Loughner, Hasan, Anthony, and the psychology of health-care supply

Prosecutors have requested that Jared Loughner, the man who shot Congresswoman Gabrielle Giffords and several other people in Arizona back in January, be ordered to undergo a psychological evaluation to establish his competency to stand trial.  In such a high-profile case, especially one in which the defendant looks like such a complete nut every time we see his picture on television, it’s important to keep in mind that competency to stand trial is different from culpability for the offenses with which he’s charged.  In order to be competent to stand trial, he basically has to understand, in the present, the nature of the charges against him, understand the nature of the proceedings that will take place and the roles of the various participants therein (judge, defense attorney, prosecutor, jury), understand what could happen to him if he’s found guilty, and be able to assist in his defense.  That’s actually not a very tall order.  In practice, it’s fairly tough to be incompetent to stand trial.  Now, once he’s on trial, as I expect he will be, attention is likely to turn away from his mental status in the present and toward his mental status in the past.  A person can be competent to stand trial in the present and still be not guilty by reason of insanity for a crime committed in the past if, at the time of the crime, the person either didn’t know what he was doing or didn’t know that it was wrong (and by wrong, I mean “against the law” — otherwise we could all just do whatever we wanted and say we thought it was the right thing, which would be total chaos).  Given what we’ve already heard about the philosophizing, planning, preparation, etc. that apparently went into the shootings of the congresswoman and the others in Arizona, Loughner certainly doesn’t sound mentally-healthy, but he also doesn’t sound like a guy who didn’t know what he was doing or that it was wrong.  So, at this point, I’d predict that he’ll be found both competent and guilty, but this one will take a long time to play out (the defense is already saying that they can’t be ready for a trial by September), so stay tuned.

Speaking of cases that are taking a long time to play out, prosecutors have announced that they’re seeking the death penalty for another mass shooter, Nidal Hasan, the military psychiatrist who went on that murderous, terroristic rampage at Ft. Hood in Texas in 2009.  That one seems like a no-brainer.

And, in the Casey Anthony case (in case you’ve forgotten, she’s the “mother” who’s accused of killing her toddler daughter, making it look like a kidnapping/murder, and dumping the body in some Florida woods), the judge has said that he won’t announce the venue for jury selection until a week or two prior to its commencement (it’s not a traditional change of venue in that the trial will still be held in Orlando, in the county where the alleged crimes were committed, but the jurors will be selected outside of Orlando and brought into Orlando for the trial in order to guard against potential bias among citizens of Orlando, who’ve been exposed to tremendous pre-trial publicity).  The defense doesn’t like that (it wanted a traditional change of venue, in which the entire trial would’ve been relocated), claiming it won’t have enough time to “study” the attitudes of the community from which the jury pool will be drawn and to make sure that its citizens can reasonably be expected to give Anthony a fair trial.  What defense counsel is referring to is a community-attitudes survey (essentially polling) by litigation consultants in an attempt to predict juror behavior based on statistical analyses of the data collected (e.g. women in the community tend to have preconceived notions about Anthony’s guilt — I do some litigation consulting, but generally not this kind).  I understand why defense counsel wants more time to study the potential jury pool, but if I were the judge, I wouldn’t grant it.  Clearly, the jurors will be drawn from a community where the locals can reasonably be expected to have had significantly less prior exposure to the case.  Given that, with or without a community-attitudes survey to confirm it, I think the biases of individual prospective jurors should be more than adequately ascertainable during voire dire (jury selection, direct written and oral questioning of members of the actual jury pool).  Developing voire dire questions to uncover potential juror biases is among the kinds of things that I could help with, but not in this case of course — unless there’s a last-minute plea deal, which I still think is possible, I’ll be here and on television telling you about developments in the trial as they happen.

And finally, back on 7/28/09, I wrote about the psychology of demand for health-care services.  Since then, we’ve been warned repeatedly that the anticipated effects of health-care “reform” are causing fewer people to go into health-care professions, just as we’re making it easier for more patients to access more services for more conditions.  So, I thought it might be time to say a little about the psychology of supply for health-care services.

