As Few As Possible

by Decius2 min read10th Jul 202013 comments

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All of economics, every last bit of it, is about scarcity. About what is scarce and what is not, and about who does and who doesn’t get their needs (and sometimes wants) satisfied.

Much of the debate about healthcare is in fact a scarcity problem. There aren’t enough practitioners in practice to handle every patient, so some people don’t get doctors. It’s a combination of self-selection where people who can’t afford to take time off to have an ingrown toenail treated professionally hack at it with a pocketknife instead, and insurance selection where granny’s insurance will pay for hospice but not a new hip, and actual medical discretion now and then.

But this is about what medical care does right. Triage.

In times of very acute scarcity when many people are injured and need medical attention to survive, but few doctors are available to treat them, medicine does triage. The details can be complex, but one of the features of triage is that if doctors are too scarce to save everyone, they prioritize saving *as many people as possible*, even though that often means giving specific people no treatment at all. The scarcity is distributed so that *as few people as possible* suffer from scarcity.

This is not about mass trauma triage.

Imagine for a moment how utterly absurd it would be if there was an earthquake, but there were enough doctors to simultaneously treat everyone injured in it, but they insisted on following triage protocols and the very worst injured were given black tags indicating “do not treat”, even as surgeons who could save them sat idle, because everyone else was being treated. No civilized person would defend that kind of thing.

But this is not about hypothetical earthquakes with plenty of doctors.

The world produces significantly more food than needed to feed everyone. Quite a few people actually are angry that much of it is destroyed even though many people starve for lack of food. Many agree that is unacceptable that, even though there is enough to go around, not enough goes around.

This is not about hunger or food waste, or stores throwing bleach in the dumpsters to keep people from eating stale crackers.

This is about scarcity, and who gets it.

By it’s very nature as a lack of enough, if scarcity exists then someone must get it; there’s no accounting trick to pay Tuesday if there is no hamburger today. Various economic philosophies try to distribute scarcity in various ways. Some try to give the scarcity to the least productive, some try to split it as evenly as possible, still others just admit that the scarcity goes to the lowest status or losers at violence. Various implementations of those philosophical principles handle those philosophies to varying degrees of faithfulness and effectiveness.

But this is not about economics. This is about one of the fundamental decisions of morality: who gets the scarcity?

There is only one answer I can possibly accept:

As few people as possible, and no more.

A nurse in a triage ward who has to mark the patient who will not be treated should not be so sad at what they do as the one who orders that food be destroyed, lest some bargain hunters pilfer from the dumpster instead of buying from the commercial establishment. The hypothetical trolley controller standing as his hypothetical lever and wondering if he is a murderer would be aghast if he understood a zoning board’s decision that causes dozens of non-hypothetical to die of exposure so that a handful of high-status people, the eldest sons of the ones who got credit for industrializing the land that was credited to the winners of violence.

Any political or economic philosophy or policy that ever wantonly destroys a scarce thing, or fails to produce a scarce need that could have been produced, is evil. Those who manufacture scarcity for their own profit, to accumulate their own positional goods, have created a new hell. Not for themselves, but for their victims, and on Earth.

When there is not enough to go around, it doesn’t go all the way around. The answer is the same whether it be food, shelter, textbooks, medical attention, love, mosquito nets, or anything else that people need. Who should miss out?

As few as possible.

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13 comments, sorted by Highlighting new comments since Today at 2:19 PM
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For a given amount of scarcity at a point in time, the fewer people who have it, the more of it they each must have. For the fewest to have it supposes that it is better for 100 to die of starvation than for 400 to live on short rations, better for one person to suffer abominably if it enables everyone else to live in paradise. Is this your view?

No, and you failed to comprehend what I was saying as soon as you said "For a given amount of scarcity".

Also, the fewer people die, the less scarcity there was. Pretty much linearly.

So you mean as little scarcity as possible? At what point does the number of affected people enter into it?

The number of people killed by scarcity is the measure of scarcity. At least until there's enough that nobody is being killed by it. There's no point in trying thought discussion about whether scarcity changes nature after we stop killing people with it, not until we're a lot closer to that.

