وصیت نامه: نشخوارهای یک اقتصاددان
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|31358||2009||صفحه PDF||سفارش دهید||محاسبه نشده|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : The Journal of Socio-Economics, Volume 38, Issue 1, January 2009, Pages 25–30
The typical living will is an awfully imperfect instrument for doing what it is supposed to do. This paper is one economist's attempt to make sense of living will. The foray takes one deep into the domain of mainstream economics. The paper concludes that, despite its shortcomings, living will makes good economic sense and its future is bright.
A living will is a set of written instructions on how one's life is not to be extended. There is probably nothing more antithetical to economic theory, other than suicide. Suicide at least may be brushed aside as an irrational behavior, beyond the realm of economic theory. 1 A living will, in contrast, is a decision made by a presumably rational person, and a rational person in mainstream economics wants to live a longer, not shorter life. Not surprisingly, therefore, economists have had little to say about living wills. 2 This paper is my attempt to say something. Naturally I began with the question: Why does anyone not wish to live a longer life? I was immediately stymied by the long-standing assumption of economics that a longer life is a better life. 3 Yet it hardly seems necessary to cite academic research to show that not all people all the time want to live longer. The popularity of living wills speaks to that eloquently. The long-standing assumption had to go. With the path cleared, I proceeded to explain why one's life, if left to others to decide, might be prolonged beyond the point of one's maximum happiness. To do that I realized that I would have to explain how the medical care system deals with dying and death and why it does not necessarily serve the interest of the patient. The following explanation I came up with is the simplest. When an old person is dying, whether at a hospital or at a nursing home, it is highly likely that physicians and nurses are present.4 They determine how much longer the patient will live. They are not required to do whatever the patient wishes. They are not compelled to maximize the hospital's profit. Rather, they come together to preserve a life. That does not mean the patient's life would be prolonged to the biological maximum. Their coordination is far from perfect, thus limiting what they can do as a team. Further, it takes effort on their part to preserve a life. Clearly, then, I needed a theory of team. The following theory I eventually settled for is the simplest also. Suppose that a physician and a nurse are trying to save the dying patient. The physician determines how much effort to make by taking as given how much effort the nurse is making, and vice versa. Thus they make decisions by reaction rather than by cooperation. Their decisions collectively determine what would happen to the dying patient. Whatever their collective decision is, a living will is simply the patient's vote against it. A living will is form of intervention, in hope of a better outcome. However, a patient's capacity for developing a living will is severely limited. There are at least two reasons. First, a patient's knowledge of the medical system is likely terribly imperfect. He is not able to predict exactly what the physicians and the nurses will do to him and what the consequences of their actions are. A good prediction as such would require good knowledge of the organization of medicine in a hospital as well as the science of medicine itself. The average patient does not know much about either. Second, the typical template for a living will – downloadable from the Internet – is a crude instrument. It falls far short of being a complete contract. It does not specify exhaustively how much and what kind of technology should be applied, nor in any detail how it is to be combined with other factors like nursing services. Instead, it consists of a set of multiple choices of medical procedures to be excluded, such as cardiopulmonary resuscitation, mechanical breathing, intravenous feeding, antibiotics, and blood transfusion. It says little else. One reason for this emphasis on technology is that technology is easier to specify than labor. People know exactly what a “ventilator” does, but not exactly what a nurse does. The typical living will is an incomplete contract. Critics of living will are bothered by the possibility that it results in technology being withheld prematurely. I wondered about the opposite possibility: Can one end up living longer (i.e., suffering more) with a living will than without it? I thought of one such scenario, and I will explain it in the paper. Here is a sketch. Suppose a patient believes that so much technology would be used to prolong his life that he would suffer more than he prefers. So he designs a living will to limit the amount of technology. Suppose that the patient subsequently falls into coma and the nurse, in response to the withholding of technology pursuant to the living will, increases effort. The extra effort may be such as to completely offset the effect of withholding technology. This is an example of the kind of possibilities that an economist tends to think about first. In the next three sections I will elaborate my thoughts above, somewhat more formally, while still striving to remain intuitive. In Section 2, I describe the extension of life as a matter of production and organization. In Section 3, I define a living will in that framework. In Section 4, I show the paradox of a nearly perfect living will backfiring on the patient. In the final section, I place living will in the broader context of the economic theory of governance. Many implications then become evident. The most encouraging is that, despite its shortcomings, living will has a secure future. The demand for self-determination of dying continues to increase as the population ages. Yet social and market institutions that can replace living wills have been slow to emerge.