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Comment by paul | Hacker News Reader

My daughter had a similar birth and hospital stay, which also produced a million dollar insurance bill. It costs about $10,000/day to stay in the NICU. I was never able work out why it costs so much, except that this is a major profit center for hospitals, and they use the money to cover other, money losing, departments.

Fortunately Google is run by good people, and they were never anything other than supportive. I'm grateful for having had access to the best care for her. I do think our medical system needs some rethinking though.

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It is unfortunate that Tim Armstrong made these statements and all of us who have had this experience need to relive it.

My daughter also had an extraordinary birth, and was saved by the incredibly expert care of a dedicated team of medical professionals at multiple hospitals in Seattle and Bellevue. The bill I saw was north of 250K and I paid the max of that (which was a few thousand)

It occurred while I was at a startup which i had co-founded (and currently employs over 100 people). I tend to go from startup to startup, with some contract / FTE work in between, and have swung from COBRA to COBRA to keep my health insurance consistent.

Because of ACA, this is the first year that I didn't have to "get a real job" in order to keep pursuing startups.

> I do think our medical system needs some rethinking though.

You probaby don't want to hear it, but if I were running a medical system I'd decree that gestating one-and-a-half-pound globs (from the article: "One doctor, visibly shaken, described [the fetus's skin] as 'gelatinous'") outside the womb is a waste of resources. To me, if miscarriages aren't the end of the world, neither are "babies" that die of natural causes within a few minutes of being delivered.

There's just no way spending a million dollars to raise a fetus up to the age of zero passes any kind of cost-benefit analysis. The cost of replacing the thing is much, much lower.

I'm aware of that kind of thinking, which is why I'm glad you aren't running the medical system.

Consider who you're talking about when you say, "The cost of replacing the thing".

If several dollars a day will keep people in certain parts of the world alive, doesn't the question become how many must die to save this one life? http://www.globalissues.org/article/26/poverty-facts-and-sta...

I am hopeful that this is not a zero-sum game...

And for the record, I think this is the wrong battle, health care is entirely too expensive in the first place.

No it doesn't - these are not mutually exclusive choice. How are expenses for US health care and aid to foreign countries related? You could just as well budget the money for the latter against the expense for a coffee, an aircraft carrier or Armstrong's salary.

I totally agree that health care is too expensive at the moment.

I agree with your parent and thus don't want you in charge of "running the medical system," either. But we don't have to have one or the other. You buy your insurance policy that covers whatever it takes to save your fetus and I'll buy my policy that doesn't (and spend the difference on improving the lives of my healthy children).

This is pretty obviously preferable to the situation we have in health care today in the U.S., where you're (more or less) forced to get employment and health insurance from the same company.

Cruelty#2... https://news.ycombinator.com/item?id=7204184

This kind of attitude is why articles like this get written: http://online.wsj.com/news/articles/SB1000142405270230366140...

Failure to think critically about how to value life results in harmful abortion and euthanasia laws and is contributing to the high cost/benefit ratios of our healthcare system. We have quite enough people thinking only emotionally about these issues.

I don't necessarily agree, but I don't think your opinion should be downvoted.

Consider this: We as a society have more than enough wealth to give ICU care to every infant that needs it. Our medical system is what makes it expensive.

A minor point:

> We as a society have more than enough wealth to give ICU care to every infant that needs it.

I'm not particularly informed here, but this is a claim I'm willing to accept.

> Our medical system is what makes it expensive.

This isn't right. Giving intensive care to extremely premature infants is inherently expensive, in much the same way that mining is expensive because you have to move tons and tons of dirt. It's difficult, and it requires a very large quantity of dedicated resources; it will not be cheap at any point in the foreseeable future no matter what organizational changes we make. We'd need technological changes.

How many tons of dirt do you need to move to give intensive care to an infant? I spent quite a bit of time in the NICU and was never able to locate the $10,000/day expense. Medical expenses have more to do with billing codes and reimbursement rates than anything fundamental.

This information comes from consulting my mother (who is an obstetrician):

The most "direct" cost of NICU care is 24-hour supervision by a nurse. In the best (cheapest) case, this will cost the same as 12 hours of minimum wage per day, as nurses might be in a 1:1 or 1:2 ratio with patients. More realistically, the nurse will be making higher than minimum wage.

The NICU fee also covers the amortized cost of three major pieces of capital: the ventilator, which causes the baby to breathe, the incubator, which keeps it at an appropriate temperature, and the negative pressure room. A particular infant may or may not need the negative pressure room, but it exists as a (physically separate) part of the NICU, the hospital must have one, and it's hugely expensive to create.

Additionally, the baby is expected to suffer various bodily failures which will require treatment. Diagnosis and treatment of these will be charged separately; they are not covered in the NICU fee. But they do reflect that these babies would really rather die, and it's difficult and expensive to get them to live.

