Rational Actors and Happy Actors

By Nathaniel Counts

Politics, theoretically at least, is a process designed to enhance the sense of wellbeing of its citizens.  The success of this process, the amount of wellbeing that can be created, is hamstrung by biology – we have basal levels of felt wellbeing that are determined through some amount of nature and nurture, and that are independent of our present circumstances.  Because there is a biological component to it, we may be able to alter an individual’s basal wellbeing before they reach adulthood.  For example, if hypomania, a psychological condition where the individual only experiences the manic part of bipolar disorder, were found to have a definitively genetic etiology, gene therapy could be used on embryos so that they would grow up to experience the constant heightened state of wellbeing associated with the condition (for an interesting article on hypomania and wellbeing, see here).

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Health Class and Personal Preferences

By Nathaniel Counts

High school health classes that are effective in preventing high-risk behaviors employ two educational models: the social influences model and the life skills model.  The social influences model teaches children about social norms and techniques for resisting social influences.  The life skills focuses on developing child autonomy, self-esteem, and self-confidence to help children resist social influences and gain a sense of self.  There are two explanations for why health classes premised on these models would be effective: either they replace the preferences the children were likely to develop with different preferences or they help children develop their own preferences which, for some reason, consistently disfavor high-risk behaviors.

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Admissions and Mental Health

By Nathaniel Counts

In our legal system, colleges may not make admissions decisions in order to ameliorate historical (or presumably other) inequalities, but may make decisions that take into account the particular situation of the applicant or that strive to create a diverse student body.  Justice Powell rejected the former two goals in Part IV of his Bakke opinion, which went uncontradicted in the Grutter opinion that followed it and, most recently, the Fisher opinion almost exclusively focused on the diversity justification.  Whether or not it appears in court opinions however, the issue of transformative justice is very much at stake – colleges, as the gatekeeper to many of the high honors and offices of our society, can control the distribution of a set of goods to the rising generation and decide how equally they are distributed among certain groups.  Here we will imagine that transformative justice is indeed the goal of affirmative action.

Colleges have two tools by which they can currently select among students based on disadvantage (historical or otherwise).  First, there is the demographic and socioeconomic information disclosed in the application.  Although these questions are optional, for those students who answer the questions, schools may use these answers as signals for disadvantage and take this into account.  Second, there is the essay questions, which frequently ask about an instance in which the applicant overcame adversity.  Here the applicant can demonstrate the degree of disadvantage experienced or explain some more nuanced disadvantage not revealed in the first part.

These two tools are far from perfect, but let us take our imagining further and envision a world in which colleges could accurately determine disadvantage.  If it decides to take on the latter, mental health may pose an insurmountable problem – individuals with intellectual disabilities may not be able to thrive in the setting offered by the institutions that select them.

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Diagnosing Mental Disorders from Internet Use

By Nathaniel Counts

We live in a time when increasingly our personal information is publicly available on the internet.  This personal information includes our names and phone numbers, things we’ve written and things we’ve done, along with a good deal of information that only exists because we interact with others on the internet – thoughts that we might not have otherwise externalized, or that we certainly would not have saved so that others could read.

If all of this information is publicly available, all of this information can be gathered.  Already advertisers analyze our behaviors to better target products to us.  It is not hard to imagine a not so distant future where the government analyzes this data to determine whether we have a DSM mental disorder.  By looking at the online behaviors of those already diagnosed – the way the syndrome affects their usage patterns, the sites they visit, and how they interact with others online – it is likely that one can find statistically significant usage patterns that can distinguish individuals with a diagnosis from those without.  The available data could then be mined to identify other individuals that exhibit the usage pattern and allow for presumptive diagnosis.

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Social Signaling and the Undoing of the Harm Principle

By Nathaniel Counts

In On Liberty, John Stuart Mill asserted that “[t]he only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.”  This has since become known as the harm principle and is foundational for much of American political discourse, especially for libertarianism and civil rights.  At the time of Mills’ writing, On Liberty having been published in 1859, this logic could protect a lot of conduct that involved consenting adults or did not appear to directly impact others.  If the harm principle was controlling, we could never have a soda ban.  Today however, with our advances in social science, clear lines of harm and no harm have become fuzzy.

Few people buy cigarettes in a vacuum.  Someone offers you cigarettes or you see other people smoking and then you buy cigarettes.  This phenomenon, in which we make decisions based on the decisions of others in relationship to our esteem for them (if we see someone we respect smoking, we will be more likely to smoke; if we see someone we do not respect smoking, we will be less likely to smoke) is called social signaling (The Origin, Development, and Regulation of Norms is a great article on a related topic, the generation of norms, which explains this phenomenon quite well).

