Something Not Unlike Research

Informed Consent and Standards of Care

post by Paul Kelleher

Austin Frakt has an important post today about the still rocky terrain of informed consent in medicine. You should read the whole (short) post, which revolves around this case:

The date was July 19, 1999, when as a third-year resident I saw a highly educated 53-year-old patient. In June 2002, my residency and I were served with court papers.[...]

On that day in July 1999 I saw the 53-year-old man for a physical examination. I discussed with him, and documented in his chart, the importance of colon cancer screening, seat belts, dental care, exercise, improved diet, and sunscreen use. I also presented the risks and benefits of screening for prostate cancer and documented the discussion. I never saw the patient again, and after I graduated, he went to another office. His new doctor ordered prostate-specific antigen (PSA) testing without discussing the risks and benefits of screening with him. Unfortunately for the patient, his PSA level was very high and he was subsequently diagnosed with incurable advanced prostate cancer. [...]

My residency was found liable for $1 million.

Frakt gives a little more background on the trial that led to this verdict:

[S]everal physicians testified that it was standard to conduct a PSA test without asking the patient. Hence, in the eyes of the law and despite the shared decision making process he employed, Merenstein delivered sub-standard care.

Perhaps the rationale for defining adequate care as that which would be provided by most of one's peers can be ratified by adapting that old Churchillian quip: it's the worst form of government, except for all the rest. After all, do we really want courts to be making decisions about what appropriate medical care consists in, especially when so much of the profession is united on what should be done? On the other hand, it is just as easy--and maybe easier---to raise important worries about determining the standard of care in this "prevailing practice"-based way. Perhaps Frakt's case of the resident and the PSA test is enough to convince you that we need a different standard. If not, consider this case, which comes from Rebecca Skloot's book The Immortal Life of Henrietta Lacks (pp. 129-135): 

Southam injected HeLa and other living cancer cells into more than six hundred people for his research...Patients who'd unknowingly been injected with cancer cells by Southam read the articles and began contacting reporters. New York State Attorney General Louis Lefkowitz learned about Southam's research through media as well, and immediately lauched his own investigation. In a scathing five-page document filled with exclamation points, he accused Southam and Mandel of fraud and unprofessional conduct, and demanded that the Board of Regents of the University of the State of New York revoke their medical licenses. [...]

Many doctors testified before the Board of Regents and in the media on Southam's behalf, saying they'd been conducting similar research for decades. They argued that it was unnecessary to disclose all information to research subjects or get consent in all cases, and that Southam's behavior was considered ethical in the field. Southam's lawyers argued, "If the whole profession is doing it, how can you call it 'unprofessional conduct'?" [...]

The suspensions of Southam's and Mandel's licenses were stayed...[and] soon after the end of his [one year] probationary period, Southam was elected president of the American Association for Cancer Research. 

Our mothers were right: just because everyone else is pushing cancer patients off the Brooklyn bridge doesn't mean it's OK for us to do it. And perhaps, just perhaps, the fact that most other doctors conduct the PSA test without first getting informed consent from the patient does not mean that this is acceptable conduct either. I won't pretend there aren't forcing pulling in different directions. But that is why we need clear examples of when informed consent is required, so we can distill generalized lessons from them.  

Ubel on Bloomberg's Soda "Ban"

post by Paul Kelleher

Peter Ubel writes:

Unfortunately, the Big Gulp ban is a bad idea.

...

Where the trans-fat and soda bans differ, however, is in the coherence with which New York City officials can explain how they draw the line between banned and unbanned goods.

...

Coke and Pepsi are artificially manufactured processed foods, too. And they contain an undeniably harmful substance. But herein lies the problem. The harmful substance is sugar, and the sugar in Coca-Cola is no more harmful than the sugar in apple juice or a milkshake.

This is understandably confusing to the public, who can’t understand why New York City is planning to ban large sodas but not triple-decker chocolate cakes, or why the 280 calories in a 24-ounce Coke are somehow worse for them than the 330 calories in a Starbucks peppermint mocha.

The success of most policies depends upon public support. But incoherent policies are difficult to embrace.

