorter anogenital distance. It’s possible this won’t cause any complications. But baby boys with shorter anogenital distance were more likely to have undescended testicles and less penile volume, and phthalates have been linked in humans to problems with sperm count and sperm quality.
In China, researchers found that female rats given phthalates gave birth to males with a penis deformity called hypospadias (in which the urethra exits the side or base of the penis, not the tip). Many other animal studies around the world have found similar results.
Some endocrinologists refer to the “phthalate syndrome,” including hypospadias and undescended testicles.
“Accumulating human epidemiological data point to a relationship between adverse fetal development and phthalate exposure,” concluded an article this spring in the journal Trends in Endocrinology and Metabolism. Just last month, the Endocrine Society — composed of thousands of doctors in the field — issued a powerful warning that endocrine disruptors including phthalates are “a significant concern to public health.”
One of the conundrums for scientists and journalists alike is how to call prudent attention to murky and uncertain risks, without sensationalizing dangers that may not exist? Increasingly, endocrinologists are concluding that the mounting evidence is enough to raise alarms.
Indeed, there has also been a flurry of scientific articles questioning whether endocrine disruptors are tied to obesity, autism and allergies, although the evidence there is less firm than with genital abnormalities and depressed sperm count.
The American Chemistry Council argues that phthalates are not a problem, that they do not migrate out of products easily and that they quickly break down in the body. The chemical industry has noted an apparently reassuring study in the Journal of Urology finding that hypospadias does not seem to be increasing in New York State (although different studies showed increases both in the United States and in Denmark).
James Yager, a professor of toxicology at the Johns Hopkins Bloomberg School of Public Health, agrees that there are huge uncertainties but says that pregnant women and children should be cautious. “When my wife was pregnant, we worried about drinking or smoking,” Professor Yager said. Now, he said, he would be more focused on exposure to chemicals such as phthalates in baby bottles.
Dr. Theo Colborn, the founder of the Endocrine Disruption Exchange, goes further. She tells researchers working with her to toss out plastic water bottles and use stainless steel instead. “I don’t have plastic food containers in my house,” she added. “I use glass.”
Certain phthalates have been banned from new toys sold in the United States, but kids continue to be exposed to these chemicals from the moment they are conceived. Dr. Ted Schettler of the Science and Environmental Health Network says that the way regulators examine risks — studying the impact of one chemical at a time — is bankrupt, for we’re exposed to a cocktail of them daily. Regulation is so pathetic that there’s not even disclosure when products contain phthalates.
If terrorists were putting phthalates in our drinking water, we would be galvanized to defend ourselves and to spend billions of dollars to ensure our safety. But the risks are just as serious if we’re poisoning ourselves, and it’s time for the Obama administration and Congress to show leadership in this area.
3 Days of the Sotomayor GAIL COLLINS
NYTimes
DAY 1
JUDICIARY COMMITTEE CHAIRMAN PATRICK LEAHY: Judge Sotomayor, welcome to you and your large and lovely family, including your mother, who I believe saved up to buy your first encyclopedia when she was a hard-working widow. Let me begin the opening statements by noting that you have more federal court judicial experience than any nominee to the United States Supreme Court in nearly a hundred years. And the Constitution — is that a great document or what? And now, the ranking Republican from Alabama.
SENATOR JEFF SESSIONS: Thank you, Chairman. Judge Sotomayor, let’s talk about empathy. I find it shocking that President Obama said that judges should have empathy. I hate empathy. My Republican colleagues hate empathy. In fact, I am proud to say that we’ve reached an all-time low in the “understands the problems of ordinary people” category.
SENATOR RUSS FEINGOLD: Judge Sotomayor, if confirmed, you will join the Supreme Court with more federal judicial experience than any justice in the past 100 years. And, therefore, I will devote my time to complaining about the way the Bush administration pummeled our civil liberties.
SENATOR ORRIN HATCH: Mr. Chairman, thank you for the opportunity to point out that we once had a Hispanic nominee for something, and the Democrats filibustered him.
SENATOR KIRSTEN GILLIBRAND: Mr. Chairman, as the newly appointed junior senator from New York, I want to thank you for the opportunity to introduce Judge Sotomayor. Normally I speak really, really fast, but due to the importance of this occasion I am going to go really, really slow. Which will mean that my five minutes will be over before I get anywhere near ...
JUDGE SOTOMAYOR: Thank you, committee members. In recent weeks, I have had the pleasure and privilege of meeting with 89 senators. Thank God Senator Inhofe said he didn’t need to talk to me because he’d already made up his mind to vote No.
DAY 2
CHAIRMAN LEAHY: We’re now going to start with the question period. I would like to begin by asking how it feels to have more federal court judicial experience than any nominee to the United States Supreme Court in nearly a hundred years.
JUDGE SOTOMAYOR: Thank you for that interesting question. What my 17-year record on two courts has taught me is the importance of keeping an open mind. And following precedent. And not answering any hypothetical questions about abortion or gun control.
SENATOR SESSIONS: Judge, to get back to that “wise Latina” speech, I want to know if you think judges should allow their prejudices to impact decision-making. For instance, if I were a plaintiff before your court, would you be less inclined to rule in my favor because my middle name is Beauregard?
JUDGE SOTOMAYOR: Senator, I do not permit my sympathies, personal views or prejudices to influence the outcome of my cases. But thank you for sharing.
SENATOR HERB KOHL: I believe I heard somewhere that you would join the Supreme Court with more federal judicial experience than any justice in the past 100 years. Doesn’t your very, very low reversal rate show how exceptionally well you have performed?
JUDGE SOTOMAYOR: Senator, thank you for that softball question. Which reminds me to point out that in 1995 I ended the baseball strike.
SENATOR LINDSEY GRAHAM: Judge, before I read a string of anonymous comments about your temperament problem, I’d like to make you repeat that wise Latina remark again just for the heck of it.
JUDGE SOTOMAYOR: Thank you, Senator, for the opportunity to revisit that matter. I appreciate that the man who once said he’d drown himself if North Carolina went for Obama has a special contribution to make when it comes to the importance of thinking before you speak.
DAY 3
SENATOR ARLEN SPECTER: Before we get to my questions, I would like to tell you several anecdotes about my own interesting history. Did I mention that I used to be chairman of this committee?
SENATOR JOHN CORNYN: I have here a newspaper story quoting a corporate lawyer who worked with you 17 years ago as saying that you would vote for abortion rights. What does he know that we don’t?
JUDGE SOTOMAYOR: That was sometime between my graduating summa cum laude from Princeton and the year I ended the baseball strike. While I can’t answer your question, perhaps it would help if I said that I am bound by precedent and my mind is always open.
SENATOR TOM COBURN: Judge, I’d like to ask you a number of hypothetical questions about abortion and gun control. A lot of Americans are watching these hearings.
JUDGE SOTOMAYOR: Hardly likely at this point, Senator.
DAY 1
JUDICIARY COMMITTEE CHAIRMAN PATRICK LEAHY: Judge Sotomayor, welcome to you and your large and lovely family, including your mother, who I believe saved up to buy your first encyclopedia when she was a hard-working widow. Let me begin the opening statements by noting that you have more federal court judicial experience than any nominee to the United States Supreme Court in nearly a hundred years. And the Constitution — is that a great document or what? And now, the ranking Republican from Alabama.
SENATOR JEFF SESSIONS: Thank you, Chairman. Judge Sotomayor, let’s talk about empathy. I find it shocking that President Obama said that judges should have empathy. I hate empathy. My Republican colleagues hate empathy. In fact, I am proud to say that we’ve reached an all-time low in the “understands the problems of ordinary people” category.
SENATOR RUSS FEINGOLD: Judge Sotomayor, if confirmed, you will join the Supreme Court with more federal judicial experience than any justice in the past 100 years. And, therefore, I will devote my time to complaining about the way the Bush administration pummeled our civil liberties.
SENATOR ORRIN HATCH: Mr. Chairman, thank you for the opportunity to point out that we once had a Hispanic nominee for something, and the Democrats filibustered him.
SENATOR KIRSTEN GILLIBRAND: Mr. Chairman, as the newly appointed junior senator from New York, I want to thank you for the opportunity to introduce Judge Sotomayor. Normally I speak really, really fast, but due to the importance of this occasion I am going to go really, really slow. Which will mean that my five minutes will be over before I get anywhere near ...
JUDGE SOTOMAYOR: Thank you, committee members. In recent weeks, I have had the pleasure and privilege of meeting with 89 senators. Thank God Senator Inhofe said he didn’t need to talk to me because he’d already made up his mind to vote No.
DAY 2
CHAIRMAN LEAHY: We’re now going to start with the question period. I would like to begin by asking how it feels to have more federal court judicial experience than any nominee to the United States Supreme Court in nearly a hundred years.
JUDGE SOTOMAYOR: Thank you for that interesting question. What my 17-year record on two courts has taught me is the importance of keeping an open mind. And following precedent. And not answering any hypothetical questions about abortion or gun control.