My mother says (paraphrased), "if you are the army, you buy all the machines yourself, you pay everyone army salaries, and you just assign them 'you'll do this job, you'll do this job', etc., I don't know what it would cost to run an NICU. There's definitely room for it to be cheaper."

"Is there room for it to be cheap?"

"No."

Can't reply one level down.

From what I've read, it is the very nature of the beast (purely private, for profit health insurance) that causes the costs to be higher.

As I said in another comment, an earlier claim of "13 to 18 $K" for health insurance seems ridiculous, coming from a country where $6k gets top-level private insurance (to cover electives, get a private room vs shared, etc) on top of "free" health care) for a family.

You place more importance on $1M than on a human life? What if it was your child, would you be doing a cost/benefit analysis and turning to your wife and saying "sorry honey, it will cost more than $100,000 to save our child. might as well get her put down"?

This depends on how much I need $100K (odds are I can pull this together if I'm attached to the child), and, crucially, on the age of the child. I place essentially no value on a child at negative eighteen weeks old.

I mean, would you personally pay a million dollars to save my child? I'm no more attached to a new nonviable fetus than you are to my (imaginary) 11-year-old.

Your clearly limited imagination can't even begin to give you an idea of what having an 11-year-old child will do to how you live and think.

If I ran a business that turned over $1.05B, and you and I had some form of relationship be that employment or friendship, of course I would. If I had any reasonable number of resources I would prioritise saving lives over building a collection of sports cars or properties. Especially so if I ran a hospital.

Of course this perspective is easy to take from the UK where we don't have to face tough financial decisions over healthcare.

> If I ran a business that turned over $1.05B, and you and I had some form of relationship be that employment or friendship, of course I would.

Sure. But you don't; we've never met.

> one-and-a-half-pound globs

This is a human being we are talking about. A child.

I like to think of myself as someone who can usually empathize with folks who hold a different point of view, but I have never been able to understand someone who looks at a human life in terms of a "cost-benefit" analysis.

> This is a human being we are talking about. A child.

This glob we're talking about has less in common with a (prototypical) human being than does a 29-week fetus still implanted in the womb. You're taking a strong stand here in the abortion debate; is that intentional?

No, I'm very pro-choice. But a 1 lb baby is still a baby. If we were talking about an actual clump of cells, I'd have agreed with you.

You know I don't agree with the point you've tried to make but it's good to read arguments from various perspectives. Having said that, your last sentence is unnecessarily and (perhaps intentionally?) hurtful to Paul. Would you really call someone else's child "the thing" in person?

There's just no way spending a million dollars to raise a fetus up to the age of zero passes any kind of cost-benefit analysis

If you look at the cost in dollars per QALY, it's not that bad. That million dollar treatment probably produces 40 QALYs, for a cost of $25,000 per QALY; Americans typically pay $50-100k per QALY.

I see the logic here, but I don't really agree with it. Obviously, if the fetus had a million dollars of its own, it would happily spend them for the purpose, and that would be a sensible investment. But it doesn't, and I don't think it's a sensible investment for any third party, even the parents.

> There's just no way spending a million dollars to raise a fetus up to the age of zero passes any kind of cost-benefit analysis. The cost of replacing the thing is much, much lower.

Second-order emotional (and nth-order social and monetary) costs are part of a comprehensive cost-benefit analysis.

The cost of even thinking in terms of "replacing the thing" is predominantly the cost of complete societal ostracism.

The thing is, children's medical care as a whole is not relatively expensive. Elderly care is.

This kind of event is super rare. However,it's not nearly so rare to have an older person go through tons of procedures and spend months in the hospital.

This is called triage: http://en.wikipedia.org/wiki/Triage

It's difficult to discuss these things as people tend to get emotionally involved, but be discussed they must.

Just curious, do you have kids? I might have agreed with you before I held my preemie (only 5 weeks, nothing like the baby we are talking about) in my hand:

http://www.mcvoy.com/lm/photos/1999/04/16.html

It's easier to make the calls before you have a kid, they are calls in theory. After you have a kid you are changed, what was an obvious call becomes much much more complex.

If you can make that call after holding your own kid, wow.

For your reference:

I don't have children of my own. When I was 16, my mother gave birth to twins, so I have more parenting experience than the typical childless American, including that of holding closely-related infants.

> It's easier to make the calls before you have a kid, they are calls in theory. After you have a kid you are changed

Very true, but I don't see myself reversing on this.

Not sure if this helps or not but before we had our first my wife and I sounded a little like we were on the same page as you, more black and white. For example, we were mid 30's when "we" got pregnant so there were concerns about Downs and other stuff that happens when the eggs are older. We were pretty darn sure that if there were any "major" problems such as Downs, we would abort. It seemed pretty obvious what the right call was.