If Mayor Bloomberg were defending his policy in front of the Supreme Court, the justices would be asking him for a limiting principle – a rationale that would help us know where this policy begins and ends. The ban on large sodas doesn’t pass this test.

I think a lot more rides in this case on pragmatic and context-specific considerations than Ubel acknowledges here. Ubel adopts the language of the Supreme Court oral arguments over the ACA when he says that Bloomberg cannot provide a "limiting principle" that explains why large sodas should be banned but not Starbucks peppermint mochas. But I wonder: is there a limiting principle that explains why one can buy Tylenol over the counter but not fentanyl patches? Each one can be very harmful if used improperly, and each works by containing narcotics, just as both soda and milkshakes taste delicious because of their sugar content. This suggests that sometimes pragmatic, context-specific considerations can serve to justify otherwise "incoherent" policies governing the sale of similar substances. A paradigm example of a pragmatic consideration is how likely it is that Tylenol (or soda) will be consumed in degrees that trigger the public's interest. Another example may well be how likely it is that a key demographic--kids and adolescents, e.g.--will overconsume one product rather than another. (Another may concern the degree to which specific consumption patterns negatively impact the already cash-strapped budgets for essential social services.)

I'm not yet saying that the consumption patterns of soda raise do in fact raise pragmatic concerns that render Bloomberg's specific proposal justified in the final analysis. (I need to read more of the empirical work on the issue.) I'm only pointing out that sometimes pragmatic considerations can justify a policy response that can't be neatly expressed in a tidy limiting principle.  

Kenneth Arrow and the Overdemandingness Argument for Discounting Future Health Benefits

post by Paul Kelleher

There are a number of different arguments in the economics literature for assigning less value to future benefits than to present ones (this includes health benefits). This practice is called discounting, and standard economnic analyses of programs that produce benefits in the future will discount those benefits at some positive rate. For example, a cost-benefit analysis using a discount rate of 3.0% will say that 1.3 expected lives saved in 10 years are equivalent in value to 1 life saved today. 

One common argument in defense of discounting is what I shall call the Overdemandingness Argument. This argument takes the form of a reductio ad absurdum. Here is an example of it in the literature (I give other examples in a paper on discounting out just today):

There has been considerable debate about the value of [the discount rate] since Ramsey. He argues that it is ethically indefensible to use a positive value, as this would discount future generations’ well-being relative to the present one. However, Arrow shows that weighting all generations’ welfare equally results in very high rates of savings being required of the current (or even of every) generation. He demonstrates that, under reasonable parameter values, the current generation could be required to save approximately two-thirds of its income! To avoid this result, a positive pure rate of time preference should be employed. (Moore et al. 2004, p. 804)

As stated here, the Overdemandingness Argument is woefully incomplete. For it relies on a crucial, unstated premise, namely Premise 3 in the following more complete version of the argument:

1. Assume a discount rate of 0%. (This means a benefit provided today will be not be valued more than an exactly similar benefit provided at any point in the future.)
2. So long as the current generation’s consumption is not perilously close to zero, a dollar productively invested today on behalf of future generations will enable them to derive more “raw” (i.e. undiscounted) benefit than that dollar could provide if consumed by the current generation.
3. We have a moral obligation to maximize total net benefits across time.
4. Therefore, the current generation has an obligation to sacrifice its own consumption for investment in behalf of future generations.
5. But Conclusion 4 is absurd, so there must be something wrong with the argument that leads to it.
6. The only plausible weakness is Premise 1.
7. Therefore, Premise 1 is false, and a positive discount rate should be used to convey that future benefits are less valuable than present ones.

Premise 3--the premise that Moore et al. left unstated--could be rewritten thus: we have a moral obligation to pursue efficiency singlemindedly. This view is called consequentialism in moral philosophy, and utilitarianism is its most well-known variant.  If the Overdemandingness Argument does not contain a premise about consequentialism, it is incomplete. Once that assumption is added, the argument is complete, and premises 1-3 do logically entail the ostensibly problematic Conclusion 4. But in order for the Overdemandingness Argument to be a successful argument in favor of discounting, Premise 1 must be the only possible problematic premise. And it is precisely because they leave Premise 3 unstated that the economists I quoted above view Premise 1 as entirely responsible for the problematic Conclusion 4. However, someone who rejects that conclusion may now choose to reject consequentialism (Premise 3) instead. The Overdemandingness Argument's case against Premise 1 is therefore significantly weakened.