SENATOR SESSIONS: Judge, to get back to that “wise Latina” speech, I want to know if you think judges should allow their prejudices to impact decision-making. For instance, if I were a plaintiff before your court, would you be less inclined to rule in my favor because my middle name is Beauregard?
JUDGE SOTOMAYOR: Senator, I do not permit my sympathies, personal views or prejudices to influence the outcome of my cases. But thank you for sharing.
SENATOR HERB KOHL: I believe I heard somewhere that you would join the Supreme Court with more federal judicial experience than any justice in the past 100 years. Doesn’t your very, very low reversal rate show how exceptionally well you have performed?
JUDGE SOTOMAYOR: Senator, thank you for that softball question. Which reminds me to point out that in 1995 I ended the baseball strike.
SENATOR LINDSEY GRAHAM: Judge, before I read a string of anonymous comments about your temperament problem, I’d like to make you repeat that wise Latina remark again just for the heck of it.
JUDGE SOTOMAYOR: Thank you, Senator, for the opportunity to revisit that matter. I appreciate that the man who once said he’d drown himself if North Carolina went for Obama has a special contribution to make when it comes to the importance of thinking before you speak.
DAY 3
SENATOR ARLEN SPECTER: Before we get to my questions, I would like to tell you several anecdotes about my own interesting history. Did I mention that I used to be chairman of this committee?
SENATOR JOHN CORNYN: I have here a newspaper story quoting a corporate lawyer who worked with you 17 years ago as saying that you would vote for abortion rights. What does he know that we don’t?
JUDGE SOTOMAYOR: That was sometime between my graduating summa cum laude from Princeton and the year I ended the baseball strike. While I can’t answer your question, perhaps it would help if I said that I am bound by precedent and my mind is always open.
SENATOR TOM COBURN: Judge, I’d like to ask you a number of hypothetical questions about abortion and gun control. A lot of Americans are watching these hearings.
JUDGE SOTOMAYOR: Hardly likely at this point, Senator.
Wednesday, July 15, 2009
WOULD YOU DIE FOR LOVE? Suicide Sweethearts?
With Help, Conductor and Wife Ended Lives By JOHN F. BURNS
LONDON — The controversy over the ethical and legal issues surrounding assisted suicide for the terminally ill was thrown into stark relief on Tuesday with the announcement that one of Britain’s most distinguished orchestra conductors, Sir Edward Downes, had flown to Switzerland last week with his wife and joined her in drinking a lethal cocktail of barbiturates provided by an assisted-suicide clinic.
Although friends who spoke to the British news media said Sir Edward was not known to have been terminally ill, they said he wanted to die with his ailing wife, who had been his partner for more than half a century.
The couple’s children said in an interview with The London Evening Standard that on Tuesday of last week they accompanied their father, 85, and their mother, Joan, 74, on the flight to Zurich, where the Swiss group Dignitas helped arrange the suicides. On Friday, the children said, they watched, weeping, as their parents drank “a small quantity of clear liquid” before lying down on adjacent beds, holding hands.
“Within a couple of minutes they were asleep, and died within 10 minutes,” Caractacus Downes, the couple’s 41-year-old son, said in the interview after his return to Britain. “They wanted to be next to each other when they died.” He added, “It is a very civilized way to end your life, and I don’t understand why the legal position in this country doesn’t allow it.”
Sir Edward, who was described in a statement issued earlier on Tuesday by Mr. Downes and his sister, Boudicca, 39, as “almost blind and increasingly deaf,” was principal conductor of the BBC Philharmonic Orchestra from 1980 to 1991. He was also a conductor of the Royal Opera House at Covent Garden in London, where he led 950 performances over more than 50 years.
Lady Downes, who British newspapers said was in the final stages of terminal cancer, was a former ballet dancer, choreographer and television producer who devoted her later years to working as her husband’s assistant.
“After 54 happy years together, they decided to end their own lives rather than continue to struggle with serious health problems,” the Downes children said in their statement.
British families who have used the Zurich clinic in the past have said that Dignitas charges about $6,570 for each assisted suicide.
Scotland Yard said in a statement on Tuesday that it had been informed on Monday “that a man and a woman” from London had died in Switzerland, and that it was “looking into the circumstances.” The information that prompted the police inquiry appeared to have been given voluntarily by the Downes family, which, Caractacus Downes said, “didn’t want to be untruthful about what had happened.”
“Even if they arrest us and send us to prison, it would have made no difference because it is what our parents wanted,” he said.
Attempting suicide has not been a criminal offense in Britain since 1961, but assisting others to kill themselves is. But since the Zurich clinic run by Dignitas was established in 1998 under Swiss laws that allow clinics to provide lethal drugs, British authorities have effectively turned a blind eye to Britons who go there to die.
None of the family members and friends who have accompanied the 117 people living in Britain who have traveled to the Zurich clinic for help in ending their lives have been charged with an offense. Legal experts said it was unlikely that that would change in the Downes case.
But British news reports about the Downeses’ suicides noted one factor that appeared to set the case apart from others involving the Dignitas clinic: Sir Edward appeared not to have been terminally ill. There have been at least three other cases similar to the Downeses’, in which a spouse who was not terminally ill chose to die with the other.
Sir Edward was known for his support for British composers and his passion for Prokofiev and Verdi. After studying at the Royal College of Music in London, he joined the Royal Opera House in 1952. His first assignment was prompting the soprano Maria Callas. He traveled widely as a conductor and became music director of the Australian Opera in the 1970s.
Friends of Sir Edward said that his decision to die with his wife did not surprise them. “Ted was completely rational,” said Richard Wigley, the general manager of the BBC Philharmonic. “So I can well imagine him, being so rational, saying, ‘It’s been great, so let’s end our lives together.’ ”
Jonathan Groves, Sir Edward’s manager, called their decision “typically brave and courageous.”
But even among those who support decriminalizing assisted suicide, Sir Edward’s death raised troubling questions. Sarah Wootton, chief executive of Dignity in Dying, said in a BBC interview that the growing numbers of Britons going abroad to die, and the manner of their deaths, made it more urgent to amend Britain’s laws. There are “no safeguards, no brakes on the process at all,” she said.
The British Medical Association voted this month against legalizing assisted suicide, or lifting the threat of prosecution from “friends and relatives who accompany loved ones to die abroad.” Last week, the House of Lords defeated a bill that would have allowed people, subject to safeguards, to travel abroad to help people choosing to die.
This article has been revised to reflect the following correction:
Correction: July 16, 2009
An article on Wednesday about the double assisted suicide of a distinguished British conductor and his wife at a clinic in Switzerland misstated British law on suicides. Assisting others to commit suicide is a criminal offense, not attempting suicide. (The prohibition on attempting suicide was decriminalized in 1961.).
LONDON — The controversy over the ethical and legal issues surrounding assisted suicide for the terminally ill was thrown into stark relief on Tuesday with the announcement that one of Britain’s most distinguished orchestra conductors, Sir Edward Downes, had flown to Switzerland last week with his wife and joined her in drinking a lethal cocktail of barbiturates provided by an assisted-suicide clinic.
Although friends who spoke to the British news media said Sir Edward was not known to have been terminally ill, they said he wanted to die with his ailing wife, who had been his partner for more than half a century.
The couple’s children said in an interview with The London Evening Standard that on Tuesday of last week they accompanied their father, 85, and their mother, Joan, 74, on the flight to Zurich, where the Swiss group Dignitas helped arrange the suicides. On Friday, the children said, they watched, weeping, as their parents drank “a small quantity of clear liquid” before lying down on adjacent beds, holding hands.
“Within a couple of minutes they were asleep, and died within 10 minutes,” Caractacus Downes, the couple’s 41-year-old son, said in the interview after his return to Britain. “They wanted to be next to each other when they died.” He added, “It is a very civilized way to end your life, and I don’t understand why the legal position in this country doesn’t allow it.”
Sir Edward, who was described in a statement issued earlier on Tuesday by Mr. Downes and his sister, Boudicca, 39, as “almost blind and increasingly deaf,” was principal conductor of the BBC Philharmonic Orchestra from 1980 to 1991. He was also a conductor of the Royal Opera House at Covent Garden in London, where he led 950 performances over more than 50 years.
Lady Downes, who British newspapers said was in the final stages of terminal cancer, was a former ballet dancer, choreographer and television producer who devoted her later years to working as her husband’s assistant.
“After 54 happy years together, they decided to end their own lives rather than continue to struggle with serious health problems,” the Downes children said in their statement.
British families who have used the Zurich clinic in the past have said that Dignitas charges about $6,570 for each assisted suicide.
Scotland Yard said in a statement on Tuesday that it had been informed on Monday “that a man and a woman” from London had died in Switzerland, and that it was “looking into the circumstances.” The information that prompted the police inquiry appeared to have been given voluntarily by the Downes family, which, Caractacus Downes said, “didn’t want to be untruthful about what had happened.”
“Even if they arrest us and send us to prison, it would have made no difference because it is what our parents wanted,” he said.
Attempting suicide has not been a criminal offense in Britain since 1961, but assisting others to kill themselves is. But since the Zurich clinic run by Dignitas was established in 1998 under Swiss laws that allow clinics to provide lethal drugs, British authorities have effectively turned a blind eye to Britons who go there to die.