After having the first one? Things changed. Downs really didn't seem that bad compared to a life. I'm still pro choice and I don't think you could pay me enough to judge someone else's decision, that's their choice and it's hard enough without my irrelevant opinion in the mix. But for me personally? The bar on where I would go with an abortion went WAY up after having a kid. Way up.

Just trying to say having a kid really changed my thinking and I suspect I'm not that unusual in that respect.

There's no comparison. I don't think it's possible to understand parenting without actually being a parent. I certainly wasn't able to understand it before, and I thought more as you do now.

You are an ignorant, arrogant idiot, and a callous asshole.

BTW, we already knew you didn't have kids. We knew that both from your beliefs, and moreso from the the hurtful language you chose to use.

We all already knew you were childless. And single. And white. And male. And a programmer. And an asshole.

Now do the world a favor, and shut up. Forever.

I was once a childless single white male programmer. Oh, and an asshole. Didn't realize it at the time but I wised up. Give him time and cut him a little slack, he's entitled to his opinion.

He's entitled to his (ignorant) opinions, but he's not entitled to be so pointlessly rude and cruel with his method of expressing it.

If this was a dinner party, I'd quietly ask him to excuse himself, and he'd never be invited again. His choice of language was pointlessly cruel and outrageous.

I suspect he didn't view it as being rude, he viewed it as doing the right thing. He probably truly believes what he is saying, I used to think stuff sort of like that. My guess is he is somewhere between 23-32 years old, that was my stupid range :)

I guess the point is don't assume he's being an asshole, a real asshole would troll harder. I think he believes what he is saying. Yeah, it's rude but I'm not sure I'd be willing to write the guy off.

If all conversations were limited to dinner-party politeness, we'd remain trapped in a state of childlike obliviousness about the real disagreements and difficulties of the world.

(My dinner party would welcome both paul and thaumasiotes, as people able to speak about a difficult topic calmly, with strong and contrasting perspectives based on real experience. In contrast, yscale would be asked to apologize or leave for content-free name-calling.)

Saying "cost of replacing the thing" about a baby, to a father, was not calm speech about a difficult topic.

It was pointlessly rude and provocative. It was an indefensible way to express his underlying opinion.

And if you were paying attention, you would've realized I emphasized his method of expressing the opinion far more than the opinion itself.

> And single. And white. And male. And a programmer.

Ok, asshole childless person is at least mildly related to the topic at hand, but the rest of these just seem like irrelevant ad hominems.

>Now do the world a favor, and shut up. Forever.

Why do I get the feeling your tumblr is full of equally venomous "go kill yourself"s?

I'd also be willing to bet that he programs in languages like Ocaml and Haskell.

I agree with your point of view, but I don't think you've phrased it productively, let alone respectfully. I know it's a touchy topic, but you'll be a better advocate if you avoid flying off the handle.

It is impossible to do a cost-benefit analysis on something like that. It is worth any amount of money if the child can be saved. I'd go to the ends of the earth for my children.

Who knows what these children could end up being or doing as adults? Who knows what value they could end up bringing the world? What they might invent? What health issues they could solve? What priceless works of art they may create?

No it's not. We're dealing with the scarcity of goods and services here. Healthcare needs are unlimited and supply of the goods and services is constrained. Whatever the amount of money needed to save that child's life, you need to consider how many more children, not your own, could be saved instead had the money been spent on other people's children with life-threatening issues that are cheaper to treat.

Who knows what those other children who didn't get treatment so that this one could end up being or doing as adults? Who knows what value they could end up bringing the world? What they might invent? What health issues they could solve? What priceless works of art they may create?

What if this couple had been given the choice to forgo saving their own child's life and instead donate that $1 million to saving many children's lives in some other country that don't have the resources we have here in the US. Every time society chooses to save one life at considerable cost, it is also choosing to condemn others. What if you had to make the same choice, what would you do?

If the child lives to 80, she only needs to contribute an additional $12,500 worth of value to civilization per year for this to make economic sense.

Another way to look at this: the government has various estimates for the value of a human life. It averages about $7MM. The "extraordinary" expense of this child actually only requires a 14% increase in value over the average citizen to make sense.

Most importantly though, we must recognize that the actual cost is actually just the cost of risk spread across society, so instead of one person taking the brunt of this cost, we as a society take it together. As a whole, it is negligible on all of us, and it's a risk that any of us can fall into. The value of having a system that supports each other is invaluable. Way more valuable than a measly $1MM. We have strength in numbers and we all benefit when a society supports each other. If we ostracize the statistical outliers in this support system, then the support system itself (the one which we all benefit from) falls apart.

In short, more important than the economic argument (which I argue, still makes sense to spend $1MM on a baby), is the argument that the value to society from supporting each other results in a negligible cost for individuals and a near-priceless benefit to everyone within that society. It's exceptionally difficult to put a price tag on that, and it's orders of magnitude higher than $1MM.

