The consolation of philosophy

My thanks to the commenters on my post about my father -- and thank you particularly for sharing some of your own stories. I try to let my personal life intrude minimally here, but as a disciple of the late Irving Kenneth Zola I take very much to heart his insistence that sociology can only be called objective when we disclose ourselves. It may seem paradoxical but only if you haven't thought about it very hard. Obviously, I have a personal stake in the issues I write about here. You should only conisder me credible to the extent I reveal it.

I've often wondered whether some readers might consider me a bit morbid because I write about death a fair amount, but the fact is, in the field of public health, it is unavoidable. Death is, after all, one of the central facts of life. One of the chief metrics of population health is life expectancy, and that is synonymous with death expectancy. Furthermore, bereavement is the lot of all of us and so our response to it as an important contributor to our quality of life. Death is also an important problem in public health because, in our society anyway, it just costs so damn much. It's a big burden on our health care financing and delivery systems, and when we worry about the future sustainability of Medicare and Medicaid, in one way or another it's a central issue.

So, as we continue the Thinking Deep Thoughts project, it's time we turn to what, for many, is the deepest thought of all. What should we consider to be the goal of public health? That is essentially equivalent to asking what we value about human existence. It's as fundamental as it gets.

Obviously the answer is not the maximum possible life span for every human. I'm sure that if we devoted the NIH budget to achieving that it would not be long before we could keep the colonies of cells that originated as human organisms alive indefinitely. That blob on the bed with the tubes sticking out of it might be nothing but a mass of cancer cells or a circulatory system nourishing a body with no cerebral cortex, no heart pumping and no gas exchange happening in the lungs but by God, human life is sacred.

But short of such a reductio ad absurdum, it does become a puzzle, given the reality of scarcity and competing interests. The Ayn Rand objectivist/libertarian view which is popular in the high tech industry is that we should each try to get whatever we want and not give a shit what happens to anybody else unless we just happen to feel like helping somebody out. The Christian -- and Republican -- version of that philosophy these days is that it extends to everybody who has a functioning cerebral cortex, but we need to extend the protection of the law to entities with human DNA that lack human consciousness.

Us non-Christians, who feel empathy for our fellow human beings and some loyalty to the species have various approaches to the problem. One is to invoke a concept of basic needs -- some fundamental level of entitlement that each person is granted. If kids are dying before their 5th birthday, that is unacceptable -- except, of course, to Christians, because we're talking about children who have already been born. We should make sure that everybody has adequate nutrition, some minimal standard of housing, education, meaningful employment, and health care.

In contrast to such a rights based view, there are theories of distributive justice. These are more difficult to describe because it is not easy to formulate a theory of deserts -- maybe people who work harder or contribute more should get more back, but of course we can contribute in a lot of ways, including being nice, or nurturing, or amusing, as well as doing things that make money in the marketplace.

Then there are utilitarian theories, in which we try to define the good in some measurable way and maximize the quantity of it. "The good" usually includes some amount of justice, and basic rights, of course, so they get more than a bit mixed up, but they represent different starting places.

In public health people try to quantify the good through concepts such as Quality Adjusted Life Years and Disability Adjusted Life Years. Survey a bunch of people and ask how much life span they would give up to avoid going blind at age 55 or developing crippling osteoarthritis or whatever, and discount years of life in said condition by the appropriate amount. Alas, how people answer these questions depends on culture and circumstances. People who don't expect to live to be 55 anyway can't exactly answer it. We need some degree of justice before we can even undertake this exercise; the only way to break out of the inherent circularity is by starting with a basic rights formulation, and trying to figure out how we can toward justice or the good from there.

So what does all this mean when we are contemplating bereavement, or our own mortality? My view is that we should ask ourselves what is, to us, the good, and then ask what we can do to contribute to it in the time we have. When we can no longer do so, our time has been enough. We hope that it has been well spent.