None of the family members and friends who have accompanied the 117 people living in Britain who have traveled to the Zurich clinic for help in ending their lives have been charged with an offense. Legal experts said it was unlikely that that would change in the Downes case.
But British news reports about the Downeses’ suicides noted one factor that appeared to set the case apart from others involving the Dignitas clinic: Sir Edward appeared not to have been terminally ill. There have been at least three other cases similar to the Downeses’, in which a spouse who was not terminally ill chose to die with the other.
Sir Edward was known for his support for British composers and his passion for Prokofiev and Verdi. After studying at the Royal College of Music in London, he joined the Royal Opera House in 1952. His first assignment was prompting the soprano Maria Callas. He traveled widely as a conductor and became music director of the Australian Opera in the 1970s.
Friends of Sir Edward said that his decision to die with his wife did not surprise them. “Ted was completely rational,” said Richard Wigley, the general manager of the BBC Philharmonic. “So I can well imagine him, being so rational, saying, ‘It’s been great, so let’s end our lives together.’ ”
Jonathan Groves, Sir Edward’s manager, called their decision “typically brave and courageous.”
But even among those who support decriminalizing assisted suicide, Sir Edward’s death raised troubling questions. Sarah Wootton, chief executive of Dignity in Dying, said in a BBC interview that the growing numbers of Britons going abroad to die, and the manner of their deaths, made it more urgent to amend Britain’s laws. There are “no safeguards, no brakes on the process at all,” she said.
The British Medical Association voted this month against legalizing assisted suicide, or lifting the threat of prosecution from “friends and relatives who accompany loved ones to die abroad.” Last week, the House of Lords defeated a bill that would have allowed people, subject to safeguards, to travel abroad to help people choosing to die.
This article has been revised to reflect the following correction:
Correction: July 16, 2009
An article on Wednesday about the double assisted suicide of a distinguished British conductor and his wife at a clinic in Switzerland misstated British law on suicides. Assisting others to commit suicide is a criminal offense, not attempting suicide. (The prohibition on attempting suicide was decriminalized in 1961.).
White Man’s Last Stand MAUREEN DOWD
NYTimes/Washington
You can’t judge a judge by her cover.
Despite the best efforts of Republicans to root out any sign that Sonia Sotomayor has emotions that color her views on the law, the Bronx Bomber kept a robotic mask in place.
A wise Latina woman with the richness of her experiences would more often than not know that a gaggle of white Republican men afraid of extinction are out to trip her up.
After all, these guys have never needed to speak inspirational words to others like them, as Sotomayor has done. They’ve had codes, handshakes and clubs to do that.
So when Republican Senator Jon Kyl, without so much as a howdy-do, went at Sotomayor, and soon was asking her if she agreed with Barack Obama’s contention, when he voted against John Roberts, that a judge’s heart is important, the would-be justice was as adroit as her idol Nancy Drew.
“No, sir,” she said, indicating that the only bleeding-heart thing about her was the color of her jacket. She added that “it’s not the heart that compels conclusions in cases. It’s the law.”
President Obama wants Sotomayor, naturally, to bring a fresh perspective to the court. It was a disgrace that W. appointed two white men to a court stocked with white men. And Sotomayor made it clear that she provides some spicy seasoning to a bench when she said in a speech: “I simply do not know exactly what the difference will be in my judging, but I accept there will be some based on gender and my Latina heritage.”
The judge’s full retreat from the notion that a different life experience is valuable was more than necessary and somewhat disappointing. But, as any clever job applicant knows, you must obscure as well as reveal, so she sidestepped the dreaded empathy questions — even though that’s why the president wants her.
“We apply law to facts,” she told Kyl. “We don’t apply feelings to facts.”
She even used a flat tone when talking about the “horrific tragedy” of 9/11, when she was living near the World Trade Center. And she was mechanical in explaining to a grumpy Senator Orrin Hatch that banning nunchaku sticks did not dent the Second Amendment because the martial-arts weapons’ swing “can bust someone’s skull.”
Democratic Senator Chuck Schumer gamely tried to make the judge seem even more coldhearted. Recalling the sad plight of poor families from the Bronx who sued T.W.A. after a jet crashed off Long Island in 1996, he quoted the Bronx jurist’s dispassionate dissent: “The appropriate remedial scheme for deaths occurring off the United States coast is clearly a legislative policy choice, which should not be made by the courts.”
Schumer also cited the case of an African-American woman who filed suit after being denied a home-equity loan, even after the loan application was conditionally approved based on her credit report.
Sonia Legree ruled that the woman’s claim was filed too late, the same argument that the Supremes used on Lilly Ledbetter when she belatedly learned that her male coworkers were much better paid. President Obama has cited the Ledbetter decision as a reason the court needs a more “common touch.”
“The law requires some finality,” Sotomayor explained about her case, with an iciness that must have sent a chill up the conservative leg of Alabama’s Jefferson Beauregard Sessions III, even as it left Obama hanging out on an empathy limb.
Republican Lindsey Graham read Sotomayor some anonymous comments made by lawyers about her, complaining that she was “temperamental,” “nasty,” “a bit of a bully.” Then he patronizingly lectured her about how this was the moment for “self-reflection.” Maybe Graham thinks Nino Scalia has those traits covered.
But the barbed adjectives didn’t match the muted performance on display before the Judiciary Committee. Like the president who picked her, Sotomayor has been a model of professorial rationality. Besides, it’s delicious watching Republicans go after Democrats for being too emotional and irrational given the G.O.P. shame spiral.
W. and Dick Cheney made all their bad decisions about Iraq, W.M.D.’s, domestic surveillance, torture, rendition and secret hit squads from the gut, based on false intuitions, fear, paranoia and revenge.
Sarah Palin is the definition of irrational, a volatile and scattered country-music queen without the music. Her Republican fans defend her lack of application and intellect, happy to settle for her emotional electricity.
Senator Graham said Sotomayor would be confirmed unless she had “a meltdown” — a word applied mostly to women and toddlers until Mark Sanford proudly took ownership of it when he was judged about the wisdom of his Latina woman.
And then there’s the Supreme Court, of course, which gave up its claim to rational neutrality when the justices appointed by Republican presidents — including Bush Sr. — ignored what was fair to make a sentimental choice and throw the 2000 election to W.
Faced with that warped case of supreme empathy, no wonder Sotomayor is so eager to follow the law.
You can’t judge a judge by her cover.
Despite the best efforts of Republicans to root out any sign that Sonia Sotomayor has emotions that color her views on the law, the Bronx Bomber kept a robotic mask in place.
A wise Latina woman with the richness of her experiences would more often than not know that a gaggle of white Republican men afraid of extinction are out to trip her up.
After all, these guys have never needed to speak inspirational words to others like them, as Sotomayor has done. They’ve had codes, handshakes and clubs to do that.
So when Republican Senator Jon Kyl, without so much as a howdy-do, went at Sotomayor, and soon was asking her if she agreed with Barack Obama’s contention, when he voted against John Roberts, that a judge’s heart is important, the would-be justice was as adroit as her idol Nancy Drew.
“No, sir,” she said, indicating that the only bleeding-heart thing about her was the color of her jacket. She added that “it’s not the heart that compels conclusions in cases. It’s the law.”
President Obama wants Sotomayor, naturally, to bring a fresh perspective to the court. It was a disgrace that W. appointed two white men to a court stocked with white men. And Sotomayor made it clear that she provides some spicy seasoning to a bench when she said in a speech: “I simply do not know exactly what the difference will be in my judging, but I accept there will be some based on gender and my Latina heritage.”
The judge’s full retreat from the notion that a different life experience is valuable was more than necessary and somewhat disappointing. But, as any clever job applicant knows, you must obscure as well as reveal, so she sidestepped the dreaded empathy questions — even though that’s why the president wants her.
“We apply law to facts,” she told Kyl. “We don’t apply feelings to facts.”
She even used a flat tone when talking about the “horrific tragedy” of 9/11, when she was living near the World Trade Center. And she was mechanical in explaining to a grumpy Senator Orrin Hatch that banning nunchaku sticks did not dent the Second Amendment because the martial-arts weapons’ swing “can bust someone’s skull.”
Democratic Senator Chuck Schumer gamely tried to make the judge seem even more coldhearted. Recalling the sad plight of poor families from the Bronx who sued T.W.A. after a jet crashed off Long Island in 1996, he quoted the Bronx jurist’s dispassionate dissent: “The appropriate remedial scheme for deaths occurring off the United States coast is clearly a legislative policy choice, which should not be made by the courts.”
Schumer also cited the case of an African-American woman who filed suit after being denied a home-equity loan, even after the loan application was conditionally approved based on her credit report.
Sonia Legree ruled that the woman’s claim was filed too late, the same argument that the Supremes used on Lilly Ledbetter when she belatedly learned that her male coworkers were much better paid. President Obama has cited the Ledbetter decision as a reason the court needs a more “common touch.”
“The law requires some finality,” Sotomayor explained about her case, with an iciness that must have sent a chill up the conservative leg of Alabama’s Jefferson Beauregard Sessions III, even as it left Obama hanging out on an empathy limb.