> If the child lives to 80, she only needs to contribute $12,500 worth of value to civilization per year for this to make economic sense.

No, that's not correct. You're not thinking at the margin.

Still makes sense at the margin. Updated wording slightly to clarify.

Have you looked around lately ? Worldwide, I'd say at least 50% of the population does not make economic sense. That number is going up, fast.

What do you intend to do about them ?

That's still a terrible argument.

> The "extraordinary" expense of this child actually only requires a 14% increase in value over the average citizen to make sense.

Ok, fair enough, we'll ignore the question of whether average really makes sense, but there's a bigger problem: there's absolutely no reason to expect this hugely premature baby to have >14% increase of value. Why? This is completely unfounded, completely unjustified. In fact, as a premature baby with massive expensive health problems, wouldn't we expect the opposite? Early childhood trauma seems like it'll matter to their future prospects: https://en.wikipedia.org/wiki/Preterm_birth#Prognosis (As makes sense. If babies could be born months premature with no negative effects, why aren't they being born that way already so they can start growing up quicker?)

> That's still a terrible argument.

It was one of three points made, the last point being the most significant. Our humanity should take priority over negligible costs.

> there's absolutely no reason to expect this hugely premature baby to have >14% increase of value

Without a standard deviation on the average, there is no way to say whether or not 14% is reasonable. Regardless, I was simply pointing out that it's a small fraction rather than orders of magnitude greater. Even if the child winds up providing 50% of the value of an average person, it can still be a net gain.

Economic reasoning is just one (minor) aspect to this situation though. There is very real value in simply helping a fellow human survive.

> as a premature baby with massive expensive health problems, wouldn't we expect the opposite?

The stats you cite are for extreme cases on the edge of viability and the odds still slightly favor normal or near-normal development.

This particular baby was born with a 66% chance of living and deserves more than a quick dismissal.

> If babies could be born months premature with no negative effects, why aren't they being born that way already so they can start growing up quicker?

That's horrible reasoning. The human body has evolved over millions of years for birth. It is the optimal gestation machine. We're working on approximating this optimal machine with artificial machines and continue to rapidly make progress. In the rare situation where the human body fails for some reason, we attempt to augment it with the best artificial machines we've got. Nobody claims that premature births are better, but a hiccup during pregnancy shouldn't mean the end of a life if we can avoid it.

Humanity progresses when a society looks out for each other. In particular, without bias. That starts at birth.

What you're proposing is barbaric and borderline infantcide.

> Without a standard deviation on the average, there is no way to say whether or not 14% is reasonable.

There is no reason to expect the expectation of preemies to be above average, never mind 14%, never mind standard deviations. And there is substantial empirical evidence which I linked you to expect it to be far below average. Rescuing a preemie, even if it were free, would be a bad idea compared to alternatives like simply trying again.

> Even if the child winds up providing 50% of the value of an average person, it can still be a net gain.

And we're right back to your original problem: you are not thinking on the margin. The alternative to spending millions on premature babies is not no babies ever. (And even if it was, there's still superior alternatives: for example, lobbying for Open Borders. Think of all the millions of immigrants who'd love to come to the USA, for free! We wouldn't even have to pay them! Why, even if they're 99% below average, it's still a gain!)

> The stats you cite are for extreme cases on the edge of viability and the odds still slightly favor normal or near-normal development.

Which is what we are discussing, is it not? Or do even slightly premature babies come with million-dollar pricetags...?

> That's horrible reasoning. The human body has evolved over millions of years for birth. It is the optimal gestation machine. We're working on approximating this optimal machine with artificial machines

I'm not seeing any disagreement here. Yes, the human body is the optimal gestation machine. That's why premature babies come with all the penalties. (And note that those citations are just the penalties sufficient to be documented with small samples; there's not much reason to expect the penalty to abruptly cut off somewhere, it's just the long-term effects shrink enough to be hidden by noise and methodological problems and researcher careers' limits.)

> That starts at birth.

An arbitrary line is not a good basis for a system of ethics and governance.

> What you're proposing is barbaric and borderline infantcide.

I'm happy to own to that. It is infanticide. Premature fetuses are not humans in the moral sense: they have no hopes, they have no dreams, they have no desires or preferences, they do not think, and they have the moral status of a puppy or kitten. Given the disabilities they come with, throwing away hundreds of thousands of dollars in heroic medical measures is a crime against society and the person the parents could have raised instead.

That still doesn't maximize overall benefit. What if the money were instead spent on 10 individuals that needed 1/10 the money to save their lives? The cost benefit analysis to determine what medical issues make most sense should try to maximize the number of person-years-lived across the entire population.

