Topic: Political Philosophy

Science, Values and Politics

Today’s NYT features a front page, above-the-fold story about former surgeon general Richard Carmona’s charge that the Bush administration interfered with his office by (in the words of the NYT) ”repeatedly [trying] to weaken or suppress important public health reports because of political considerations.” He made the charge yesterday in testimony before the House Committee on Oversight and Government Reform.

Carmona described Bush administration behavior that ranged from petty (urging him not to attend Special Olympics events because of the Kennedy family’s connection to the program) to outright worrisome (directing him, again in the words of the NYT, “to put political considerations over scientific ones”). His claims add to the image of a Bush White House in which political considerations and ideology trump all others.

However, Carmona’s prepared statement suggests that the Bushies aren’t the only folks caught up in ideology.

Carmona considers himself a person of science, and scientists have an important role in policymaking. They try to determine the existence of various empirical relationships (e.g., certain emissions trap heat in the atmosphere; exposure to tobacco smoke increases the risk of cancer) and use those determinations to make predictions about the future (e.g., ongoing emission of greenhouse gases at certain levels will affect the climate; reduced tobacco use will decrease the incidence of cancer). In this way, science informs policymaking by predicting the outcomes of various policy choices.

But though science informs policy choices, it cannot make those choices. Science is a non-normative endeavor, and cannot answer such questions as whether climate change should be avoided, and whether reducing tobacco use should be used as a means to reduce the incidence of cancer. Those are the subject of value judgments — and, for public decisions, of politics.

Many “people of science” do not appreciate this limit on science’s role in policymaking. They assume that once a relationship is established scientifically, policy choices cogently follow. In making this assumption, they enter their own value judgments as suppressed premises in their analyses. Many doctors see bad health outcomes as not just undesirable, but so undesirable that they should be avoided even at high costs; many environmental scientists have the same opinion about environmental damage. Hence, they would argue that “objective, nonpartisan science” calls for policies to limit greenhouse emissions and reduce smoking. In fact, science can do no such thing; value judgments call for (or against) various choices.

To better understand this, consider the role of a doctor. Five separate times in his testimony, Carmona refered to the surgeon general as “the nation’s doctor” (conjuring the image of 300 million Americans sticking out their collective tongues and saying “ahh”). I trust my doctor to make a scientific determination of the state of my health and to lay out various courses of action concerning my health (e.g., lose weight, take medication, exercise more, quit smoking). But I am the one who sets policies concerning my health — I decide whether the costs of some course of action (e.g., the side effects of some drug, or the pleasure forgone by dieting) is worth the health benefits. Likewise, public health policy should be set by elected representatives who are directly accountable to the citizenry, not by “the nation’s doctor.”

But Carmona apparently wants the surgeon general to become a policymaker. He told the House committee:

[T]he Surgeon General [should] speak and act openly and as often as necessary on contemporary health and scientific issues so as to improve the health, safety, and security of the nation.

Indeed, that role may be too modest for Carmona’s surgeon general; he repeatedly argued that the surgeon general should “serve the people and the world.” He offered lawmakers a five-point plan for the U.S. Public Health Service that included the following:

  • Recognize and plan for the fact that tomorrow’s best hope to achieve millennium goals, extinguish asymmetries, eradicate social injustices, and make the world [a] healthier, safer and more secure place may be the newer, softer force projection of health diplomacy via prospective ongoing sustainable missions globally.

So, instead of just being the nation’s doctor (with policymaking power), Carmona’s surgeon general would be a force projector for the world.

Carmona is correct that politicians should not interfere with the scientific analysis of the surgeon general — the surgeon general should follow an empirical question wherever the science leads. And he may even state his personal opinion — couched as such — on the value judgments that ensue from the science. But the surgeon general should not supplant the politicians in making public policy decisions, nor supplant private individuals in making personal health decisions. And, of course, the surgeon general should not doctor scientific findings to conform them to his own value judgments.

