Wednesday, April 30, 2008

health care as a moral issue

Preventable deaths accounted for 32% of all deaths in 2002, and this map and link convey where those deaths are occurring (PS - I love these types of maps).

It's not surprising more preventable deaths are occurring in Africa and India, but the magnitude might be a bit jarring.

One of the issues I have with the health care debate is my liberal side agrees that no American should live a diseased life that ends in premature, painful death because they can't afford the treatment. That seems wrong. On the other hand, I don't think these people deserve to be healthy simply because they are Americans, I think they deserve it because they are human beings. The argument 'they deserve to be healthy because they live in the United States' doesn't resonate well with me -- there is no moral high ground there. All your doing is expanding the privilege of birth to not just include those born into a high-income family in the US, but all who happen to be born in the US. The message for health care justice shouldn't be "share your privilege with a few more people nearby," it should be that health is not a privilege at all, but something all people deserve.

This distinction has major ramifications for health policy, as it speaks to where 'justice-minded' folks should direct their intellectual, political financial capital. Given the map above, I think it's clear that the choice would fall outside America. Spending tons of resources trying to change people's eating and exercise habits in the US, or providing relatively straightforward fixes to preventable diseases and conditions that we overcame a century ago?

To continue to focus on domestic policy (even if carving out time for foreign missions as well) would be to a) deny the obvious opportunity costs of domestic efforts and/or b) forsake the moral imperative for the mantle of nationalism (one step closer to conservatives, one step further away from winning them over to your policies).

The odor of local poverty and disease may be stronger given my location, but I should remember that this odor pales in comparison to the stench of death found abroad. There is a continuum of health problems -- and America's are way down on the list.

On a related note, Megan McArdle has an old post on the morality of health care finance, where she makes the argument that most believe in a single-payer system because they feel it is indeed more just, and she explores the alleged violations of justice that the proponents are seeking to rectify.

"1. They are needy. The class we propose to benefit has greater need for the money than the class from whom we propose to take.

2. It's not fair. The class we propose to benefit has been unluckier than the class from whom we propose to take.

3. They are responsible. The class from whom we propose to take has in some way contributed to the problems we are trying to rectify."

In the end, she argues convincingly that these reasons fall flat. Check it out to see if you buy it.


Andrew Cheesman said...

food for thought: why are we even considering where to spend our money, time, and effort now, anyway? shouldn't we take a step back first and even question if we should be thinking about non-americans? after all, the money, time, and effort that we as americans would use to help those less fortunate belong to americans.

i'm not sure that moral imperative is strong enough to justify asking me to give up my money for another person. i'm not saying i won't do it - i'm as pro-aid as the next (intelligent) guy - but i'm not motivated by moral imperative, and i don't think anyone else really is, when you get down to it.

Publius said...

My response to your question is another question: Why should I or rich americans be concerned about poor Americans, outside of the times when it is in our interest? If they all live in ghettos I am isolated from, why should I care about helping them?

Andrew Cheesman said...

i think part of the basis for any nation-state (and definitely for the one in question) is a union of members for the greater good of all. so, as long as you rich people want to be americans, you'll have to pay.

remember, freedom ain't free - it costs a hefty f*****' fee.

Publius said...

the basis for any nation-state is a central government. Everyone within the nation has to play by the rules set by the state.

By staying in the country, you are consenting to the rules the central government sets.

A nation-state government can decide to provide for the greater good of all, but there is nothing saying it has to.

The way our government is setup means that individuals will try to get elected based on promises to improve the greater good of each voting group, but that's politics.

If the rich act purely in their direct self-interest, the rich really only need to be concerned with laws that restrict their ability to improve their lot in life.

The government wins support of the rich (and non-rich) for policies that distribute income because a) the rich think they will indirectly benefit and/or b) they think it's right to do.

Freedom for the rich isn't free, but it costs only as much as the wall to keep the poor from storming the Bastille.

The agreement between the poor and the rich would be much more lop-sided were the rich united in an interest to extract rents from the poor (as many think they are). Fortunately, Madison was right and the rich factions check each other in many cases, but beyond that, it is belief in human entitlement to certain goods that leads to redistribute policies.

There is a logical disconnect where human entitlement morphs into country-specific human entitlement because of national pride.

Put another way, do New York kids in the Bronx NOT deserve education as much as the kids in upstate New York? No would deny they do, and the reason they don't receive the same education is because of this same localism.

