Tuesday, November 10, 2009

Health reform and the Ordinal Fallacy--Why delaying health reform is a bad idea

The Conduct of Inquiry by Abraham Kaplan is one of the books that had the greatest influence on my thinking about life, politics, leadership and human behavior. Among the others are Human Competence by Thomas F. Gilbert, Management: Task, Responsibilities, Practices by Peter F. Drucker, and Leadership by James MacGregor Burns. Kaplan’s place on this list is due to his discussion of something he calls the “ordinal fallacy” which is highly relevant to our current discussion of health reform.

In his book, Kaplan discusses a debate between scientists over the proper role of behavioral science in shaping public policy. Some argued at the time (this was 1964) that science should be divorced from policy because behavioral scientists “never know enough, or with enough certitude, to proved a scientifically valid basis for adopting one policy rather than another.” Kaplan admits that this is true. He writes, “what we actually know with confidence about human behavior is pitifully little compared with the magnitude and complexity of the problems confronting us…more research will always be needed, at least research into the particularities of specific concrete situations.” On the other hand, says Kaplan, those who would argue that science has no role in shaping public policy because of this lack of certainty are mistaken.

“It is not required that we know everything, but only that we know something relevant. A scientific approach does not suddenly come into being at the magical moment when we know ‘enough’; such moments never arrive. To await them constitutes what I have called the ‘ordinal fallacy’: first this, then that—first I will achieve power, then use if for the public good; first I will master my medium, then use it to say something significant; first I will pursue wealth, then use it in the pursuit of happiness. And as in politics, art, and morality, so here—first I will acquire the knowledge, then use it as a basis for sound policy. But whether it be due to human failing or to the human condition, we must do as we aspire from the beginning, or else resign ourselves to not doing at all…We are playing lightning chess—with this difference, that if we stop to analyze all the variations the move will be made for us, and with supreme indifference to its outcome.”

In the current debate over health reform, there are those who say “wait.” They argue that the Democrats and the Obama administration are moving too fast, that we should take more time and “get it right.” We should do nothing or very little now in the hope that next month, next year or next decade we will find the perfect answer and be able to draft the perfect health policy. However, to wait is to commit the ordinal fallacy since we will never know the perfect way to reform health care in this country. We can never be certain that any particular policy we adopt will fix the health care problem. What we can know with certainty is that health care will be reformed. Doing nothing doesn’t mean that nothing about our health delivery system or access to care will change. It will. We can use the incomplete knowledge we have and intervene now to reform America's health care system and hopefully direct it along a better path or we can commit the ordinal fallacy and thereby allow forces with a supreme indifference to our welfare control our destiny. It’s our choice.

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