Download and Read online, DOWNLOAD EBOOK, [PDF EBOOK EPUB ], Ebooks

download, Read Ebook EPUB/KINDE, Download Book Format PDF

Prioritization in Medicine: An International

Dialogue 1st Edition Eckhard Nagel

OR CLICK LINK
https://textbookfull.com/product/prioritization-
in-medicine-an-international-dialogue-1st-edition-
eckhard-nagel/

Read with Our Free App Audiobook Free Format PFD EBook, Ebooks dowload PDF
with Andible trial, Real book, online, KINDLE , Download[PDF] and Read and Read
Read book Format PDF Ebook, Dowload online, Read book Format PDF Ebook,
[PDF] and Real ONLINE Dowload [PDF] and Real ONLINE
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Prioritization Theory and Defensive Foreign Policy :

Systemic Vulnerabilities in International Politics 1st
Edition Hanna Samir Kassab (Auth.)

https://textbookfull.com/product/prioritization-theory-and-
defensive-foreign-policy-systemic-vulnerabilities-in-
international-politics-1st-edition-hanna-samir-kassab-auth/

Econophysics and financial economics : an emerging

dialogue 1st Edition Jovanovic

https://textbookfull.com/product/econophysics-and-financial-
economics-an-emerging-dialogue-1st-edition-jovanovic/

Hydrochemistry basic concepts and exercises 1st Edition

Eckhard Worch

https://textbookfull.com/product/hydrochemistry-basic-concepts-
and-exercises-1st-edition-eckhard-worch/

Contextual Schema Therapy An Integrative Approach to

Personality Disorders Emotional Dysregulation and
Interpersonal Functioning 1st Edition Eckhard Roediger

https://textbookfull.com/product/contextual-schema-therapy-an-
integrative-approach-to-personality-disorders-emotional-
dysregulation-and-interpersonal-functioning-1st-edition-eckhard-
Analytic Philosophy and Human Life 1st Edition Thomas
Nagel

https://textbookfull.com/product/analytic-philosophy-and-human-
life-1st-edition-thomas-nagel/

Dialogue Writing for Dubbing: An Insider's Perspective

Giselle Spiteri Miggiani

https://textbookfull.com/product/dialogue-writing-for-dubbing-an-
insiders-perspective-giselle-spiteri-miggiani/

Cannabis in Medicine An Evidence Based Approach Kenneth

Finn

https://textbookfull.com/product/cannabis-in-medicine-an-
evidence-based-approach-kenneth-finn/

9th International Workshop on Spoken Dialogue System

Technology Luis Fernando D'Haro

https://textbookfull.com/product/9th-international-workshop-on-
spoken-dialogue-system-technology-luis-fernando-dharo/

Nonsense mutation correction in human diseases an

approach for targeted medicine 1st Edition Benhabiles

https://textbookfull.com/product/nonsense-mutation-correction-in-
human-diseases-an-approach-for-targeted-medicine-1st-edition-
benhabiles/
Prioritization
in Medicine

An International Dialogue

Eckhard Nagel
Michael Lauerer
Editors

123
Prioritization in Medicine
Eckhard Nagel • Michael Lauerer
Editors

Prioritization in Medicine
An International Dialogue
Editors
Eckhard Nagel Michael Lauerer
Institute for Healthcare Management Institute for Healthcare Management
and Health Sciences and Health Sciences
University of Bayreuth University of Bayreuth
Bayreuth Bayreuth
Germany Germany

In Cooperation with
Valentin Schätzlein
Institute for Healthcare Management
and Health Sciences
University of Bayreuth
Bayreuth
Germany

ISBN 978-3-319-21111-4 ISBN 978-3-319-21112-1 (eBook)

DOI 10.1007/978-3-319-21112-1

Library of Congress Control Number: 2015952827

Springer Cham Heidelberg New York Dordrecht London

© Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business Media

(www.springer.com)
Preface

This contributed volume goes back to the interdisciplinary research group FOR 655
“Setting Priorities in Medicine: A Theoretical and Empirical Analysis within the
Context of the German Statutory Health Insurance.” Two volumes associated with
this research group have been published in German language earlier. Edited by
Wohlgemuth/Freitag (2009), the first volume focused on the presentation of objec-
tives and methods of the research group’s subprojects. The second volume, edited
by Schmitz-Luhn/Bohmeier (2013), discussed particularly relevant and controver-
sially assessed prioritization criteria. This volume addresses normative dimensions
of methodological and theoretical approaches, international experiences concerning
the normative framework and the process of priority setting as well as the legal basis
behind priorities. It also examines specific criteria for prioritization and discusses
economic evaluation.
The contributing authors are in parts members of FOR 655 and other scientists
from various academic disciplines and different parts of the world. Some of them
came together at an international conference in Bayreuth, Germany, in November
2013 were the idea for this book originated. Editors invited further colleagues to
contribute, aiming to encourage a comprehensive discussion about different
approaches and methods within this volume and beyond.
Prioritization is necessary and inevitable – not only for reasons of resource scar-
city, which might become worse in the next few years. But especially in view of an
optimization of the supply structures, prioritization is an essential issue that will
contribute to the capability and stability of healthcare systems. Therefore, our vol-
ume may give useful impulses to face challenges of appropriate prioritization.
We acknowledge the excellent cooperation and fruitful exchange with contributing
authors who made this book possible. We would also like to thank members of FOR
655 who encouraged us to realize this book project. Special acknowledgment is made
to the German Research Foundation (DFG) which financed the work of FOR 655 as
the first large-scale project on prioritization in healthcare between 2007 and 2015.
Finally, we are especially grateful to Valentin Schätzlein for his editorial assis-
tance, expert consulting, and for managing all issues along the way to this volume.

Bayreuth, Germany Eckhard Nagel

October 2015 Michael Lauerer

v
Contents

Introduction to an International Dialogue on Prioritization

in Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Michael Lauerer, Valentin Schätzlein, and Eckhard Nagel

Part I Evaluation and Decisions in Modern Healthcare

Fundamental Evaluation Criteria in the Medicine

of the Twenty-First Century. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
James R. Cochrane

Hellish Decisions in Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

J.A. Muir Gray

Part II Normative Dimensions of Methodological

and Theoretical Approaches

Accountability for Reasonableness and Priority Setting in Health . . . . . 47

Norman Daniels

Social Value Maximization and the Multiple Goals Assumption:

Is Priority Setting a Maximizing Task at All? . . . . . . . . . . . . . . . . . . . . . . 57
Weyma Lübbe

The Trade-Off Metaphor in Priority Setting: A Comment

on Lübbe and Daniels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Andrea Klonschinski

Part III International Experiences: Normative Basis and Process

of Priority Setting

Prioritisation: (At Least) Two Normative Cultures . . . . . . . . . . . . . . . . . . 85

Heiner Raspe

vii
viii Contents

Health-Care Priority Setting in Practice: Seven Unresolved

Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Gustav Tinghög

Recent Developments on the Issue of Health-Care Priority

Setting in Norway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Frode Lindemark

Part IV Legal Basis of Setting Priorities

Prioritization in Health Care: Normative Perspective . . . . . . . . . . . . . . . 117
Gerhard Dannecker

Rebalancing the Rationing Debate: Tackling the Tensions

Between Individual and Community Rights . . . . . . . . . . . . . . . . . . . . . . . 123
Christopher Newdick

The Law Behind Priorities: Implementation of Priority Setting

in Health Care – The German Example . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Bjoern Schmitz-Luhn and Christian Katzenmeier

Part V The Role of Age and Personal Responsibility

Priority Setting and Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Greg Bognar

Fair Innings as a Basis for Prioritization: An Empirical

Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Sarah M. Watters

Just Caring: Fair Innings and Priority Setting . . . . . . . . . . . . . . . . . . . . . 197

Leonard M. Fleck

Personal Responsibility as a Criterion for Prioritization

in Resource Allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Harald Schmidt

Age and Personal Responsibility as Prioritization Criteria?

The View of the Public and of Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Adele Diederich
Contents ix

Part VI Economic Evaluation

Using Economic Evaluation in Priority Setting: What Do We
Know and What Can We Do? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Iestyn Williams and Stirling Bryan

Let’s Talk About Health Economic Evaluation: Relevant

Contextual Factors for the German “Sonderweg” . . . . . . . . . . . . . . . . . . 273
Lars Schwettmann
Introduction to an International
Dialogue on Prioritization in Medicine

Michael Lauerer, Valentin Schätzlein, and Eckhard Nagel

Molière did not have prioritization in mind when he expressed his focal thoughts
about responsibility: “It is not only for what we do that we are held responsible, but
also for what we do not do.” However, being aware that health is one of the most
essential goods and that resources in health care systems are limited clearly shows
us that Molière’s aphorism is of major importance for allocation decisions in health
care. This applies to the decision whether or not to set priorities explicitly as well as
to the process and consequences of priority setting.
Prioritization in medicine can contribute to face the urgent challenges that arise
from scarcity in health care worldwide. The present volume offers an international
dialogue on prioritization in medicine initiated by the German research group FOR
655.1 May it be helpful to meet the responsibility for what we do and for what we
do not do.

