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Health care and quality of death issues

[ 24 ] June 14, 2011 |

Over the past couple of years four people I’ve had some sort of relationship with were diagnosed with pancreatic cancer, so I’ve gotten to know more than I ever wanted to know about this especially terrible disease. It’s estimated that about 43,000 Americans will be diagnosed with pancreatic cancer this year, and around 38,000 will die from it. The most common form of the illness remains almost incurable, with a five-year survival rate of less than 5%. Only 20% of cases are diagnosed soon enough to allow for anything other than palliative treatment; this “lucky” minority undergo a grueling operation (the so-called Whipple procedure) that produces a median increase in life expectancy of about a year. Pancreatic cancer is usually a disease of old age: the average age at diagnosis is 73, and America’s aging population has seen a steady increase in its incidence, to the point where it is now the fourth-leading cause of cancer death. (For similar demographic reasons it is beginning to become much more common in the developing world).

Recently I looked at the data from a couple of major academic medical centers who specialize in the Whipple procedure, and I was struck by, among other things, how many of these surgeries are done on patients in their 80s. The ethics and economics — or perhaps the economic ethics — of performing this surgery on very elderly patients in particular are troubling. For all patients, the median survival after the Whipple procedure is about 18 to 24 months (for patients who don’t receive the surgery because their cancer is too advanced it is around six to ten months). But these medians are age-adjusted rather than absolute. In other words, median survival is measured relative to the overall mortality rate in the patients’ age cohort. Since an 85-year-old man without pancreatic cancer has about a 50% chance of dying over the next five years, to say that the five-year survival rate for 85-year-olds undergoing the surgery is 20% means that 90% of these patients will be dead within five years. (And this is assuming that the mortality rate from the surgery and its aftermath will not be higher among the very elderly than among patients in general, which seems like a very optimistic assumption).

How much do these treatments cost? The standard treatment protocol includes post-surgery chemotherapy, and sometimes radiation treatment as well. Re-hospitalization is very common as most patients will suffer a recurrence of the disease within a year or two. In sum, treatment costs can easily exceed six figures. Indeed treatment costs are often high even in the context of the large majority of cases in which surgery is not an option: palliative chemotherapy regimens that have some value in lessening suffering but that generally extend life by no more than a few weeks can cost thousands of dollars a month.

All this raises difficult issues. On the one hand, any time anyone raises the question of whether the cost of keeping very sick people alive for a year or two longer via extremely expensive treatments should be socialized, someone is sure to start shouting about “death panels” and the like. On the other, it’s not as if there are easy answers to the dilemmas these situations raise. After all, a small minority of people live for several years, and on rare occasions even a decade or more, after undergoing the Whipple surgery. Furthermore even if purely palliative treatments are quite expensive, we’re (still) a rich country. As a society should we be less willing to spend money on lessening the suffering of the dying than we are on, for example, building yet more big beautiful bombs? Furthermore some of the money spent on pancreatic cancer ends up funding clinical trials, which at least hold out hope for developing better treatments.

Of course another issue is why these treatments, whether potentially curative or merely palliative, are so expensive. What do rich nations with more just and efficient health care systems than our own, i.e., all of them, do when confronted with the dilemmas that diseases like pancreatic cancer engender? (I have no idea).

In the end we can’t pay for everything, but our current health care “system” pays or doesn’t pay for things in ways that have little apparent relation to justice, efficiency, or any other value beyond the continuing enrichment of those who benefit from the present state of affairs.

Internet mystery

[ 116 ] May 13, 2011 |

Apparently Ann Althouse posted an item on her blog about the three finalists for the dean job at Wisconsin Law School, asking for comments regarding them. According to someone who saw the thread it didn’t turn out too well:

[A] quick thought on Althouse’s post on the Wisconsin Dean finalists: the comments not only were negative on the candidates (as you note), but degenerated into a cesspool of vile misogyny and homophobia (not only multiple calling Margaret Raymond a token “diversity” candidate, but multiple posts opining that she should get the job only if she has “big tits” and speculating that she’s a lesbian). Isn’t Althouse at risk of letting her blog turn into AutoAdmit? She has the free speech right to run whatever cesspool she wants, but is she prioritizing her desire for a widely read blog over her obligation to be a responsible member of academia? I’d prefer not to say this for attribution…only because I’m a prof at [another law school] where Margaret Raymond was named a Dean finalist too – but that’s part of why I’m so offended on her behalf; she’s a fantastic and impressive woman who deserves far better than a professor (Althouse) at a school where she’s a finalist (Wisconsin) hosting this sort of festival of misogyny and homophobia.