Andrew Cheesman said...

your cynicism re: the nation and activities of this nation aside, i think that you're severly misinterpreting and oversimplifying this situation in an effort to get a handle on it! not all people are purely self-motivated; i think you need to take a much harder look at the actions of these wealthy people you want to try to appraise.

people like warren buffet and bill gates don't give money for either of the reasons that you set forth exclusively here. how does giving money in africa help bill gates' lot in life, or even his (former) company's?

i think it's very easy (and simplifying) to relate actions to their supposed effect on well-being, but i think that's unrealistic in many ways. it may be perhaps the best model we have to appropriate human choices, but it's still inaccurate enough to make relying on it (like you do here) a dangerous proposition.

i think in the case of philanthropy, if you take longer look at the people giving and their decisions to give, you'll see a trend toward maximizing good amongst other people - they will donate or erect organizations to donate where they perceive a potential for change. you'll see this if you take a look at the actions of the gates foundation, for one. aside from the good will mr. gates may generate or the indicental benefits microsoft may see due to whatever help the organization has given to higher education, bill gates gains relatively little from the actions of this organization.

further, i don't like the rich checking each other argument - perhaps centuries (or even decades) ago, at some point when communication and cultural barriers played a larger role, this was the case - but now the "rich" are far too smart and far too connected for the argument that they're too stupid to collude to hold water. no, it seems much more likely to me that the numbe of people truly bent on self-service make up a very small portion of the global population.

i'm not going to get into answering your other questions, because i feel like they all stem from the twisted logic at the core of this argument, which i believe you should rethink.

Publius said...


There is a severe disconnect in this conversation as you seem to think I am making a variety of claims I am not.

To start, I do not think all people, or most people are purely self-motivated. I am not suggesting a model based on the presumption that people are acting in their own self-interest.

People’s self interest is one of the motivations that drives human behavior. Another is charity, which, to some degree, causes the individual to transcend the self’s interests. My point, though, is that if you asked Bill Gates or the Dalai Lama who deserved charity, they would not limit it to a specific city, country, etc. Charity emanates from an idea of HUMAN justice. People don’t give food to the poor on their corner, they do because they don’t think anyone should be hungry; they give because they think the poor DESERVE to eat — because EVERYONE deserves to eat. This is the moral imperative (call it what you will) I wrote about before, to which you replied: “i'm not sure that moral imperative is strong enough to justify asking me to give up my money for another person.” I think that moral imperatives are what cause you to give up your money, your time, and your attention to things outside your self interest.

My first contention is that people’s SELFLESS motivations emanate from a sense of justice.

My second contention is that this sense of justice is universal and categorical (e.g., every person deserves not to be killed by another person).

My third contention is that people do not act based on this abstract sense of justice

My fourth contention is that people draw selectively from this abstract sense of justice based on their experiences.

My fifth contention is that the more impactful the experience, the more the person’s sense of justice is excited.

My sixth contention is that the most impactful experiences are likely to be personal, local, and be more emotionally-charged than intellectual.

My seventh contention is that these experiences introduce considerable bias to the sense of justice, most notably in it’s local tilt.

My eighth contention is that by localizing what is inherently universal they violate their own sense of justice by extending a helping hand to the relatively well off at the expense of the worst off.

My ninth contention is that intellectual study of how a theoretical sense of justice can be applied in reality can avoid a greater number of biases and better serve the worst off.

The Bible is ONE example of a justice-applied-to-reality guide, but most books like the Bible don’t speak about welfare policy, trade restrictions, etc.

I’m going to return to an analogy, which I think is very useful (albeit a bit silly); Let’s stay instead of believing everyone deserves not to be killed, you believe everyone deserves not to live amidst trash. This is universal. Let’s say there is 100 tons of trash per person in Distant Country A, 10 tons of trash per person in an American ghetto, and 1 ton of trash person in a nice American area.

The American will notice the stench of the ghetto trash more than the Distant Country A trash, despite the fact that the trash crisis is much more dire. Because of this local subjective experience, he will direct some (if not all) his selfless intention and efforts to alleviate the ghetto trash problem, despite the fact that he could much more easily serve his true selfless aim of helping people not live amidst trash.

Now, there are a ton of assumptions implicit in the above framework, (e.g., an American can make the same difference in Africa as he can in his own community), but I want to make sure that we’re on the same page before I turn to those — for now, suffice to say I think the assumptions are true in some cases and not in others, and this process of coming up with a fully-explored framework for “doing good” would be fruitful in advancing the causes that liberals (and other people who try to act selflessly) claim to represent.

As you mentioned, people act outside their self-interest all the time, and I’m stating that when they do so, they believe themselves to be acting in accordance with a greater sense of justice.

Perhaps after this long post I am able to condense my distinction to one sentence... Self interests are not universal (what happens in Africa isn’t as important as what happens here), and selfless interests are. Parochialism, or localism, isn’t the product of selfless interests, but selfish interests, and in the cases when the framework’s assumptions are true, those advertising American redistributive policies cannot honestly sell them as “what you should believe in if you agree with justice.”

If you believe that every child should eat, you wouldn’t be putting more money into welfare, you would be working on famine abroad. It may not seem like a big deal to help the poor in one country, until you consider the opportunity cost which equals more suffering for the worst off in the world.