This actually wasn't obvious to me from the OP, fwiw.

More health care isn't necessarily better. Overtreating can lead to worse health outcomes. Meat is scarce but the push of the Chinese to reduce it's availability to improve the health of their population is likely benefitial.

Food being scarce only because so much is destroyed instead of distributed. While people are starving to death for a lack of enough food at all, it isn't "meat" that is scarce, it is "food".


For a particular person, more medical attention might be harmful, but there's no shortage of examples of cases where people are not getting enough medical care because they can't. Sometimes because they can't afford to, sometimes because doctors simply literally refuse to perform certain procedures.

There was a time where we Europeans thought that the surplus food we produce can easily gifted to Africans. As a result we destroyed a few local food markets. After that mechanism good public criticism we now. You might argue that it's totally worth destroying their local food markets if it means that we Europeans don't destroy food but it's not a straightforward argument. 

Distributing food is an issue of being good at logistics. Even within Africa plenty of food gets destroyed because people don't do the logistics well enough for it to reach the people in need of the food. 

There are plenty of poor people who have enough food to not starve but who want to eat meat but can't (or only can a few times per month) because it's too expensive.  I'm very curious what you mean with "scarce" if meat isn't. 

For a particular person, more medical attention might be harmful, but there's no shortage of examples of cases where people are not getting enough medical care because they can't. Sometimes because they can't afford to, sometimes because doctors simply literally refuse to perform certain procedures.

This basically boils down to "there are examples where more medical care helps and there are examples were less medical care helps". It's no argument against the point I made.

You're speaking of meat being a positional good, not a need. If luxury food or cosmetic surgery are easily obtained by everyone who wants them, then they stop being even positional goods.

Making more things universal is a goal that goes beyond the scope of providing basic needs, although the mechanism is rather similar. But it would be inhuman to eliminate the idea of positional goods and status entirely.


It makes no difference whatsoever why the scarcity is created- incompetence, malice, and apathy are all causes of waste. Logistical failures are no more tolerable than intentional genocide of equal total deaths.

Cosmetic surgery has little to do with the arguments I made about healthcare.

While you can argue meat being a positional good in some countries, middle-class people in the US consume a lot of it without seeing it as a positional good. The US still overcomsumes meat likely both from a health perspective and an ethical one. 

China on the other hand decided that they don't want their population to have as unhealthy diets and thus moved to reduce meat consumptions. 

China has more scarcity of meat because the government believes that eating as much meat as the US Americans do is unhealthy and thus bad for China. 

It makes no difference whatsoever why the scarcity is created- incompetence, malice, and apathy are all causes of waste. 

If you want to create change it matters a lot why the world is the way it is. 

You said "More healtchare isn't always better".

Can you give a central example about a situation where more people receiving healthcare is worse, and why we should characterize that situation as one where more people receive healthcare?

If the government restricts the supply of meat (and food generally is adequately distributed), then the finite supply of meat makes it positional, and the fact that all needs are being met (within the scope of the example, at least) makes the outcome satisfactory.

If you thought that I intended some element of "maximize production even if all needs have already been met", then we have completely failed to communicate.

Can you give a central example about a situation where more people receiving healthcare is worse, and why we should characterize that situation as one where more people receive healthcare?

If you do cancer screeing for a person, you might find things that would go away on their own. A lot of women lost part of their breasts that way.

After analysis of the issue the Obama administration restricted the amount of breast cancer screeings because the additional breast cancer screeings were not believed to reduce mortality by breast cancer. 

If you reduce the number of surgeries that surgery salesmen can perform then the surgery salesmen don't try to sell surgeries to everyone but focus on selling the surgeries to those who profit from them. 

Denmark cut  a third of their hospital beds from 2000 to 2018. The fact that every hospital bed finds it's patient whether or not there's a real need for treatment is healthcare economics 101 and you find plenty of public policy that's controls the supply of healthcare services to prevent overconsumption.

Why are you characterizing "contraindicated cancer screening" as "healthcare"? In either case, it's not central to the issue where rural specialists have two-month waits for appointments and four-hour waits from the appointment time.