Debating the Evidence of Capital Punishment

Capital punishment terminates a human life. Is there any case at all for a doctor being in favour of it? Hippocrates; first, do no harm; do we really need to spell it out?

At a recent meeting of the Council of the World Medical Association – I represent the BMA there – there was debate over a resolution deploring capital punishment and, specifically, medical involvement. Most national medical associations were in favour of such condemnation, but not all. One appeal was to justice: he shot others, the argument runs, surely he deserves to die. Another appeal was to protecting the public: he is a terrorist, he bombed and maimed, unless we execute him, he’ll kill others.

My contribution to the discussion, fully ready to be criticised by the lawyers in the room, was that there are three possible reasons for the criminal justice system: deterrence, revenge, and protecting the public.

Taking them in reverse order: protecting the public. If a dangerous killer or rapist has been caught, the public need to be protected. Locking up the convicted criminal up is a way of doing that. It is not necessary to execute them in order to protect the public. In fact, in the USA, those handed a sentence of execution, can spend twenty years or more behind bars, as the appeals go on, so the main way the public is protected is locking up the criminal – even if the criminal has been sentenced to death. After such a time, and with the public protected, why go through with the execution?

Revenge. No doubt, advocates for capital punishment would not call it revenge, but closure, satisfaction or something of that nature for the bereaved or for society as a whole. But what else is it but revenge? Does not killing a killer mean that we have descended to his level? Eye for an eye is primitive, surely beneath a civilised society. If the organs of society do not feel moral repugnance at becoming killers, then we have a long moral argument ahead of us.

Deterrence. It could be argued that if capital punishment deterred others from committing murder, killing (executing) one person could lead to a net saving of life. It is a means and ends argument. The vile means of executing someone would be justified by the end of saving lives. The proponents of capital punishment could therefore put themselves on the side of preserving human life.

Quite apart from the question of whether doctors should be complicit in executions, what does the empirical evidence show on whether there is a deterrent effect? A friend told me that there had been several reviews of the deterrent effect of capital punishment on homicide. Some found convincing deterrent effect; others found none. My friend told me that ALL the reviews that found deterrent effect were by economists; all the reviews that found none were by criminologists.

Why?

Economists believe in incentives and rational choice. Some young man is feeling violent; he weighs up the costs and benefits of committing murder; and where the curves cross he acts. If capital punishment is in force, he thinks the costs of committing murder are too high and desists. Can you believe that?

Unlikely as it may seem that real people function this way, this view of how the world works shapes the interpretation of the evidence – i.e whether the data support a deterrent effect or not.

I had a quick look at the literature and found an interesting article (2013 Columbia Law School) from Jeffrey Fagan, Professor of Law and Public Health at Columbia. He dates a particular debate from 1975:

"...when University of Buffalo Professor Isaac Ehrlich published an influential article asserting that during the 1950s and '60s, each execution "…saved eight innocent lives" by deterring murder. Inspired by an economic model of crime developed by Professor Gary Becker of the University of Chicago, Ehrlich theorized that would-be murderers would choose between illegal and legal behavior based on the threat of execution."

Gary Becker, Nobel Prize winning economist, apparently suggests that people do make rational choices based on threat of execution. The debate now takes on a  polarised tinge: Cass Sunstein (of nudge fame) and Becker are convinced. Jeffrey Fagan, presumable closer to the “criminologist” dichotomy is most certainly not. Fagan reviews more recent studies that the economists find convincing. He rejects them on methodological grounds, among which are that the analyses did not consider other causes of fluctuations in homicide rates or the possible deterrent effects of imprisonment, as distinct from homicide. A quick look at other literature show that there are questions over the assumptions that went into the choice of instrumental variables, much beloved of econometricians. Essentially, an instrument should be correlated with execution rates but not with the “outcome”, in this case homicide rates. In that way, the independent relation between execution and homicide can be determined.

This all sounds rather familiar. I have written with passion about how economists analyse the same data we do and find the causal arrow runs from health to wealth and not, as we conclude, that features connected to socio-economic position are causal of poor health. (See: A continued Affair with Science and Judgements. International Journal of Epidemiology 2009). Same data; opposite conclusions. Here we are again.

I remain interested in why people, who purport to be empirical scientists, take such opposite views of what the evidence shows. It has to be related to starting assumptions. The interesting question then is why views on the deterrent effect of capital punishment (and the health damaging effects of social conditions) vary by academic discipline. Predictably, I side with the Professor of Law and Public Health and against the rational choice theorists, in finding the deterrent effect of capital punishment unpersuasive. But then, as a doctor, I find participation in legal execution to run counter to what we do. I am hopelessly biased by concern for human life. We all have biases that colour our view of the evidence. At least my bias does not lead to my advocacy of killing people.