1
FOR 655 “Setting Priorities in Medicine” was the first research project financed by the
German Research Foundation (DFG) concerned with prioritization in medicine (2007–2015).
Nationwide 14 universities and research institutions participated in 10 working groups:
Theoretical projects focused on legal, philosophical, and economic aspects, frameworks, and
implications relating to the process of setting priorities in the statutory health insurance.
Empirical projects analyzed stakeholder preferences concerning prioritization in medicine.
(For more details, see http://www.priorisierung-in-der-medizin.de)
M. Lauerer (*) • V. Schätzlein (*) • E. Nagel (*)
Institute for Healthcare Management and Health Sciences, University of Bayreuth,
Prieserstraße 2, Bayreuth D-95444, Germany
e-mail: [email protected]; [email protected];
[email protected]

© Springer International Publishing Switzerland 2016 1

E. Nagel, M. Lauerer (eds.), Prioritization in Medicine: An International
Dialogue, DOI 10.1007/978-3-319-21112-1_1
2 M. Lauerer et al.

1 Prioritization in Medicine

Topics such as “Priority Setting in Medicine” and “Rationing in Health Care” are
widely used in the discussion about allocating scarce resources. Thereby, priority
setting and rationing are sometimes used interchangeably. But they can at least indi-
cate different stages in the process of resource allocation (Williams et al. 2012,
p. 6). While rationing regularly refers to actual withholding of health services, pri-
ority setting describes a systematic approach to figure out what is more and what is
less important in health care. It leads to a ranking order and prepares decisions
(Meyer and Raspe 2012, p. 73). Prioritizing can be understood as a prerequisite of
rationing (Raspe 2001, p. 32).
Priority setting does not necessarily have to refer to scarce resources. It can also
be used for quality assurance, for example (Meyer and Raspe 2012, p. 73). But
whether or not explicit priority setting in medicine is desirable or even inevitable
has been discussed particularly in the light of scarce resources.
Basically, limited resources lead to a competition between publicly funded health
care and other sectors, as well as among different health needs and claims within
health care (see chapter “Accountability for Reasonableness and Priority Setting in
Health”). Demand or claims on resources always exceed available resources and
therefore the meaningfulness of priorities appears regardless of whether resources are
available in very large or very small quantities (Mitton and Donaldson 2004, p. 4). It
appears regardless of whether available resources increase, decrease, or remain con-
stant (Williams et al. 2012, p. 6). Nevertheless, setting priorities seems to be the more
important, the scarcer resources are. Unanimously a growing demand, particularly in
consequence of demographic and epidemiological transition as well as medical pro-
gressions, is held responsible for an aggravation of scarcity. Accordingly, allocation
decisions are gaining in importance.
Certainly explicit priority setting is not the only option responding to limited
resources in health care. But each alternative (such as increasing efficiency or the
overall amount spent for health care, rationing by delay, rationing implicitly) goes
along with problems in principle, respectively, practice, and is not sufficiently nar-
rowing the gap that occurs between demand and supply (Williams et al. 2012,
p. 8–12). In particular there is a wide consensus that an explicit approach for fram-
ing health care is preferable over implicit rationing when tight budgets force clini-
cians to make allocation decisions in their day-to-day workload. If doctors must
offer inferior medical interventions without society taking responsibility for this
circumstance and without taking care that allocation criteria are established and
accepted, this overtaxes clinicians, possibly leads to unfair distribution patterns and
jeopardizes the physician-patient relationship (German Ethics Council 2011, p. 30).
Explicit priorities are considered to avoid these negative consequences of implicit
rationing as it happens in clinical practice.
Explicit priority setting helps to allocate scare resources fairly and transparently.
Since health care systems around the globe are faced with challenges along with
setting priorities, it is obviously reasonable to discuss prioritization in an interna-
tional dialogue.
Introduction to an International Dialogue on Prioritization in Medicine 3

2 An International Dialogue

Across nations setting priorities is an important and essential part of the debate on
managing resource scarcity in health care. Thereby, countries diverge in regard to
their experiences with discussing and implementing systematic prioritization. While
some European countries already have a long history of priority setting (e.g.,
Norway), the discussion is still in its infancy in other countries (e.g., Germany).
Additionally, those countries that have already implemented systematic priority set-
ting are following fundamentally different approaches (see chapter “Prioritisation:
(At Least) Two Normative Cultures”).
Experiences that have been made with prioritization in several countries can con-
tribute to a mutual learning process by revealing success and failure. Therefore, this
book project aims to stimulate an international dialogue on prioritization.
Contributors bring together experiences from arround the globe. They present a
broad range of professional perspectives and scientific disciplines (such as religious
studies, philosophy, medicine, (health) economics, law, psychology).
This international and interdisciplinary concept enables readers to get a compre-
hensive and balanced insight into the complex issue of setting priorities in medicine.
Hence, the structure of this volume reflects essential topics and challenges along the
way to priorities.

3 Structure of This Volume

This volume encloses six parts which, in turn, consist of two to five chapters.
Numerous cross-references indicate that a topic is discussed in greater detail in
another chapter. Some chapters introduce or comment on other contributions within
this volume.
Part I, Evaluation and Decisions in Modern Healthcare, addresses elemental
aspects of evaluation in medicine and (prioritization) decisions in health care: In
Chap. 2, Jim Cochrane reflects prioritization in a larger environment of Fundamental
Evaluation Criteria in the Medicine of the Twenty-First Century. Rather than offer-
ing an in-depth discussion of legal frameworks, medical choices, or financial chal-
lenges, he discusses the setting within these topics must be placed. Assuming that
the distinction between “vertical prioritization” and “horizontal prioritization” is
incomplete, he suggests a third category “system prioritization” described by a
dynamic adaptive system. To contextualize this general framework, Cochrane com-
ments on themes that he characterizes as central to questions of prioritization: the
bounds of science and the limits of rational choice theory. In Chap. 3, Sir Muir Gray
discusses resource allocation as Hellish Decisions in Healthcare. He initially pro-
vides an overview of changing paradigms in health care from 2nd World War until
the recent Global Finance Collapse. Subsequently, he characterizes (evidence for)
significant variations in access, quality, outcome, and investment that led to a his-
torical drift, respectively, an attempt to make resource allocation more explicit in
NHS. In this context, Sir Gray critically examines utilitarianism as influential
4 M. Lauerer et al.

principle of British thinking and deduces the need that decision makers are account-
able for reasonable resource allocation. Finally, he introduces program budgeting as
a basis for priority setting in health care.
Part II, Normative Dimensions of Methodological and Theoretical Approaches,
focuses on the concept of Accountability of Reasonableness and the critique of
priority setting as a maximization task. Its coherence is enhanced by a comment on
both issues. Norman Daniels brings together Accountability for Reasonableness
and Priority Setting in Health in Chap. 4, He suggests the concept of “Accountability
for Reasonableness” as an appeal to a type of procedural justice that can improve
the legitimacy as well as fairness of priority setting, particularly in the environment
of a far-reaching ethical disagreement about allocation decisions. Therefore, Daniels
proposes conditions that should be met at various levels where priority setting pro-
ceeds. His contribution considers the implications of the suggested concept for
health technology assessment and for efficiency frontiers (German alternative for
cost-effectiveness analysis). Finally, he assesses the feasibility of “Accountability
for Reasonableness.” In Chap. 5, Weyma Lübbe discusses the Social Value
Maximization and the Multiple Goals Assumption. She considers the focal question:
Is Priority Setting a Maximizing Task at All? To answer this question, the contribu-
tion first addresses the multiple goals assumption: It is frequently assumed that
decision makers pursue the target of fair allocation beside health maximization.
Combining both goals is understood to involve a trade-off. It is often argued that its
quantitative form should be grounded on data collected in social preference studies.
Accordingly, the modification of the health maximizing approach is thought to
involve an alteration in the direction of social value maximization. Lübbe suggests
that an appropriate conceptualization of fair allocation includes a break that goes
beyond breaking with health maximization. This break refers to the notion of maxi-
mizing any value(s) in any way. This means to break with the tie that connects
preference and value. Then, integrating fairness would be beyond the paradigm.
Lübbe exemplifies this by discussing the concept of equity weights for QALYs. In
Chap. 6, Andrea Klonschinski addresses The Trade-Off Metaphor in Priority Setting
and thereby provides A Comment on Lübbe and Daniels (chapters above). Her con-
tribution aims to help the reader to evaluate the arguments presented by Daniels and
Lübbe. It strives to strengthen and complement Lübbe’s critique of the multiple
goals assumption and to connect her considerations with Daniels’ account. It shows
that Lübbes’ objections pertain to Daniels’ contribution. Above, the contribution
itself provides important input to the debate on priority setting. Klonschinski pleads
to pay more attention to conceptual issues in the course of discussing priority
setting.
Part III, International Experiences: Normative Basis and Process of Priority
Setting, provides an international perspective on prioritization. Thereby, authors
take into consideration both the normative basis and the practice of priority setting.
Heiner Raspe analyzes in Chap. 7, Prioritisation – (At Least) Two Normative
Cultures, different models of prioritization and their normative basis: Models from
Oregon and England serve as examples for the Anglophone type. Norway and
Sweden illustrate the Scandinavian approach. Based on this, he contrasts “clinical
Introduction to an International Dialogue on Prioritization in Medicine 5

