Measuring Human Rights (16): The Right to Healthcare

(There’s a more theoretical post here about the reasons why we should call health care a human right. But even if you think those are bad reasons, you may find the following useful).

The right to health care is one of the most difficult rights to measure. You can either try to measure people’s health directly and assume that good health means good health care, or you can measure the provision of health care and assume that there will be good health with a good health care system. Doing the latter means, for example:

  • measuring the number of health workers per capita for countries
  • measuring the quality of hospitals
  • measuring health care spending by governments
  • measuring the availability and affordability of health care
  • measuring the availability and affordability of health insurance
  • etc.

Doing the former means:

  • measuring life expectancy
  • measuring infant mortality
  • measuring maternal mortality
  • measuring calorie intake
  • measuring the incidence of certain diseases
  • measuring the survival rates for certain diseases
  • etc.

Needless to say that every single one of these measurements is fraught with problems, although some more so than others. Even if you’re able to have a pretty good measurement for a single indicator for a single country, it may be difficult to compare the measurement across countries. For example, health insurance is organized in so many different ways that it may be impossible to compare the level of insurance across different countries.

But let’s focus on another measure. Life expectancy is often used as a proxy for health. And indeed, when people live longer, on average, we can reasonably assume that they are healthier and that their health care system is better. It’s also something that is relatively easy to measure, compared to other indicators, since even developing countries usually have reasonably good data based on birth and death certificates. And yet, I say “relatively” because there are some conceptual and definitional problems:

  • Exceptional events such as a natural disasters or a war can drag down life expectancy numbers, but those events need not influence health in general or the quality of health care.
  • Wealthy countries may have more deaths from car accidents than poorer countries, simply because they have more cars. This will pull their relative life expectancy down somewhat, given that younger people are more likely to die in car accidents. And if you use life expectancy to measure health you’ll get a smaller health gap compared to poorer countries than is the case in reality (at least if life expectancy is not corrected for this and if it’s not supplemented with other health indicators).
  • How are miscarriages counted? If they are counted as child mortality, they drag down life expectancy rates compared to countries where they are not counted.
  • What about countries that have more homicides? Or suicides? Although the latter should arguably count since suicides are often caused by bad mental health. If a country’s life expectancy rate is pulled down by high suicide rates, life expectancy rates are still a good indicator of health and of the quality of health care, assuming that health care can reduce suicide rates and remove, to some extent, the underlying health causes of suicide. However, homicides are different: a country with a very good health care system, a very high level of health and a high murder rate can have its health rating pulled down artificially when only life expectancy is used to measure health.
  • Differences in diet and other types of risky behavior should also be excluded when comparing health and life expectancy across countries. It’s wellknown, for instance, that obesity is more of a problem in the U.S. than in many countries that are otherwise comparable to it. Obesity drags down life expectancy and reduces the average level of health, so life expectancy rates which are not corrected for obesity rates are still a good measure for health, but they are not a good measure for the quality of the U.S. health care system. If you want to use life expectancy rates to compare the quality of health care systems you’ll have to correct for obesity rates and perhaps for other types of risky behavior such as smoking or the absence of exercise. Maybe the U.S. health care system, even though it “produces” somewhat lower life expectancy rates than in comparable countries, is actually better than in other countries, yet still not good enough to offset the detrimental effects of high average obesity.

Hence, uncorrected life expectancy rates may not be such a good indicator of national health and of the quality of a national health care system. If we return to the case of the U.S., some of this may explain the strange fact that this country spends a lot more on health and yet has somewhat lower life expectancy rates than comparable countries.

Or maybe this discrepancy is caused by a combination of some misuse and waste at the spending side – more spending on health doesn’t necessarily result in better health – and some problems or peculiarities with the measurement of life expectancy. Let’s focus on the latter. As stated above, some cultural elements of American society, such as obesity, pull down life expectancy and worsen health outcomes. But there are other peculiarities that also pull down life expectancy, and that have nothing to do with health. I’m thinking of course of the relatively high levels of violence in the U.S. Death by assault is 5 to 10 times higher in the U.S. than in comparable countries (although those numbers tend to go down with the passing of time). This affects younger people more than older people, and when more young people die, life expectancy rates drop sharper than when more old people die.