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Potato Chips and Choice Architecture

By Nathaniel Counts

If, out of concern for public health, the government banned potato chips today, a lot of people would get very angry.  Only some of these people would be angry because they missed potato chips.  For most it would be the principle of the thing – the government should not interfere with our autonomy to eat whatever we want, as long as it does not harm others, and some days this will include potato chips.  I would posit that the autonomy at issue here is a narrow understanding of autonomy, and one that we should be suspicious of.

Imagine yourself in the biggest Costco in the world.  It has every food in existence and they are all placed equidistant from you, and you may survey the scene and choose whatever food you most desire and then eat it.  This would be true autonomy.  The world we live in, however, is deeply constrained and we should question how meaningful our autonomy is.

In reality, every time someone who came to the Costco before you made a purchase, the store owners moved the product a little bit closer to you, and manufacturers began shipping more variants of it.  The decisions that determined the composition of your commercial world were made over hundreds of years by individuals with no understanding of health – diet and exercise, hypertension and heat disease all being foreign concepts until recently.  Today potato chips, in all their variety, take up quite a lot of shelf space, and healthful foods are hard to come by.

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Prioritizing Parks and Patients

By Nathaniel Counts

During the government shutdown in October 2013, a battle in part over the future of healthcare reform, a non-negligible amount of media attention focused on the shutdown of public parks.  Perhaps because the parks were the least expected casualty of the shutdown, or the most ludicrous – many are, after all, large outdoor spaces that functioned for millions of years before there were federal funds for them – Americans were frustrated or amused that they could not walk around outside some places because politicians in D.C. could not agree on a budget.

The healthcare reform debate pitted those who believed that everyone should have health insurance or that access to healthcare was a right against those who believed that health spending was already too high or that everyone does not have a right to access to healthcare.  In a world of infinite resources, where everyone could have complete access to healthcare without anyone having to give up anything of their own, it is difficult to imagine that anyone would say that there should not be universal access to healthcare, that some are not deserving of the service.  It would be strange to require a threshold public showing of effort to obtain health insurance through employment if there was no cost to giving the healthcare – if fairness is an issue, as it appears to be a concern for some, there are certainly other services that could be denied.  It is likely that for most the fairness concern only becomes salient in the face of resource constraints where these same funds could fund other programs or allow others to pursue their interests.

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Managed Care for Mental Health

By Nathaniel Counts

Managed care and integration of primary care and mental health services are major foci of the Affordable Care Act, especially as more practices are encouraged to become Patient-Centered Medical Homes.  In managed care, vitals are used to track progress, and case managers can look over an individual’s blood pressure, weight, and blood-sugar levels to work with service providers and patients to ensure best outcomes.  If an individual is receiving mental health services, then the providers will share information about the patient’s current needs in both physical and mental health.  If the individual is not referred to or does not seek out mental health services, then there is no mental health component to manage.

Meanwhile in Massachusetts, every pediatrician is mandated to offer CANS (Child and Adolescent Needs and Strengths), a lengthy evaluation form that asks a patient (aged 5 to 20 for the link above) to evaluate their own life and mental health on sets of 0-3 scales.  CANS is used to monitor children’s mental wellbeing and identify potential problematic areas, including whether a mental health referral for serious emotional disturbance is necessary.  To the best of my knowledge, this information is not stored and used as an indicator for managed care, as blood pressure and weight are. Continue reading

Managing All Care

By Nathaniel Counts

Health insurers are beginning to realize the importance of downstream cost-saving.  By paying to keep people healthy now, health insurers avoid major expenditures later when they must cover chronic conditions and hospitalizations.  For example, by paying for nutrition counseling and fitness programs for prediabetics, health insurers can reduce the rate of transition to diabetes for their clients, which both saves the insurer thousands of dollars and keeps their clients happier and healthier.   This type of innovation is possible because the law requires certain expenditures, i.e. doctors must treat individuals at the emergency room, and these expenditures tend to be quite large if incurred.

Social services in general could enjoy this type of innovation if funding were pooled between government services, and healthcare, housing, food, and direct welfare were all managed together.  Currently, each is conceived as a separate welfare program, so one can only recognize reduction within a program, not how the programs interact.  For example, it may be that the expansion of SNAP benefits would decrease emergency room visits and end up being cost-saving overall.  It may also be that certain types of subsidized housing reduce the need for other services and are more cost-saving than others, but this is hard to recognize when each program is segregated.  One could imagine that subsidized housing built in areas with better access to quality food and jobs would be more expensive upfront, but could save in money overall by reducing the need for other benefits.  Because social services currently have a system of mandatory spending in the form of entitlements, there is an incentive to ensure that individuals transition away from use of the more expensive services.