Despite being cited favorably by the economists quoted above, Kenneth Arrow saw very clearly that the assumption of consequentialism is doing essential work in Overdemandingness Argument. As he writes in "Discounting, Morality, and Gaming" (pdf),

But with zero time preference [i.e. no discounting] and a long horizon, the savings become inordinately high, possibly approaching one as the horizon goes to infinity. A reconciliation must be based on the notion that individuals are not morally required to subscribe fully to morality at any cost to themselves. (p. 13, emphasis added)

The substance of this observation is correct, but Arrow’s wording is not innocuous. He assumes here that morality is consequentialist, and thus that any deviation from consequentialism is a deviation from morality. However, many who reject consequentialism claim that morality itself permits deviations from consequentialism’s dictates. Indeed, Arrow at one point suggests precisely that:

I find this to be an incredible and unacceptable strain on the present generation...I therefore conclude that the strong ethical requirement that all generations be treated alike, itself reasonable, contradicts a very strong intuition that it is not morally acceptable to demand excessively high savings rates of any one generation, or even of every generation. (p. 16, italics added)

If it is indeed a substantive question whether morality is consequentialist or not, then this will be a question about which many economists, qua economist, wish to remain neutral. Often, this will be because economists are not formally trained to evaluate answers to this philosophical question. But even if they, like Arrow, are willing and able to make philosophical headway on the question, it is doubtful that economists, qua economist, ever need to do this. To see why, consider the following remark by Arrow and colleagues in their chapter on discounting in the 1995 report of the Intergovernmental Panel on Climate Change (pdf):

Economists are in general agreement that cost-benefit analysis, including discounting, is useful in examining policies with long or complex time paths, or policies whose effects extend across generations. At the same time, cost-benefit analysis, and the techniques that go with it, including discounting, focus on economic efficiency, and therefore have limitations as a guide to policy. (p. 130, emphasis added)

If economists are to focus on efficiency only, then it is not clear why the technique of discounting should be a part of the economist’s repertoire in the first place. After all, one can focus exclusively on efficiency (e.g. investigate its nature, make recommendations for its measurement, rank policies with respect to it, etc.) without recommending the singleminded pursuit of it. But, as we have seen, it is only the singleminded pursuit of efficiency that could generate the worry that current generations will be crushed under the weight of a duty to maximize future well-being. Since economists, qua economist, do not recommend the singleminded pursuit of efficiency, I conclude that they have no “overdemandingness”-related reason to discount the raw results of their efficiency-focused inquiry.

Of course, this does not show that discounting the value of future benefits is wrong. It just shows that one common reason for doing so is unsound.

A Clue to What Weinstein and Stason Were Thinking

post by Paul Kelleher

This is a follow-up to my recent post analyzing one argument for uniform time-discounting in cost-effectiveness analysis.

As I explained, Weinstein & Stason's (W&S) argument relies on a comparison of five hypothetical health interventions. 

(Key: $10’ = $10,000, $70’ = $70,000; “LY” means “life-year saved/generated”)

Their most controversial premise is that programs A1 and A2 are "equivalent." This is controversial because W&S also assume that programs A and A1 are equivalent. However, A and A1 can be equivalent only if $10,000 today is worth $70,000 in 40 years. But then if $10,000 today is equivalent to $70,000 in 40 years, we should conclude that program A1 is superior to A2, since A1 gets us one life-year for $60,000 less than A2 (we can just put $10,000 in the bank now and wait until the account grows to contain $70,000 in 40 years). This is why it looks absurd to say, as W&S do, that A1 and A2 are equivalent.

