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Born Obligated: A Place for Quantitative Methods in Ethics

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Behavioral economics methods may be more reliable than unsupported, sweeping assumptions in understanding the degree to which being born is okay.


Obviousness

That being born is a good thing is treated as axiomatic by the majority of thinkers who consider the issue.

Thomas Nagel, for instance, states that “All of us, I believe, are fortunate to have been born,” even while affirming that not having been born is no misfortune (Mortal Questions, “Death,” p. 7). Bryan Caplan has said, regarding IVF, “How can I neglect the welfare of the children created by artificial means? But I’m not ‘neglecting’ children’s welfare. I just find it painfully obvious that being alive is good for them [emphasis in original].”

There are two elements to this kind of thinking. First, it represents a judgment that life is, on the whole, worth getting and having; but second, all the talk of “obviousness” also implies that there is something wrong with even asking the question.

I want to address here how quantitative methods, rather than intuition and assumption, might be used to measure the downside of existence. I argue that there is a need to analyze quantitatively the obligations that we are all born with and the inherent pain of life, and that, if our lives are to be worth having on the whole, must be made up for with valuable experiences.

Work and Leisure

We might characterize the central unpleasant obligation in our lives as the obligation to “work” (broadly construed) in order to meet the salient and potentially misery-inducing needs we are born with or naturally develop. These needs include not only food, clothing, shelter, and medical care, but also status, love, sex, attention, and company.[1] We can even quantify these needs, by quantifying work done to satisfy these needs, for which we have a great deal of data.

Some of these needs, of course, may actually be satisfied by working – the need to belong, to feel valuable, to not be a burden. However, at the same time, some of these needs are actually increased by working – that is, work may create disutility as well as utility. How can you tell the difference between what people do to merely to ease the pain and discomfort of existence, and what people actually want to be doing?

Many economists have addressed the question of the difference between work and leisure, and how we may quantify and measure them. One crude-but-tempting measure of the value of leisure time is merely a person’s wage. But as Larson & Shaikh (2004) explain, this is much too crude to get at the true nature of work and leisure:

Assuming the average wage is the appropriate opportunity cost of time presumes that the individual faces no constraints on hours worked, derives no utility or disutility from work, and has a linear wage function…. This is unlikely to be true for many people….an individual’s average wage does not necessarily reveal anything about the shadow value of discretionary leisure time, either as an upper or lower bound.

The question of the value of leisure time is intimately related to the question of quantifying the unpleasant obligations placed on us by virtue of existence, so that we may have a starting point for a meaningful comparison of life’s costs and life’s benefits.

How do we characterize “work”? What is the difference between “work” and “leisure”?

Intuitively, we know the difference – or at least, there exist clear cases of “work” and clear cases of “leisure.” Operating a cash register is work. Washing dishes is work. Doing bong rips is leisure. Reading novels is leisure. Watching television and having sex are generally leisure (unless you’re in advertising or a prostitute). For most people, child care and lawn care qualify as work – whether paid or unpaid – but for some people, these may qualify as leisure some of the time.

These examples suggest that leisure is that which is done for the sake of the experience itself, whereas work is done with some goal in mind other than the experience itself, and is done only in service of that goal.[2] Running ten miles is leisure for me, because I do it for the pleasure of the experience; running those same ten miles might be work for someone else, because he does it to lose weight, not for the pleasure of running. A third person might run for both reasons, in which case the action has aspects of both leisure and work. We should not necessarily expect that every action and every hour can be neatly categorized as “work” or “leisure,” even for a particular individual.

This should give us pause when considering the definition of “leisure” preferred by Mark Aguiar and Erik Hurst in their 2006 paper “Measuring Trends in Leisure: The Allocation of Time Over Five Decades,” an hour-by-hour tally of time not spent in market or non-market work (e.g., at work, or doing unpaid work around the house or around town). In reality, a single hour may have substantial aspects of both work and leisure.