The money spend where '1/10 the money' was needed to save their lives is additional money spent, not 'instead money'.

In this particular case, the 'instead money' was pure profits for a company (and some taxes for the government).

Do you really think that the 'instead money' would have been a better choice?

Money is just money and is completely replaceable. Actually, we have machines to make it: it's printable. Actually, we don't even have to physically print the money to 'print the money'... It's a number in a computer file.

Every dollar is the same as every other dollar.

Each and every life, on the other hand, is unique.

Unfortunately, I wasn't clear in my comment above like I was in other comments in this thread. I am specifically referring to a not-for-profit focused healthcare system. If the choice is between profits and the care necessary to help a life, then it boils down to the contractual obligation of the insurer given the level of coverage purchased. In a nationalized healthcare system where costs are spread across all of society and the government has more or less determined the pool of healthcare dollars available by specifying the premium spent per citizen, there most certainly is a cost benefit analysis to consider.

You're assuming that we're at capacity on spending, but we're not. Instead, we can afford to bring 11 individuals into the world. The absolute gain to society is still greater than simply bringing 10 into the world.

Maximizing number of total person years is not sufficient because a population 100x as large but living 1/5 as long would be superior to a population of the current size but living twice as long.

I'd argue in favor of maximizing population size and average lifespan. Of course this ultimately leads to the requirement that humanity moves off of this little rock of ours.

Given X amount of money paid per person as a in premium and Y number of people paying those premiums, we should have XY available to spend on healthcare. That is a hard cap on healthcare spending.

While we can afford to maintain* 11 individuals in the world. There reaches a point where over that entire population, we need to triage the medical issues in that population into the people whose issues maximize human-hours-lived given the X*Y healthcare dollars available to spend treating those issues. Maybe it's not the first person that requires treatment costing a million dollars we need to triage, but you eventually will run out of money if you don't triage because we simply don't pay unlimited premiums to meet the unlimited demand for healthcare.

The issue about overpopulation is a red herring, and in this case isn't just of function of helping people live longer. Many countries once they reach a level of prosperity stop having children at the necessary replacement rate of 2.1 children per couple once that society becomes affluent. The dropping replacement rate often correlates with societies ability to spend more money on helping their population live longer through spending on medical treatment.

I suggest you inform yourself about the gestation process. I used to think the same way, but when we had my daughter I was surprised how early everything happened. First, embryonic age is measured from the date of the last missed period. So even people who find out early are already several weeks along. By six weeks, before many women even realize they are pregnant, the embryo has a heartbeat. By 13 weeks, most of the basic functionality is already there. By 24 weeks, or the time the baby is a pound and and a half, the fetus isn't a glob, but a fully recognizable, if fragile, human. Much of the development after that is external: hair, subcutaneous fat, etc. I don't know what you consider a coherent thought, but at our 24 week ultrasound our baby already responded as we tried to push her into a position to check her gender. I don't think infants who are born full term are more intellectually sophisticated in some fundamental way.

Yes, this has implications for abortion. I support abortion rights, but the "its just a ball of cells" is a rationale that isn't convincing after week 6-9. And lines drawn on intellectual abilities don't justify in a principled way why it isn't okay to abort full term babies. Lines based on viability are susceptible to the progress of medical technology. The typical 24-26 week line we use is fairly arbitrary in all three regards.

As callous as it is, this is the best solution under a not-for-profit health system. The cost-benefit analysis in such a system is not 1 million dollars in shareholder value versus 1 million dollars to save a life, but instead is 1 million dollars to save one life (just the first year to save the child. there most certainly will probably be a lot more money spent over the entire life of the person born under such conditions) versus splitting that million dollars over procedures and medicines to save several lives.

At the end of the day, you need to value all person-years-lived equally, and determine who gets treatment and for what based on what maximizes the number of person-years lived over the entire pool of people.

I have no numbers to back this up, but I would expect the greatest benefit from a fixed amount of healthcare dollars spent will be on people between the ages of 4 and 20.

Once you've figured out roughly the cost per medical issue, frequency per capita of each medical issue, and a distribution graphing that issue against the age at which most people are afflicted and number of years left in their lives given their demographic, you can probably come up with a reasonable algorithm for maximizing person-years-lived at a certain health premium per person per year (assuming all dollars go back into the system).

Then the only remaining question that is left for society and individuals to answer is what level of premium will be paid and the medical issues that will be covered at that premium.

Furthermore, I think it would be interesting if we gave people in medical situations the following choice:

"The procedures necessary to save this person's life are estimated to cost 1 million dollars. You can choose to save this person's life, or you can choose to donate $800 thousands dollars to save X number of lives by donating it to procedures that maximize the number of lives saved."

People choosing to exercise their right to spend healthcare dollars on a lifesaving procedure for one individual are the ones that should have to face that philosophical and ethical dilemma of deciding to value one life over many.