Social Movement and Swedish Paradox

Back in Stockholm. Whatever for? I was asked. It is true that I was in Malmo three weeks ago for the launch of the Malmo Commission on a Socially Sustainable Malmo, and in Stockholm in January. The answer is simple: our social movement on SDH is alive and thriving in local government in Sweden, and they wanted my continued input.

I went first to the Parliament for lunch as the guest of Anders Jonsson, a paediatrician who is a Centre Party MP, and secretary of the Social Committee. Paediatricians are naturals for social determinants of health because the effects on children are so plain to see. Anders Jonsson had invited other doctors who are MPs or otherwise involved in politics. Barbro Westerholm, who is a senior advisor on our European Review, gave a refreshing account of what it means to be an MP. She had been head of the Swedish Board of Health. After retiring from there she became an MP. But, she said, after a while she recognised that she had run out of fresh ideas and so left parliament to work with organisations devoted to the elderly. Working with Civil Society, she developed a bucket full of ideas, and so came back to the Parliament. 

(Good heavens! Fancy quitting being a member of parliament because you had run out of ideas. I can think of one or two who would serve our country well if they took such a view.)

I joked to the Local Government people the next day, that the Parliament is a fact-free zone – my powerpoint would not load at the post lunch seminar that I was giving to the Parliament’s social committee. So I had to ad-lib it or, as I put it, talk ideas rather than data. There is a recognisable debate in Sweden across the political spectrum about the role of the state and the individual, but it is different to the UK. 

I have been told that it was Labour’s Clement Attlee (couldn’t track the quote on Google) who returned from a trip to the US and explained to his fellow Labour Parliamentarians: They have two political parties in the US. The Republicans are a lot like our Conservative Party; and the Democrats are a lot like our Conservative Party. 

If the right-left debate in the US is to the right end of the spectrum, the UK debate is further toward the centre, and the Swedish debate is further to the left. It was put to me that none of the major parties seriously question the Swedish welfare state. The Social Democrats may have to have given way to a Centre-Right Coalition for two elections in a row, but the legacy of decades of Social Democratic government is more or less intact. 

And Sweden looks pretty good – on life expectancy, low levels of child poverty, relatively high equality on UNICEF’s Report card on children’s living conditions. And, of course, their economy is doing well.

But, as I have previously reported, questions have been raised about the magnitude of health inequalities in Sweden. The graph above, from Finn Diderchsen, using data from Johann Mackenbach’s latest effort, shows that the countries of Central and Eastern Europe have a high Gini coefficient – although not much higher than the UK – and high educational inequality in mortality; the Nordic countries have low Gini and low inequality in mortality. BUT, and this is the so-called Swedish paradox, health inequalities in Sweden appear not to be narrower than in other West European countries with higher Gini coefficients, and less generous welfare states.

Two comments. As we learnt from Olle Lundberg and CHESS: health of the most disadvantaged has been improving in Sweden. This is a societal success. Whether due to the welfare state, or not, it is a major societal success. One criterion of societal success is precisely improvement in the lot of the worst off, and Sweden looks good. But inequalities are increasing – this a second challenge that must be faced.

Espin Dahl from Norway points out that if you look at self-reported health rather than mortality, the picture is different. Now, he sees that the more generous is a country’s spending on welfare the NARROWER are health inequalities by education. 

More to do on this agenda.

The Local government conference – SALAR, Swedish Association of Local Authorities and Regions – was inspiring. 300 representatives of at least twenty local areas came together to make their commitment to pursue local policies for health equity, very much based on Closing the Gap in a Generation, the report of the CSDH. This IS our social movement in action.

Working for a fairer distribution of health

Working for a fairer distribution of health

The Institute of Health Equity released a remarkable report this week. Its plain title belied its radical intent, Workingfor Health Equity: the Role of Health Professionals.

The world of medicine has changed, for the better I would argue. When I first started making the case to doctors for social determinants of health, a common reaction was: our job is the individual patient, first, last and always. Of course it is. But, as we said when arguing for the necessity of setting up the WHO Commission on Social Determinants of Health: what’s the point of treating illness and then sending the patient back to the conditions that made them sick in the first place.

Doctors who argued that it was not their business might have been reminded by this year being the 200^th anniversary of John Snow’s birth what a concerned doctor can do. Snow, an anaesthetist, was horrified at the numbers of people in the Soho area of London dying of cholera, during an outbreak. Rather than wait for more cases and deaths, he set about determining what conditions made them sick. He sorted it out. He used good scientific reasoning to identify the causes in polluted water and, in a wonderfully dramatic public health gesture, removed the handle from the Broad St. pump. The fact that it may have been too late simply argues for evaluation of our interventions. Good intentions are not enough.

Our workforce report has brought together a remarkable group of 21^st century health professionals in the John Snow tradition. Nineteen organisations, including our own, made commitments to use their best efforts to promote health equity not only by improving access to care but by addressing social determinants of health.