Republican Lindsey Graham read Sotomayor some anonymous comments made by lawyers about her, complaining that she was “temperamental,” “nasty,” “a bit of a bully.” Then he patronizingly lectured her about how this was the moment for “self-reflection.” Maybe Graham thinks Nino Scalia has those traits covered.
But the barbed adjectives didn’t match the muted performance on display before the Judiciary Committee. Like the president who picked her, Sotomayor has been a model of professorial rationality. Besides, it’s delicious watching Republicans go after Democrats for being too emotional and irrational given the G.O.P. shame spiral.
W. and Dick Cheney made all their bad decisions about Iraq, W.M.D.’s, domestic surveillance, torture, rendition and secret hit squads from the gut, based on false intuitions, fear, paranoia and revenge.
Sarah Palin is the definition of irrational, a volatile and scattered country-music queen without the music. Her Republican fans defend her lack of application and intellect, happy to settle for her emotional electricity.
Senator Graham said Sotomayor would be confirmed unless she had “a meltdown” — a word applied mostly to women and toddlers until Mark Sanford proudly took ownership of it when he was judged about the wisdom of his Latina woman.
And then there’s the Supreme Court, of course, which gave up its claim to rational neutrality when the justices appointed by Republican presidents — including Bush Sr. — ignored what was fair to make a sentimental choice and throw the 2000 election to W.
Faced with that warped case of supreme empathy, no wonder Sotomayor is so eager to follow the law.
Why We Must Ration Health Care
NYTimes by PETER SINGER
You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.
In the current U.S. debate over health care reform, “rationing” has become a dirty word. Meeting last month with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons’ attempt to achieve reform. In a Wall Street Journal op-ed published at the end of last year with the headline “Obama Will Ration Your Health Care,” Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, “Americans will not put up with such limits, nor will our elected representatives.” And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, “There is no rationing of health care at all” in the proposed reform.
Remember the joke about the man who asks a woman if she would have sex with him for a million dollars? She reflects for a few moments and then answers that she would. “So,” he says, “would you have sex with me for $50?” Indignantly, she exclaims, “What kind of a woman do you think I am?” He replies: “We’ve already established that. Now we’re just haggling about the price.” The man’s response implies that if a woman will sell herself at any price, she is a prostitute. The way we regard rationing in health care seems to rest on a similar assumption, that it’s immoral to apply monetary considerations to saving lives — but is that stance tenable?
Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. But our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. That is, in effect, a more than $200 billion government subsidy for health care. In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals.
The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way in which we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it. Health-insurance premiums have more than doubled in a decade, rising four times faster than wages. In May, Medicare’s trustees warned that the program’s biggest fund is heading for insolvency in just eight years. Health care now absorbs about one dollar in every six the nation spends, a figure that far exceeds the share spent by any other nation. According to the Congressional Budget Office, it is on track to double by 2035.
President Obama has said plainly that America’s health care system is broken. It is, he has said, by far the most significant driver of America’s long-term debt and deficits. It is hard to see how the nation as a whole can remain competitive if in 25 years we are spending nearly a third of what we earn on health care, while other industrialized nations are spending far less but achieving health outcomes as good as, or better than, ours.
Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?
Last year Britain’s National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year. Sutent, when used for advanced kidney cancer, cost more than that, and research suggested it offered only about six months extra life. But the British media leapt on the theme of penny-pinching bureaucrats sentencing sick people to death. The issue was then picked up by the U.S. news media and by those lobbying against health care reform in the United States. An article in The New York Times last December featured Bruce Hardy, a kidney-cancer patient whose wife, Joy, said, “It’s hard to know that there is something out there that could help but they’re saying you can’t have it because of cost.” Then she asked the classic question: “What price is life?”
Last November, Bloomberg News focused on Jack Rosser, who was 57 at the time and whose doctor had told him that with Sutent he might live long enough to see his 1-year-old daughter, Emma, enter primary school. Rosser’s wife, Jenny, is quoted as saying: “It’s immoral. They are sentencing him to die.” In the conservative monthly The American Spectator, David Catron, a health care consultant, describes Rosser as “one of NICE’s many victims” and writes that NICE “regularly hands down death sentences to gravely ill patients.” Linking the British system with Democratic proposals for reforming health care in the United States, Catron asked whether we really deserve a health care system in which “soulless bureaucrats arbitrarily put a dollar value on our lives.” (In March, NICE issued a final ruling on Sutent. Because of how few patients need the drug and because of special end-of-life considerations, it recommended that the drug be provided by the National Health Service to patients with advanced kidney cancer. )
There’s no doubt that it’s tough — politically, emotionally and ethically — to make a decision that means that someone will die sooner than they would have if the decision had gone the other way. But if the stories of Bruce Hardy and Jack Rosser lead us to think badly of the British system of rationing health care, we should remind ourselves that the U.S. system also results in people going without life-saving treatment — it just does so less visibly. Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE. American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That’s rationing too, by ability to pay.
Dr. Art Kellermann, associate dean for public policy at Emory School of Medicine in Atlanta, recently wrote of a woman who came into his emergency room in critical condition because a blood vessel had burst in her brain. She was uninsured and had chosen to buy food for her children instead of spending money on her blood-pressure medicine. In the emergency room, she received excellent high-tech medical care, but by the time she got there, it was too late to save her.
A New York Times report on the high costs of some drugs illustrates the problem. Chuck Stauffer, an Oregon farmer, found that his prescription-drug insurance left him to pay $5,500 for his first 42 days of Temodar, a drug used to treat brain tumors, and $1,700 a month after that. For Medicare patients drug costs can be even higher, because Medicare can require a copayment of 25 percent of the cost of the drug. For Gleevec, a drug that is effective against some forms of leukemia and some gastrointestinal tumors, that one-quarter of the cost can run to $40,000 a year.
In Britain, everyone has health insurance. In the U.S., some 45 million do not, and nor are they entitled to any health care at all, unless they can get themselves to an emergency room. Hospitals are prohibited from turning away anyone who will be endangered by being refused treatment. But even in emergency rooms, people without health insurance may receive less health care than those with insurance. Joseph Doyle, a professor of economics at the Sloan School of Management at M.I.T., studied the records of people in Wisconsin who were injured in severe automobile accidents and had no choice but to go to the hospital. He estimated that those who had no health insurance received 20 percent less care and had a death rate 37 percent higher than those with health insurance. This difference held up even when those without health insurance were compared with those without automobile insurance, and with those on Medicaid — groups with whom they share some characteristics that might affect treatment. The lack of insurance seems to be what caused the greater number of deaths.
When the media feature someone like Bruce Hardy or Jack Rosser, we readily relate to individuals who are harmed by a government agency’s decision to limit the cost of health care. But we tend not to hear about — and thus don’t identify with — the particular individuals who die in emergency rooms because they have no health insurance. This “identifiable victim” effect, well documented by psychologists, creates a dangerous bias in our thinking. Doyle’s figures suggest that if those Wisconsin accident victims without health insurance had received equivalent care to those with it, the additional health care would have cost about $220,000 for each life saved. Those who died were on average around 30 years old and could have been expected to live for at least another 40 years; this means that had they survived their accidents, the cost per extra year of life would have been no more than $5,500 — a small fraction of the $49,000 that NICE recommends the British National Health Service should be ready to pay to give a patient an extra year of life. If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades.
Estimates of the number of U.S. deaths caused annually by the absence of universal health insurance go as high as 20,000. One study concluded that in the age group 55 to 64 alone, more than 13,000 extra deaths a year may be attributed to the lack of insurance coverage. But the estimates vary because Americans without health insurance are more likely, for example, to smoke than Americans with health insurance, and sorting out the role that the lack of insurance plays is difficult. Richard Kronick, a professor at the School of Medicine at the University of California, San Diego, cautiously concludes from his own study that there is little evidence to suggest that extending health insurance to all Americans would have a large effect on the number of deaths in the United States. That doesn’t mean that it wouldn’t; we simply don’t know if it would.
In any case, it isn’t only uninsured Americans who can’t afford treatment. President Obama has spoken about his mother, who died from ovarian cancer in 1995. The president said that in the last weeks of her life, his mother “was spending too much time worrying about whether her health insurance would cover her bills” — an experience, the president went on to say, that his mother shared with millions of other Americans. It is also an experience more common in the United States than in other developed countries. A recent Commonwealth Fund study led by Cathy Schoen and Robin Osborn surveyed adults with chronic illness in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom and the United States. Far more Americans reported forgoing health care because of cost. More than half (54 percent) reported not filling a prescription, not visiting a doctor when sick or not getting recommended care. In comparison, in the United Kingdom the figure was 13 percent, and in the Netherlands, only 7 percent. Even among Americans with insurance, 43 percent reported that cost was a problem that had limited the treatment they received. According to a 2007 study led by David Himmelstein, more than 60 percent of all bankruptcies are related to illness, with many of these specifically caused by medical bills, even among those who have health insurance. In Canada the incidence of bankruptcy related to illness is much lower.