If I were running a healthcare system, I would make it policy that everyone put in such a position would have to knowingly have to make that hard decision. It's the only sane way that would put the burden of callousness on the people with the right to to those health services. Just because you have the right to those services, doesn't mean you should exercise them in a not-for-profit healthcare system.

If we think microeconomics for a moment: healthcare for distressed infants could be a textbook example of inelastic demand. Q: How much are you willing to pay to save the life of this child? A: ALL THE MONEY! AND MORE!!

People are a little more willing to spend someone else's money on less-than-worthwhile pursuits than they are to spend their own. As long as the customers aren't bearing the cost, everything they buy will have a similarly inelastic demand. Healthcare for distressed infants is certainly not an example of inelastic demand where people have to pay for it themselves; even food for healthy infants (a much smaller, and much more cost-effective, expense) doesn't show inelastic demand.

> Healthcare for distressed infants is certainly not an example of inelastic demand where people have to pay for it themselves

Are you kidding me? If it was a question of saving my child's life, I'd spend every last cent I had and then go sell a kidney.

I gave you an example. Mothers uncertain of their ability to raise an infant will abandon it to die (this is traditionally called "exposure"). It's a practice at least as old as humanity. And it conclusively demonstrates that the demand for infant care is not inelastic; these mothers aren't killing themselves trying to preserve their nonviable children. Rather, they're killing the children so that they don't die themselves in the effort to save a doomed child.

"So that they don't die themselves" != "because they are unable to raise an infant"

If you take this view:

> If it was a question of saving my child's life, I'd spend every last cent I had and then go sell a kidney.

there is no distinction between being unable to raise a child, and being unable to survive the attempt. If you survive, the child will get raised. The only way to fail is by dying (or killing the child).

I think your example conclusively demonstrates that people in radically different economic and cultural circumstances have different attitudes towards their children. This is a completely fair conclusion, but has very little bearing when reasoning about health care for infants in modern neonatal ICUs, especially infants with rich technologist parents.

At some point you'd run out of organs to sell, and the child still might die, sad as that may be. :/

I don't really understand how anyone can lump a real child with whom you have years of shared experiences, who you've loved and taught and who has a personality of its own in with a lump of cells that's yet to have a coherent thought.

I'm assuming you'd be annoyed if you had a hand or foot amputated?

And they're just lumps of cells that have never had a coherent thought.

Did you really think my argument was that anything that is a lump of cells that has never had a coherent thought has no value?

I can understand a sense of loss in losing an infant at birth. You make plans for the child and are excited to meet the person they will become. It's a miscarriage. A similar loss is learning that your spouse can't get pregnant in the first place. It's not the same as losing a child of 3, 6, 12 or 24.

Just correction a misconception here. The human brain "boots" on the 18th day after conception (you can set your watch to it). It is obvious on echo pictures that coherent thoughts are present on the 21st day after conception (e.g. if awake, most kids are aware that they're being pictured and attempt to find and play with the source of the sound, I think that qualifies as coherent thought).

It is quite obvious on the 23rd day that fetuses are swimming around and exploring their environment purposefully. They are at least as alive and coherent at that time.

The reason for this is that your DNA does not contain a plan for a human being. It contains a plan for a bilobite (an very old and presumed extinct form of life), and a way to transform a bilobite into a trilobite, a trilobite into something that resembles a fish, that fish into something very similar to a frog larva, and so on and so forth until you get a human. Other species have the same evolution in the womb/egg, except it diverges at some point.

The fish has a working brain (and it is unknown whether the trilobite does, it grows active neurons), generally referred to as a neural tube. That brain is working during the whole gestation period.

Thanks, that's very interesting. Whether it's a fish brain or frog larva brain or something more, though, my point is that it's not yet intrinsically worth protecting as human life. Its worth is all potential. Consider: how much would would this life be worth if brain development stopped at this point? For a newborn or earlier, the answer is not much.

I am strongly "pro choice" - i would allow abortion on demand upto 21 weeks and after that with medical need. I think the way we deal with children who have very poor quality of life and very little chance of living beyond a few months after being born is really poor.

None of this is incompatible with saying that the "clump of cells" is precious and worth preserving, and that parents should have support before, during, and after pregnancy to help this child.

That's reasonable. Again, my original comment was comparing the "clump of cells" to an older child.

>It is quite obvious on the 23rd day that fetuses are swimming around and exploring their environment purposefully. They are at least as alive and coherent at that time

Um well it isn't a fetus at 23 days its an embryo...

This is not true:

http://evolution.berkeley.edu/evolibrary/article/history_15

> You make plans for the child and are excited to meet the person they will become. It's a miscarriage.

