Ending Net Asset Value; or, Hook up, hat up, and let go: “Calling Dr. Bartleby!”

Atul Gawande is a Harvard trained surgeon who writes eloquent prose on health and illness. His New Yorker pieces “Letting Go” and “The Way We Age Now” are full of pathos, ethos, and logos on how and when to die decisions and the bedpan reality of growing old. If he continues his work combining writing, doctoring, and educating, he may some day be up for a Nobel Prize. Gary Becker is a Nobel Prize winning economist and professor at the University of Chicago who writes in his blog, The Becker-Posner Blog, pedestrian prose sometimes infected with either-or fallacies. He shares weekly blog posts with Federal Judge and University of Chicago Law School Professor Richard Posner.

What usually passes for health care in our current reasoning is health care insurance. Those with insurance believe they have health care; those without may think they have neither. And the health care debate is derailed with decisions before legislators that have to do not so much with health care but with health care insurance.

Last Sunday, Becker included in his post what appears to be an economist based claim that includes a formula for calculating the value of a year of life: “Presumably, frail elderly people tend to receive less utility from a year of their current life since their lack of health prevents them from greatly enjoying their leisure time and consumption of different goods. However, the utility cost of any time and money they might spend on prolonging their lives is also lower for them. The fundamental measure of the value of a life year is the ratio of the utility gained to this marginal utility spent on prolonging life. This ratio could even be higher for the old and frail than for healthy younger persons.”

We are becoming increasingly Spartan by the moment, for the reductio ad absurdum of Becker’s argument would have us carrying individuals of any age whose disabilities or frailties preclude utility or whose cost to live outweighs their ability to “enjoy their leisure time and consumption of different goods” out to the rocks to die, as did the Spartans.

“Welcome to the 23rd Century: The Perfect World of Total Pleasure,” heads the poster for the sci-fi film “Logan’s Run,” which depicts a dome-covered society that eliminates growing old problems by zapping all citizens when they turn the age of 30. The police, called Sandmen, hunt down and kill those who would run from their forced to die moment. Yet there’s a myth, an old story, of life beyond the dome, where people are allowed to grow old. The place where people are allowed to grow old is called Sanctuary.

But there appears to be no Sanctuary for our elderly these days, at least not provided for by Medicare, for there’s simply not enough money to go around, the Becker-Posner argument seems to go, and we should spend what money there is to go around on those able to enjoy life and consume goods. Perhaps enjoying life, in the worldview of the economist, is consuming goods. In any case, the argument has been boiled down to an either-or moment: either we let old people grow old and die sooner than they would with life prolonging health care (including the R&D necessary to develop that care), or we go broke.

But there are other solutions. Yet there is another problem with Becker’s formula: the value of an old person’s life is not necessarily limited to what that person can enjoy or consume; the lives of the elderly may have intrinsic value to others. But not, apparently, to young doctors, for Gawande points out the current dearth of young doctors going into gerontology. There’s a shortage, and there’s no short-term remedy to what will be an ongoing need for specialists to treat the elderly. Gawande’s solution is for every health care practitioner to be versed in basic elderly care issues.

But to be fair to Becker and Posner this week, they do focus on quality of life versus quantity of life and the avoidable invasions of quality by a system not guided by health care concerns but by health care insurance. And Atul Gawande does also question quality versus quantity. What separates Gawande’s argument from Becker-Posner’s is his value of human life expressed in human versus econometric terms. It’s one thing to force someone to die at the age of 30; but is it something else again to force, or even to encourage, that same person to live beyond what most of us, including our ancestors, would recognize as living? Ah, Bartleby! Ah, Doctor!

Related: An Object Lesson in Health and Happiness

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