When a Washington Post journalist asked Daniel Zemel, a Washington rabbi, what he thought about federal agencies putting a dollar value on human life, the rabbi cited a Jewish teaching explaining that if you put one human life on one side of a scale, and you put the rest of the world on the other side, the scale is balanced equally. Perhaps that is how those who resist health care rationing think. But we already put a dollar value on human life. If the Department of Transportation, for example, followed rabbinical teachings it would exhaust its entire budget on road safety. Fortunately the department sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million. Other government agencies do the same. Last year the Consumer Product Safety Commission considered a proposal to make mattresses less likely to catch fire. Information from the industry suggested that the new standard would cost $343 million to implement, but the Consumer Product Safety Commission calculated that it would save 270 lives a year — and since it valued a human life at around $5 million, that made the new standard a good value. If we are going to have consumer-safety regulation at all, we need some idea of how much safety is worth buying. Like health care bureaucrats, consumer-safety bureaucrats sometimes decide that saving a human life is not worth the expense. Twenty years ago, the National Research Council, an arm of the National Academy of Sciences, examined a proposal for installing seat belts in all school buses. It estimated that doing so would save, on average, one life per year, at a cost of $40 million. After that, support for the proposal faded away. So why is it that those who accept that we put a price on life when it comes to consumer safety refuse to accept it when it comes to health care?
Of course, it’s one thing to accept that there’s a limit to how much we should spend to save a human life, and another to set that limit. The dollar value that bureaucrats place on a generic human life is intended to reflect social values, as revealed in our behavior. It is the answer to the question “How much are you willing to pay to save your life?” — except that, of course, if you asked that question of people who were facing death, they would be prepared to pay almost anything to save their lives. So instead, economists note how much people are prepared to pay to reduce the risk that they will die. How much will people pay for air bags in a car, for instance? Once you know how much they will pay for a specified reduction in risk, you multiply the amount that people are willing to pay by how much the risk has been reduced, and then you know, or so the theory goes, what value people place on their lives. Suppose that there is a 1 in 100,000 chance that an air bag in my car will save my life, and that I would pay $50 — but no more than that — for an air bag. Then it looks as if I value my life at $50 x 100,000, or $5 million.
The theory sounds good, but in practice it has problems. We are not good at taking account of differences between very small risks, so if we are asked how much we would pay to reduce a risk of dying from 1 in 1,000,000 to 1 in 10,000,000, we may give the same answer as we would if asked how much we would pay to reduce the risk from 1 in 500,000 to 1 in 10,000,000. Hence multiplying what we would pay to reduce the risk of death by the reduction in risk lends an apparent mathematical precision to the outcome of the calculation — the supposed value of a human life — that our intuitive responses to the questions cannot support. Nevertheless this approach to setting a value on a human life is at least closer to what we really believe — and to what we should believe — than dramatic pronouncements about the infinite value of every human life, or the suggestion that we cannot distinguish between the value of a single human life and the value of a million human lives, or even of the rest of the world. Though such feel-good claims may have some symbolic value in particular circumstances, to take them seriously and apply them — for instance, by leaving it to chance whether we save one life or a billion — would be deeply unethical.
Governments implicitly place a dollar value on a human life when they decide how much is to be spent on health care programs and how much on other public goods that are not directed toward saving lives. The task of health care bureaucrats is then to get the best value for the resources they have been allocated. It is the familiar comparative exercise of getting the most bang for your buck. Sometimes that can be relatively easy to decide. If two drugs offer the same benefits and have similar risks of side effects, but one is much more expensive than the other, only the cheaper one should be provided by the public health care program. That the benefits and the risks of side effects are similar is a scientific matter for experts to decide after calling for submissions and examining them. That is the bread-and-butter work of units like NICE. But the benefits may vary in ways that defy straightforward comparison. We need a common unit for measuring the goods achieved by health care. Since we are talking about comparing different goods, the choice of unit is not merely a scientific or economic question but an ethical one.
As a first take, we might say that the good achieved by health care is the number of lives saved. But that is too crude. The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved, rather than simply the number of lives saved. If a teenager can be expected to live another 70 years, saving her life counts as a gain of 70 life-years, whereas if a person of 85 can be expected to live another 5 years, then saving the 85-year-old will count as a gain of only 5 life-years. That suggests that saving one teenager is equivalent to saving 14 85-year-olds. These are, of course, generic teenagers and generic 85-year-olds. It’s easy to say, “What if the teenager is a violent criminal and the 85-year-old is still working productively?” But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.
Health care does more than save lives: it also reduces pain and suffering. How can we compare saving a person’s life with, say, making it possible for someone who was confined to bed to return to an active life? We can elicit people’s values on that too. One common method is to describe medical conditions to people — let’s say being a quadriplegic — and tell them that they can choose between 10 years in that condition or some smaller number of years without it. If most would prefer, say, 10 years as a quadriplegic to 4 years of nondisabled life, but would choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life or 10 years with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life. (These are hypothetical figures, chosen to keep the math simple, and not based on any actual surveys.) If that judgment represents a rough average across the population, we might conclude that restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.
This is the basis of the quality-adjusted life-year, or QALY, a unit designed to enable us to compare the benefits achieved by different forms of health care. The QALY has been used by economists working in health care for more than 30 years to compare the cost-effectiveness of a wide variety of medical procedures and, in some countries, as part of the process of deciding which medical treatments will be paid for with public money. If a reformed U.S. health care system explicitly accepted rationing, as I have argued it should, QALYs could play a similar role in the U.S.
Some will object that this discriminates against people with disabilities. If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics. That clashes with the idea that all human lives are of equal value. The problem, however, does not lie with the concept of the quality-adjusted life-year, but with the judgment that, if faced with 10 years as a quadriplegic, one would prefer a shorter lifespan without a disability. Disability advocates might argue that such judgments, made by people without disabilities, merely reflect the ignorance and prejudice of people without disabilities when they think about people with disabilities. We should, they will very reasonably say, ask quadriplegics themselves to evaluate life with quadriplegia. If we do that, and we find that quadriplegics would not give up even one year of life as a quadriplegic in order to have their disability cured, then the QALY method does not justify giving preference to procedures that extend the lives of people without disabilities over procedures that extend the lives of people with disabilities.
This method of preserving our belief that everyone has an equal right to life is, however, a double-edged sword. If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it. That implication, no doubt, would have been vigorously rejected by someone like Christopher Reeve, who, after being paralyzed in an accident, campaigned for more research into ways of overcoming spinal-cord injuries. Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition.
The QALY tells us to do what brings about the greatest health benefit, irrespective of where that benefit falls. Usually, for a given quantity of resources, we will do more good if we help those who are worst off, because they have the greatest unmet needs. But occasionally some conditions will be both very severe and very expensive to treat. A QALY approach may then lead us to give priority to helping others who are not so badly off and whose conditions are less expensive to treat. I don’t find it unfair to give the same weight to the interests of those who are well off as we give to those who are much worse off, but if there is a social consensus that we should give priority to those who are worse off, we can modify the QALY approach so that it gives greater weight to benefits that accrue to those who are, on the QALY scale, worse off than others.
The QALY approach does not even try to measure the benefits that health care brings in addition to the improvement in health itself. Emotionally, we feel that the fact that Jack Rosser is the father of a young child makes a difference to the importance of extending his life, but his parental status is irrelevant to a QALY assessment of the health care gains that Sutent would bring him. Whether decisions about allocating health care resources should take such personal circumstances into account isn’t easy to decide. Not to do so makes the standard inflexible, but taking personal factors into account increases the scope for subjective — and prejudiced — judgments.
The QALY is not a perfect measure of the good obtained by health care, but its defenders can support it in the same way that Winston Churchill defended democracy as a form of government: it is the worst method of allocating health care, except for all the others. If it isn’t possible to provide everyone with all beneficial treatments, what better way do we have of deciding what treatments people should get than by comparing the QALYs gained with the expense of the treatments?
Will Americans allow their government, either directly or through an independent agency like NICE, to decide which treatments are sufficiently cost-effective to be provided at public expense and which are not? They might, under two conditions: first, that the option of private health insurance remains available, and second, that they are able to see, in their own pocket, the full cost of not rationing health care.
Rationing public health care limits free choice if private health insurance is prohibited. But many countries combine free national health insurance with optional private insurance. Australia, where I’ve spent most of my life and raised a family, is one. The U.S. could do something similar. This would mean extending Medicare to the entire population, irrespective of age, but without Medicare’s current policy that allows doctors wide latitude in prescribing treatments for eligible patients. Instead, Medicare for All, as we might call it, should refuse to pay where the cost per QALY is extremely high. (On the other hand, Medicare for All would not require more than a token copayment for drugs that are cost-effective.) The extension of Medicare could be financed by a small income-tax levy, for those who pay income tax — in Australia the levy is 1.5 percent of taxable income. (There’s an extra 1 percent surcharge for those with high incomes and no private insurance. Those who earn too little to pay income tax would be carried at no cost to themselves.) Those who want to be sure of receiving every treatment that their own privately chosen physicians recommend, regardless of cost, would be free to opt out of Medicare for All as long as they can demonstrate that they have sufficient private health insurance to avoid becoming a burden on the community if they fall ill. Alternatively, they might remain in Medicare for All but take out supplementary insurance for health care that Medicare for All does not cover. Every American will have a right to a good standard of health care, but no one will have a right to unrationed health care. Those who opt for unrationed health care will know exactly how much it costs them.