Now, I was trying to be charitable in my first post. So instead of claiming that W&S were simply wrong to claim that A1 and A2 are equivalent, I introduced a notion of equivalence on which A1 is indeed equivalent to A2. I called that static-equivalence, and it was meant to convey that both A1 and A2 involve buying 1 LY for $70,000 at the time the LY can actually be purchased. For A1, that is in 40 years. For A2, it is now. I then went on to note that programs A and A1 are not equivalent in that same sense. Rather, A and A1 are dynamically-equivalent, since their equivalence relies on the fact that productive forces can transform $10,000 into $70,000 over time. Finally, since W&S wanted to create a "chain of equivalences" running from program A through to program A3, I claimed that this chain cannot even get started, since there are two completely different notions of equivalence at work here.

I still stand behind this analysis, and I still think W&S's argument is plainly invalid. But I was always unsatisfied that I couldn't explain why W&S (or anyone!) would assert that A1 and A2 are equivalent. I now I think I may have the answer. (The explanation I'm about to give is also suggested by Erik Nord in the paper of his linked to in my first post, but I didn't quite see this until my second or third reading of it).

To understand where W&S may be coming from, it helps to return to the Washington Panel Report chapter on discounting. The "W" of W&S (Weinstein) was a co-author of that chapter. After restating W&S's argument, the Panel writes (my emphasis): "Closely related to [W&S's] consistency argument is the paradox of Keeler and Cretin...The following simple example...summarizes the essence of the argument:"

Assume that an investment of $100 today would result in saving 10 lives (or 1 life per $10 of investment). If the $100 were invested at a 10% rate of return, in 1 year it would be worth $110; and with this $110, it would be possible to save 11 lives. If the original $100 were invested for 2 years at 10%, it would be worth $121, and 12 lives could be saved. If the social decision maker is attempting to maximize the health output obtainable from the original $100, and if the value of future lives saved is not discounted [at the same 10% rate], then the cost-effectiveness of the investment would be...postponed "until next year" on a perpetual basis.

The Panel's example highlights two potential problems. The first is that decision makers may be tempted to hold onto allocated health funds indefinitely, since it always seems a good idea to save the money for one more year. The second problem arises even if we avoid the first by establishing an end-date by which the health funds must be spent. Even with an end-date, decision makers will still prioritize those who need help at end of the imposed time-window, since more lives can be saved by waiting as long as possible (assuming, as is being done here, that the nominal cost of saving a life does not increase over time). Thus the Washington Panel concludes:

Hence, setting [the discount rate for costs equal to the discount rate for health] creates what economists term horizontal equity among potential beneficiaries.

In other words, uniform discounting removes the basis for systematically prioritizing future beneficiaries over present ones. If the amount of good one can do declines at the same rate as the real costs of saving those lives, then there is no incentive to wait to save lives. 

I think this may provide the best clue to what W&S must've been thinking. Given that the Washington Panel Report was co-written by Weinstein, and given that the Report says that W&S's logic is "closely related" to the logic used to avoid the "postponement problem," some sense can now be made of W&S's claim that A1 and A2 are equivalent: W&S may have wanted to rule out the perceived intertemporal inequity that exists when there is systematic reason to postpone health expenditures. To say that A1 is superior to A2 is to invite "horizontal inequity."

I was aware of the so-called "postponement problem" when I wrote my previous post. But I was not aware that W&S's argument might be influenced by it. If this new explanation of their argument is correct, I can give the response to W&S that I'm inclined to give to the postponement problem itself: Since cost-effectiveness analysis is intended to be a framework for evaluating efficiency only, economists should not build equity-related considerations into their calculations of efficiency. If one is interested solely in quantifying efficiency (as cost-effectiveness analysis is intended to be), why not just admit that more good can be done by waiting until one's health budget is as large as possible? If we think it's wrong to wait that long, this reveals that we have concerns other than efficiency. Big surprise.

At the very least, the Washington Panel Report can be commended for being open about letting equity-based considerations shape its ostensibly efficiency-based economic framework. 

A Critique of Weinstein & Stason’s Consistency Argument for Time-Discounting (wonky)

post by Paul Kelleher

UPDATE: I have a follow-up post here that offers a hypothesis as to why W&S accept what most others believe is a patently false premise (i.e. that programs A1 and A2 are equivalent). 

