I
Let's do a healthcare thought experiment.
Alice isn't feeling well, and goes to visit the doctor. She learns that she has an aggressive form of cancer. Over the course of the next year, she visits a number of different specialists, many of them operating at the top of their field. She undergoes a number of different treatments, including the most advanced, cutting-edge techniques. At the end of the year, she has a difficult conversation with her doctor. Her doctor tells her that they've tried everything they could, but none of it is working. Her cancer is just too aggressive. She is projected to die in six months. Alice goes home, tells her family, and asks them to help her make the next six months the best they can be. She passes away six months later surrounded by friends and family.
Bob's situation is very similar to Alice's. He receives the same diagnosis, visits the same specialists, and receives all the same treatments. The only difference is that, when he sits down with his doctor to have the difficult talk, the doctor tells him they have done all they can do - except for one thing. They believe that if Bob were to take an unobtanium pill, he would have a 50% chance of making a full recovery. However, unobtanium is incredibly rare and wildly expensive. The pill Bob needs would cost $50 million. There is no chance of getting insurance or anyone else to pay for it. If Bob wants the treatment, he will need to come up with the money out-of-pocket. Bob and his family set up a GoFundMe, they get themselves on every news show that will have them, and they call every politician they can find. They try as hard as they can to raise the $50 million. But they're only able to raise $5 million. Bob passes away after six months.
The question is: who was better off?
You can make a case that they were about the same. After all, they both received the same treatments and got the same result. Bob was unable to obtain the unobtanium pill, so the possibility of it ended up being irrelevant.
You could also make the case that Bob was better off. At least that he was given a chance. Perhaps if he had tried other things, worked harder, or been a little luckier, he would have been able to get the pill. The possibility of the pill gave him a hope that was never even presented to Alice.
But to me, the more intuitive case is that Alice was better off. She spent her last six months doing things she enjoyed with the people she loved. Bob spent his last six months in a hellish grind trying to raise an impossible sum of money.
I think Alice also got something subtle, but important - Alice got peace. Alice could plausibly tell herself that she had genuinely done everything she could. She had seen all the specialists and done all the treatments. She had, in some sense, done her part. Anything bad that happened to her after all that was definitively not her fault.
Bob's best chance at that sort of peace is to convince himself that the pill was never really an option. That amount of money was completely out of his reach, and he would be fully justified in simply dismissing the option as unrealistic. But I think a lot of people would have trouble convincing themselves of that. There are big forces working on us encouraging us to always push, to always fight, to never say never. So Bob is stuck - he goes to his grave believing if he had just done things differently, he'd have had a real shot at decades more of life.
II
I think about this thought experiment whenever I hear about some new drug or treatment hitting the market for some obscenely high price.
The reason for these incredibly high prices are patent protections, of course. Patents mean that companies have a legally protected monopoly on any new drug for twenty years (under current US law). While a drug is under patent, companies can charge whatever they want, and nobody can undercut them.
The argument for patent protection is pretty good. Patents are the main way we incentivize companies to come up with new drugs. Coming up with new drugs is both expensive and risky, so it makes sense for the rewards to be substantial. And over time, we generally expect that prices will be pushed down. New, even better drugs will come on the market to compete. And after the patent expires, generic manufacturers will be able to take things over and push the price down even more.
All of the above is rooted in the idea that new, better drugs coming on to the market is a positive good, even if the new drugs start off mostly unaffordable. After all, even if you can't afford a fancy new drug, you've still got all the old drugs available. And even if prices stay high forever, which happens to some drugs, it seems like nobody would be harmed by some fancy designer drug floating around out there. And in the normal case where prices do come down over time, it seems like everyone benefits.
The story of Alice and Bob, though, suggests a scenario in which the mere availability of a superior, costly treatment could cause genuine harm.