One final comment. It is common for opponents of health care rationing to point to Canada and Britain as examples of where we might end up if we get “socialized medicine.” On a blog on Fox News earlier this year, the conservative writer John Lott wrote, “Americans should ask Canadians and Brits — people who have long suffered from rationing — how happy they are with central government decisions on eliminating ‘unnecessary’ health care.” There is no particular reason that the United States should copy the British or Canadian forms of universal coverage, rather than one of the different arrangements that have developed in other industrialized nations, some of which may be better. But as it happens, last year the Gallup organization did ask Canadians and Brits, and people in many different countries, if they have confidence in “health care or medical systems” in their country. In Canada, 73 percent answered this question affirmatively. Coincidentally, an identical percentage of Britons gave the same answer. In the United States, despite spending much more, per person, on health care, the figure was only 56 percent.
Peter Singer is professor of bioethics at Princeton University. He is also laureate professor at the University of Melbourne, in Australia. His most recent book is “The Life You Can Save: Acting Now to End World Poverty.”
You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.
In the current U.S. debate over health care reform, “rationing” has become a dirty word. Meeting last month with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons’ attempt to achieve reform. In a Wall Street Journal op-ed published at the end of last year with the headline “Obama Will Ration Your Health Care,” Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, “Americans will not put up with such limits, nor will our elected representatives.” And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, “There is no rationing of health care at all” in the proposed reform.
Remember the joke about the man who asks a woman if she would have sex with him for a million dollars? She reflects for a few moments and then answers that she would. “So,” he says, “would you have sex with me for $50?” Indignantly, she exclaims, “What kind of a woman do you think I am?” He replies: “We’ve already established that. Now we’re just haggling about the price.” The man’s response implies that if a woman will sell herself at any price, she is a prostitute. The way we regard rationing in health care seems to rest on a similar assumption, that it’s immoral to apply monetary considerations to saving lives — but is that stance tenable?
Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. But our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. That is, in effect, a more than $200 billion government subsidy for health care. In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals.
The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way in which we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it. Health-insurance premiums have more than doubled in a decade, rising four times faster than wages. In May, Medicare’s trustees warned that the program’s biggest fund is heading for insolvency in just eight years. Health care now absorbs about one dollar in every six the nation spends, a figure that far exceeds the share spent by any other nation. According to the Congressional Budget Office, it is on track to double by 2035.
President Obama has said plainly that America’s health care system is broken. It is, he has said, by far the most significant driver of America’s long-term debt and deficits. It is hard to see how the nation as a whole can remain competitive if in 25 years we are spending nearly a third of what we earn on health care, while other industrialized nations are spending far less but achieving health outcomes as good as, or better than, ours.
Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?
Last year Britain’s National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year. Sutent, when used for advanced kidney cancer, cost more than that, and research suggested it offered only about six months extra life. But the British media leapt on the theme of penny-pinching bureaucrats sentencing sick people to death. The issue was then picked up by the U.S. news media and by those lobbying against health care reform in the United States. An article in The New York Times last December featured Bruce Hardy, a kidney-cancer patient whose wife, Joy, said, “It’s hard to know that there is something out there that could help but they’re saying you can’t have it because of cost.” Then she asked the classic question: “What price is life?”
Last November, Bloomberg News focused on Jack Rosser, who was 57 at the time and whose doctor had told him that with Sutent he might live long enough to see his 1-year-old daughter, Emma, enter primary school. Rosser’s wife, Jenny, is quoted as saying: “It’s immoral. They are sentencing him to die.” In the conservative monthly The American Spectator, David Catron, a health care consultant, describes Rosser as “one of NICE’s many victims” and writes that NICE “regularly hands down death sentences to gravely ill patients.” Linking the British system with Democratic proposals for reforming health care in the United States, Catron asked whether we really deserve a health care system in which “soulless bureaucrats arbitrarily put a dollar value on our lives.” (In March, NICE issued a final ruling on Sutent. Because of how few patients need the drug and because of special end-of-life considerations, it recommended that the drug be provided by the National Health Service to patients with advanced kidney cancer. )
There’s no doubt that it’s tough — politically, emotionally and ethically — to make a decision that means that someone will die sooner than they would have if the decision had gone the other way. But if the stories of Bruce Hardy and Jack Rosser lead us to think badly of the British system of rationing health care, we should remind ourselves that the U.S. system also results in people going without life-saving treatment — it just does so less visibly. Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE. American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That’s rationing too, by ability to pay.
Dr. Art Kellermann, associate dean for public policy at Emory School of Medicine in Atlanta, recently wrote of a woman who came into his emergency room in critical condition because a blood vessel had burst in her brain. She was uninsured and had chosen to buy food for her children instead of spending money on her blood-pressure medicine. In the emergency room, she received excellent high-tech medical care, but by the time she got there, it was too late to save her.
A New York Times report on the high costs of some drugs illustrates the problem. Chuck Stauffer, an Oregon farmer, found that his prescription-drug insurance left him to pay $5,500 for his first 42 days of Temodar, a drug used to treat brain tumors, and $1,700 a month after that. For Medicare patients drug costs can be even higher, because Medicare can require a copayment of 25 percent of the cost of the drug. For Gleevec, a drug that is effective against some forms of leukemia and some gastrointestinal tumors, that one-quarter of the cost can run to $40,000 a year.
In Britain, everyone has health insurance. In the U.S., some 45 million do not, and nor are they entitled to any health care at all, unless they can get themselves to an emergency room. Hospitals are prohibited from turning away anyone who will be endangered by being refused treatment. But even in emergency rooms, people without health insurance may receive less health care than those with insurance. Joseph Doyle, a professor of economics at the Sloan School of Management at M.I.T., studied the records of people in Wisconsin who were injured in severe automobile accidents and had no choice but to go to the hospital. He estimated that those who had no health insurance received 20 percent less care and had a death rate 37 percent higher than those with health insurance. This difference held up even when those without health insurance were compared with those without automobile insurance, and with those on Medicaid — groups with whom they share some characteristics that might affect treatment. The lack of insurance seems to be what caused the greater number of deaths.
When the media feature someone like Bruce Hardy or Jack Rosser, we readily relate to individuals who are harmed by a government agency’s decision to limit the cost of health care. But we tend not to hear about — and thus don’t identify with — the particular individuals who die in emergency rooms because they have no health insurance. This “identifiable victim” effect, well documented by psychologists, creates a dangerous bias in our thinking. Doyle’s figures suggest that if those Wisconsin accident victims without health insurance had received equivalent care to those with it, the additional health care would have cost about $220,000 for each life saved. Those who died were on average around 30 years old and could have been expected to live for at least another 40 years; this means that had they survived their accidents, the cost per extra year of life would have been no more than $5,500 — a small fraction of the $49,000 that NICE recommends the British National Health Service should be ready to pay to give a patient an extra year of life. If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades.
Estimates of the number of U.S. deaths caused annually by the absence of universal health insurance go as high as 20,000. One study concluded that in the age group 55 to 64 alone, more than 13,000 extra deaths a year may be attributed to the lack of insurance coverage. But the estimates vary because Americans without health insurance are more likely, for example, to smoke than Americans with health insurance, and sorting out the role that the lack of insurance plays is difficult. Richard Kronick, a professor at the School of Medicine at the University of California, San Diego, cautiously concludes from his own study that there is little evidence to suggest that extending health insurance to all Americans would have a large effect on the number of deaths in the United States. That doesn’t mean that it wouldn’t; we simply don’t know if it would.
In any case, it isn’t only uninsured Americans who can’t afford treatment. President Obama has spoken about his mother, who died from ovarian cancer in 1995. The president said that in the last weeks of her life, his mother “was spending too much time worrying about whether her health insurance would cover her bills” — an experience, the president went on to say, that his mother shared with millions of other Americans. It is also an experience more common in the United States than in other developed countries. A recent Commonwealth Fund study led by Cathy Schoen and Robin Osborn surveyed adults with chronic illness in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom and the United States. Far more Americans reported forgoing health care because of cost. More than half (54 percent) reported not filling a prescription, not visiting a doctor when sick or not getting recommended care. In comparison, in the United Kingdom the figure was 13 percent, and in the Netherlands, only 7 percent. Even among Americans with insurance, 43 percent reported that cost was a problem that had limited the treatment they received. According to a 2007 study led by David Himmelstein, more than 60 percent of all bankruptcies are related to illness, with many of these specifically caused by medical bills, even among those who have health insurance. In Canada the incidence of bankruptcy related to illness is much lower.