solidarity” with “social solidarity.” Furthermore, Raspe provides remarks on work-

ing with the Swedish national model particularly in the German debate on prioriti-
zation in medicine. In Chap. 8, Gustav Tinghög discusses Seven Unresolved
Problems of Healthcare Priority Setting in Practice. Additionally to the contribu-
tion of Raspe, this chapter outlines four lessons learned from Oregon and three les-
sons learned from Sweden. These experiences of explicit priority setting in practice
exemplify approaches that have emphasized two contrasting perspectives on dis-
tributive fairness from the start: maximizing health benefit, on the one hand, and
giving priority to the greatest need, on the other hand. Frode Lindemark analyzes
Recent Developments on the Issue of Health-Care Priority Setting in Norway in
Chap. 9. Particularly he refers to work of the third committee on health priorities
that delivered its report “Open and fair –priorities in the health service” to the
Ministry of Health and Care Services in November 2014. This committee suggests
that the aim of priority setting could be to strive for the “greatest number of healthy
life years for all, fairly distributed”. Lindemark gives an overview of present devel-
opments and discussions against the background of prioritization in Norway.
Part IV, Legal Basis of Setting Priorities, highlights aspects of legal regulation
with a focus on Germany and UK. Gerhard Dannecker outlines Prioritization in
Health Care from a Normative Perspective in Chap. 10. His contribution is an intro-
duction to the chapters in the following. With a focus on Germany, it emphasizes the
importance of ethical and legal principles, the meaning of the (constitutional)
admissibility of prioritization and prioritization criteria, and the necessity to con-
sider the interdependence between different areas of law. In Chap. 11, Rebalancing
the Rationing Debate – Tackling the Tensions between Individual and Community
Rights, Christopher Newdick attends to the tension that occurs when choices that
favor needs of individuals disfavor needs of communities: He discusses limitations
of the individual perspective and the necessity of clearer population-based targets.
His contribution alleges examples from the English NHS, though the questions it
reflects are global in scope. In Chap. 12, Bjoern Schmitz-Luhn and Christian
Katzenmeier discuss The Law Behind Priorities with a focus on the Implementation
of Priority Setting in Health Care using The German Example. They emphasize that
prioritization cannot forgo instruments of implementation: Transforming allocation
concepts into practice requires mechanisms for the steering and governance of pri-
oritization principles. Changing the ways of allocation can diversely impact health
systems and their legal framework. The underlying regulatory frame may even be a
barrier toward the application of prioritizing schemes or raise questions of permis-
sibility and impact on present regulatory equilibria. Schmitz-Luhn and Katzenmeier
show some of the challenges to introduce a scheme of prioritization in Germany.
Part V, The Role of Age and Personal Responsibility, provides a discussion on
two controversial criteria for prioritization. Both, theoretical and empirical analyses
contribute to this discussion. Greg Bognar focuses on Priority Setting and Age in
Chap. 13. He stresses the importance of elucidating the role that age can play in
resource allocation since age considerations permeate health systems worldwide.
Therefore, Bognar presents a broad outline of notions that defend the relevance of
age. Furthermore, he reflects on the recent Norwegian discussion about the role of
6 M. Lauerer et al.

age in priority setting. In Chap. 14, Sarah M. Watters analyzes Fair Innings as a
Basis for Prioritization from An Empirical Perspective. She differentiates two ver-
sions of the fair innings argument that advocates for age-based prioritization. Her
review of empirical evidence indicates that the acceptance of intergenerational
equity due to the fair innings principle is mixed and support appears to be dependent
on context. In Chap. 15, Just Caring: Fair Innings and Priority Setting, Leonard
M. Fleck raises the pointed question: Does a 90-Year-Old Have a Just Claim to an
Artificial Heart? He suggests that some form of age-based rationing, vindicated
partly by fair innings aspects, is not unjust: Relevant, he argues, is a flexible contex-
tual interpretation of fair innings in a spectrum of conditions for the determination
of just claims to health care for the elderly. Fleck emphasizes in this regard that a
complex theory of rational democratic deliberation as well as according political
practices are required. In Chap. 16, Harald Schmidt analyzes Personal Responsibility
as Criterion for Prioritization in Resource Allocation. This contribution first out-
lines how one could think about the normative groundwork for policies that have
reference to personal responsibility. It takes a closer look at major rationales under-
lying its promotion in resource allocation. Moreover, Schmidt discusses several
essential dimensions of incentives for promoting personal responsibility. Adele
Diederich completes this part of the present volume with her contribution in
Chap. 17, Age and Personal Responsibility as Prioritization Criteria? The View of
the Public and of Physicians. Rather than focusing on philosophical debates, she
reports the views of a representative sample of the German population and of a
sample of physicians as well: The contribution first presents citizens’ and physi-
cians’ attitudes towards age, then towards personal responsibility. Moreover, it
brings together the other contributions in this part of the volume.
Part VI, Economic Evaluation, addresses, on the one hand, the role of economic
evaluation in priority setting in general. On this basis, it discusses, on the other
hand, a special type of evaluation in Germany. In Chap. 18, Using Economic
Evaluation in Priority Setting: What Do We Know and What Can We Do?, Iestyn
Williams and Stirling Bryan comprehensively examine cost-effectiveness analysis
(CEA) in priority setting. At that, they comment on the evidence base and highlight
two types of barriers toward the use of CEA (accessibility and acceptability). They
reflect the neglect of context when it comes to explanations of the use of
CEA. Focusing on the context, they argue, contributes to explain the disparity
between national and local decision making tiers in regard to using CEA. Williams
and Bryan suggest that for the purpose of CEA to have an increasing impact at local
levels, analysts should consider more the restrictions in which decision makers act
and that greater clearness over roles, responsibilities, and relationships is necessary
in the process of resource allocation. Moreover, they plead for researchers to focus
on closing theoretical gaps as well as empirical gaps in comprehension across health
systems and contexts. In the last chapter (Chap. 19), Let’s Talk About Health
Economic Evaluation: Relevant Contextual Factors for the German “Sonderweg,”
Lars Schwettmann draws on the contribution of Williams and Bryan. First, he com-
ments on selected aspects raised by their analyses of barriers toward the usage of
health economic information. Beyond, he outlines the limited role of economic
Introduction to an International Dialogue on Prioritization in Medicine 7

evaluations in the German statutory health insurance system. In this, Schwettmann

also sketches the special methods of evaluation evolved by the German “Institute for
Quality and Efficiency in Health Care.” By summarizing findings of qualitative
research, his contribution in addition identifies possible reasons for the specific
limitations and regulations in Germany.