I'm honestly not sure how big a deal this is in practice. One case that comes up a lot is insulin. It is often noted that insulin prices have increased to pretty ludicrous levels, especially considering that insulin was relatively cheap not that long ago. Untangling the complexity of the insulin market is pretty difficult - but part of what's going on is that it IS possible to find cheap insulin (Walmart has a store brand that can be purchased for $25). But the cheap insulin is a lot worse than the expensive insulin. Back when the only insulin available was the cheap insulin, diabetics lived worse lives and died younger. Newer, more expensive insulin lets diabetics live better and longer than before. But it's a lot more expensive.
From what I can tell, actual medical improvement is only part of the story - there's a lot of other stuff going on in the insulin market, and a lot of it seems very shady. But even if we set the shady parts aside, I worry that the core of it sends us into Alice and Bob territory. In a world where the insulin available is cheap but only somewhat effective, diabetics get to live their lives mostly unburdened by the cost of their medication. They don't have to spend very much money, and they still get the peace of mind that comes from knowing they're doing everything right. If you drop a better, but wildly more expensive, insulin into the mix, diabetics suddenly have to become amateur economists, figuring out what they're willing to spend on quality-of-life improvements. There are real benefits here - people who can afford the more expensive insulin (or can convince insurance to cover it) will live longer, better lives. But it seems like there are costs too.
III
So probably the logical place to go from here is to talk about socialized medicine. I do think socialized medicine solves a lot of the problems I've mentioned above. I don't know if it solves everything - for instance, some entity at some point needs to make tough decisions about what it will pay for and what it won't. Being told that there's an experimental treatment you could try, but the government refuses to pay for it, isn't necessarily an improvement over being told you could get it if you manage to scrounge up enough money (though in practice well-run government institutions have a lot more market leverage than individual healthcare consumers, rendering a lot of these scenarios less likely).
Honestly though, other people have made lots of great cases for socialized medicine, and the topic has been debated to death. I don't really feel like I have a ton to add to the discussion. So I want to go in a slightly different direction: what other scenarios have Alice and Bob properties?
To me at least, the core of what makes the Alice and Bob story interesting is that, in many life situations, it is important to us to feel like we did the right thing. For instance, suppose that I hire an inspector to look over my new house and they tell me everything's up-to-code. If my house burns down later due to a freak electrical issue, I will be upset about my house burning down, but I probably won't feel guilty over it. On the other hand, if everyone told me to hire an inspector, and I didn't, and then my house burned down, I would feel like I'd made a terrible mistake.
Let's make it worse. Imagine that there are a dozen different accrediting agencies for home inspectors, and they all hate each other and say the others are frauds. Some of them are quite affordable, while others are incredibly expensive. My official goal in hiring an inspector is to avoid having my house burn down. But actually, a big part of what I want is peace of mind. I want to feel like I did the right thing. And I want to know that, if something bad does happen, it wasn't my fault. But the situation I'm presented with now makes that impossible. Whoever I hire, I'll know there are some people out there who think I'm a huge idiot and deserve whatever I get for hiring the wrong type of inspector.
Maybe what I need to do is just buck up and take responsibility. I need to do my research, figure out which inspector is the best, and then hire them. With so much competition, it seems likely that the quality of inspection available to someone willing to do the work on this is really high. But truly, the probability of my house burning down is pretty low no matter what I do. And the probability of me being frustrated, anxious, and uncertain is rapidly approaching certainty.
To circle back around to medicine, what I think a lot of people want from the doctor is to feel like they're doing the right stuff. A doctor's job isn't just to offer medical expertise. Part of the point of a doctor is to take on the burden of medical decision-making. A patient's duties are straightforward - they need to show up at the right times and follow instructions. This might be difficult in some cases (for instance, if your doctor tells you to lose weight or quit smoking). But your responsibilities as a patient are clear. If a doctor offers a choice to a patient, it is the doctor's job to present only the best options and clearly explain all the relevant considerations.