When a Washington Post journalist asked Daniel Zemel, a Washington rabbi, what he thought about federal agencies putting a dollar value on human life, the rabbi cited a Jewish teaching explaining that if you put one human life on one side of a scale, and you put the rest of the world on the other side, the scale is balanced equally. Perhaps that is how those who resist health care rationing think. But we already put a dollar value on human life. If the Department of Transportation, for example, followed rabbinical teachings it would exhaust its entire budget on road safety. Fortunately the department sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million. Other government agencies do the same. Last year the Consumer Product Safety Commission considered a proposal to make mattresses less likely to catch fire. Information from the industry suggested that the new standard would cost $343 million to implement, but the Consumer Product Safety Commission calculated that it would save 270 lives a year — and since it valued a human life at around $5 million, that made the new standard a good value. If we are going to have consumer-safety regulation at all, we need some idea of how much safety is worth buying. Like health care bureaucrats, consumer-safety bureaucrats sometimes decide that saving a human life is not worth the expense. Twenty years ago, the National Research Council, an arm of the National Academy of Sciences, examined a proposal for installing seat belts in all school buses. It estimated that doing so would save, on average, one life per year, at a cost of $40 million. After that, support for the proposal faded away. So why is it that those who accept that we put a price on life when it comes to consumer safety refuse to accept it when it comes to health care?
Of course, it’s one thing to accept that there’s a limit to how much we should spend to save a human life, and another to set that limit. The dollar value that bureaucrats place on a generic human life is intended to reflect social values, as revealed in our behavior. It is the answer to the question “How much are you willing to pay to save your life?” — except that, of course, if you asked that question of people who were facing death, they would be prepared to pay almost anything to save their lives. So instead, economists note how much people are prepared to pay to reduce the risk that they will die. How much will people pay for air bags in a car, for instance? Once you know how much they will pay for a specified reduction in risk, you multiply the amount that people are willing to pay by how much the risk has been reduced, and then you know, or so the theory goes, what value people place on their lives. Suppose that there is a 1 in 100,000 chance that an air bag in my car will save my life, and that I would pay $50 — but no more than that — for an air bag. Then it looks as if I value my life at $50 x 100,000, or $5 million.
The theory sounds good, but in practice it has problems. We are not good at taking account of differences between very small risks, so if we are asked how much we would pay to reduce a risk of dying from 1 in 1,000,000 to 1 in 10,000,000, we may give the same answer as we would if asked how much we would pay to reduce the risk from 1 in 500,000 to 1 in 10,000,000. Hence multiplying what we would pay to reduce the risk of death by the reduction in risk lends an apparent mathematical precision to the outcome of the calculation — the supposed value of a human life — that our intuitive responses to the questions cannot support. Nevertheless this approach to setting a value on a human life is at least closer to what we really believe — and to what we should believe — than dramatic pronouncements about the infinite value of every human life, or the suggestion that we cannot distinguish between the value of a single human life and the value of a million human lives, or even of the rest of the world. Though such feel-good claims may have some symbolic value in particular circumstances, to take them seriously and apply them — for instance, by leaving it to chance whether we save one life or a billion — would be deeply unethical.
Governments implicitly place a dollar value on a human life when they decide how much is to be spent on health care programs and how much on other public goods that are not directed toward saving lives. The task of health care bureaucrats is then to get the best value for the resources they have been allocated. It is the familiar comparative exercise of getting the most bang for your buck. Sometimes that can be relatively easy to decide. If two drugs offer the same benefits and have similar risks of side effects, but one is much more expensive than the other, only the cheaper one should be provided by the public health care program. That the benefits and the risks of side effects are similar is a scientific matter for experts to decide after calling for submissions and examining them. That is the bread-and-butter work of units like NICE. But the benefits may vary in ways that defy straightforward comparison. We need a common unit for measuring the goods achieved by health care. Since we are talking about comparing different goods, the choice of unit is not merely a scientific or economic question but an ethical one.
As a first take, we might say that the good achieved by health care is the number of lives saved. But that is too crude. The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved, rather than simply the number of lives saved. If a teenager can be expected to live another 70 years, saving her life counts as a gain of 70 life-years, whereas if a person of 85 can be expected to live another 5 years, then saving the 85-year-old will count as a gain of only 5 life-years. That suggests that saving one teenager is equivalent to saving 14 85-year-olds. These are, of course, generic teenagers and generic 85-year-olds. It’s easy to say, “What if the teenager is a violent criminal and the 85-year-old is still working productively?” But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.
Health care does more than save lives: it also reduces pain and suffering. How can we compare saving a person’s life with, say, making it possible for someone who was confined to bed to return to an active life? We can elicit people’s values on that too. One common method is to describe medical conditions to people — let’s say being a quadriplegic — and tell them that they can choose between 10 years in that condition or some smaller number of years without it. If most would prefer, say, 10 years as a quadriplegic to 4 years of nondisabled life, but would choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life or 10 years with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life. (These are hypothetical figures, chosen to keep the math simple, and not based on any actual surveys.) If that judgment represents a rough average across the population, we might conclude that restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.
This is the basis of the quality-adjusted life-year, or QALY, a unit designed to enable us to compare the benefits achieved by different forms of health care. The QALY has been used by economists working in health care for more than 30 years to compare the cost-effectiveness of a wide variety of medical procedures and, in some countries, as part of the process of deciding which medical treatments will be paid for with public money. If a reformed U.S. health care system explicitly accepted rationing, as I have argued it should, QALYs could play a similar role in the U.S.
Some will object that this discriminates against people with disabilities. If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics. That clashes with the idea that all human lives are of equal value. The problem, however, does not lie with the concept of the quality-adjusted life-year, but with the judgment that, if faced with 10 years as a quadriplegic, one would prefer a shorter lifespan without a disability. Disability advocates might argue that such judgments, made by people without disabilities, merely reflect the ignorance and prejudice of people without disabilities when they think about people with disabilities. We should, they will very reasonably say, ask quadriplegics themselves to evaluate life with quadriplegia. If we do that, and we find that quadriplegics would not give up even one year of life as a quadriplegic in order to have their disability cured, then the QALY method does not justify giving preference to procedures that extend the lives of people without disabilities over procedures that extend the lives of people with disabilities.
This method of preserving our belief that everyone has an equal right to life is, however, a double-edged sword. If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it. That implication, no doubt, would have been vigorously rejected by someone like Christopher Reeve, who, after being paralyzed in an accident, campaigned for more research into ways of overcoming spinal-cord injuries. Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition.
The QALY tells us to do what brings about the greatest health benefit, irrespective of where that benefit falls. Usually, for a given quantity of resources, we will do more good if we help those who are worst off, because they have the greatest unmet needs. But occasionally some conditions will be both very severe and very expensive to treat. A QALY approach may then lead us to give priority to helping others who are not so badly off and whose conditions are less expensive to treat. I don’t find it unfair to give the same weight to the interests of those who are well off as we give to those who are much worse off, but if there is a social consensus that we should give priority to those who are worse off, we can modify the QALY approach so that it gives greater weight to benefits that accrue to those who are, on the QALY scale, worse off than others.
The QALY approach does not even try to measure the benefits that health care brings in addition to the improvement in health itself. Emotionally, we feel that the fact that Jack Rosser is the father of a young child makes a difference to the importance of extending his life, but his parental status is irrelevant to a QALY assessment of the health care gains that Sutent would bring him. Whether decisions about allocating health care resources should take such personal circumstances into account isn’t easy to decide. Not to do so makes the standard inflexible, but taking personal factors into account increases the scope for subjective — and prejudiced — judgments.
The QALY is not a perfect measure of the good obtained by health care, but its defenders can support it in the same way that Winston Churchill defended democracy as a form of government: it is the worst method of allocating health care, except for all the others. If it isn’t possible to provide everyone with all beneficial treatments, what better way do we have of deciding what treatments people should get than by comparing the QALYs gained with the expense of the treatments?
Will Americans allow their government, either directly or through an independent agency like NICE, to decide which treatments are sufficiently cost-effective to be provided at public expense and which are not? They might, under two conditions: first, that the option of private health insurance remains available, and second, that they are able to see, in their own pocket, the full cost of not rationing health care.
Rationing public health care limits free choice if private health insurance is prohibited. But many countries combine free national health insurance with optional private insurance. Australia, where I’ve spent most of my life and raised a family, is one. The U.S. could do something similar. This would mean extending Medicare to the entire population, irrespective of age, but without Medicare’s current policy that allows doctors wide latitude in prescribing treatments for eligible patients. Instead, Medicare for All, as we might call it, should refuse to pay where the cost per QALY is extremely high. (On the other hand, Medicare for All would not require more than a token copayment for drugs that are cost-effective.) The extension of Medicare could be financed by a small income-tax levy, for those who pay income tax — in Australia the levy is 1.5 percent of taxable income. (There’s an extra 1 percent surcharge for those with high incomes and no private insurance. Those who earn too little to pay income tax would be carried at no cost to themselves.) Those who want to be sure of receiving every treatment that their own privately chosen physicians recommend, regardless of cost, would be free to opt out of Medicare for All as long as they can demonstrate that they have sufficient private health insurance to avoid becoming a burden on the community if they fall ill. Alternatively, they might remain in Medicare for All but take out supplementary insurance for health care that Medicare for All does not cover. Every American will have a right to a good standard of health care, but no one will have a right to unrationed health care. Those who opt for unrationed health care will know exactly how much it costs them.