Now Blogger claims that Althouse (the site) no longer exists.

I have a certain personal interest in this incident because we’re currently trying to hire Margaret Raymond at CU, so if readers could hold off on the temptation to post a festival of misogyny and homophobia in the comments here that would be super helpful.

Update: Curiouser and curiouser.

The politics of killing bin Laden

[ 184 ] May 7, 2011 |

Leaving aside all legal considerations, a mission that reflected a rational anti-terrorism policy — at least in a country not in the grip of continual hysteria — would have aimed to capture him alive.

Instead, the White House opted for justice the catharsis of sudden violent revenge and the advantages of cheap political theater. That as a matter of practical domestic politics it probably had no choice is ironic testimony to how far bin Laden actually succeeded in his crusade against the United States.

Update: Speaking of strawmen, I’ve written nothing that criticizes the SEAL team for their actions, since those actions are most reasonably interpreted as a precisely calibrated carrying out of their orders. Unlike the commentators who seem to think the SEALs shot bin Laden because they were frightened by the possibility that he might set off a booby trap of some sort, I have no doubt that the SEAL team would have captured bin Laden rather than shot him if their mission had been in fact to capture him, whatever concerns they might have had about danger to themselves.

Anyway the whole “booby trap” line of thinking is rather absurd — if OBL had booby trapped his bedroom then attempting to kill him rather than capture him would only slightly reduce the risk to the team, if at all. If OBL was going to set off a bomb he had several minutes to get himself ready to do so, and I doubt he would have given the team a chance to shoot him first. It’s just a bald rationalization to make the mission look more ambiguous than it was (it’s instructive that I haven’t seen a single right-winger argue that this was anything other than a kill mission, even though in their eyes that interpretation actually makes Obama look better).

Righteous killers

[ 132 ] May 2, 2011 |

(1) Was the killing of Osama bin Laden an execution, or would the military team have taken OBL alive if he hadn’t resisted or had been rendered harmless? Government officials have made contradictory statements on this point, and it’s unlikely we’ll ever know the truth with certainty. (Update: A senior administration official is now saying that OBL did not have a weapon when he was shot). Note that from a legal perspective, if the team had orders to kill OBL in any event, it wouldn’t make any legal difference if OBL shot back, any more than it would for police officers in a similar situation. The laws of war don’t allow you to kill combatants under any and all circumstances. Of course the situation could be ambiguous in a number of ways — for instance it’s quite possible that the commanders of the military operation weren’t given explicit orders to kill their target, but that it was made clear to them what a successful operation would entail. Certainly there’s little to no evidence that attempting to capture OBL alive was a priority.

(2) Leaving aside whatever the actual orders were, would capturing OBL have been a more desirable outcome, without regard to questions regarding the legal status of the operation? On this question I agree with Glenn Greenwald’s take.

(3) Progressives should take note that enthusiastic celebrations of the violence of the state, whether it manifests itself in strictly legal or extra-legal ways, tend to reinforce certain attitudes about authority and authoritarianism. See, for example, this passage from a Commentary essay on the execution-style killing of a couple of famous American outlaws, which ponders why there isn’t a movie about the Texas Ranger who ambushed them:

That movie, however, certainly could not have been made in 1967 and it certainly can’t be made in 2009: Hamer is too straight, too commanding, too uncompromising for such a treatment. The irony is that Hamer is forgotten while Clyde and Bonnie live on. Hamer stood for something: the idea of right and the guts to make it stick. Clyde and Bonnie stood for nothing, except perhaps infantile nihilism, unformed, incoherent, vicious. If they were ambushed without warning, it’s because each had weapons at hand, and so they wouldn’t widow and orphan other police families. If they were shot to pieces, it’s because the old-time law enforcement guys knew you shot them, and then you shot them some more.