References
German Ethics Council (2011) Nutzen und Kosten im Gesundheitswesen – Zur normativen
Funktion ihrer Bewertung. Deutscher Ethikrat, Berlin
Meyer T, Raspe H (2012) Priority setting: Priorisierung: Was ist das und wie geht das? Rehabilitation
51(2):73–80
Mitton C, Donaldson C (2004) Priority setting toolkit: guide to the use of economics in healthcare
decision making. BMJ Books, London
Raspe H (2001) Prioritizing and rationing. In: Breyer F, Kliemt H, Thiele F (eds) Rationing in
medicine: ethical, legal and practical aspects. Springer, Berlin/Heidelberg/New York, pp 31–38
Williams I, Robinson S, Dickinson H (2012) Rationing in health care: the theory and practice of
priority setting. The Policy Press, Bristol, pp 8–12
 Part I
Evaluation and Decisions in Modern
Healthcare
Fundamental Evaluation Criteria
in the Medicine of the Twenty-First
Century

James R. Cochrane

It is an extraordinary gesture, and a significant risk, to be asked as a religion scholar

to keynote a meeting on prioritization in medicine. At the outset let me state clearly
that I have no expertise to address specific legal frameworks governing health care,
to discriminate scientifically between medical choices, or to analyze the financial
challenges involved. At the same time, I will say something about the larger envi-
ronment within which these matters are necessarily placed.
Similarly, it is beyond my province to judge the problem in the terms used by this
research group, namely, “vertical prioritization” (a hierarchy of choice within a spe-
cial field or group of patients) and “horizontal prioritization” (a hierarchy of choice
between special fields or types of illness or disease). I will suggest, though, that this
distinction is incomplete and offer a third “system prioritization.”
My remarks come from an engagement over the last decade with an international
transdisciplinary collaboration of people engaged in researching health care, health
systems, and public health with a view to unpacking the interface between health
and “religion.” Broadly understood, the key questions here have revolved around a
double recognition: that religious entities of one kind or another are widely and
deeply involved in delivering health care and medicine in most corners of the world,
often where there are few or no other formal state or private facilities or services,
and that religion, as an efficacious worldview linked to particular cultural and tradi-
tional constructs of health and healing with practical implications (more often than
is usually granted), plays a significant role in how health care and medicine is
received and understood.
To be clear, the point for the purposes of this discussion is not to put religion on
the agenda (though there are instances where that might not be a bad idea). Rather,
it so happens that dealing with the interface between religion and health rapidly

J.R. Cochrane
Religious Studies and School of Public Health & Family Medicine, University of Cape Town,
Altensteiger Strasse 28, Seewald 72297, Germany
e-mail: [email protected]

© Springer International Publishing Switzerland 2016 11

E. Nagel, M. Lauerer (eds.), Prioritization in Medicine: An International
Dialogue, DOI 10.1007/978-3-319-21112-1_2
12 J.R. Cochrane

forces one to consider crucial issues that are often sidelined by the problematic yet
pervasive Cartesian split between mind and body or spiritual and material reality.
That split dominates a great deal in governance, policy, and practice in the field of
medicine and health care, and it often confounds their aims and objectives. That
religion is invoked (and it is in any case a tricky notion1) should not derail us.
Besides challenging the Cartesian split, our work on the interface between religion
and health has also spawned general concepts that I wish to reflect upon of some
relevance to the most fundamental issues around health-care provision that also
concern this research group, in particular, ideas about health assets, healthworlds,
causes of life, and deep accountability.
The approach I adopt places the question of medical prioritization within a larger
framework of evaluation criteria for medicine in the Twenty-First Century. Here I
suggest an additional category of prioritization that cuts across the notions of verti-
cal and horizontal prioritization, namely, that described by a dynamic (or emergent)
adaptive system. To provide some necessary context to this general framework
while simultaneously highlighting some important fault lines that bedevil many
attempts to solve the major challenges we face, I first wish to comment on two top-
ics that mediate much discussion around medicine and its organization and generate
considerable controversy: the bounds of science and the limits of economics or,
more specifically, of “rational choice” theory as a defining viewpoint.

1 The Lure and Allure of Science

Undoubtedly one cannot but be mesmerized by the astounding science and the
breathtaking technologies of our time. As an example of one typical piece of magic
at an institution to which I have connections, Dr Anthony Atala and his team at
Wake Forest Medical Center in North Carolina are responding to a growing crisis in
organ availability resulting from in medicine: an aging population and a lack of suf-
ficient organ donors. They engage in regenerative medicine to produce artificial
bladders, spinal bones, and more; with three-dimensional printers, they are build-
ing, layer-by-layer, an artificial kidney, with the promise of other organs to come.
One may cite many other remarkable scientific innovations in fields such as genet-
ics, neuroscience, nanotechnology, and the like.
Such empirical science, given its evident power, is alluring. It is hard not to be
fascinated by it, to place one’s hopes in it, to promote it, and to invest in it. So the
demand grows to allocate major human, intellectual, material, and financial
resources to its work through every relevant institution, private or public.
Where, however, does this often impel us? Even if the manifest intention is to
heal, the explicit practice is often reminiscent, metaphorically speaking, of

1
Smith (1998).
Fundamental Evaluation Criteria in the Medicine of the Twenty-First Century 13

veterinary science or perhaps bioengineering. More generally, one could say that we
embrace one of the four “sins” of global health,2 namely, the lust for technological
solutions (the other three sins being “coveting silo gains, leaving broad promises
largely unfulfilled, and boasting of narrow successes”). I would portray this as an
instrumental, technical response to setting priorities. It is best captured in the idea
of a “magic bullet” and raised virtually to a Holy Grail in the form of randomized
controlled trials which are less reliable than are widely believed or acted upon.3
Pushed in this direction, it is easy to set aside fundamental questions about which
or, more tellingly, whose interests drive research and technological innovation.
Another side of the lure and allure of science is its potential hubris. This rests not
just on its undoubtedly effective utility but also on an epistemological and ontologi-
cal conviction: that “causes” (e.g., of disease or illness) can be determined with
great and increasing certainty and that only the ignorant or the disingenuous person
would reject the superior authority of science. Science, it is assumed, uncovers real-
ity “as it is” and gives us an increasingly firm grip on it.
Yet, as the best scientists well know and Kant long ago theorized, we never per-
ceive causes directly but only via a world of appearances. To these appearances we
necessarily add inferences of order, but we do so only by making fundamental
(supersensible) assumptions we cannot prove. Irrespective of our powers of inven-
tion, this places a fundamental limit on our grasp of reality. We never see fully. And
the order we place upon reality has, can, and will change, not simply according to a
rule of diminishing ignorance and increasing knowledge but in principle and always.
We have and can have no “God’s-eye view” of the real.
In short, though we do grasp the real with greater adequacy and increased power
(which is not inconsequential and can indeed can be profoundly exciting), we never
do so other than by means of generating “laws,” that is, by overlaying a unity and an
order on the appearances that is not intrinsic but of our making—which is why para-
digm shifts in our understanding are both possible and inevitable. At the same time,
this capacity is a measure of our creative freedom, which we exercise in ordering the
appearances of both the natural order and the human order, inseparably. Both must
thus be comprehended together, as the interplay between theoretical reason and
practical wisdom. This applies to the sphere of medicine and health as much as any.
One challenge, then, is how to grasp the complexity with which we are thereby
confronted without reducing it to an instrumental, technical logic. We tend to look
for an order that, to be manageable, is necessarily simplified, made legible, and
measurable—in a word, reductionist. Paraphrasing James Scott’s Seeing Like a
State4 and thinking not of polity but of the field of medical science, we may then

2
See Panter-Brick et al. (2014).
3
Ioannidis (2005).
4
Scott (1998).
14 J.R. Cochrane

speak of its practitioners being disposed to “seeing like a medic”: imagining that
they have grasped reality through their deeply rooted training in instrumental
knowledge and the powerful tools it gives them, supported by powerful accrediting
and grant agencies who see things similarly. In fact it simultaneously tends to blind
them, as Scott notes, to “essential features of any real, functioning social order,”
demoting or setting aside “the indispensable role of practical knowledge, informal
processes, and improvisation in the face of unpredictability.”5
Why is this so important? From a complexity theory point of view, for the simple
but rather profound reason that life is uncontrollable, at least in the sense that its
dynamic, emergent, and unpredictable properties, however much we may grasp
them in one way or another, always exceed that grasp. Whereas it is possible to
understand this complexity in part, sometimes even with astounding depth (say, in
neuroscience), in principle and for epistemological reasons it can always only be
grasped partially.
One way to think of this partial kind of understanding is to regard it as “sufficient
for the purpose”; in many situations we do not require anything more. Yet increas-
ingly, across many fields of inquiry and professional practice, we are realizing that
this is not enough: that linear analyses or diagnoses of a particular lived reality (say,
a health condition) are in many cases misleading and potentially capable of under-
mining the very thing one seeks to achieve. This becomes obvious in the case of
diseases or illnesses like HIV and AIDS or obesity and diabetes and in the face of
the rapidly growing reality of long-term chronic conditions.
To think otherwise is to ensure that we will continually be confounded by our
attempts to control life. This is true even when our focus is death—or mortality and
morbidity—and our knowledge and action are urgently geared toward addressing
pathologies.