It’s one thing to say that millions more people are going to be able to “afford” non-emergency health care services.  It’s another thing to actually deliver those services.  The latter requires highly-trained people, who spent years of their lives and lots of money learning their respective fields, as well as highly-specialized, high-cost equipment and medicines that are extremely expensive to develop.  At the same time, the people who deliver health-care services and the people who make the equipment and the medicines do so at great risk of being sued for any error that they might make that results in damage to a patient.

In light of all of this, it’s important to consider the reasonableness of expecting them to want to continue delivering their services and products if the rewards (extrinsic rewards; of course there are also intrinsic rewards) that they get for doing so keep diminishing.  We did away with slavery in America long ago, so we can’t just order people to do more work for less money.  The people who provide health-care services and products ultimately get to decide how great the extrinsic rewards have to be to keep them motivated to start doing, and to continue doing, what they do.

Bottom line:  Health care is never going to be cheap.  And why should it be?  It’s difficult and risky to deliver.  And aside from food, water, and shelter, what’s really more important?  So, given the difficulty, risk, and importance involved in delivering health-care services and products, they should be some of the most expensive services and products that we buy and use, and the people who provide them deserve to be well compensated.

Now, does that mean there’s nothing we can do to help control health-care costs?  Not at all.  What we can do is get “middlemen” out of the way wherever possible.  “Middlemen” include insurance bureaucracies and, the biggest “middleman” of them all, the government.  It used to be that most health-care transactions had two participants:  the patient and the provider.  For example, when people had sore throats, they went to a doctor, paid for the doctor’s time and some relatively-cheap antibiotics, and went home.  The vast majority of people could afford to do it that way because there weren’t any “middlemen,” at least not unless/until a catastrophe required surgery, protracted treatment of a chronic illness, etc., which is what people bought insurance for, and given the rarity of such catastrophes relative to sore-throat-type events, insurance was relatively inexpensive, too.  Competition among providers of health-care services and products kept prices affordable for the masses while still allowing the providers to be well-compensated.

It was when we started getting “middlemen” involved in the more minor transactions as well as the big-ticket transactions, putting people in between patients and providers trying to squeeze dollars out of both parties, that costs started to take off, increasing at ever-increasing rates.  So, when possible, i.e. for more minor health-care transactions, rewinding the clock and eliminating or minimizing the participation of “middlemen” would be steps in the cost-control direction.  And for transactions big enough to still require “middlemen,” i.e. major health-care transactions, we could at least make it easier for people to choose their “middlemen,” forcing the “middlemen” then to compete on a wider scale and become less wasteful and more efficient (i.e. let people buy insurance from any insurer in the country, not just the ones anointed by the insurance commissioners of each state).

But that’s not what we’re doing.  No, instead we’re increasing the participation of “middlemen,” most of all the “mega-middleman,” government.  That’s why it’s important to understand that there’s a supply side to this issue.  If the government wants the cost of care to be “affordable” (read:  artificially-low) on the patient’s side of the transaction, then the other side, the provider side, is going to continue to get squeezed, and at some point (it’s already happening), providers and future providers are going to be saying, “no, thanks” — “no, thanks” to the years and expense of training, “no, thanks” to the stress of working with life-and-death stakes, “no, thanks” to the liability, “no, thanks” to what starts to feel like thanklessness when others who’ve learned less, sacrificed less, and risked less are rewarded equally or better for doing less-important work.

If/when smart young men and women, taking all intrinsic and extrinsic factors into account, consistently conclude that they can live better lives by, for instance, becoming mailing/shipping/copying-store franchisees instead of going into medicine, we’re going to have big problems, just as we are if/when investors consistently conclude that they can do better risking their dollars on mailing/shipping/copying-store chains instead of on companies that make medical devices and medicines.  If we keep letting the government take the profit out of delivering health-care services and products, we’re going to end up in a “progressive”-ly unhealthy place.


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