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Only a Right to Health

By Nathaniel Counts

Human rights disaggregates otherwise related issues into separate rights.  We discuss rights to health, education, housing, association, etc., and, in countries where these rights are codified, we litigate each one separately in the courts.  We also know that each of these issues for which there is a corresponding right is, to some extent, a symptom of poverty.  In some cases it might not be possible to treat the symptoms without addressing the root cause.  For example, in 1966, the Coleman study on equality in education found that “[s]chools bring little influence to bear on a child’s achievement that is independent of his [or her] background and general social context.”  These findings have been contested, but it is likely that socioeconomic factors are a determinant of a child’s academic success, along with the educational experience itself.  If the socioeconomic background is the greater determinant, it may not make sense to use scarce government resources to fund school improvement rather than addressing poverty itself.  In a country with a right to education, school improvement could be litigated and potentially derail national efforts to address root causes.

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Personal Responsibility and the Procrastination Problem

By Nathaniel Counts

We have all been confronted with the procrastination problem in one form or another.  You have a paper due in a month, and you have two options.  You can either work on it a little every day, or you can save it for the last two days and finish it all then.  If you do not procrastinate, you will be happier – the work will feel like less of a burden and you will be less stressed out.  However, one of your primary interests is spending time with your friends.  Your friends are all in class with you, and you do not have other friends.  If you decide not to procrastinate and they procrastinate, your little bit of work every day will mean that you will have to miss out on trips that your friends go on, and when you are available nearer to the paper’s due date, your friends will all be busy.

Your friends all procrastinate.  What do you do?  You procrastinate as well.  In your calculus, the additional stress of having to do the paper in less time is offset by the additional time with friends.

Now re-imagine the scenario with the same closed social group, but the decision is whether or not to do drugs.  If you decide not to do drugs, you will likely live a longer, healthier life, but if your friends decide to do drugs and trade in health for pleasure in the short-term, you are once again presented with the procrastination problem.  If you choose the “responsible” choice, you miss out on activities with your friends now and will be healthy and capable later when your friends are not.  What do you do?

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Toward an Epidemiological Definition of Community

By Nathaniel Counts

With the coordination and additional funding afforded by the National Prevention, Health Promotion, and Public Health Council and the Prevention and Public Health Fund under the Affordable Care Act, scholars may have a unique opportunity to work toward an epidemiological definition of community.  The evaluation and record-keeping components of the different interventions will inevitably lead to a great deal of additional information about individuals, including their beliefs, behaviors, and health, over time.  If one’s behaviors, and in particular the Leading Health Indicators (ten factors chosen by Health and Human Services that contribute to health, including substance abuse, exercise levels, condom use, etc.) and health status are determined in part by social signaling, it may be possible to use this data to determine which individuals seem to be part of a community.  Various environmental, and possibly even genetic, factors could be controlled for to find groups of individuals whose Leading Health Indicators affect one another’s, and whose health statuses are linked.  This grouping would be a functional “community,” a group of people who influence one another, whether they realize it or not. Currently, the notion of community is usually defined geographically – your community are those that are close to you, unless it is a city, in which case your community are those who are nearby of similar socioeconomic class.  This method would allow for greater precision in determining groups that influence another.

A more precise understanding of community would be useful for assessing the impact of interventions, public health or otherwise.  If you can see the initial community structures at the beginning of an intervention, you could target the individual communities for change and see how their Leading Health Indicators and health statuses evolve.  You could also, and more importantly, see how an intervention changes the make-up of a community.  A new basketball program in a local gymnasium will bring together different arrangements of individuals, who may in turn influence one another, joining them into a community and linking their health statuses.  This could determine choices of programs – a youth basketball league will shape communities differently than a family program or an adult program, and conscious choices could be made about how to bin people based on their current risk behaviors.  This type of information could also provide caution to those planning any sort of intervention – any interaction could reshape communities, subtly changing individual’s values and even their health in ways unbeknownst to them and unintended by the intervener.

Economics, Morality, and End of Life Care (Part II)

By Nathaniel Counts

[Part I is here.]

First, let us consider whether opting for end of life care is morally problematic on its own, without reference to its resource costs.  Certainly wanting to live longer on its own is not morally problematic in our society – we do not consider exercise or healthy eating wrong and many tout it as a social good.  On the other hand, wanting to die early, for example through suicide, has traditionally been viewed as a moral wrong and is illegal in many areas.  It similarly seems that there is nothing problematic with wanting even a short amount of additional time, even with arguably compromised quality.  If end of life care involved only pressing a button for an additional day of life, even in severe pain, it is unlikely that anyone would consider the pressing of the button good or bad morally.

It may be that opting for intensive curative end of life care is irrational, even if it is were cost-free.  If palliative and hospice care would have led to greater overall life enjoyment for that time period, regardless of its length, then opting for the intensive treatments would not have been the right choice, even for that individual.  This does not make it immoral however – individuals are generally allowed to make choices that are worse for themselves as long as they do not violate norms, and the pervasiveness of these intensive treatments at end of life may indicate that they are in fact the norm.