2 On the Rationality of Choice and the Question

of the Common Good

In several publications the research group on prioritization in medicine has addressed

the crucial decisions in the economics of health provision and care to be made about
the generation, appropriation, and allocation of resources. In a time when the eco-
nomic version of rational choice theory, supplemented by game theory, has largely
been taken as standard wisdom, I wish to raise an old, seemingly antiquated, and
often disparaged question of the common good.
It has been heavily undermined by the penetration of market rationalities into all
spheres of life. Some even speciously equate it with notions of social engineering or
command economies (not a necessary equation at all, as is clear in the alternative
phrasing, “common weal” or commonwealth). What largely now holds sway is a
philosophy, perhaps more accurately an ideology, that gives heavy or even

5
Scott (1998): 6.
Fundamental Evaluation Criteria in the Medicine of the Twenty-First Century 15

hegemonic priority to a calculus of opportunity costs and preferences and thus to a

particular mathematical modeling of reality that aspires to define and guide all deci-
sions that humans make. Like those who imagine that science is the answer to our
problems, a similar hubris attaches to this effort.
As with the hubris of science, it is fundamentally reductionist and similarly fails
at the level of its anthropological assumptions (and probably its ontology as well) to
take into account the complexity of human beings or of life per se. It prioritizes the
autonomy of individual “rational” choice, a limited and morally misleading under-
standing of autonomy. Specifically, the autonomy associated with choice or prefer-
ence is what is limited. Preferences are rooted in desire and inclination and, as such,
are incapable of transcending self-interest; yet the capacity to do so and the capa-
bilities that go with that capacity suggest that a much richer view on autonomy is
needed, one that is able to transcend self-interest.6 Finally, it is forcefully used to
promote private enterprise as a determining reference point in governance in par-
ticular and in social life in general. This extends very widely. In South Africa, for
example, pharmaceutical companies, so central to medicine, are patenting and plac-
ing a price on bits of nature per se, “privatizing” many of South Africa’s unique and
ancient indigenous medicinal plants and claiming rights over their properties. The
trend is toward privatization and includes the move in many public or semi-public
facilities to outsourcing activities to private enterprise. Defensible only on limited
economic grounds, this attitude is ruled—an appropriate metaphor—by a market
logic of exchange relations. In turn, this posits a clearly reductionist view of the
human being as, par excellence, a unitary, isolated, or “point-like” ego with no his-
tory or context involved in rationally weighing up opportunities and balancing costs
and benefits as the basic strategy of life.
This calculating, ahistorical creature establishes the anthropological basis of
many key decisions about how to set priorities in society. Characterizing the human
as having a price rather than intrinsic worth,7 it supports the talk and practice of
rationalization. Narrowed definitions of efficiency and effectiveness, based heavily
on economic and bureaucratic rationality, accompany it. Such a gaze, only partially
accounting for the human being and his or her agency, cannot help but turn toward
an instrumental approach to the real—or to use Habermas’s language (taken from
Weber) to a purposive-rational rather than communicative action logic.8 And so, it
turns our view decisively away from what efficiency and effectiveness might mean

6
See Jaggar (2006), Nussbaum (2001).
7
This Kantian distinction, linked to the second form of his categorical imperative (“treat persons
as ends in themselves and never as means to another end”), has recently been explored with con-
siderable profundity in relation (inter alia) to the new South African Constitution, German Basic
Law, and the Canadian Constitution in (2012).
8
Habermas (1984). Here his distinction between the “system imperatives” of money (markets) and
power (state bureaucracies) and their driving logic—inherently instrumental and purpose-rational
rather than communicative—is evoked.
16 J.R. Cochrane

for a relationally embodied human being defined as person (where the concept of
“decency” becomes helpful).9
The ideology has another deleterious effect too. The public, as such, disappears
from view. At best, it emerges in the form of representation at the level of gover-
nance or the state. But this sphere, too, is easily overtaken by an increasingly
restricted group of actors who have the expertise or means to act and who do so
through highly planned, if volatile, interlocking affiliations, groupings, and interac-
tions that ironically can, and sometimes do, contain elements of a command econ-
omy with little accountability to anyone but themselves (notwithstanding the
supposed democratization of ownership that shareholder or stakeholder approaches
are purported to bring).10
When the sphere of the public is diminished and progressively brought under the
control of entrepreneurs, technocrats and bureaucrats, what might we understand by
the health of the public per se? What becomes of the common good; that is, what
becomes of our accountability not just to ourselves but also to all and indeed to that
which nurtures and sustains us in our environment?
Whether we consider (1) the current, destructive casino logic of financial capital
or (2) the disappearance of the “real human being” from the sphere of economy in
favor of a “virtual person” that is a shareholder without face or responsibility beyond
self-interest with regard to dividends accruing in the market or (3) the troubling
effects of our presence on the earth that have begun to change it in ways we may not
be able to manage, the question of the common good confronts us. The common
good now cannot be understood in nation-state or similarly narrow terms but only
with respect to humanity as a whole in our interdependence and dependence upon
the earth we inhabit in consort with its other creatures. Nor can it be understood as
giving priority to those who seek to socially engineer our lives “from the top down,”
so to speak, always legitimated on the grounds that they have the expertise, the
mandate or the wisdom to know what we all need and want. Yet the search for a new
understanding of the common good cannot be set aside either.
Perhaps this question provides us right now with no specific criteria for how we
prioritize medicine in the time ahead. But it does suggest that some criteria must be
found that enable us to measure the science and practice of medicine in terms of its
contribution to the common good. At least one clue to this is provided by an element
of the contemporary form of the Hippocratic Oath, namely, the Declaration of
Geneva or “Physician’s Oath” which includes a commitment to human rights. Like
the basic injunction that one should do no harm, it is phrased in the negative, how-
ever, requiring that one not violate any rights. There is no suggestion that one seek
to enhance such rights, which would imply a proactive role.

9
See Karpf et al. (2008).
10
See Letza et al. (2004); also Ireland (2005).
Fundamental Evaluation Criteria in the Medicine of the Twenty-First Century 17

In any case, a rights approach has particular limits, especially given the de facto
reality that they are largely articulated juridically as individual rights negatively
defined (what should not be done) and with difficulty as social rights positively
defined (what should be done). Can decisions about prioritization in medicine find
a meaningful relation to a deepened understanding of human rights? This would
mean pushing beyond first-generation or negative rights into the tricky legal terri-
tory of second- and third-generation rights. First-generation rights are largely indi-
vidual rights, whereas second- and third-generation rights are more general and
include, for example, those of unborn generations. To consider the impact of our
actions on unborn generations is to begin to think in terms of the common good
through time.
Another related limit to any consideration of the common good is the notion of
contractual rights, a legal articulation of rights that dominates jurisprudence in most
contexts today—notably (given the context of this discussion), in the use of medi-
cine, the provision of health care, and the status of private corporations (such as the
ultimately bizarre predilection to define corporations as “persons with rights,”
legally entrenched in some places in law with seriously negative impact on demo-
cratic life). It also contains within it certain dangers. A contract is inherently an
expression of exchange relations and not of any common good. Hence, even though
a contract may formally appear symmetrical, those who have greater power, wealth,
access, or authority readily leverage it to their advantage and self-interest. In prac-
tice, then, especially where a great deal is at stake in terms of influence and money,
a contractual right readily expresses deeply asymmetric power relations.
We once had a notion of covenantal rights. This evokes a relationship that goes
beyond contractual limitations. It appeals to a foundation that transcends self-
interest (individual or corporate). Avoiding the religious constructs within which
the term originates, we might now refer to this as the priority of the Just,11 the “law
above the law” (Kant) that transcends specific particular constructs of justice.12
Clearly, there is a normative dimension here, and though it is not defined culturally
or contextually (it is universal, in that regard), it would not find favor with those who
adopt a merely empirical or pragmatic view of law.
This, then, describes in shorthand the alternative before those responsible for the
provision of health and medicine in any society: either autonomy understood as the
discrete nature of an individual who, out of self-interest, makes free choices from
among available goods according to a calculus of costs and benefits (opportunity
costs included) or autonomy understood as the exercise of the will to maximize the
benefits accruing from the use of our creative freedom (in the form of science and

11
Ricoeur (2000).
12
This transcendental law, it should be clear, is not rooted in nature, but in the conditions of pos-
sibility that define the human being (at least) as of intrinsic worth. It is also, in principle, the basis
for the expression of any particular law (culturally, contextually, historically established) and for
its criticism.
Another random document with
no related content on Scribd:
consigned to flames on Lumi Island on Bellingham Bay, Wash.
Two incidents stand out above all the rest in the palmy days of the
Nipsic. She was of Admiral Farragut’s fleet at Mobile and she was the only
American vessel to come out whole in the typhoon at Aphia, Samoa, in
1889.