Aguiar and Hurst remark on a potentially definitional characteristic of leisure: the degree to which market inputs (money, technology) are consumed to reduce the amount of time spent in the activity. They say:

one definition of whether an activity is “leisure” may be the degree of substitutability between the market input and the time input in the production of the commodity. That is, the leisure content of an activity is a function of technology rather than preferences. In the examples above, one can use the market to reduce time spent cooking (by getting a microwave or ordering takeout food) but cannot use the market to reduce the time input into watching television (although innovations like VCRs and Tivo allow some substitution). [Emphasis mine.]

Let me give a definition of my own, to fit my question:

Work is any action (or omission, perhaps) that we undertake in order to prevent or remedy some unpleasant state, and that we would not undertake if the unpleasant potential state were not a factor. An activity has a strong work component if technology is demanded by individuals to reduce the amount of time they spend in the activity.

In other words, work is what you do only because you have to eat, and you spend as little time doing it as is possible to satisfy your (present and projected future) needs.

Many studies since the 1980s have found that physicians’ demand for leisure directly affects the prevalence of cesarean sections. Cesarean sections are highly correlated to time variables associated with doctors wanting to get the hell out of there, although (further strengthening the theory) this correlation is dependent on the type of insurance covering the patient.

Instead of relying on the “imaginary survey justification” to “prove” that coming into existence is a good thing, economists and ethicists could use more creative, quantitative methods to examine the question of how bad (and how good) life is. Specifically, we need to figure out how to tell the difference between suffering people attempting to remedy their shitty situation, and happy people chilling out – both of which may describe any of us at different times in our life, or even our day. “Are you glad you were born?” is unsubtle, an all-or-nothing approach that relies heavily on people knowing the answer to questions they may have only limited capacity to understand. Analyzing behavior in smaller chunks would give us a better idea of just how happy people are to be here.

Poverty and Pain

Behavioral economics is a strong tool for understanding ourselves and each other. However, many behavioral economists, consciously or unconsciously, rely heavily on the “imaginary survey justification,” and no economist, to my knowledge, has attempted to use behavioral economics methods to figure out how bad, or how good, life is to individuals.

Bryan Caplan published a fascinating, even audacious paper in 2007 entitled “Behavioral Economics and Perverse Effects of the Welfare State.” In it, he argues that giving the poor more life choices through charitable assistance seems to actually harm them, because they are irrational and fail to choose the best option for them. From his abstract:

Critics often argue that government poverty programs perversely make the poor worse off by encouraging unemployment, out-of-wedlock births, and other “social pathologies.” However, basic microeconomic theory tells us that you cannot make an agent worse off by expanding his choice set. The current paper argues that familiar findings in behavioral economics can be used to resolve this paradox. Insofar as the standard rational actor model is wrong, additional choices can make agents worse off. More importantly, existing empirical evidence suggests that the poor deviate from the rational actor model to an unusually large degree. The paper then considers the policy implications of our alternative perspective.

The option Caplan fails to consider is this: the lives of the poor are unacceptably bad without charitable aid.

We don’t think it irrational, exactly, when a person in extreme pain does something to relieve his pain that may have negative future consequences. A shrieking, sweating patient in horrible pain might be perfectly aware of the potential for developing a long-term addiction to opiates, but we do not consider his decision to take opiate medication to be irrational. His pain is so bad that we think it makes sense for him to use any means to stop it, even if they harm his future interests.

Connecting to my discussion of work vs. leisure, I think it a valid hypothesis that poverty is actually dreadfully painful – not only physically, but emotionally and socially. There is only so much pain we can expect a being to endure before his attempts to relieve it through future-damaging means becomes perfectly understandable and, in fact, rational.

The Demand for Pain Relief

An economic theory of rationality, to be in touch with human ethical reality, must include an account of pain. We must attempt to define and study pain (in the broad sense) in a behavioral economics context, rather than to define it away, as Caplan attempts to do.

Karl Smith notes that studies consistently show that health care consumers do not seem to take into account mortality data when choosing between health care providers, even when very good mortality data is widely available in a user-friendly format. Perhaps the demand for life is not as high as we might think. People seem to like spending money on health care, but not to care about outcome. One approach suggested by this is to study revealed preferences/willingness-to-pay for death risk reduction and pain relief (broadly defined), respectively, in different contexts and populations.