In 1996, an expert panel appointed by the U.S. Public Health Service released a report on improving the methods of cost-effectiveness analysis in health policy. That report, known in the biz as the Washington Panel Report, included a chapter on discounting the health benefits produced by medical interventions. Discounting is a super tricky issue that raises questions of ethics and economics, which is why I like it. It is also a super important issue, as I hope will be made plain by this post.

The Washington Panel recommended (1) that both the future costs of health promoting policies and their future benefits should be discounted, and (2) that costs and benefits should be discounted at the same rate. What does this mean? Put simply, to discount is to treat as less valuable. So consider costs first. The main reason for treating a dollar in the future as less valuable than a dollar today is that today’s dollar can be invested productively to yield more than one dollar in the future (even after adjusting for inflation). This means a cost of 100 (inflation-adjusted) dollars borne in 20 years can be covered by an investment of less than $100 today. Hence, future costs should be discounted relative to present costs.

So that’s discounting costs. What does it mean to discount health benefits that lie in the future?

Gaps in the Recent Infanticide Argument

post by Paul Kelleher

Bill and I have already posted some "meta" comments on the controversial paper by Giubilini and Minerva that purports to prove that infanticide is permissible in cases involving all the same reasons that would've made early abortion permissible. I noted that even if philosophical argument seems airtight, we can have commonsensical reasons to doubt the conclusion (and to believe there must be something wrong somewhere with the argument). But I actually don't think that G&M's argument is airtight. Instead, I think we can point to some real gaps in their reasoning.

Here is their argument as I understand it. Quoted parts come straight from the paper. Everything else is intended as a faithful reconstruction of their argument.

1. "A necessary condition for a subject to have a right to X is that she is harmed by a decision to deprive her of X." 
2. Full-fleged persons are harmed when their aims or life-goals are thwarted.
3. Fetuses and newborns don't have aims or life-goals.
4. So fetuses and newborns cannot be harmed in the goal-thwarting sense of harm.
5. However, fetuses and newborns do in fact have the potential to form life-goals.
6. But "in order for harm to occur, it is necessary that someone is in the condition to be harmed."
7. Fetuses and newborns are not in fact in the condition to be harmed in the goal-thwarting sense.
8. Therefore, "there is no harm at all" when a fetus or newborn is killed (assuming it is done painlessly).  
9. "Therefore, the rights and interests of the actual people involved should represent the prevailing consideration in a decision about abortion and after-birth abortion."
10. "Among these interests, we also need to consider the interests of the mother who might suffer phychological distress from givign her child up for adoption."
11. Therefore, "if the interests of actual people prevail, then after-birth abortion should be considered a permissible option for women who would be damaged by giving up their newborns after adoption."

Assume for the sake of argument (but only for the sake of argument) that G&M's argument from 1 to 10 works perfectly. That is, assume that it is only the interests of actual people that matter in deciding whether abortion and infanticide are permissible (and of course that the mother's interests are relevant). Does it follow from this that no one else's interests are relevant? It does not. And G&M never argue that other people's interests and feelings about infanticide are irrelevant. All they claim is that a woman may be so distressed by adoption that she'd rather kill her baby. They don't even take pains to argue (as they must) that being driven to choose infanticide by post-partum distress really is in the woman's interests. 

So the leap from 1-10 to conclusion 11 is a HUGE leap. The gap that must be traversed includes arguing that the mother really would be better off in some circumstances if infanticide would occur, and that other people's interests and feelings about infanticide can never, ever, ever trump a woman's desire that the newborn die. (If other people's feelings about trees and wetlands can justify protections of them, why not feelings about newborns?) M&G do not do the work to close this gap. They are therefore not entitled to their very strong conclusion #11.