One final comment. It is common for opponents of health care rationing to point to Canada and Britain as examples of where we might end up if we get “socialized medicine.” On a blog on Fox News earlier this year, the conservative writer John Lott wrote, “Americans should ask Canadians and Brits — people who have long suffered from rationing — how happy they are with central government decisions on eliminating ‘unnecessary’ health care.” There is no particular reason that the United States should copy the British or Canadian forms of universal coverage, rather than one of the different arrangements that have developed in other industrialized nations, some of which may be better. But as it happens, last year the Gallup organization did ask Canadians and Brits, and people in many different countries, if they have confidence in “health care or medical systems” in their country. In Canada, 73 percent answered this question affirmatively. Coincidentally, an identical percentage of Britons gave the same answer. In the United States, despite spending much more, per person, on health care, the figure was only 56 percent.
Peter Singer is professor of bioethics at Princeton University. He is also laureate professor at the University of Melbourne, in Australia. His most recent book is “The Life You Can Save: Acting Now to End World Poverty.”
The next hacking frontier: Your brain?
Story Highlights
Scientists can use thoughts to operate computers, wheelchairs and Twitter
As tech develops, risk of "brain hacking" become more real, scientists say
Neurosurgical Focus article says risks are slim now
But security "should proceed in lockstep with the technology," expert says
WWW.WIRED.COM
Hackers who commandeer your computer are bad enough. Now scientists worry that someday, they'll try to take over your brain.
In the past year, researchers have developed technology that makes it possible to use thoughts to operate a computer, maneuver a wheelchair or even use Twitter -- all without lifting a finger. But as neural devices become more complicated, and go wireless, some scientists say the risks of "brain hacking" should be taken seriously.
"Neural devices are innovating at an extremely rapid rate and hold tremendous promise for the future," said computer security expert Tadayoshi Kohno of the University of Washington.
"But if we don't start paying attention to security, we're worried that we might find ourselves in five or 10 years saying we've made a big mistake."
Hackers tap into personal computers all the time. But what would happen if they focused their nefarious energy on neural devices, such as the deep-brain stimulators used to treat Parkinson's and depression, or electrode systems for controlling prosthetic limbs?
According to Kohno and his colleagues, who published their concerns July 1 in Neurosurgical Focus, most devices carry few security risks. But as neural engineering becomes more complex and more widespread, the potential for security breaches will mushroom.
"It's very hard to design complex systems that don't have bugs," Kohno said. "As these medical devices start to become more and more complicated, it gets easier and easier for people to overlook a bug that could become a very serious risk. It might border on science fiction today, but so did going to the moon 50 years ago."
Some might question why anyone would want to hack into someone else's brain, but the researchers say there's a precedent for using computers to cause neurological harm. In November 2007 and March 2008, malicious programmers vandalized epilepsy support Web sites by putting up flashing animations, which caused seizures in some photo-sensitive patients.
"It happened on two separate occasions," said computer science graduate student Tamara Denning, a co-author on the paper. "It's evidence that people will be malicious and try to compromise peoples' health using computers, especially if neural devices become more widespread."
In some cases, patients might even want to hack into their own neural device. Unlike devices to control prosthetic limbs, which still use wires, many deep brain stimulators already rely on wireless signals. Hacking into these devices could enable patients to "self-prescribe" elevated moods or pain relief by increasing the activity of the brain's reward centers.
Despite the risks, Kohno said, most new devices aren't created with security in mind. Neural engineers carefully consider the safety and reliability of new equipment, and neuroethicists focus on whether a new device fits ethical guidelines. But until now, few groups have considered how neural devices might be hijacked to perform unintended actions. This is the first time an academic paper has addressed the topic of "neurosecurity," a term the group coined to describe their field.
"The security and privacy issues somehow seem to slip by," Kohno said. "I would not be surprised if most people working in this space have never thought about security."
Kevin Otto, a bioengineer who studies brain-machine interfaces at Purdue Universty, said he was initially skeptical of the research. "When I first picked up the paper, I don't know if I agreed that it was an issue. But the paper gives a very compelling argument that this is important, and that this is the time to have neural engineers collaborate with security developers."
It's never too early to start thinking about security issues, said neural engineer Justin Williams of the University of Wisconsin, who was not involved in the research. But he stressed that the kinds of devices available today are not susceptible to attack, and that fear of future risks shouldn't impede progress in the field. "These kinds of security issues have to proceed in lockstep with the technology," Williams said.
History provides plenty of examples of why it's important to think about security before it becomes a problem, Kohno said. Perhaps the best example is the Internet, which was originally conceived as a research project and didn't take security into account.
"Because the Internet was not originally designed with security in mind," the researchers wrote, "it is incredibly challenging -- if not impossible -- to retrofit the existing Internet infrastructure to meet all of today's security goals." Kohno and his colleagues hope to avoid such problems in the neural device world, by getting the community to discuss potential security problems before they become a reality.
"The first thing is to ask ourselves is, 'Could there be a security and privacy problem?'" Kohno said. "Asking 'Is there a problem?' gets you 90 percent there, and that's the most important thing."
Scientists can use thoughts to operate computers, wheelchairs and Twitter
As tech develops, risk of "brain hacking" become more real, scientists say
Neurosurgical Focus article says risks are slim now
But security "should proceed in lockstep with the technology," expert says
WWW.WIRED.COM
Hackers who commandeer your computer are bad enough. Now scientists worry that someday, they'll try to take over your brain.
In the past year, researchers have developed technology that makes it possible to use thoughts to operate a computer, maneuver a wheelchair or even use Twitter -- all without lifting a finger. But as neural devices become more complicated, and go wireless, some scientists say the risks of "brain hacking" should be taken seriously.
"Neural devices are innovating at an extremely rapid rate and hold tremendous promise for the future," said computer security expert Tadayoshi Kohno of the University of Washington.
"But if we don't start paying attention to security, we're worried that we might find ourselves in five or 10 years saying we've made a big mistake."
Hackers tap into personal computers all the time. But what would happen if they focused their nefarious energy on neural devices, such as the deep-brain stimulators used to treat Parkinson's and depression, or electrode systems for controlling prosthetic limbs?
According to Kohno and his colleagues, who published their concerns July 1 in Neurosurgical Focus, most devices carry few security risks. But as neural engineering becomes more complex and more widespread, the potential for security breaches will mushroom.
"It's very hard to design complex systems that don't have bugs," Kohno said. "As these medical devices start to become more and more complicated, it gets easier and easier for people to overlook a bug that could become a very serious risk. It might border on science fiction today, but so did going to the moon 50 years ago."
Some might question why anyone would want to hack into someone else's brain, but the researchers say there's a precedent for using computers to cause neurological harm. In November 2007 and March 2008, malicious programmers vandalized epilepsy support Web sites by putting up flashing animations, which caused seizures in some photo-sensitive patients.
"It happened on two separate occasions," said computer science graduate student Tamara Denning, a co-author on the paper. "It's evidence that people will be malicious and try to compromise peoples' health using computers, especially if neural devices become more widespread."
In some cases, patients might even want to hack into their own neural device. Unlike devices to control prosthetic limbs, which still use wires, many deep brain stimulators already rely on wireless signals. Hacking into these devices could enable patients to "self-prescribe" elevated moods or pain relief by increasing the activity of the brain's reward centers.
Despite the risks, Kohno said, most new devices aren't created with security in mind. Neural engineers carefully consider the safety and reliability of new equipment, and neuroethicists focus on whether a new device fits ethical guidelines. But until now, few groups have considered how neural devices might be hijacked to perform unintended actions. This is the first time an academic paper has addressed the topic of "neurosecurity," a term the group coined to describe their field.
"The security and privacy issues somehow seem to slip by," Kohno said. "I would not be surprised if most people working in this space have never thought about security."
Kevin Otto, a bioengineer who studies brain-machine interfaces at Purdue Universty, said he was initially skeptical of the research. "When I first picked up the paper, I don't know if I agreed that it was an issue. But the paper gives a very compelling argument that this is important, and that this is the time to have neural engineers collaborate with security developers."
It's never too early to start thinking about security issues, said neural engineer Justin Williams of the University of Wisconsin, who was not involved in the research. But he stressed that the kinds of devices available today are not susceptible to attack, and that fear of future risks shouldn't impede progress in the field. "These kinds of security issues have to proceed in lockstep with the technology," Williams said.
History provides plenty of examples of why it's important to think about security before it becomes a problem, Kohno said. Perhaps the best example is the Internet, which was originally conceived as a research project and didn't take security into account.
"Because the Internet was not originally designed with security in mind," the researchers wrote, "it is incredibly challenging -- if not impossible -- to retrofit the existing Internet infrastructure to meet all of today's security goals." Kohno and his colleagues hope to avoid such problems in the neural device world, by getting the community to discuss potential security problems before they become a reality.
"The first thing is to ask ourselves is, 'Could there be a security and privacy problem?'" Kohno said. "Asking 'Is there a problem?' gets you 90 percent there, and that's the most important thing."
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