I actually think a lot of decisions people make in life are driven by this sort of thinking. People from middle-class families go to college because that's what you do. Lots of folks are told that if they study hard, go to a good school, pick a good major and avoid trouble, then they've done their part. I think most people realize this doesn't specifically guarantee anything. After all, in our initial thought experiment, Alice did all the best treatments and none of them worked. But they feel that if they do all the right things, then they will have done what was expected, and come what may, dignity and honor will be retained.
I think older generations had more scripts like this, and larger sections of their life were controlled by those scripts. The obvious examples here are around marriage and kids, and are highly gendered. If a woman married a good man, kept a good house and raised happy kids, she was doing everything right. That didn't guarantee happiness - bad things happen all the time to good people. But the script lets her offload some of the responsibility. If she's following the script and things go wrong, she can hold her head high knowing she did the right thing.
IV
I want to make one more distinction here to try and emphasize what I'm talking about.
I think a lot of people are already aware of how the complexity of the modern world is overwhelming. Having to constantly sift through endless options is a lot of work. And though a lot of people are out there making guides, explainers, etc. to help parse the ocean of information available to us, I think there is still a lot of work to be done here.
But that isn't actually the problem I'm getting at. Or at least, it's only part of the problem I'm getting at. What I'm talking about is something more subtle, but perhaps also deeper. It's not just that the modern world makes us do more work sifting through options. It's that the modern world gives us fewer opportunities to offload moral responsibility. When we have fewer options available to us, it is easier to simply accept things for what they are. When there's no treatment for a condition, we can turn away from trying to solve the problem and focus on making peace with what must be. But as the space of viable options expands, it becomes harder and harder to accept that things simply are as they are, because we know for a fact there are many other ways things could have been.
I don't think this is entirely bad. For instance, I think it is bad that, for much of human history, it has been simply accepted that when duty calls, a man picks up his weapon and marches out to fight the enemy. Martial tradition is full of scripts that encourage soldiers to offload their moral responsibility for terrible acts of violence. Weakening the scripts that shield people from taking responsibility for violence seems important to me. I also think it is good for men and women both to think more seriously about what they want out of life. Abandoning easy scripts leaves people psychologically vulnerable, but also opens up possibilities that would be otherwise impossible.
But I do wonder if the classically millennial temperament - anxious, scared, confused, insecure, uncertain - is influenced by the additional burden of responsibility millennials have had to carry through their lives. I also wonder if some of the weirder, more intense online political communities are working as a release valve, letting people offload moral responsibility on to ideologies that supply straightforward answers to difficult questions. I think you can even see some of this emerge in influencer culture or "grindset" thinking, which encourage people to throw everything they have into the pursuit of incredibly specific lifestyle goals.
I don't know if any of what I've said is super original. What I'm saying sounds kind of similar to other ideas I've heard before, like ennui, anomie, nausea, and other french words. But to me, these french words imply a certain passivity, or giving up, in the face of the machinery of the modern world. And I don't think that's really what's happening. People aren't giving up - in many cases, they're kicking into overdrive and burning themselves out trying to do everything, or they're endlessly guilt-tripping themselves for every little decision they've ever made.
We could try and bring back all the old stuff that managed these burdens for us. But I think that would be, in some ways, a step back. Ultimately, I think the true way forward is probably learning to live with less certainty and more choice. We need to learn how to accept things as they are, even when the way things are is our fault. We need to get better at avoiding sunk-cost thinking so we don't make the perfect the enemy of the good. And we need to learn to articulate our values clearly so that, even when things go wrong, we can say with confidence that we did the best we could given what we had to work with.
A couple of differences from previous generations are competition and the scale of expected benefits. College degrees used to be much rarer than they are now and to confer significantly higher wage premiums in the labor markets.
@TomThought, I have been reading Substacks for a while but not adding to the public conversation. I saw your comment on Graeber's Bullshit Jobs and was hoping to discuss it with you. Is there a DM function or could you start a chat?