Old Lady, Seventy-nine, is Some Rider.

With the mercury at one hundred degrees, Mrs. Cynthia E. Davis, of
Goshen, Ind., celebrated her seventy-ninth-birthday anniversary by riding a
bicycle to New Paris and return, a distance of twelve miles. Again at home
she said to two nephews and a pair of slender gazelles who may have some
right to be called second or third cousins: “Come on, chickens, I’ll scramble
ye a few aigs.”

Loud Siren Screecher Terrorizes Hundreds.

“Bob” Maynard is known to be one of the best logging engineers in
Chireno, Texas, but he doesn’t like to run a wheezy, prancing old steam
hurdy-gurdy. Not at all; give Bob a likely hummer and he is the chap that
will keep her humming. Thus it was that he no sooner had engaged with a
logging outfit than he demanded and got a brand-new engine. The whistle
on the new power producer was too much like a boy’s penny trumpet to suit
the fastidious Bob. Bob had had some experience along the Mississippi and
had heard the noisy whistles that adorn some of the big flat-bottom boats.
And in due time there arrived from the big shop up north a siren screecher
warranted to be heard ten miles, in either direction, on a still day.
Everything adjusted to Bob’s practical taste, he proceeded to run the new
beauty over to where it was to do duty at a busy lumber camp. Arrived in
that vicinity at about the same time was a full-fledged Sunday school out
for a picnic in the woods. When Bob let loose with the great siren screecher
—now low and mournful—then wild and alarming—and again to its limit,
as if some eighty-foot, hundred-ton dinosaurus had suddenly come to life
and was setting up an unearthly howl for its mate, Bob’s heart fluttered with
delight.
Hearing the awful sounds, four of the Sunday-school girls rushed back to
the grove where half a hundred children and adults stood spellbound, and
cried out: “Wolves—panthers—bears—monsters—save us! save us!”
After long consultation, half a dozen men, with guns and dogs, started
out to scour the country for the “roaring hyenus,” as one of the men called
it.
By this time scores of people came rushing pell-mell from a near-by
settlement, armed with shotguns, rifles, axes, pitchforks, and fence stakes.
“Whatever is it?” they shouted, and “What is to become of us?” from many
of the women formed into groups with their young ones shielded behind
their barriers of skirts.
“Go, men, and slay that awful beast before we are all devoured like the
martyrs of yore,” yelled one tall, wild-eyed matron, pointing a long, bony
finger in the direction of the terrifying sounds, which again broke forth,
with even greater fury.
Soon there was a crashing of underbrush, wild cries of excited men,
barking and howling of numerous hounds, occasional shots, as the attackers
advanced toward the spot from which the alarming sounds came.
Now hundreds of telephones were in use throughout the country. “What
is it?” one would ask. “What is what?” comes the reply. “That awful noise
we hear,” another would explain. “Cyclone, I guess,” still another would
answer.
In time the attacking force came to the clearing where Bob was amusing
himself with the try-out of his screeching pet. The attackers and their dogs,
the former seeing that the enemy was nothing worse than a man of average
height and weight and some sort of hissing locomotive, made a football
rush, and, as they came to a halt, all exclaimed as one man:
“Well, what the h—l!”
“Jest tunin’ her up,” said Bob, with a characteristic grin.
“Tunin’ her up!” angrily exclaimed one of the Sunday-school scouts.
“Don’t ye know yer tunin’ up the whole county with that thar crazy
whangdoodle affair? Want ter skeer people ter death?”
“Oh,” said Bob calmly, “they’ll like it in time—it’s more fun than a cage
o’ monkeys.”
“Jes’ so, I don’t think,” said the angry man. “And I’ll tell you what,
mister, ef thet thingumbob scares any of them wimmen and children to
death, we’ll bring heavy damage suits against the company, that’s what
we’ll do.”
“You can’t blow that thing around these diggings any more,” said the
superintendent of the Sunday school.
“Now, see here,” said Bob, “you go fetch all the women and little ones
over here to the camp and let me demonstrate to them, and if this here
whistle isn’t the one big, entertaining feature of your picnic, I’ll promise
never to blow her again.”
This was finally agreed upon, and, true to Bob’s claim, the whole crowd
found the noisy siren to be “more fun than a cage of monkeys.”
Before breaking up at nightfall the picknickers declared Bob was the
hero of the day, and tendered him a vote of thanks.
Even so, the big laugh was reserved to the last. Just as Bob was banking
his fire and the crowd were shouting and waving their good-bys and good
nights, the faces of three wild-eyed Indians loomed up from behind a clump
of sagebrush and continued to stare with what might be called frozen
amazement. When finally induced to speak, one of them said, with a smile,
“Injin heap fool. Come much far. All day climb tree when hear noise. No
can tell what. Injin heap fool. Odder Injin now much laugh.”

Finds Some Use for Dogfish.

Dogfish are so numerous in Long Island waters that they are cluttering
up the fishermen’s lines. No use had been found for them until Roger
Carman, of Freeport, N. Y., cut the two little horns off one of the fish and
used them for needles on his phonograph.
Carman says these dogfish horns reproduce the records perfectly,
without any grating noise, and that there does not seem to be any wear out
to them. Contrary to expectations, there was no barking sound, no more
than there would be mewing if catfish horns were used.
All the fishermen hereabouts are now saving the two little horns on each
dogfish, with the expectation that there will be a big demand for them by
phonograph users.

Look Out for Towel Inside.

 Doctor Edgar Todd, of Toms River, N. J., is feeling better and his
“unaccountable illness” has at last been explained. Doctor Todd was
operated on last December for kidney trouble, but failed to improve.
Recently he was operated on again and a surgeon’s towel, ten inches in
diameter, was removed from his body.

Man and Wife Keep Up Mum Game Fifty Years.

Fifty-two years married and fifty years gone by without speaking to each
other.
This is the remarkable record of a South Westport, Mass., couple, Mr.
and Mrs. Charles Wing. Outside of their neighbors, who have known of the
estrangement for years, but have carefully refrained from mentioning it, the
unique conversational separation of the old people did not become known
to the world at large until their home was destroyed by fire.
Few people know the cause of the gulf between the two, and they
treasure their secret. It began shortly after their marriage, half a century ago.
Both have endured the situation and both apparently have lived happy,
contented, and useful lives. Their only conversation during that long span of
time has been carried on through the medium of a third person.
Mr. Wing is a farmer, eighty-eight years old, while his wife is sixty-nine.
Until their farmhouse burned down, Mrs. Wing lived in the house, while
Mr. Wing lived in a sort of shanty which he styled his “den.” He has been
living in the den since, and Mrs. Wing has gone to live with her son, whose
residence is a short distance away.

Snakes and Snake Oil While Customers Wait.

About nine miles from Neosho, Mo., Adelbert Tibbins and J. J. Wilson
are operating one of the most unique “farms” in the country. This is nothing
less than a “rattlesnake ranch,” and this enterprise, which is conducted on
Indian Creek, being in a neighborhood where snakes are plentiful, the two
men are doing a thriving business. They say that there seems to be an
unusually large number of reptiles in this part of the Ozarks this summer.
For three years the two men have been building up this business, and
now have in the neighborhood of 600 snakes in their pits, which are so
constructed that the reptiles cannot escape. The principal profits of this
enterprise come from the extracting of poison from the rattlesnakes, which
is sold at high prices to doctors, chemists, and others. Physicians use this
poison, after it has been prepared in a scientific manner, for the treatment of
epilepsy and other diseases.
Tibbins and Wilson also have a large revenue from the sale of live
reptiles to traveling shows and to museums, at the established rate of
twenty-five cents per pound. A large, fat serpent usually brings several
dollars. The smaller, poorer specimens are killed and their flesh converted
into rattlesnake oil, which has a steady sale at one dollar an ounce. This oil
is said to be a specific for the treatment of rheumatism.
Most of the capturing of rattlesnakes for the “ranch” is done by the two
partners themselves. Seldom can they find a white man who will take a
chance on the rather dangerous duty, though occasionally an Indian or negro
is found who is willing, for a good price, to run the risk of taking them
alive. It is said that the best time for the hunting of rattlesnakes is in the
early spring, when they first come out of their winter’s sleep and are still
sluggish. They are caught by means of a forked stick, with which their
heads are pinned to the earth and the captor can pick them up and place
them in a sack.
When they intend to sell a live snake by weight it is fattened on rabbits
or rats. They take on weight rapidly. Tibbins and Wilson have found as
many as one hundred snakes in one cave. The same family of reptiles will
occupy a cave for years if left undisturbed, the two men say.