Hillary the Neocon

Don’t miss Ed Crane in today’s Financial Times: “Is Hillary Clinton a neocon?” (Subscribers only, alas; you may have to run out and buy a copy.) Here’s a taste:

“You know, when I ask people, ‘What do you think the goals of America are today?’ people don’t have any idea. We don’t know what we’re trying to achieve. And I think that in a life or in a country you’ve got to have some goals.” Senator Hillary Clinton, MSNBC, May 11 2007

Senator Hillary Clinton’s worldview, as formulated above, is starkly at odds with that of America’s founders. The idea that the American nation had “goals”, just as individuals do, would have been wholly alien to them. For them the whole undertaking of government was to protect our “self-evident” rights to life, liberty and the pursuit of happiness. This emphasis on the primacy of the individual is the essence of true American exceptionalism.

National goals are a euphemism for concentrated national political power. The “Old World” was full of nations with goals, almost all pernicious. The concept of national goals is not so much un-American as it is non-American. But Mrs Clinton persists in promoting the concept, saying at a recent campaign speech in New Hampshire that rather than an “ownership society” she would “prefer a ‘we’re all in it together’ society”. She frequently invokes the notion that Americans want “to be part of something bigger than themselves”.

She has an unusual ally in this. The one other powerful political force in the US today that shares her frustration over the lack of national goals is neoconservatism.  …

UPDATE: Read the whole piece here.

The Anti–Universal Coverage Club Is Rolling Along

I started the Anti–Universal Coverage Club in part to make a point, but also because I was curious to see how many people agreed with its basic premises

I’m pleased to report that such people do exist. As of today, I count 86 club members.  Rather than list them all, I’ll run through just those who might be recognizable to the policy community. Affiliations are provided for identification purposes only and do not imply that any of those organizations agree with us. At all. Unless I list an organization by itself.

Nathan Benefield
Director of Policy Research
Commonwealth Foundation

Greg Blankenship
President
Illinois Policy Institute

David Brown
Editor
Laissez Faire Books Blog

Joseph Coletti
Health Care Policy Analyst
John Locke Foundation

Karla Dial
Managing Editor
Health Care News

Paul Gessing
President
Rio Grande Foundation

John Graham
Director, Health Care Studies
Pacific Research Institute

Curly Haugland
Republican National Committeeman
North Dakota

Carla Howell
President
Center For Small Government

Arnold Kling
Economist/Blogger
Cato Institute/Library of Economics & Liberty

Frayda Levy
President
Moving Picture Institute

Mark Litow
Consulting Actuary
Milliman, Inc.

Montana Liberty Project

National Review

Michael Ostrolenk
Director of Government Affairs
Association of American Physicians and Surgeons

Tom Patterson
Chairman
Goldwater Institute

Jared Rhoads
Director
Lucidicus Project

James Rottet
Legislative Specialist
The Heartland Institute

Herbert Rubin
Professor
UCLA School of Medicine

Thomas Saving
Professor of Economics
Texas A&M University

Greg Scandlen
Founder
Consumers for Health Care Choices

Greg Schneider
Health Care Fellow
Flint Hills Center for Public Policy

Jeffrey Singer
Contributing Editor
Arizona Medicine

Henry Stern
Blogger
Insure Blog

Mary Katherine Stout
Vice President
Texas Public Policy Foundation

Andrew Sullivan
Journalist
The Atlantic Online

The club has received a fair number of favorable mentions from blogs I had heard of (Coyote Blog, MooreWatch.com, SPN Blog, and Wisdom From Wenchypoo’s Mental Wastebasket) and some I had not (Blog of Bile, Chaos From Order, A Chequer-Board Of Nights & Days, Con Law Geek, DeadBeef.com, Health Care BS, I Was The State, and JasonPye.com).

Not everyone had a favorable reaction. Neil Versel’s Healthcare IT Blog described our one recruitment email as “unbelievably shocking.”  Ezra Klein of The American Prospect wished us well in recruiting members, I think because he’s happy to have someone else compile his enemies list for him. Matthew Yglesias of The Atlantic Online congratulated me for starting the club but then deftly missed the point when he wrote, “I’m fairly certain that, politically, ‘we don’t care if you can’t afford health insurance’ is a losing slogan.”

