Apr 27, 2009

Report Ignores Revealed Preference [LINK]

A letter in response to a report on my local NPR station:

Tonight WBUR aired an engaging report by Rachel Gotbaum on palliative care, one that focused on the diminishing returns end-of-life medical interventions often bring, especially as medical advances extend lives further and make people more likely to die of long-drawn-out chronic diseases.

I found one aspect of the report questionable, however: its conclusion that patients are ill-served by the medical establishment's focus on doing everything in their power to keep their older patients alive. Instead, the report cited a "national survey" that people would prefer to die at home, surrounded by family, and with no pain -- a preference we're clearly not meeting because 80% of us die in institutions.

The problem with such survey data is that it's far less reliable than data on how people actually behave. Of course, when asked, people will naturally respond that they don't want to die in pain, but that's not necessarily a realistic option if your goal is to live longer. Those who value a pain-free death so highly would commit suicide well before their chronic conditions caused such discomfort. A proper survey should mirror such real-life constraints, e.g., by asking: "which would you rather do, die peacefully at 80, or more painfully at 85, but at least be able to see your grandchildren grow a few more years?"

By ignoring the manifest preference expressed by the behavior of health care consumers, the report instead focuses exclusively on the role of health care providers. It refers to a "health care system determined to keep everyone alive," as if patients have no choice in that determination. The report hints that increased rationing of health care is the appropriate response, which only seems natural given its narrow focus on cost-efficiency.

It's certainly appropriate to consider alternate systems that deliver a lower level of health care, especially when the costs of such expensive end-of-life care are not internalized. However, the suggestion that we'd prefer not to avail ourselves of such care is a dubious one.

This argument based on "revealed preference" reminded me of a similar one I posed concerning the death penalty.
UPDATE: Sure enough, the following day's report told the heart-wrenching story of a man who wanted to die from a chronic condition at home, but who after collapsing there was taken to an emergency room, where he was force-fed with a feeding tube, and tied down to prevent him from yanking it out of his mouth, until finally he died. This truly horrifying story was taken to mean health care providers should not go to great efforts to keep patients alive. But this seems a simple issue of communicating the patient's wishes. Assuming the patient is competent, the decision is his.

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