You often interact with children in utero before they are born. Also, at about 4 - 5 months (it'll vary from jurisdiction to jurisdiction) a miscarriage becomes a stillbirth and requires a birth and death certificate.

And while I have not lost a child at 3/6/12/24, I have lost a child at 6 months into a pregnancy, and it was quite probably the worst experience of my life - worse than my experiences during this: http://en.wikipedia.org/wiki/2011_Christchurch_earthquake - and I was trying to dig crushed people out from underneath rubble.

Births are (these days anyway), normally a joyous event wherein a new life comes into the world. A stillbirth is the polar opposite - especially if the baby died sometime before the birth was induced.

>Healthcare for distressed infants is certainly not an example of inelastic demand where people have to pay for it themselves

I take it you don't have a child?

My father in law is a neonatologist and was given an ownership stake of the NICU he started in a midwestern hospital.

He makes around $4 mil/year.

Granted, he does sometimes stay at the hospital for two weeks at a time with only very brief visits home but at this point he also owns apartment complexes, office buildings, a gentleman's ranch with a few dozen horses and staff and on and on.

I think it is shameful, personally, that he profits so much. He works hard and he saves lives, it's true, but how much is enough?

Speaking as someone who is also familialy-related to a neonatologist and a cardiologist -- both of whom earn more than a few million per year, I'd say they deserve every last dollar of it. They had to go to school for some while, and work under very tiring schedules. Hell, their schedules are still to this day pretty sucky -- they often tell me how much they envy me for my startup I'll-do-whatever-I-want-whenever-I-want lifestyle.

I think they both earn somewhere between 2 to 5 mil/year, but they spend it extravagantly and handsomely -- that's a very good thing. They're spending it on boats, cars, houses, nannies, restaurants, vacations, etc. etc. They're keeping the money going, they're spreading it out. They save lives, get money, and then help the economy by spending this money.

Now, what IS shameful is what the salaries of these social-app CEOs are. Why is Zuck worth some 20 BILLION? He's just going to sit on it, unlike my uncles he's not going to spend the majority of it. Zuck isn't helping the economy, Uber isn't helping the economy (it's externalizing costs, privatizing profits -- if they didn't exist that'd be a good thing). What is shameful is the profiting from rent-seeking, from making a killing on capital gains, etc. etc. Getting a few million per year isn't that bad, because believe it or not, in the large scheme of things that's little money -- most importantly, it's money that one can realistically spend from year to year. Spending a billion -- that's a challenge.

It's a good thing for them and the people selling them things but it is not so great for everyone else struggling to pay for decent insurance.

I am sure those people would be happy to spend that money and keep it flowing as well.

You're worrying about the wrong things. The problem here is not the pay of heart surgeons and neonatologists, the problem is with insurance companies, our healthcare system, etc. etc. Focus directly on fixing those issues, large salaries for surgeons is only a red herring.

But large incomes for people like Zuck is a problem. That makes no sense to me.

Why is Zuck worth $28.8 billion? Private property rights and a tremendous success. How do you know he's just going to sit on it? You don't, which null and voids your entire premise.

Spreading money out, ie redistribution of previously existing funds through service based consumption industries, is a very mediocre example of "keeping the economy going." Production is what bolsters an economy, not consumption. The faltering US economy has been demonstrating how that works in practice for decades, while China's production-centric economy demonstrated the exact opposite (and the same principle that the US economy was originally built on: production creates wealth, consumption destroys wealth, which is easy to deduce logically).

And sitting on wealth is a tremendously benevolent thing: it removes that purchasing power from circulation, boosting the net purchasing power of every other person holding, for example, dollars. If Zuck puts his $28.8 billion in a bank account, it does two wonderful things for the economy: it becomes available to be lent out by the bank in question, to help fund businesses or similar, and it temporarily removes $28.8 billion worth of dollars from the economy, increasing what other people's dollars can buy.

I think it is shameful, personally, that he profits so much.

Profits from saving human lives. Can a price be really put on a human life? Sure you can cite economics and a number like $7MM or whatever, but would you, personally, decide against paying that amount (assuming you had the money) to save your or your loved one's life, push come to shove?

And of course, it is always about resource availability, in this case the resource being money.

He works hard and he saves lives, it's true, but how much is enough?

Demand and supply. He works at a level of specialization that is a cluster of "black swan" events. Hence also, his crazy hours and most importantly, responsibilities. Do you have experience working at a position that is a nexus of similar conditions? Have you ever felt responsible for the life of not one but multiple human beings? And have that responsibility extend over your entire career, each day, every day? Now tell me, how much money would be enough to do work like that and keep doing it well?

Note: I am specifically focusing on money, because that is the question that was raised. Let's not divert the conversation into job satisfaction or humanity and all that, in this particular discussion.

>Can a price be really put on a human life?

This is the crux of the problem. You can't really.