Infanticide and the thing about philosophical argument

post by Paul Kelleher

Philosophical argumentation is a wonderful thing. It promotes clear thinking about the structure and substance of lines of reasoning, and it helps to locate problematic logical gaps. Sometimes, however, it is not philosophical argument that identifies the gaps, but rather our common sense. Sometimes, we just know there's a mistake somewhere, even if philosophical argument presents itself as ironclad. Consider The Surprise Test Paradox:

A teacher announces that there will be a surprise test next week. A student objects that this is impossible: “The class meets on Monday, Wednesday, and Friday. If the test is given on Friday, then on Thursday I would be able to predict that the test is on Friday. It would not be a surprise. Can the test be given on Wednesday? No, because on Tuesday I would know that the test will not be on Friday (thanks to the previous reasoning) and know that the test was not on Monday (thanks to memory). Therefore, on Tuesday I could foresee that the test will be on Wednesday. A test on Wednesday would not be a surprise. Could the surprise test be on Monday? On Sunday, the previous two eliminations would be available to me. Consequently, I would know that the test must be on Monday. So a Monday test would also fail to be a surprise. Therefore, it is impossible for there to be a surprise test.” 

But obviously logic does not make it impossible for the teacher to throw a surprise test. Indeed, do you know what would make a surprise test an absolute certainty? Yep, that's right: if all the students accepted the seemingly ironclad line of reasoning presented above. If they all believe a surprise test is impossible, they will all be in a rude awakening when they don't study for it and then find blue books on their desks on Wednesday.

The lesson here is that one's intellect must always be on guard, even against seemingly airtight philosophical argumentation. Common sense always retains a key role, even while it itself undergoes continuous scrutiny. That's our predicament.

All this leads me to be less sanguine than Bill about a recent paper in Journal of Medical Ethics by Alberto Giubilini and Francesca Minerva that defends infanticide. Bill clearly states that he wishes to "defend Giubilini and Minerva's arguments, while disagreeing strongly with their conclusions." In particular, he says that "G & M are doing what ethicists are supposed to do: pursuing ethical arguments to their conclusions." In G & M's case, that conclusion is this:

[W]e argue that when circumstances occur after birth such that they would have justified abortion, what we call after-birth abortion should be permissible.

However, given the lesson of the Surprise Test Paradox, there is another thing the authors could have concluded. They could've said:

We have constructed a very strong argument for the conclusion that post-birth abortion is permissible. If that conclusion is false, then (1) there must be a problem with one of our premises, or (2) there must be a problem with the logical structure of the argument. We do not find either sort of problem, although it is of course possible one exists. We do not wish to advocate for permitting infanticide (at least not yet). But that seems to be where the argument leads. Evidently, those who oppose this controversial conclusion have some work to do.

Instead, the authors chose to declare--assert--that that infanticide really is permissible. If I sit here and declare that they should have deferred more to common sense, am I thereby claiming that I have a more highly evolved common sense than they do? I guess so. But at least I'll be prepared for Wednesday's surprise exam.

(I'll post Monday on what I do think is a clear substantive flaw in M & G's argument.)

Is mandated insurance coverage of contraception an assault on religious liberty?

post by Bill Gardner

The health insurance reform that was part of the Affordable Care Act requires health insurance plans to pay for prescribed contraceptive services. Some, but not all religious institutions are exempted from this requirement. An exemption means that is they offer their employees health insurance, that health insurance does not need to require coverage of prescribed contraception. Under current rules, churches are exempted, but a church-run hospital or hospital is not. There is currently a dispute about whether the exemption should be broadened to include all church-run institutions.

As a matter of health policy, I support the broadest possible access to contraception. Control over reproductive decision making is a fundamental freedom. However, I agree with the editorialist in the Christian Century, that there was a competing public good that would have justified a broader exemption:

we think the common good is also enhanced when religious believers—and religious institutions—are free to act in the public square without sacrificing their religious identity.

The Catholic Bishop of Charleston, however, takes the stronger view that the failure to broaden the exemption is an assault on

the fundamental right to religious liberty  for all citizens of any faith.

This is, I think, an overstatement: I don't think this rises to the level of an assault on a fundamental right and I do not think he is speaking for all US citizens of any faith. Try looking at this from my point of view.