Is Loss Aversion Irrational?

A recent paper on behavioral economics, using tufted capuchin monkeys as subjects, demonstrated that the monkeys exhibit what is considered a typical human departure from rationality, “loss aversion.” That is, monkeys trained to use metal discs as money preferred to buy fruit from a graduate student who would give them a smaller food reward but sometimes add a few grapes to it, rather than from a graduate student who would give them a larger food reward but then maybe remove a few grapes. The monkeys weren’t maximizing the number of grapes they got; they specifically exhibited a preference to have things added, rather than have things taken away.

This does not, I think, exactly illustrate irrationality in the capuchins: it illustrates that they are utility maximizers, not grape maximizers. Monkeys experience a loss of utility from losing grapes that is greater than the utility produced by those grapes. Losing grapes, we might say, is painful. Doing the resource-maximizing thing does not necessarily equate with doing the utility-maximizing thing.

A Place for Quantitative Methods

Caplan’s conclusion is that we must not treat the poor as rational actors, because they deviate so heavily (compared to the wealthy) from being long-term best-interest maximizers. Therefore, he says, we should not expect to solve their problems by giving them money or other charitable aid.

An equally supported conclusion would be that being poor is so awful it is unendurable, like severe physical pain, and poor people actually are rational, taking this into account. Caplan also gives us a hint at what might be an indicator of painfulness: the degree to which the actor deviates from resource maximization. He says, “The behavioral literature has documented that the average person frequently violates neoclassical assumptions. But it rarely investigates variation in the tendency to violate neoclassical assumptions. Casual empiricism and limited formal evidence suggest that the poor do deviate more. A great deal more could be learned at low cost if new behavioral studies collected information on participants’ income and education to test for heterogeneity. [Citations omitted.]” Analyzing LOTS of factors for correlation to deviation from resource-maximization rationality, not just income, education, and intelligence, could help us understand the circumstances under which life is so painful that we act irrationally.


1. The extreme seriousness of the basic human need for affiliation and belonging is not widely acknowledged, even though data is available to that effect from a wide variety of sources. Kipling Williams’ meta-studies, Ostracism: The Early Detection System and Ostracism: Consequences and Coping are a good place to start to review the literature on the consequences of failed belonging. For instance, Williams explains experiments using Cyberball, an interactive computer game that can be used to give test subjects the impression of being ostracized in a controlled way. He says experimenters have “found strong negative impact on mood and need levels for those participants who were ostracized” in the Cyberball game, and when the experiment was conducted under fMRI, participants “showed significant increases in activity in their anterior cingulate cortexes, where people also show significant activity when enduring physical pain.” Further, he states that “In all of these Cyberball studies, the effects sizes of the ostracism manipulation are over 1.00 (often above 1.50) indicating strong effects, and subsequent meta-analyses indicate it takes only three people per condition to reach standard levels of significance. [Citations omitted.]” See pp. 17-19 of Ostracism: The Early Detection System. What’s especially amazing is that the effect is clearly not rational – it holds even when ostracized participants have been explicitly told that they’re only playing against a computer (NPCs).

Thomas Joiner’s book Why People Die by Suicide (see my review here) is a book-length treatment of an empirically-tested theory of the causes of suicide, and concludes that three factors are the best predictors of suicidality: failed belonging, feelings of burdensomeness, and competence (ability to physically do it). Two of the three factors are measures of failed social affiliation. Other kinds of sadness (including sadness for other reasons and clinical depression) are not very predictive of suicide. And Phillipe Rochat’s excellent book Others in Mind details the formation of the human “self” through child development studies and other empirical research, concluding that what he terms the Basic Affiliation Need is not only an extremely critical need, but one that is primordial to, and directly causes, the formation of the self. The need to belong and to have a place in society is not a luxury, but a basic need the absence of which is more painful than prolonged hunger or injury.