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Economics, Morality, and End of Life Care

By Nathaniel Counts

Over a quarter of Medicare spending goes toward a patient’s last six months of life.  This monopolizes limited resources, both in the hospital and in the federal budget.  Much of the blame for this overspending is placed on institutional incentives or medical training for promoting aggressive end of life care, but some would also place the blame on patients or their families, arguing that this behavior is a flaw in our culture.  The argument goes that if people would learn to be less afraid of death, then they would forego this costly life extending care and die peacefully, while allowing these resources to be available for use elsewhere with greater utility.  In this argument, there is potentially a worrying conflation of moral and economic reasoning, which would be problematic if applied in other contexts.

It would be one thing to say that, given a limited pool of resources, a cost-benefit analysis indicates that end of life care is inefficient and quality-adjusted life years across the system would best be maximized if the money was spent elsewhere, and those in need of end of life care and their families will need to adjust their expectations.  But integral to the argument in the first paragraph is that this misallocated spending is the result of a moral failing, perhaps not of the individual but of the society that imbued the person with the preference for aggressive treatment, and that this failing is worth changing, not only because it will save money and make individuals more comfortable with the fact that there are no longer the resources to support end of life care, but because it will provide some moral benefit to those whose values are changed.

My curiosity is how the economic argument (that it would be a better use of resources to spend money elsewhere) informs the moral argument (that it would be better if people accepted their death).  This is peculiar to me because this type of reasoning does not show up consistently throughout health rationing: if a country decides to spend limited resources on HIV prophylactic drugs rather than HIV treatment drugs, no one would argue that it was in any way unreasonable for the HIV positive individuals to want treatment and that they should be more at peace with a terminal illness.

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The Whitehall Studies and Human Rights

By Nathaniel Counts

Professor M. G. Marmot et al. conducted two studies, Whitehall I and Whitehall II, in which they studied morbidity and mortality in the British civil service sector in the 1960s and the 1980s.  British civil servants are under the same plan with the National Health Service, so the studies controlled for access to healthcare.  But what these famous studies found was that morbidity and mortality still correlated with income.  Further research and analysis has concluded that it is job satisfaction and social status more so than income that determines health outcomes.  Does an individual feel like she has control over the work she does?  Is she stressed out a lot?  How does she feel about herself in relationship to those around her?  Does she feel healthy?  Does she like her life?  Those who feel in control of their lives, feel valued by society, and feel good about their health actually end up living longer and healthier lives on average compared to those who don’t share these beliefs.

Deep structural inequalities exist in every society, and social justice groups work toward greater social equality everywhere.  Does the notion that social inequalities are hurting people in a physiological way change the way we feel about the mission of equality?  Is health so fundamentally different that individuals who accept economic inequality might mobilize over health inequality?  It is certainly implicated in the right to a dignified life, a concept underpinning the human rights movement as whole.  It may be though that the social inequalities on their own terms are an equal evil, because the limitations on one’s abilities to pursue her interests are as inimical to human rights as worse health.

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Disabilities and Behavioral Disorders

By Nathaniel Counts

The Americans with Disabilities Act of 1990 (ADA) and related statutes and regulations creates a cause of action that allows children and young adults with disabilities to be able to participate equally in public schools and universities.  “Disability” can include behavioral and other mental health disorders, such as depression, anxiety disorder, obsessive-compulsive disorder, phobias, or conduct disorder, to the extent that it interferes with the child’s ability to thrive at school.  Over the period of any individual’s school-going career, quite a few people might be considered disabled under the law.

Actual prevalence of behavioral disorders is of course very difficult to measure, but the prevalence in young children for serious emotional disturbances, behavioral disorders that substantially impair a child’s ability to participate in school, has been most frequently estimated at between 10% and 20% as of 2006, and the prevalence for behavioral disorders that do not rise to the level of serious emotional disturbances is likely somewhat higher.  For college students in 2012, one study found that about 30% of students reported feeling so depressed within the past 12 months that it was difficult to function and about 20% of the students reported being diagnosed or receiving treatment for some type of mental health disorder within the past 12 months.  Even given these limited statistics, it is evident that a significant percentage of the population is currently affected by, or will be affected at some point in their lifetime by, a behavioral disorder and that a sizable proportion of these individuals would likely benefit from some form of services or accommodation in their schooling.

The prevalence of behavioral disorders begs the question: what if the majority of the population experiences some form of behavioral disorder?

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Introducing the 2013-2014 Petrie-Flom Student Fellows

The Petrie-Flom Center is pleased to welcome our 2013-2014 Student Fellows. During the coming year, each of the fellows will pursue independent research under the supervision of Center faculty and fellows. They will also be regular contributors at the Bill of Health on issues relating to their research.

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