Reaffirming the BMA’s commitment to this area, the launch meeting was opened by the BMA President Baroness Hollins. Malcolm Grant, was there in his dual role. As Provost of UCL he supported the IHE. As Chair of the NHS Commissioning Board, he was keenly interested in what the health workforce can do to reduce health inequalities.

Dr Cecil Wilson is current President of the World Medical Association and former President of the American Medical Association. In his inaugural presidential address in Bangkok last October, he said that a theme of his presidency was the social determinants of health. Listening to him, then, I thought: if I should die now, I’ll die a happy man. (Be careful what you wish for. Four days after I returned from Bangkok I had a dreadful bicycle accident and nearly did. I came away with a fractured femur. Luckily it wasn’t worse.)

Cecil spoke at our launch as did Anna Reid, President of the Canadian Medical Association. The CMA, working with us, has developed its own programme of work on social determinants of health. Anna herself, practices in Yellowknife in the North West Territories. A large proportion of her patients are First Nation or Innuit. She sees the operation of social determinants in her daily practice.

We heard, too, from Jonathan Sexton representing the Academy of Medical Royal Colleges, and Adrian Tookman telling us what the Royal Free, an advanced teaching hospital is doing. Inspiring stuff.

We see the launch not as a culmination but as the start of a process as all of the nineteen organisations that made commitments make them real. It really is exciting.

Stockholm Royal Swedish Academy of Science

If I am to start travelling again after a fractured femur, what better place to start than Stockholm, albeit the temperature was -11 C, and I was using a walking stick. The Swedes do things remarkably well. I am always struck at Swedish meetings when the chair gives a gracious introduction and welcome, summarises the state of play of the field, lays out the questions we are to address, and does all this inside his allotted ten minutes. Each of the chairs did this admirably.

Things come together. Denny Vagero took the initiative to approach the Royal Swedish Academy of Science to hold a meeting on Health Inequalities in Modern Welfare States. Meanwhile, a few years ago in Kuala Lumpur, I had given a lecture to the Interacademy Medical Panel – an organisation of national academies of medical science. After my lecture I had a meeting with the executive committee, one of whose members was from Sweden, and he was keen for Sweden to be involved in discussions on social determinants of health. Thus the meeting happened with joint sponsors.

The whole meeting was excellent. 

A key question for the meeting was the so-called welfare state paradox. Johann Mackenbach said that Sweden has already implemented perhaps 95% of the CSDH recommendations, why do they still have health inequalities. More, he argues, health inequalities in Nordic countries are not narrower than elsewhere. Hence the paradox. Part of his answer, and that of Pekka Martikainen in Finland, is consumption – social differentials in smoking and alcohol. He says that trends in social inequalities may be explained by consumption, and persistence by material conditions and psychosocial factors. He acknowledges in discussion that smoking and alcohol are proximal causes – we need to look at the circumstances that give rise to them. In our language, that is the causes of the causes.

Espen Dahl, from Norway, takes a different view. He says too much of the analysis relies on mortality. Using self-reported health, he shows interactions across Europe: educational inequalities in health are narrower, the more generous in welfare spending. Similarly, a slide that we have been using, unemployment gradients are smaller with more generous welfare spending. Generous welfare spending reduces the unemployment disadvantage of having illness.

Clare Bambra, from Durham, using a post-Black report framework, explores six possible explanations for persisting health inequalities in Nordic welfare states: artefact, health selection, cultural/behavioural, materialist, psycho-social, and life course. No clear answers, but some of the last three.

For me, a high point came in the session on engaging with the political implications. Anders Jonsson is a member of the Swedish parliament for the Centre party, and chair of parliament’s Committee on Health and Welfare. He began by saying that most reports of international commissions are scarcely read and mostly ignored. Emphatically, this was not the case with Closing the Gap in a Generation, the final report of the CSDH. He said it is much discussed, still, in the Swedish parliament.

Made the trip worthwhile right there. I nearly skipped out without my walking stick. It is particularly encouraging because the Swedish government, nationally, has been reluctant to take up the social determinants issue. Discussion of the CSDH findings by parliamentarians over a four year period is a less tangible benchmark of success than setting up of a national commission but it is encouraging, nevertheless. Though there may have been some reluctance at the national government level, there is clear interest in local government. The Malmo Commission on a socially sustainable Malmo is due to report in March; and Margareta Kristenson, from Linkoping told me that she is to chair a new commission on social determinants of health, cross-party, for the region that includes Linkoping, OsterGotland. Anders Jonsson  knew of the interest from local government and was strongly supportive.