2. Yesterday, I overheard two high school girls having a conversation. One revealed to her friend that although she realized it meant giving up one’s life, she could see the upside to a diagnosis of terminal cancer – a kind of peace, and an exemption from the future-oriented unpleasantness we must all endure if we are to be considered socially responsible. “You could just have fun in school,” she said. “I work my ass off every day with work and schoolwork, but if you were going to die anyway, you could just relax. You wouldn’t have to worry.” Her friend agreed, but said she wanted to see what it was like to be an adult anyway. “I’m not sure I do,” said the first little girl. School is generally work, not leisure.

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Written by Sister Y

April 27, 2011 at 4:02 pm

Why Physician-Assisted Suicide is Not Good Enough

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The political position in favor of a general right to suicide has few advocates; in terms of numbers, it is a rather extreme position. Much more common – common enough to be the majority in a few states – is support for a limited right to suicide for terminally ill people, with physicians as gatekeepers for that right.

I have often written on why restricting suicide rights to terminally ill people makes no ethical sense. But there is another major problem with “Death With Dignity” laws like that of Oregon and Washington: physicians are the gatekeepers to the right to suicide, taking control of death away from the individual. “Patients” must depend on physicians in order to be allowed to die. And enough physicians are refusing to “assist” that the right to suicide is empty of practical meaning.

It has been months since Washington’s Death With Dignity law passed, which allows a terminally ill person to access a prescription for a lethal drug. But the scheme requires the cooperation of doctors; and in areas outside Washington’s big cities, doctors simply aren’t cooperating, reports Kim Murphy in the Los Angeles Times (“In rural Washington state, law allows assisted suicide, but most doctors don’t,” May 7, 2009).

Personally affected by this injustice was Stephen Wallace, a victim of terminal pancreatic cancer. Wallace was unable to find a single physician in his area willing to make the lethal prescription at his request. From the article (emphasis mine throughout):

Cancer of the pancreas has a cruel reputation, delivering what some say is the most intense pain humans can imagine. It killed Wallace on April 8.

“It was very hard to watch my father die that way,” said Tricia Crnkovich, who took turns with her brothers and sisters in Wallace’s small bedroom as he shrank from 250 pounds to 60, losing most of the weight in the two months before he died. “I’ll tell you, if I ever get cancer,” she said, “I don’t want to put my kids through that.”

Wallace’s treatment at the hands of medical professionals was appalling. Even beyond the fact that his request to die was ignored, his pain was not being adequately managed because of “concerns” of his nurses.

. . . . Crnkovich said her father had been given strong medications when he went home from the hospital, but that his nurses had resisted increasing the dosage as his pain grew more intense.

Soon Wallace’s mental state began to deteriorate. Because the assisted-suicide law requires a 15-day waiting period between the first oral and the first written requests for lethal medication, and an additional 48 hours before the prescription can be written, he no longer qualified.

“He couldn’t talk for the last eight days,” son Steve Wallace said. “He was not in contact with reality. I’d come in there, and he’d call me somebody else.”

Mr. Wallace’s nightmare had come true. He had, the article states, watched his wife die of cancer, in miserable and unrelieved pain; he did not want to die like that.

Near the end, Steve and Ginny could hardly stand to be in the house because his father was in so much pain. By the time the doctor said his medication should be increased despite the nurses’ concerns, it was too late.

“He was just moaning and screaming, and it got really bad on Friday,” Ginny said. “By Monday when we left, he was just screaming at the top of his lungs.”

Meanwhile, major hospitals in Washington are refusing patients’ right to die as a matter of policy, making the extremely limited right to “Death With Dignity” even more meaningless. From the Seattle Times:

Olympia area hospitals won’t offer assisted suicide services

OLYMPIA — Providence St. Peter Hospital and Capital Medical Center officials said Thursday that the hospitals will not participate in physician-assisted suicide under the state’s new Death with Dignity law, but instead will refer terminally ill patients to their primary doctors.

