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M. Reiber

This article hits the nail on the head. Americans seem to have a terrible fear to pass away. For me this is a quite normal procedure and i myself don't want a large public spending to extend my life by a few months with huge public spending. I will even forbid doctors to do this (if I'm able to) and bring them to court.
The critical point is: Who will be allowed to decide in hospital what treatment is to be granted?
M.R. Germany


As always, precient remarks. Some perspective seems in order, however. Medical intervention, even cases involving the elderly and advanced procedures that produce modest extensions or improvements in quality of life, are among the MOST cost efficient dollars spent on life-extension, per -year.
You may be familiar with Lomborg's 'Skeptical Environmentalist' (if not, the title is a bit of a misnomer). In it he cites Harvard's Center for Risk Analysis survey of life-saving/extending public initiatives. Their results (in part): for 182,000$ it is possible to screen african-american newborns for sickle cell anemia and save 769 life years, at an average cost of 236$ a life-year; 253 million dollars spent on heart transplants yearly, gains an extra 1,600 life-years, at an average cost of 158,000$ per life-year; equiping school-buses with safety belts would cost 58million, but because less than one child would be saved, that shakes out to 2.8 million per life-year; benzene emission controls enacted in tire-manufacturing plants gain one life-year for every 20million spent (Lomborg, pg. 340; Tengs, et al. 1995).

Becker's position is correct, fear of death and feeling for our fellows is what prompts us to spend what we do on medicine - even if it is profligate and inneficient. However, if Becker and Posner wish to address the inneficient allocation of resources, then medicine is NOT the place to start! Public-health dollars are some of our most efficient. Some of our least are spent in programs administered by the EPA. Tengs et al. calculate that the efficient distribution of public funding to life-saving programs would have doubled the number of life-years gained at the same cost. Despite our rapidly aging populace, there are other better places to first look for inefficiencies or a disconnection between those responsible for the costs, and those who benefit from them.


Ken Costello

I believe that as a society we need to address the following question: given our limited resources to spend on health care, wouldn't societal benefits be much greater if the money now spent to prolong old people's lives (much of it taxpayer funded) be better spent on providing better health care to the younger population? I would conjecture, with a high degree of confidence, that reallocating monies from health care to the old to health care for the younger would have a much higher societal payoff in terms of both extending life expectancy and improving the quality of life (i.e., this redistribution of taxpayer's monies would easily be more cost-beneficial. Of course, this is an empirical question, but inutition invariably tells me that better medical treatment for the younger population would extend life expectancy, aggregated across all persons receiving such treatment, more than if the same dollars were spent in prolonging old people's lives, especially those for whom treatment would extend their low-quality lives for only a few months.


The key point here is not whether the government should spend on medical care programs mainly for the elderly, but how it should spend. I really think the government should focus on the basic aspects of medical care and ensure the basic demand for all the people. Some expensive-even luxurious-methods of treatment are unnecessary for the government to supply; maybe it is better for commercial insurances to do it. By the way, most of people have an enormous fear of death, but it doesn’t mean that they will extend their lives regardless of cost. I don’t clear the circumstances of the USA, nevertheless, I did some investigation in China to ask cancer patients whether they would pay anything to cure their disease, and the majority of participants chose they didn’t quite agree.

Incidentally, I have confusion about this article. If the public spending for medical care increases and takes more part in the total spending, commonly, the total cost of medical care will decrease since the public payer have more incentives to control the cost. But the recent situation is that while the government spends much more on medical care, the total cost is still increasing rapidly. How can it be explained?

Wang Yikai

The benefit of health insurance is that it can reduce the risk that an individual assumes, by sharing the risk among a great number of individuals.

However, health insurance is different from other kinds of insuraces such as car accident insurance, since an individual who suffer from the disease can decide the cost by choosing different hospitals and drugs. Therefore, the cost is shared among the taxpayers, which means that the individual who suffers from certain disease only gives a part of the total cost while enjoy the whole benefit. The individual makes his decision so that his marginal cost equals his marginal utility, thus the marginal cost of the society is much larger than the marginial utility.
So, the fact that the patients decide the cost will certainly leads to that the cost about health is much larger than what it should be.

The effective way of avoiding the waste of money spent on health is to restrict the freedom of patients on deciding the cost. If the insurance company gives the patients fixed compensation according to the levels of diseases, there will be no gap between the marginal cost of an individual and the counterpart of the society.

Scott R. Monroe

Mr. Becker wrote that fear of death, altruism and bad publicity "make it difficult for me to conclude that the large medical spending to extend the lives of elderly persons is clearly socially wasteful."

I find it difficult to swallow that fear, logically-disconnected emotions and bad press lead to socially resourceful spending. _Any_ spending could be justified on these illogical grounds.

Since a society is simply a large number of individuals, and we're talking about spending large sums of public money on small increases in the net utility of a few, my suggestion would be to cut off publicly-funded payments for expensive and minimally life-extending treatments altogether and to inform the opinion of the public- not to economically rationalize wasteful government spending to pander to the emotions of weaping altruists.

Those who wish to give away their money based on guilt and altruism have private charities if they wish to give to the cause of marginally extending the lives of the elderly using large sums of their own cash. And, those who fear death have the option of spending their own money or using private insurance. Those who didn't make the sacrifice of saving for medical care shouldn't have the right to force that sacrifice on everyone else. This situation cries out moral hazard, discouraging people from making informed decisions about the costs of risk management. To force everyone to pay into a system that's wasteful and transfers huge sums of money for the marginal benfit of a few could be seen as tyranical, which is certainly how I view it.

If, however, Mr. Pecker's point is that a shift in Medicare policy is unlikely based on the aforesaid reasons, which are basically political, he is quite right.


Come back and talk to me when you've been diagnosed with a terminal illness and the insurance companies won't cover you and you've run out of money to finance your own medical payments. Know what my response would be? "Tough luck kid, but here's a Delta-pill, that is if you can screw down your courage to take it."

One of the marks of an advanced civilization is how well it takes care of its ill and elderly. It makes for some tough decisions.

Scott R. Monroe

Mr. Hatfield,

Why take the Delta-pill when I can have the IRS come to your house and forcibly take ten years worth of your labor so I can extend my last painful days by a few months?

I'm not advocating the elimination of all medical provisions- just those that are publically funded and unjustified by their benefits measured against their costs.

As for your comment about civilization, I agree. And, a civilized nation contains individuals with the compassion to give to medical charities, family members, and friends who are ill because they deem the contribution of the fruits of their labor to be worthy of the cause-not because they were forced by the government. Forced giving is not charity. If you and I were standing on a street corner and you had pity for a homeless person, I would not consider myself to be charitable or giving if you took my wallet against my will and gave my money to him. Nor would that make me "civilized". But that's precisely what you suggest.


Just one comment, without taxation there is no civilization. Just a state of nature with the all against the all.


NE, I agree that taking care of the weakest is crucial if we want to consider ourselves an advanced civilization. But we shouldn't forget that the money we spend on the elderly could instead have been spent on children, who haven't had a lifetime of opportunities to save for end of life, take measures to prevent preventable diseases, or do anything else for that matter. Taking care of the elderly is not the only compassionate use for taxpayer money, and we must try to remain rational when it comes to allocating resources.


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