Hamer stands for your grandfather’s authority, annoyance at fools, and the willingness to kill in the belief that he was saving the weak by eliminating their predator. He was a righteous killer, a dinosaur whose time has passed. He’s what Barack Obama swears he’ll change about America.

Can we declare victory now?

[ 49 ] May 2, 2011 |

Or at least start being a little less hysterical?

See also Yglesias and Fallows.

Update: This kind of thing was inevitable, and no doubt we’ll be hearing from lots of anonymous officials to the same effect in the days to come:

WASHINGTON (AP) — Officials say CIA interrogators in secret overseas prisons developed the first strands of information that ultimately led to the killing of Osama bin Laden.

Current and former U.S. officials say that Khalid Sheikh Mohammed, the mastermind of the Sept. 11, 2001 terrorist attacks, provided the nom de guerre of one of bin Laden’s most trusted aides. The CIA got similar information from Mohammed’s successor, Abu Faraj al-Libi. Both were subjected to harsh interrogation tactics inside CIA prisons in Poland and Romania.

The news is sure to reignite debate over whether the now-closed interrogation and detention program was successful. Former president George W. Bush authorized the CIA to use the harshest interrogation tactics in U.S. history. President Barack Obama closed the prison system.

It sounds as if Bin Laden may have been executed

[ 171 ] May 2, 2011 |

This ABC News story indicates that the only other people killed in the “firefight” in which OBL was supposedly killed were his son, two “couriers,” and a woman who one of the others used as a human shield. This strongly suggests that OBL didn’t even have a security detail of any kind within the compound, which in turn makes it natural to speculate on why a Navy SEAL team with an overwhelming force advantage didn’t take him alive. (I wouldn’t be surprised if OBL himself was unarmed during the live fire part of the operation, which probably only lasted a few seconds). The further fact that he was shot once in the head, and then another time “to make sure he was dead” only highlights that question. My guess is that, for politically understandable reasons, taking him alive was at the least not a mission priority, and indeed the team may have been under orders to terminate OBL’s command with extreme prejudice.

It’s unclear whether this sentence . . .

Remarkably, Bin Laden was hiding almost under the nose of the Pakistani military, which has a major garrison in Abbottabad and the Pakistani version of West Point.

. . . is intended ironically.

Update: Reuters is quoting a U.S. official to the effect that the team was under orders to kill rather than capture OBL.

More on law school shenanigans

[ 5 ] May 1, 2011 |

There’s a good piece in the NYT this morning on how law schools hand out merit scholarships to significantly more students than will end up being able to retain them, given traditional law school grading practices (Paul Caron has a useful summary of the article here). This practice, which is quite new — a generation ago law schools handed out almost no merit scholarships — is driven, like so many other questionable things law schools do, by the rankings game. The GPA and test scores of entering students account for nearly a quarter of a school’s ranking, so, just as in the case of graduate employment figures, there’s a powerful incentive to game the numbers.

Of course in AynRandLand none of this is necessarily a problem:

The ABA seems unaware of the issues raised by merit grants. Its annual survey of law schools is granular enough to ask for the number of hours the library is open, but it doesn’t ask how many students lose their scholarships each year.

The schools already know that number. Why not publish it?

“That is a good question, a legitimate question,” said Bucky Askew, who directs the ABA division that accredits schools. “It hasn’t been an issue brought to our attention. Nobody has written us, contacted us, to say, ‘This needs to be on the table.’ ”

Why is merit scholarship retention not part of the U.S. News data haul? “The main reason is that we haven’t thought about it,” said Robert Morse, who oversees the rankings. “It’s not a great answer, but it’s an honest answer.”

Then Mr. Morse thought about it. “This isn’t meant to be sarcastic,” he said, “but these students are going to law school and they need to learn to read the fine print.”