However, even if you correct U.S. life expectancy rates for this, the rates don’t move up a lot (see here). The reason is that the numbers of deaths caused by homicide pale in comparison to other causes. Obesity levels, for instance, are a more important cause. But correcting life expectancy rates for obesity levels doesn’t seem appropriate, because we want to measure health. If you leave out all reasons for bad health from life expectancy statistics, your life expectancy rates go up, but your average health doesn’t. Obesity isn’t the same as homicide. Correcting life expectancy statistics for non-health related deaths such as homicide makes them a better indicator of health. Removing deaths from obesity doesn’t. If you have life expectancy rates without obesity, they may be a fairer judgment of the health care system but not a fairer judgment of health: a health care system in a country with a lot of obesity may be equally good as the one in another country and yet result in lower life expectancy. The former country does not necessarily have lower life expectancy because of its underperforming health care system – we assumed it’s of the same quality as elsewhere – but because of its culture of obesity.

However, if you really want to judge health care systems, you could argue that countries plagued by obesity should have a better quality system than other countries. They need a better quality system to fight the consequences of obesity and achieve similar life expectancy rates as other countries that don’t need to spend so much to fight obesity. So, life expectancy is then reinstituted as a good measure of health.

The Ethics of Human Rights (30): Organ Donation and Presumed Consent

Health and survival are human rights. Many people’s health and survival depend on organ transplants. However, there are more people requiring organs than people donating them. Hence, the question of how to increase organ availability, which I have discussed many times before on this blog (see here for instance). My favorite policy is presumed consent : if people during their lifetime don’t explicitly opt-out and deny the use of their organs after death, it is assumed that they consent to this use. There’s evidence that presumed consent raises donation rates by perhaps 20-30%.

However, presumed consent may perhaps not be enough to eliminate the shortage. And although it may solve part of the problem, it may also create some problems. Some people might feel uneasy when the state can automatically decide what happens to their bodies or to the bodies of their loved ones after death. The public might also start to wonder whether surgeons would become too eager to harvest organs, stop life support somewhat early and move the border between life and death (the definition of the moment one dies isn’t an unchanging variable throughout human history). But that’s also a problem with opt-in systems.

Another problem with presumed consent, but also other types of cadaveric donation such as opt-in, is the constraint imposed by the number of people who die in a way that makes their organs available for transplant.

Does all this mean we have to abandon cadaveric donations in general and presumed consent in particular? And rush towards a free market in organs for the living? That could perhaps eliminate the shortage completely, at least for those able to buy the organs and on the condition that there are enough desperate souls “willing” to sell. The latter is of course a condition that’s easily met when we allow international free trade – many places in the world are vast resources of desperateness.

(If you doubt the risk of free trade pushing desperate people to sell their organs, look at Iran. Most donors in Iran are extremely poor. Maybe you think it’s good that poor people have options to do something about their poverty. I agree, but I prefer that they have other options and aren’t forced to commodify themselves, especially when this commodification entails health risks).

I don’t think free organ trade of live donations is a good idea, given the problems with that option outlined here. (Although I might be persuaded by the argument that prohibition of a widespread activity is always futile and a regulated market a lesser evil; e.g., one could offer tax credits for live donations). There’s still a lot of elasticity in presumed consent and the few problems it raises can be solved, in my opinion. The horror story of doctors switching off life support and plundering bodies is precisely that, a story. Countries that are reluctant to implement presumed consent because of such reasons can be convinced, I think, especially given the success of other countries that have it.

Even in countries that have presumed consent and that have therefore increased organ availability, things can be improved. The rights of relatives to veto could be restricted. (Personally, if I would have made the conscious choice of opting in or of not opting out, I wouldn’t be comfortable with the possibility that my relatives have the right to disrespect my will after death). In addition, the transplant system (logistics, transport, availability, procurement etc.) could be made more effective, including in countries that decide to stick with opt in.

Beyond presumed consent of cadaveric donation, live donation of certain organs could be encouraged (though preferably not through market systems). Countries that don’t want to go to presumed consent could make it more likely for people to opt in in a system of cadaveric donation: Israel for example allows opt-in donors and their families to jump the waiting line for transplants when they should need an organ themselves. That’s an interesting idea, but it could throw up some other problems. Also, technology could come to our aid; perhaps in some time we can make organs from stem cells.