Some members (not listed above) asked that I not use their real names because they feared giving offense — or even receiving offense, in the form of professional reprisals.  Some think my name is spelled “Canon.” Others think my name is spelled “Tanner.”  That’s fine. I’m just happy to have them aboard.  I especially love that we have a Curly.

Not bad considering how little effort I’ve put into this.

Michael Gerson and the Fantasy-Based Community

In today’s Washington Post, former Bush speechwriter and policy adviser Michael Gerson sees the online role-playing game Second Life as a “large-scale experiment in libertarianism.” And since the world of Second Life apparently features its share of weirdness — violent, sexual, and otherwise — Gerson concludes that the libertarian concept of spontaneous order is a fantasy. Because of what he saw in a fantasy game. 

I know, I can’t follow the logic either, but remember that Gerson runs with a crowd that thinks “We’re an empire now, and when we act, we create our own reality,” so he may not be all that clear on the distinction between what’s real and what’s make-believe.  

I don’t know much about Second Life, and what I hear about it makes me feel crotchety and unhip beyond my years. But however bizarre the game is, it seems that nobody actually gets hurt. In that respect at least, it’s superior to the large-scale experiment in “compassionate conservatism” that Gerson helped conduct for the last several years. That experiment has left us with an exploding federal budget, a metastasizing welfare state, and a vast humanitarian disaster in Iraq. It’s little wonder some people prefer virtual reality to the real thing.     

Full-Spectrum Lindsey

Cato vice president for research Brink Lindsey tries to be a uniter, not a divider. In his much-discussed “Liberaltarians” article for the New Republic, Brink held out an olive branch to liberals. TNR’s Jonathan Chait was, well, less than enthusiastic.

In his “A Farewell to the Culture Wars,” recently published in National Review, Brink does much the same for conservatives, advising them to seek to conserve the “great American heritage of limited government, individual liberty, and free markets,” instead of, say, exclusively heterosexual marriage and a not-so-Mexican America. Perhaps unsurprisingly, NR’s Ramesh Ponnuru has declined the advice. Brink’s rejoinder, published online this Tuesday, is smart and effective:

Ramesh Ponnuru concedes the main point I was trying to make. Specifically, he admits that “[i]t really is pointless to pine for the social order that existed prior to the late 1960s,” and that “most conservatives would not want to go back if they could.”
 
Ramesh makes this concession almost casually, as if it were no big deal. But I’m sorry, it’s a very big deal indeed. After all, a great deal of intellectual and emotional energy on the right has been expended over the years in precisely the kind of pining Ramesh now regards as pointless. Conservatives have defended, with great conviction and moral passion, positions on race relations, the role of women in society, and sexual morality that most conservatives today would disown as ludicrous or offensive. I don’t think it suffices to dismiss these glaring errors of judgment with an Emily Litella-like “Never mind.”

While commentators left and right may be hesitant to pick up what Lindsey’s laying down, that doesn’t mean he’s about to stop trying to transcend the stale terms of yesterday’s political dialectic.

Tune into Cato Unbound on Monday, where Brink will kick off a fresh round of discussion on “The Politics of Abundance” with a panel of blogosphere luminaries. On the left, we’ll have The Atlantic’s Matthew Yglesias. On the right, National Review’s Jonah Goldberg. And in the … middle? … Reason contributing editor Julian Sanchez.  

Does Cost-Sharing for Rx Reduce Health?

Unknown, say Dana Goldman, Geoffrey Joyce, and Yuhui Zheng of the RAND Corporation. 

In this week’s Journal of the American Medical Association, the team presents a meta-analysis of “132 articles examining the associations between prescription drug plan cost-containment measures, including co-payments, tiering, or coinsurance[;] pharmacy benefit caps or monthly prescription limits[;] formulary restrictions[;] and reference pricing[;] and salient outcomes, including pharmacy utilization and spending, medical care utilization and spending, and health outcomes.”