In other words, caveat emptor, as they say in first year contracts.

On a related note, it’s good to see that a less laissez faire attitude taken by students at one Top Ten law school has successfully shaken some money out of the pockets of not only the school’s administration, but also from some of the faculty.

White House releases photo of birth certificate

[ 99 ] April 27, 2011 |

This is interesting.

Apparently Obama is holding a PC later this morning to address the “issue.” My off the cuff reaction is that this is a mistake. From a political standpoint I think it’s great that Donald Trump is out there saying crazy stuff on Anderson Cooper about how the real birth certificate is missing. What’s the percentage in even giving a hint of legitimacy to the combination of pure paranoia and even purer cynicism that fuels the birther nonsense? I suppose the angle the Obama people have decided to play is to present their man straightforwardly as a victim of slanderous accusations from Trump types, and/or coy non-denial denials from prominent Republicans who purport to remain birther curious. Going even more meta, the idea may be to whip up even more “controversy” over this, since it goes without saying that this “birth certificate” is typed in a font that didn’t exist in 1961 on paper synthesized from chemicals that were never combined before 1977 etc etc.

Update: White House statement

The President believed the distraction over his birth certificate wasn’t good for the country. It may have been good politics and good TV, but it was bad for the American people and distracting from the many challenges we face as a country. Therefore, the President directed his counsel to review the legal authority for seeking access to the long form certificate and to request on that basis that the Hawaii State Department of Health make an exception to release a copy of his long form birth certificate. They granted that exception in part because of the tremendous volume of requests they had been getting. President Barack Obama’s long form birth certificate can be seen here (PDF). Correspondence with the Hawaii State Department of Health can be seen here (PDF).

Trump is holding a press conference. Quotes:

“Today I’m very proud of myself, because I’ve accomplished something that nobody else has been able to accomplish.” ..

“Our president has finally released a certificate. I want to look at it, but I hope it’s true.”

“I am really honored, frankly, to have played such a big role…”

“I’m taking great credit.”

Somehow I doubt all this is what James Madison had in mind.

The triumph of Mr. Pink?

[ 63 ] April 25, 2011 |

Goodbye waiters?

Well not exactly. Somebody still has to bring you your food:

Suri stresses that the console is not designed to replace waiters. “You still need people to bring the food, to fill up the glasses, for customers to [interact with] if they want to make, like, a really complicated burger order. It’s up to the restaurant to decide how to use it,” he says.

The Presto aspires to be the food-services version of the airline check-in kiosk or the ATM or the self-checkout at your local pharmacy. It makes a person’s job a computer’s job, and that cuts costs. Each console goes for $100 per month. If a restaurant serves meals eight hours a day, seven days a week, it works out to 42 cents per hour per table—making the Presto cheaper than even the very cheapest waiter.

The story goes on to speculate that one reason these types of things are not yet in wide use, even though the technology is pretty simple by contemporary standards, is that when restaurants use traditional waiters “labor costs are not 42 cents per table per hour, but they actually aren’t much more than that. Many waiters earn as little as $2 or $3 an hour, making the rest of their living in tips.”
I’m not following the economic logic here: given the standard structure of waitstaff compensation, surely tips are part of the restaurant’s labor costs as much as anything else?

Which makes me wonder how well the tipping structure works in general. I assume this the kind of thing enterprising social scientists have studied in detail. What percentage of customers tip at a sit-down restaurant? How much do they leave? How much does this vary depending on factors like actual quality of service, swankiness or lack thereof, type of food, region of the country, age of clientele etc etc? What about buffets? And what ramifications does all this have for systems like this, where the waiters will still be doing much of the work they’ve always done?

The law school employment crisis

[ 80 ] April 25, 2011 |

I have a piece in TNR that tries to answer what ought to be a straightforward question: What percentage of graduates of the 198 ABA-accredited law schools are getting real legal jobs within nine months of graduation?