The interesting thing is that his brother is a physician with very similar training in the UK (they both went to Trinity in Dublin). Does he get $4 million a year? Not by a long shot. Is he hurting for money? No. He has a large house and equally large family, travels all over the world and in general has a wonderful life. Granted he's never bought a yacht on a whim 6 states away, neglected the insurance and have it sink in a hurricane before he ever got it out of the marina (true story) but he is not hurting. Is he any less responsible or hardworking than his brother? Were any fewer lives saved under his care?

You can't measure these things in terms of widgets and currency.

To do so is mere rationalization as if the current state of affairs isan economic inevitability. It clearly is not.

All else being equal, would the brother turn down the money if he were given it? Would he turn it down merely and strictly due to the number of zeroes tacked after the first six digits? How would anyone in his position make a decision either way? All questions worth thinking about. And IMHO, intricately woven of human nature and our immediate economies. I fail to see the foundation of a moral dilemma, leave alone outrage, in all this. But then again, I plead that I am merely following my own moral compass!

>Would he turn it down merely and strictly due to the number of zeroes tacked after the first six digits?

Of course not. And I don't blame my father in law for taking the money either. Why wouldn't he?

I understand your confusion. I was not clear.

I don't think it is personally shameful for my father in law to accept the money. I think it is shameful that we, as a society, have allowed a system to function where he is offered that kind of money. You can cite 'market forces' as the reason that state of affairs exist but the truth is that the market doesn't exist in a vacuum. It is shaped by regulations, standards and bureaucracy put in place by intention or by accident by human beings. No place is that more true than healthcare.

Whether it is doctors that own a hospital or surgical center that, on paper, operate at razor thin margins while paying their principal shareholders, who happen to be employees, exorbitant amounts of money or urine testing companies charging thousands of dollars for a single drug screening while giving kickbacks to doctors in the form of leasing office space in their clinics for far more than market rates for their representatives, or medical supply companies that charge more for refilling oxygen tanks than the tanks themselves cost new and filled then we have some inefficiencies that could use the light of day below the surface.

None of these things are crippling in and of themselves. All of them together are creating a crisis that affects almost every person in the United States.

"... except that this is a major profit center for hospitals, and they use the money to cover other, money losing, departments ..."

I think you, like many people, misunderstand the reimbursement regime as it works in American hospitals currently. A patient in an ICU will typically have a DRG associated with him/her. This DRG relates to the acuity, and these in turn, impact the reimbursement level. This is because the complexity of care, as indicated by the acuity level, implies higher resource utilization. For instance, the patient-nurse ratio in a typical hospital room is somewhere right around 4:1. In ICUs this ratio is, more often, 1:1. The ICU also needs an array of techs for a patient... highly specialized techs capable of analyzing and acting on information coming off of the monitor that the tech is responsible for.

So hospitals are not saying, "Hey... we have these people here who we can get a lot of money out of!" The system, as it currently stands, is "volume based", so money comes in for ICU care regardless of what the hospital wants. One of the issues with being volume based in this fashion, is that money does NOT come in for things like data analytics, nutrition departments and occupational therapy for instance. Now here's the rub... how do you offer comprehensive ICU care without due consideration of nutrition? Without the ability and expertise to analyze the data coming off of what could very well be an extensive array of monitoring equipment?

It actually goes further than that... Most hospitals MUST have a clinical equipment department for which they are not reimbursed at all. Of course, the creation of an ICU withOUT a clinical equipment department is out of the question.

So while there do exist cross subsidies in any given hospital, it misses the mark to view the departments on the receiving end of the subsidies as "money losing". This sort of thinking has led the industry to all of the issues we see presently. A good example is the poor reimbursement of primary care... and so primary care becomes "money losing" when viewed in that manner. Instead, I think these departments would better be viewed in the fashion that they are viewed in the "value based" reimbursement regime that the industry is currently transitioning to.

Not only will care delivery facilities be in a better position to provide care to families like your own and others, but the quality of care will increase across that enterprise. Your family was given high quality care because the hospital took money from a "volume based" reimbursement system, and distributed those monies based on the judgement of what were probably some very clever "value based" administrators. I can pretty much guarantee you that they did not view Clinical Equipment, Data Analytics or Nutrition as "money losing" departments.

One of the things that has been missing in the discussion about the health care system is the education of the typical citizen about the tradeoffs and compromises that, for example, hospitals are making internally to deliver the quality of care that they do. I think if the citizenry had a more full understanding of the nuances of things like the reimbursement system, we could have a more productive debate on the issue of healthcare.

I didn't mean it as a judgement. It's just the reality that some procedures and areas of the hospital reimburse at much higher rates than others, and it's often unrelated to actual expenses. This isn't random speculation on my part -- I've spoken to hospital administrators as well as entrepreneurs working on fixing it.

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