Here are their principal findings and conclusions, from the abstract:

Increased cost sharing is associated with lower rates of drug treatment, worse adherence among existing users, and more frequent discontinuation of therapy. For each 10% increase in cost sharing, prescription drug spending decreases by 2% to 6%, depending on class of drug and condition of the patient. The reduction in use associated with a benefit cap, which limits either the coverage amount or the number of covered prescriptions, is consistent with other cost-sharing features. For some chronic conditions, higher cost sharing is associated with increased use of medical services, at least for patients with congestive heart failure, lipid disorders, diabetes, and schizophrenia. While low-income groups may be more sensitive to increased cost sharing, there is little evidence to support this contention.

That last sentence was certainly interesting. But here comes the kicker.

While increased cost sharing is highly correlated with reductions in pharmacy use, the long-term consequences of benefit changes on health are still uncertain.

That echoes points I’ve made previously in this blog:

  • The mere fact that cost-sharing causes people to reduce their consumption of prescription drugs (or other medical care) does not mean that their health suffers. 
  • Even if cost-sharing does cause some people’s health to suffer, that does not mean that the overall health effects of cost-sharing are harmful. 

Indeed, as Goldman et al. conclude that these studies leave open the question of long-term health effects, the best evidence on this point remains the RAND Health Insurance Experiment, which showed that the overall health effects of cost-sharing are nil.

But as Tom Firey has argued in this blog, even if it could be shown that cost-sharing does reduce overall health outcomes, that is not a public policy problem.  It means that people prefer to spend their money on things other than medical care.  That is their right.  We might try to persuade them to spend their money differently.  But we are not justified in taking their money away from them to spend it according to our preferences – or more likely, those of the health care industry – rather than their preferences.  Whose life is it, anyway?

Unequal Justice?

There it was, emblazoned across the front page of the Washington Post, a headline made especially disturbing by its publication on July 4:

Justice Is Unequal for Parents Who Host Teen Drinking Parties

What did it mean, I wondered. Poor parents go to jail, rich parents walk? The law is enforced in black neighborhoods, winked at in white suburbs?

Not exactly. In fact, the Post reported,

In Virginia and the District, parents who host such parties can be charged with contributing to the delinquency of a minor, a misdemeanor that can carry jail time. In Maryland, hosting an underage drinking party is punished with a civil penalty, payable with a fine, even for multiple offenses.

So it’s not a story about unequal justice, just about different jurisdictions with different laws. But the Post sees it differently:

The stark contrast in punishments is just one inconsistency in a patchwork of conflicting legal practices and public attitudes about underage drinking parties.

“Inconsistency.” “Patchwork.” “Conflicting legal practices.” This is ridiculous. Move along, folks, nothing to see here. On the Fourth of July, let’s pause to remember: The United States is a federal republic, not a unitary centralized state. Different states and even different cities and counties have different laws.

One of the benefits of a decentralized republic is that laws can reflect people’s different values and attitudes. Decentralism also allows states and counties to be “laboratories of democracy.” If voters in Maryland and the District of Columbia read about how Virginia sentences parents to 27 months in jail for serving alcohol to teenagers after taking away their car keys — and they think that sounds like a good idea — then they can change their own laws. Or if Virginia voters notice that Maryland has a slightly lower highway fatality rate, then they might decide to change their laws.

States in our federal republic have different laws about lots of things, certainly including alcohol since the repeal of national Prohibition. I grew up in a dry county in Kentucky — no legal sales of alcohol of any kind — but neighboring counties were wet. The old joke was that Bourbon County was dry while Christian County was wet, but that seems not to be true any more. First cousins can marry in some states but not in others. The rules used to vary on interracial marriage until the Supreme Court stepped in and banned laws against it. In the past couple of years we have begun to experience different state laws on same-sex marriage.

Some people seem to want all laws to be uniform across this vast nation, from California to the New York Island, from the redwood forest to the Gulf stream waters, from sea to shining sea. They use their power in Congress to impose national speed limits, national environmental rules, national school testing laws, national marijuana bans, and so on. But the beauty of America is that we have resisted many of those pressures, and there are still real differences in the laws of San Francisco and San Antonio; Manhattan, New York, and Manhattan, Kansas; Wyoming and Wyomissing, Pennsylvania.

The laws are even different in Virginia and nearby Maryland. That does not mean that justice is unequal.