If a real legal job is defined as a permanent full-time job that requires a law degree, the answer appears to be something on the order of 30% to 35%. Of course this figure will vary enormously between schools, but given that the overall “employment” rate for their graduates reported by law schools is over 90%, it’s safe to say that the real rate is drastically lower than what individual schools are claiming it is, wherever they may be in the hierarchy.

The real rate is a problem for several reasons, the two most pressing being skyrocketing tuition and declining legal salaries. In constant inflation adjusted dollars, media annual law school tuition since 1985 has gone from $3582 at public schools to $17,757, and from $14,762 to $37,950 at private schools. (In other words public law schools cost more now than private ones did 25 years ago). The median law school debt incurred by students (not overall educational debt, let alone overall debt) is approaching six figures, and is above that already among private school grads (60% of ABA law schools are private).

Then there’s the salary situation. Legal services are being rationalized in ways that are driving down salaries, especially entry-level salaries. Accurate entry level salary information is very difficult to obtain (less than half of graduates report any salary information at all, and those that do are not anything like a representative sample), but it appears that only a minority of the perhaps one-third of law graduates who are getting real legal jobs are getting jobs with salaries that would allow a person to service a six-figure law school debt amortized over ten years (the traditional period) and still eat and pay rent.

Then there’s the matter of how many of the few legal graduates who are getting high paying real legal jobs are doing the kind of work they wanted to do when they went to law school. There’s a lot of data suggesting that associates at big law firms are currently even more miserable than usual, as firms increase billable hour requirements, as they attempt to maintain profits while under increasing pressure from cost-conscious clients.

One obvious question all this should raise is: Why does law school cost so much more than it did just a few years ago? It’s a question to which legal academics haven’t paid nearly enough attention.

The politics of birtherism

[ 30 ] April 23, 2011 |

A new CBS/NY Times poll finds that 47% of Republican voters say Barack Obama was born outside the United States. (Only a third say he was born in this country, while another 22% say they don’t know one way or another).

This can be interpreted in a number of ways. Jon Chait points out that part of the explanation could be low-information voters who don’t really care much about the issue but have some vague idea that questions have been raised regarding it. That’s true — I know several people who tend to vote Republican who fall into this category: they say they don’t care much whether or not Obama was actually born in the US, but they don’t understand why he doesn’t [sic] release his birth certificate and “end the controversy.” But the problem with this explanation is that barely a fifth of Republican voters express doubts about the issue, while nearly half claim to know Obama is lying about being constitutionally eligible to be president, which hardly seems like a trivial complaint.

My take on the matter is that the astonishing number of Republicans who claim to have gone Full Birther is evidence of the extent to which the GOP base has been even more fully taken over by the classic mindset seen among many members of marginalized minority groups — a mindset that is particularly prone to accepting exotic conspiracy theories, and demanding that others in the group accept those theories too, if they wish to fully share in the group identity.

It’s important not to under-estimate the role of Fox News in all this. Fox’s commercial success is based on its intense appeal to a quite narrow demographic: Old white men dominate Fox’s audience to a startling extent (the network’s median viewer is 65, nearly 99% are non-black, and the audience skews heavily male). That appeal is based in large part on Rupert Murdoch’s and Roger Ailes’s canny calculation that many members of this demographic now perceive themselves to belong to a besieged minority group, and many of these people are beset by the classic paranoia that is common among such groups. The genius of Fox is that it has transformed the cohort that has run the country forever – older white Christian men (see, e.g., it’s more than comprehensive coverage of the “War on Christmas”) – into an oppressed minority group, that buys into fantasies of conspiratorial oppression. Indeed, the modern Republican party is based in part on its ability to transform, on a national scale, whiteness into a distinct and defining social identity, which allows people who share it to bond self-consciously over that identity. Fox’s shameless flogging of the barely concealed crypto-racism at the heart of birther fantasies is of a piece with its overall commercial/ideological strategy, which could be summed up as selling identity politics for white people.

New and improved Kinetic Humanitarian Intervention now includes robot killing machines

[ 6 ] April 23, 2011 |

blade runner

Still not a war though.

Interesting thoughts from former Pentagon analyst on the politics of drone warfare.

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