Sportsmen Rescue Squirrel.

Joining forces, five trout fishermen in Orangeville, Minn., saved the life
of a red squirrel which was on the point of being crushed by a huge
blacksnake.
Hearing shrieks of terror, which none of the men had ever before heard,
the men dropped their poles and rushed into the bushes, where they found a
squirrel struggling to free itself from the coils of a big blacksnake, which
was slowly winding itself around the little animal.
The snake was hacked into pieces in an instant, and the squirrel
scampered up a tree, where he sat and chattered at his rescuers, who declare
they are sure the animal was thanking them.
 Ever-bearing Cherry Tree.
An ever-bearing cherry tree is the valuable possession of Mrs. Oliver
Slimmer, of Russell, Kan. The freak tree has an abundance of ripe fruit on
it, has green fruit, and is still blossoming. From present prospects the tree
will bear cherries well into the fall.

Scarlet Diving Girl Author of New Fad.

Frog parties are likely to become popular with bathers at other inland
water resorts when the experience of a girl, clad in a bright-red bathing suit,
becomes generally known.
The girl in scarlet was bathing in shallow water at Highland Lake, near
Winsted, Conn., when she felt frogs strike her repeatedly. Being a great
lover of that delectable dish—frog legs—the girl turned her experience to
good account.
She repaired to a cottage, sewed about fifty fishhooks in the bright-red
bathing suit, and then reëntered the lake. When she emerged from the water,
nearly every hook held a bullfrog.

Hears the Dog Bark; Yes, Dogs Have Eyes.

The mystery of the Blue Island ax murders of July, 1914, has solved
itself. To escape the tortures of his own conscience, Casimir Areiszewski,
the murderer, gave himself up to the police of Buffalo, N. Y., and wrote and
signed a confession.
It was for the little hoard which he knew to be hidden in Jacob Mislich’s
bedtick, said Areiszewski, that he killed Mislich, his wife, his daughter, and
his granddaughter. But the crime did not yield even the sordid reward for
which it was committed. Just as Areiszewski had cleared his way to the
money, a dog barked—and ever since, he says, he has been unable to sleep
without hearing and being awakened by a dream dog’s barking.
“I was born in Russia and am a brickmaker by trade,” ran Areiszewski’s
statement. “I came to this country when I was fourteen, and worked in
Chicago for a year or two. Then I got a job in a brickyard in Blue Island,
and rented a room from Mislich.
 “A couple of years later I went West. When I came back to Blue Island, I
got my old job and my old room. I knew old Mislich had money hidden in
his bedtick. I got up early in the morning of July 5th and crept downstairs. I
found an ax out in the shed and carried it back to the house. I was in my
stocking feet, and they did not hear me coming. I killed them as they slept.
“It was as I killed the last—the granddaughter—that the watchdog
barked, I was afraid to stay any longer, and I went away without the money.
I have heard the dog barking ever since. When I try to sleep he wakes me. I
have traveled all over the country, but the dog is still with me.”

Makes Lucky Strike in Zinc.

Six months ago, George A. Tibbans, of Carterville, Mo., was “powder
monkey” or shot firer at the old “Hero” zinc mine, at a wage of $3.50 per
day. By the time he paid rent, household expenses, car fare, et cetera, he
was in no danger of being forced to pay an income tax.
Believing he could do better for himself and family by working for
himself, he secured a lease on the “Last Chance,” an old, abandoned mine
that had never paid on account of the low price of ore. For several weeks he
barely made wages, but as the price of ore gradually went higher, he began
to receive weekly checks of forty and fifty dollars. Then he discovered a
“pocket” of exceedingly rich ore, and right on top of this zinc ore jumped to
$130 per ton.
Tibbans has leased a 100-ton mill and is now cleaning up something
over $1,000 a week, with a good chance of doing even better, for the
“pocket” is becoming richer, and zinc ore seems to be due for still higher
prices.

Big Brewery Becomes Malted-milk Concern.

Coors Brewery, at Golden, Col., one of the largest in the State, will
discontinue the manufacture of beer and will employ the same force of men
in the manufacture of malted milk. The plant represents an investment of a
million dollars.
 The Nick Carter Stories
ISSUED EVERY SATURDAY BEAUTIFUL COLORED COVERS
When it comes to detective stories worth while, the Nick Carter Stories
contain the only ones that should be considered. They are not overdrawn
tales of bloodshed. They rather show the working of one of the finest minds
ever conceived by a writer. The name of Nick Carter is familiar all over the
world, for the stories of his adventures may be read in twenty languages. No
other stories have withstood the severe test of time so well as those
contained in the Nick Carter Stories. It proves conclusively that they are
the best. We give herewith a list of some of the back numbers in print. You
can have your news dealer order them, or they will be sent direct by the
publishers to any address upon receipt of the price in money or postage
stamps.
730—The Torn Card.
731—Under Desperation’s Spur.
732—The Connecting Link.
733—The Abduction Syndicate.
738—A Plot Within a Plot.
739—The Dead Accomplice.
746—The Secret Entrance.
747—The Cavern Mystery.
748—The Disappearing Fortune.
749—A Voice from the Past.
752—The Spider’s Web.
753—The Man With a Crutch.
754—The Rajah’s Regalia.
755—Saved from Death.
756—The Man Inside.
757—Out for Vengeance.
758—The Poisons of Exili.
759—The Antique Vial.
760—The House of Slumber.
761—A Double Identity.
762—“The Mocker’s” Stratagem.
763—The Man that Came Back.
764—The Tracks in the Snow.
765—The Babbington Case.
766—The Masters of Millions.
767—The Blue Stain.
768—The Lost Clew.
770—The Turn of a Card.
771—A Message in the Dust.
772—A Royal Flush.
774—The Great Buddha Beryl.
775—The Vanishing Heiress.
776—The Unfinished Letter.
777—A Difficult Trail.
782—A Woman’s Stratagem.
783—The Cliff Castle Affair.
784—A Prisoner of the Tomb.
785—A Resourceful Foe.
789—The Great Hotel Tragedies.
795—Zanoni, the Transfigured.
796—The Lure of Gold.
797—The Man With a Chest.
798—A Shadowed Life.
799—The Secret Agent.
800—A Plot for a Crown.
801—The Red Button.
802—Up Against It.
803—The Gold Certificate.
804—Jack Wise’s Hurry Call.
805—Nick Carter’s Ocean Chase.
807—Nick Carter’s Advertisement.
808—The Kregoff Necklace.
811—Nick Carter and the Nihilists.
812—Nick Carter and the Convict Gang.
813—Nick Carter and the Guilty Governor.
814—The Triangled Coin.
815—Ninety-nine—and One.
816—Coin Number 77.
NEW SERIES
 NICK CARTER STORIES
1—The Man from Nowhere.
2—The Face at the Window.
3—A Fight for a Million.
4—Nick Carter’s Land Office.
5—Nick Carter and the Professor.
6—Nick Carter as a Mill Hand.
7—A Single Clew.
8—The Emerald Snake.
9—The Currie Outfit.
10—Nick Carter and the Kidnapped Heiress.
11—Nick Carter Strikes Oil.
12—Nick Carter’s Hunt for a Treasure.
13—A Mystery of the Highway.
14—The Silent Passenger.
15—Jack Dreen’s Secret.
16—Nick Carter’s Pipe Line Case.
17—Nick Carter and the Gold Thieves.
18—Nick Carter’s Auto Chase.
19—The Corrigan Inheritance.
20—The Keen Eye of Denton.
21—The Spider’s Parlor.
22—Nick Carter’s Quick Guess.
23—Nick Carter and the Murderess.
24—Nick Carter and the Pay Car.
25—The Stolen Antique.
26—The Crook League.
27—An English Cracksman.
28—Nick Carter’s Still Hunt.
29—Nick Carter’s Electric Shock.
30—Nick Carter and the Stolen Duchess.
31—The Purple Spot.
32—The Stolen Groom.
33—The Inverted Cross.
34—Nick Carter and Keno McCall.
35—Nick Carter’s Death Trap.
36—Nick Carter’s Siamese Puzzle.
37—The Man Outside.
38—The Death Chamber.
39—The Wind and the Wire.
40—Nick Carter’s Three Cornered Chase.
41—Dazaar, the Arch-Fiend.
42—The Queen of the Seven.
43—Crossed Wires.
44—A Crimson Clew.
45—The Third Man.
46—The Sign of the Dagger.
47—The Devil Worshipers.
48—The Cross of Daggers.
49—At Risk of Life.
50—The Deeper Game.
51—The Code Message.
52—The Last of the Seven.
53—Ten-Ichi, the Wonderful.
54—The Secret Order of Associated Crooks.
55—The Golden Hair Clew.
56—Back From the Dead.
57—Through Dark Ways.
58—When Aces Were Trumps.
59—The Gambler’s Last Hand.
60—The Murder at Linden Fells.
61—A Game for Millions.
62—Under Cover.
63—The Last Call.
64—Mercedes Danton’s Double.
65—The Millionaire’s Nemesis.
66—A Princess of the Underworld.
67—The Crook’s Blind.
68—The Fatal Hour.
69—Blood Money.
70—A Queen of Her Kind.
71—Isabel Benton’s Trump Card.
72—A Princess of Hades.
73—A Prince of Plotters.
74—The Crook’s Double.
75—For Life and Honor.
76—A Compact With Dazaar.
77—In the Shadow of Dazaar.
78—The Crime of a Money King.
79—Birds of Prey.
80—The Unknown Dead.
81—The Severed Hand.
82—The Terrible Game of Millions.
83—A Dead Man’s Power.
84—The Secrets of an Old House.
85—The Wolf Within.
86—The Yellow Coupon.
87—In the Toils.
88—The Stolen Radium.
89—A Crime in Paradise.
90—Behind Prison Bars.
91—The Blind Man’s Daughter.
92—On the Brink of Ruin.
93—Letter of Fire.
94—The $100,000 Kiss.
95—Outlaws of the Militia.
96—The Opium-Runners.
97—In Record Time.
98—The Wag-Nuk Clew.
99—The Middle Link.
100—The Crystal Maze.
101—A New Serpent in Eden.
102—The Auburn Sensation.
103—A Dying Chance.
104—The Gargoni Girdle.
105—Twice in Jeopardy.
106—The Ghost Launch.
107—Up in the Air.
108—The Girl Prisoner.
109—The Red Plague.
110—The Arson Trust.
111—The King of the Firebugs.
112—“Lifter’s” of the Lofts.
113—French Jimmie and His Forty Thieves.
114—The Death Plot.
115—The Evil Formula.
116—The Blue Button.
117—The Deadly Parallel.
118—The Vivisectionists.
119—The Stolen Brain.
120—An Uncanny Revenge.
121—The Call of Death.
122—The Suicide.
123—Half a Million Ransom.
124—The Girl Kidnapper.
125—The Pirate Yacht.
126—The Crime of the White Hand.
127—Found in the Jungle.
128—Six Men in a Loop.
129—The Jewels of Wat Chang.
130—The Crime in the Tower.
131—The Fatal Message.
132—Broken Bars.
133—Won by Magic.
134—The Secret of Shangore.
135—Straight to the Goal.
136—The Man They Held Back.
137—The Seal of Gijon.
138—The Traitors of the Tropics.
139—The Pressing Peril.
140—The Melting-Pot.
141—The Duplicate Night.
142—The Edge of a Crime.
143—The Sultan’s Pearls.
144—The Clew of the White Collar.
145—An Unsolved Mystery.
146—Paying the Price.
147—On Death’s Trail.
148—The Mark of Cain.
Dated July 17th, 1915.
149—A Network of Crime.
Dated July 24th, 1915.
150—The House of Fear.
Dated July 31st, 1915.
151—The Mystery of the Crossed Needles.
Dated August 7th, 1915.
152—The Forced Crime.
Dated August 14th, 1915.
153—The Doom of Sang Tu.
Dated August 21st, 1915.
154—The Mask of Death.
Dated August 28th, 1915.
155—The Gordon Elopement.
Dated Sept. 4th, 1915.
156—Blood Will Tell.