Inspiring Kids... and the rest of us

 

It’s not surprising that everyone refers to her as Camila. Could I trust myself to pronounce her surname, Batmanghelidjh? Actually one doesn’t need to. Camila’s reputation precedes her. She fills a room. Draped in multicoloured garb from her turban, via wrist guards, to her long dress, she shows me to an armchair and reclines on a couch. There the flamboyance gives way to sharpness. Self-confessed as dyslexic, she is good with numbers: 97% of children self-refer to Kids Company. They have programmes in 40 schools; three street level centres; 14,000 children and young people access Kids Company services each year.

Their main office itself is astonishing. An unpromising building on Blackfriars Road, south of the Bridge, blossoms inside into a profusion of child friendly coloured spaces that house varied proportions of their 500 employees and thousands of volunteers. Damaged young people, damaged by extremes of the social determinants of health, find their way here. Camila explains that the central principle of their operation is “attachment”, yes, Bowlby-type attachment. Camila says that conventional wisdom is that professional carers should not allow their clients to become attached to them. By contrast, Kids Company recognises that these young people desperately need attachment. They are in trouble, at least in part, because of lack of a consistent person with whom they might have formed a relationship of attachment.

               Do they do any good? I felt good just being there. From the enthusiastic young men who showed me around to the originality of having a sandwich and coffee with Camila in what felt like her living room, the whole place feels eccentric and caring. But what do the numbers show? I was shown around their research rooms and certainly they are taking seriously the task of evaluation. The counting up of the outcomes in the government funded youth development scheme looks impressive with respect to getting young people back into education and training. They have several research collaborations with good research groups.

                The combination of research findings and moving testaments both to the problems of children and young people, and solutions to those problems, is exactly what we need.

Two Years On

“Measurement is radical” was my message yesterday at the Press Launch of our Two Year On monitoring report on health inequalities. By keeping robust measurements on the agenda, we can chart progress on health inequalities and their social determinants and make clear that we hold governments, and the wider society to account.

On publication of Fair society Healthy Lives in 2010 we developed a simple monitoring framework with two health measures: life expectancy and healthy life expectancy for men and women;  and three social determinants to capture the life course: early child development, young people not in employment, education or training (NEET), and an adult poverty measure.  We announced the baseline for that framework this time last year, thanks to our partnership with the London Health Observatory.

The Institute of Health Equity commissioned the LHO to provide data showing key indicators for monitoring health inequalities and the social determinants of health for the 150 ‘upper tier’ local authorities in England. We are able to compare and comment on any changes that have happened over the last year. As one could expect few changes in one year, I did not expect very much in the way of press interest. I am surprised at the wide coverage we got, validating the importance of monitoring to keep health inequalities on the agenda.

That said, there have been changes. Life expectancy continues to increase, as has been the trend over time, by about 0.3 years every year. Most important though and more worryingly, the inequalities in life expectancy also continue to rise. Inequalities within local authorities have increased in most of the 150. For men in 104 out of 150, and for women in 92 out of 150.

Children achieving a good level of development at age five has improved slightly on last year’s figures (59% of children are achieving a good level of development instead of 56%). But that’s nothing to celebrate. Because it means a staggering 41% of children are NOT achieving a good level of development. Good development scores show a close link with measures of deprivation – a social gradient in child development that runs from least deprived to most. And if we compare how this country is doing to others, the picture is clearer: we are doing very badly indeed.

Poor early child development and socioeconomic disadvantage predict poor performance through children’s whole school careers. Although there is an intimate link between deprivation and development there is variation around the line – at similar levels of poverty some areas do better than others.  Last year when I visited Tower Hamlets to discuss child development, and showed data on the clear link between deprivation and school performance a director of education said: “we tell ourselves every day, poverty is not destiny”. It isn’t. We need to address poverty – the causes of the causes – and we need to focus on early child development and education.

Our next indicator: young people not in employment, education or training (NEET), age 16-19. Again a slight improvement on last year, and that improvement was seen in the majority of upper tier local authorities. So we’re having some success in getting 16 year olds to stay on at school or take part in training programmes. I ask myself why our data seems to be at odds with what’s reported in the news – that the NEETs figure has reached record levels at over 1 million. And we think that’s because we measure until 19 – it’s beyond age 19 that levels of NEET have increased so dramatically.

Our last indicator for the social determinants is the percentage of people in households on means tested benefits. There’s a slight reduction here, both in terms of actual receipt and the inequalities between neighbourhoods with different levels of deprivation. But what’s particularly interesting, and shocking, is the variation within local authorities.

I was asked by various members of the press this morning at our briefing what is going to happen to health inequalities as a result of the Coalition Government’s policy changes. Of course, I am concerned, particularly in relation to cuts in local authority funding of early years. But that’s an important part of our mission – to watch, evaluate and comment. And with our robust monitoring framework, which of course we will update where appropriate according to government policy changes, we can comment in confidence.

For more information on the data, please see our website.