1. I am a Buddhist who has taken a number of religious vows, including not killing. If I were an absolute pacificist, which I am not, I could conscientiously object to military service. But I cannot conscientiously refuse to pay any portion of my taxes, even though I am thereby funding killing in wars that have, in my view, no moral justification. Is this an assault on my religious liberty? 
2. I am absolutely opposed, on religious and ethical grounds, to capital punishments (the graph tracks capital punishments in the US). Nevertheless, they are regularly carried out in my name and paid for with my taxes. Is this an assault on my religious liberty? 
3. I abstain from eating meat, because it kills animals. However, the US government purchases many tons of meat every day for the armed forces, and hence procures the slaughter of thousands of animals. So again, I am paying for this killing. Is this an assault on my fundamental right to religious liberty?
4. Finally, the Catholic Church has historically supported the banning of contraception. Wasn't this religiously-motivated restriction of access an assault on the fundamental right to religious liberty of persons whose religion (or lack thereof) did not bar them from using contraceptives?

The answer to each question is, to some degree, yes: my religious liberty is infringed by points 1-3 and it would have been infringed if there were still restrictions on access to contraception. The government makes me pay for executions. I think that's a more serious  assault on my religious liberty than forcing a Catholic hospital to pay for a diaphragm. Where was the Bishop when I needed him?

The thing is, it turns out that if you are a religious person in a religiously diverse society there will always be some important infringements on your liberties. 

I'm for raising taxes on the affluent. Am I a hypocrite?

post by Bill Gardner

I support an increase in the taxes paid by the wealthiest and highest income Americans. I want this to happen to reduce the deficit and to fund some essential services to benefit the poor. This is not retribution. I don't think incomes are or could be based on what people 'deserve.' Finally, I am not motivated by envy, because I am in the group that should be taxed.

At this point, you may respond, "If you believe in increased taxes on persons like yourself, take the option to give the government more." And if I do not take that option -- which I do not -- I am a hypocrite.

So, there is no question that I am not nearly as generous or charitable a person as I should be. But that is a separate issue. I want the US to be a society where every child gets essential health care and education. Charities have never achieved these goals. Governments funded by progressive taxation get closer, in many developed societies. 

Inequality? Oh we'd love to help, but...

post by Bill Gardner

Arnold Kling and Nick Schulz argue that the growth in US inequality derives from two factors:

• Technology that allows a few very able persons to achieve extraordinary things (think Sergey Brin), and
• Defective families and assortative mating based on ability that result in large groups of people at the bottom who lack the talent to produce much of value.

These are important causes of inequality. Kling and Schulz would do something about these things if they could, they really would, but 

there may be less that government can do than one might hope. Research from Heckman suggests that education is a relatively feeble remedy for the effects of family background (although Heckman believes that early intervention, in preschool or even before, shows promise). In order to make a dramatic impact on inequality, government would have to do something about the fundamental causes: technology and marriage patterns. However, putting a brake on technological progress seems hardly feasible or desirable. And forcing people to select mates at random rather than on the basis of similar backgrounds and tastes seems similarly unlikely. As much as inequality may be a problem, no real solution is in sight.

OMG, if the only alternatives are freezing technological progress or making people marry random partners (on second thought, this is the best explanation for my first marriage, and the kids turned out great anyway), then I guess there really is nothing to be done.

Or maybe we could try the following:

• We could give every mother good prenatal care, and institute programs to reduce premature delivery. 
• We could provide every child with universal, high-quality preschool education. Please, read Heckman for yourself. He isn't saying that early interventions "show promise." He's saying that "Early interventions promote schooling, reduce crime, foster workplace productivity, and reduce teenage pregnancy." 
• We could reform our criminal justice system. The US has 751 persons in prison per 100,000 population. Canada has 117. England's rate is 151; Germany's is 88; and Japan's is 63. Mexico has 204. The global median is 125. Are Americans really six times as violent and criminal as the rest of the world? The burden of US incarceration falls on the poor and above all on people of color. It destroys families. But it could be fixed.

America could do these things and it would still have considerable inequality. But these are solutions that would help and, contrary to Kling and Schulz, they are in plain sight.