Providence Health & Services spokeswoman Karina Jennings said Thursday that the same standard applies for all of its medical facilities and nursing homes in Washington and Oregon. The key reason: Providence is a Catholic health care organization, and physician-assisted suicide is “not a path conducive to our values,” she said.

“We don’t believe that health care providers should be put in the position of taking someone’s life,” Jennings said.

Because of its extensive involvement in health care, the Catholic church is able to impose its values on millions of non-Catholics – and Washington’s law does nothing to prevent this. We have already seen the morally repugnant position of the Catholic Church on assisted suicide and suffering: suffering is good for you. Says the Most Rev. Carlos Sevilla:

Initiative 1000 is an attack on our most fundamental beliefs and teaching, and placing it on the November ballot would contradict our proclamation of the gospel of life . . . Pain and suffering and illness are important parts of our faith experience. [Emphasis mine.]

He would probably be so bold as to say to Stephen Wallace’s children that screaming at the top of his lungs in pain as he died was an important part of Wallace’s faith experience. Which might have come as a surprise to Wallace.

The ethical arguments about physician-assisted suicide often focus on physicians’ autonomy, emphasizing the right of a physician to avoid helping someone commit suicide (or, as hospital spokeswoman Karina Jennings misleadingly puts it above, “taking someone’s life”). But the physician’s “right” must be considered against the background of “rights” that have, in our system, been taken away from the patient and given to the physician. Perhaps a physician shouldn’t have to assist in a suicide; but the patient will not be able to help himself and exercise his own autonomy without the physician’s action, because of the drug prohibition. The only comfortable sort of suicide – a suicide by overdose of fast-acting barbiturates – is only “assisted suicide” in that competent adults are generally prohibited from accessing the necessary drugs. Given our existing laws, it is either naive or cruel to refuse physician “assistance” (drug provision) to a would-be suicide.

At any rate, suicide should not be a medical matter. Physicians should not be the gatekeepers of suicide rights – it is unfair to physicians and unfair to people who want to die. The choice to die, and the responsibility for the act, should fall on the individual, not on his physician. From Thomas Szasz, in Fatal Freedom: The Ethics and Politics of Suicide:

Although performing an abortion and developing effective methods of birth control entail the use of medical knowledge and skill, abortion and contraception are not medical matters. The same is true for suicide. Although killing oneself with a drug entails the use of medical knowledge and requires access to the necessary substance, suicide is not a medical matter. We ought to deal with death control the same way we have dealt with birth control: by removing it from the purview of Medicine and the State, by repealing all medical and legal interference with the act. [Bolded emphasis mine; italics in original; citations omitted.]

Written by Sister Y

May 10, 2009 at 3:03 am

The Primacy of Physical Pain

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Many who do not support a general right to suicide nevertheless allow that a person in extreme physical pain has a right to have that pain alleviated through palliation, even where such palliation could render the person unconscious, cause addiction, or, in some cases, even hasten his death. However, although the technology exists to alleviate the suffering of individuals in extreme mental and emotional pain, no right to palliation for emotional pain is widely recognized. Although drugs such as opiates, barbiturates, and benzodiazepines are very effective at reducing mental suffering, they are seen as being counter-indicated for use in patients who experience so much suffering that they want to die. Where the suffering is extreme physical pain, the risks of addiction, excessive sedation, and even death are seen as slight in comparison to the harm of forcing a patient to experience the pain; however, when the suffering is “merely” mental, addiction, sedation, and the risk of death are suddenly more important than relieving the patient’s suffering. Patients with mental suffering are instead given drugs that do little to relieve their suffering, such as the SSRI antidepressants recently revealed to have no effect beyond that of placebo. The logic is cruel: “You are suffering so much that you want to die; but you can’t have this drug that might relieve your suffering, because you might use it to die. Better for us to force you to suffer needlessly than to allow you to possibly die.”

Where a society forbids its resources to be used to relieve the extreme mental suffering of its citizens, it is especially cruel to also prohibit suicide for those citizens who have been denied palliation.

Written by Sister Y

May 9, 2008 at 8:50 pm