PRICE, FIVE CENTS PER COPY. If you want any back numbers of our
weeklies and cannot procure them from your news dealer, they can be
obtained direct from this office. Postage stamps taken the same as money.

STREET & SMITH, Publishers, 79-89 Seventh Ave., NEW YORK CITY
*** END OF THE PROJECT GUTENBERG EBOOK NICK CARTER
STORIES NO. 158, SEPTEMBER 18, 1915: THE BLUE VEIL; OR,
NICK CARTER'S TORN TRAIL ***

Updated editions will replace the previous one—the old editions will
be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright in
these works, so the Foundation (and you!) can copy and distribute it
in the United States without permission and without paying copyright
royalties. Special rules, set forth in the General Terms of Use part of
this license, apply to copying and distributing Project Gutenberg™
electronic works to protect the PROJECT GUTENBERG™ concept
and trademark. Project Gutenberg is a registered trademark, and
may not be used if you charge for an eBook, except by following the
terms of the trademark license, including paying royalties for use of
the Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is very
easy. You may use this eBook for nearly any purpose such as
creation of derivative works, reports, performances and research.
Project Gutenberg eBooks may be modified and printed and given
away—you may do practically ANYTHING in the United States with
eBooks not protected by U.S. copyright law. Redistribution is subject
to the trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free

distribution of electronic works, by using or distributing this work (or
any other work associated in any way with the phrase “Project
Gutenberg”), you agree to comply with all the terms of the Full
Project Gutenberg™ License available with this file or online at
www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand, agree
to and accept all the terms of this license and intellectual property
(trademark/copyright) agreement. If you do not agree to abide by all
the terms of this agreement, you must cease using and return or
destroy all copies of Project Gutenberg™ electronic works in your
possession. If you paid a fee for obtaining a copy of or access to a
Project Gutenberg™ electronic work and you do not agree to be
bound by the terms of this agreement, you may obtain a refund from
the person or entity to whom you paid the fee as set forth in
paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be

used on or associated in any way with an electronic work by people
who agree to be bound by the terms of this agreement. There are a
few things that you can do with most Project Gutenberg™ electronic
works even without complying with the full terms of this agreement.
See paragraph 1.C below. There are a lot of things you can do with
Project Gutenberg™ electronic works if you follow the terms of this
agreement and help preserve free future access to Project
Gutenberg™ electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright law in
the United States and you are located in the United States, we do
not claim a right to prevent you from copying, distributing,
performing, displaying or creating derivative works based on the
work as long as all references to Project Gutenberg are removed. Of
course, we hope that you will support the Project Gutenberg™
mission of promoting free access to electronic works by freely
sharing Project Gutenberg™ works in compliance with the terms of
this agreement for keeping the Project Gutenberg™ name
associated with the work. You can easily comply with the terms of
this agreement by keeping this work in the same format with its
attached full Project Gutenberg™ License when you share it without
charge with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside the
United States, check the laws of your country in addition to the terms
of this agreement before downloading, copying, displaying,
performing, distributing or creating derivative works based on this
work or any other Project Gutenberg™ work. The Foundation makes
no representations concerning the copyright status of any work in
any country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project Gutenberg™
work (any work on which the phrase “Project Gutenberg” appears, or
with which the phrase “Project Gutenberg” is associated) is
accessed, displayed, performed, viewed, copied or distributed:
 This eBook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this eBook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is derived

from texts not protected by U.S. copyright law (does not contain a
notice indicating that it is posted with permission of the copyright
holder), the work can be copied and distributed to anyone in the
United States without paying any fees or charges. If you are
redistributing or providing access to a work with the phrase “Project
Gutenberg” associated with or appearing on the work, you must
comply either with the requirements of paragraphs 1.E.1 through
1.E.7 or obtain permission for the use of the work and the Project
Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted

with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any
additional terms imposed by the copyright holder. Additional terms
will be linked to the Project Gutenberg™ License for all works posted
with the permission of the copyright holder found at the beginning of
this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files containing a
part of this work or any other work associated with Project
Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this

electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg™ License.
1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if you
provide access to or distribute copies of a Project Gutenberg™ work
in a format other than “Plain Vanilla ASCII” or other format used in
the official version posted on the official Project Gutenberg™ website
(www.gutenberg.org), you must, at no additional cost, fee or expense
to the user, provide a copy, a means of exporting a copy, or a means
of obtaining a copy upon request, of the work in its original “Plain
Vanilla ASCII” or other form. Any alternate format must include the
full Project Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™ works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing

access to or distributing Project Gutenberg™ electronic works
provided that:

• You pay a royalty fee of 20% of the gross profits you derive from
the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt that
s/he does not agree to the terms of the full Project Gutenberg™
License. You must require such a user to return or destroy all