Sharon Begley in today’s WSJ raises the issue of rationing in a life or death situation:
You have 100 doses of a vaccine against a deadly
strain of influenza that is sweeping the country, with no prospect of
obtaining more. Standing in line are 100 schoolchildren and 100 elderly
people.The elderly are more likely to die if they catch the
flu. But they also have fewer years left to live and don’t get out
enough to easily spread or catch the disease. The kids are more likely
to act like little Typhoid Marys, sneezing virus over anyone they
encounter, and have almost their whole life ahead of them. But they’re
also less likely to die if they get sick.Whom do you vaccinate?
This dilemma is haunting experts concerned that avian
influenza might start spreading from person to person instead of (as
far as we know) mainly from birds to people. But it also applies to
regular old flu, which always has the potential to reach pandemic
proportions. In response, studies now are shedding light on the ethical
issues and the most effective strategy for reducing illness and death
if vaccine must be rationed. Sadly, they make a pretty good case that
current U.S. policies leave a lot to be desired.
But how could we possibly find ourselves in this situation. We never ask, if there’s not enough shoes to go around, should young or old people get the shoes. Or the oranges. Or the houses. Or cars. We don’t even have to ask these questions about the rich and the poor, let alone, the young and the old. It certainly is a tough question, once you only have 100 vaccines or some number less than people would like. But how could that possibly happen?
But it has been happening. In the winter of 2004 there were serious shortages with the President reduced to begging healthy people to forego flu vaccination to leave enough for those at risk. So it could easily happen again.
Why?
Part of the answer is that in the name of making sure that everyone has equal access to vaccine, we have taken the profit out of making vaccines. In addition, Attorneys General threaten anyone who charges what the market will bear in a time of shortage. So we have protected the poor and elderly and the children and made sure that they will not be outbid by the rich and the relatively healthy. And through that protection we have created a situation where increasing numbers of Americans cannot be sure of getting medicine. As a result, a political mechanism, rather than a market mechanism, must be used. Some form of rationing becomes inevitable. And inevitably, that rationing will be subject to political rather than truly ethical influences.
But even if politicians stepped aside (something they are genetically and psychologically incapable of) the most benevolent philosopher cannot answer the question of who should live or die when there is a vast shortage.
But if we let markets work, there would be fewer people at risk of death.
In every other market, innovation, driven by the profit motive, improves access to life-giving, life-enhancing devices, products and services.
People often say that medicine or some other good is too important to be left to the marketplace.
The opposite is true. Medicine is too important to be left outside the marketplace.
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There are only two ways to ration: based on markets or based on politics.
Why would anyone think it's wiser to trust the latter over the former?
The market incentives for drug companies to research and make vaccines are not efficient. There is far more profit in drugs that treat chronic problems that have regular users for years, even decades. On the consumer side the optimum is that every on else is vaccinated, then you won't be exposed, since vaccinations carry some discomfort and risk. Therefore there is no real hope that people will pay enough for vaccines to provide the drug companies with the profits that would cause them to substitute vaccine research or even production for research into chronic problems, except under immediate threat. One example of the problem is that there is almost no effort to find vaccines for tropical diseases that affect mostly the countries that have few people with enough money to pay western prices. As a consequence we live under the threat of them being carried to the US. The shortages of flu vaccine are just the most visible part of the problem. In cases where markets fail governments get involved, especially when it concerns public health. You can find much wrong with how they intervene, but the claim that they are responsible for the problem is not true.
Joan,
Why did drug companies research and manufacture drugs in the numbers they once did but don't anymore? Evidently, discovering vaccines and manufacturing were once very profitable. But in recent years, the number of companies that are willing to manufacture vaccines for sale in the United States has dwindled dramatically. Please see the posts I did back in 2004 (there is a link in this post referring to "profit" that takes you to those posts.) Government is the source of the problem not the cure.
Ancient wisdom teaches us: Women and children first…. that ensures the continuing history of human species…
One good move in case of a future pandemic would be to start now with vaccinating school children for the flu every year (with the required two doses their first year). This would build up their immunity, so that even in a pandemic they would have a better chance of resisting, which would reduce the spread to others.
And, if schoolchildren were vaccinated every year, there would generally be less flu spreading around, which would be nice for all of us. When Japan required schoolchildren to get flu vaccinations, it cut the flu death toll among the elderly.
But even in years with no shortage, it's very hard to get flu shots for children. Most of those convenient flu clinics refuse to take anyone under 18.
At least part of the problem with vaccines is that lawsuits have quelled production. That is probably also why vaccine clinics refuse to treat kids.
John Stossel reports:
"Why do we have to worry about shortages of flu vaccine? Because only a handful of companies still make it. And why is that? Because when you vaccinate millions of people, some get sick and sue. Between 1980 and 1986, personal-injury lawyers demanded billions of dollars from vaccine manufacturers. That scared many American drug companies out of the business.
In 1986, Congress stepped in. To help curb the lawsuits that discouraged vaccine production, the government established a fund called the National Childhood Vaccine Injury Compensation Program. It would pay victims' families directly so they wouldn't have to hire lawyers and suffer the delays of litigation. This was supposed to entice vaccine makers back into production, but drug companies were still leery, fearing that plaintiffs' lawyers would sue them anyway.
They were right to worry. Eli Lilly developed a mercury-based preservative called Thimerosal that was used in many children's vaccines. Plaintiffs' lawyers jumped on scaremongers' claims that mercury causes autism in children. Although a government-issued review found no such link, more than 100 autism lawsuits have been filed against vaccine makers since the National Childhood Vaccine Injury Compensation Act passed. No wonder most drug manufacturers still steer clear of vaccine research.
Even when new vaccines are discovered, drug companies are sometimes afraid to sell them. The FDA has approved a vaccine against Lyme disease. Want some? Forget about it. No company wants to take the risk."
http://www.realclearpolitics.com/articles/2006/08/lawsuits_make_us_less_safe.html
And why do we have frivolous lawsuits? It's a classic case of the tragedy of the commons. There is no cost to losing a lawsuit. As long as the courts remain a free resource, people will over-utilize it.
I don't know of any problem in getting flu shots for kids. My 17-month-old is getting his when the supplies arrive at his doctors in the next three weeks.
Joan says "In cases where markets fail governments get involved,"
This is true, but only because the first rule of politics is "Ignore economics". Frequently, when markets fail, it is because the problem is difficult. Market failure does not EVER imply that governments will find the problem any more tractable.
http://blog.russnelson.com/economics/bad-economist-no-donut.html
John -
You can get flu shots for children through your doctor, if he/she has enough, but you usually can't get them anywhere else. A few years ago when there was a shortage and my doctor had to reserve his for 'high risk' cases, there were flu clinics all over town at drugstores and other places, ready to give the shots to any adults that would pay $6 and roll up their sleeves, but none of them would take children.
Why shouldn't it be rationed on the basis of positive externality. Those who are the 'spreaders' should get the vaccine. It would increase the positive externalitiness of the vaccine. That point is what I understand the point of a vaccine is. Not just to protect those who have the vaccine but to limit the risk to those who have not had a chance to get the vaccine.