About a month ago, I wrote a post about whether or not it made sense to let people die if they elected not to have health insurance. One libertarian blogger took issue with my basic assumption, namely that people want to live longer and, if they become ill and can’t afford medical care, ought to be able to seek treatment (even if doing so comes at my expense as a taxpayer). It’s a fairly lengthy critique of my position, which I invite you to read at your leisure, but in the end it really all boils down to a stark difference in the way we understand the purpose of a political community:
The assumption behind the curtain, the card you’re palming, is that everyone will always seek medical treatment, and that someone will always provide it to them, and that someone will therefore be stuck with the bill.
While I can’t speak for every “small-government conservative” and other hanger-on, nor even every libertarian, with all due respect, we aren’t children here. Speaking as one of the Great Uninsured, who voluntarily chose to forgo employment and its associated health insurance in exchange for a life of self-employment without it (because early start-ups don’t pay very well, which I point out merely because there’s always some idiot who turns up at this point to say “well, that’s all very well for you bloated plutocrats”), because of my values, I knew perfectly well what the deal was going in. We all know perfectly well what the deal is going in.
And what the deal is is that if we should get sick, and need medical treatment, and not be able to pay for it, and not be able to obtain help from friends, family, charity, lenders, or Internet donors, we have a moral responsibility to sit down, shut up, acknowledge that we gambled and lost, and then either live with our medical issues, or, if necessary, lie down and die quietly.
The history of political philosophy tells me that human beings benefit from interaction and collaboration with other human beings, that attempting to go it alone might seem noble but ultimately misses something absolutely fundamental about us as a species: namely, that the flourishing of each one of us is intimately bound up with the actions of the rest of us.
As Aristotle famously wrote in the Politics, “A man without a city is either a beast or a god” (1253a4-5). My libertarian interlocutor exemplifies this way of thinking, taking the position that, if things don’t work out in his/her quest for godliness, the rest of us ought to treat him bestially.
For me, a political community means something; it’s all about a collective project whereby human beings agree that working together is a vast improvement over an attempt to live by and for oneself. For these libertarian bloggers (as a fair number have written to me of late), the only thing such a community can do is oppress us. And, interestingly, the more such a community emphasizes the ties between us as members (something I think allows us to reach our full potential as human beings), the more these folks think it’s oppressive.
This is a fundamental rift, one that suggests that we’re simply living in two completely different worlds that overlap in unpleasant ways for both of us.
I think the other thing that needs to be talked about here is the “theoretical niceness” of the Libertarian writer’s argument. In theory, their moral argument works. But in practice, people in desperate or life threatening situations are quick to abandon even strongly held moral prescriptions in order to receive relief. Indeed, being exposed to desperate circumstances are the most common type of situation in which people change their fundamental beliefs. they come to understand through experience what they couldn’t understand through reasoned inquiry alone.
None of this is meant to condescend or disparage the libertarian writer’s conclusions and moral beliefs. I am quite certain that he earnestly holds his beliefs only after careful and lengthy consideration. However, I might suggest that even if he is personally capable of seeing through the “risk of failure” in his gamble, many people confronted with desperate circumstances are not. And when we deal with questions of how to structure society, we must necessarily address tendencies of the populace generally in at least equal proportion to potential proclivities of any one person individually. A society which structures itself with those tendencies in mind will be able to more efficiently deal with the consequences those tendencies generate. And desperate circumstances clearly generate tendencies in practical human action that lead people to seek immediate relief, even when doing so contradicts prior-held theoretical convictions.
This might be referred to as the “atheist-in-a-foxhole” phenomenon of human experience (which is an imperfect metaphor, but well suited for the purposes at issue here). I brought up a similar situation recently in a post about H.R. 358, where I questioned whether a staunchly pro-life woman, who supports a religious exemption allowing healthcare providers to refuse an abortion even if necessary to save the woman’s life, would retain her convictions when facing certain death from pregnancy complications. The libertarian writer’s “gamble calculus” applies with equal force to the troubled pro-life mother (after all, forcing the healthcare provider to do something he doesn’t want to do would be a form of slavery, right?). But I think human experience demonstrates that most people in that situation would not simply bite their lip and accept their fate. Being faced with their mortality, they are granted an insight into the human condition that bare reasoned inquiry alone cannot reach; and indeed, will not ever reach. The result of this phenomenon is that a person in desperate circumstances is far more likely to make entreaties for aid than to silently consign themselves to their fate, even where they previously held principles that demanded they accept that fate.
This phenomenon of human experience is extremely relevant with respect to provision of healthcare; and is largely the basis of EMTALA, a law which stands for a proposition that a person who can’t afford to pay for life-saving care at the time they need it should still receive it. The view espoused by the Libertarian writer above simply ignores the fact that people in desperate situations often abandon theoretical principles for practical reasons. And laws such as EMTALA are simply an acknowledgement of this fundamental piece of the human experience.
The libertarian writer’s view also leaves no room for alternatives which might still satisfy Libertarian principles: for example, the “gamble calculus” this writer asserts leaves no room for the possibility of paying off one’s medical debt with future income. It hardly seems to make any sense, from a utilitarian standpoint, to condemn individuals to death who may be able to bring future earnings to bear for the purpose of paying for treatment in the present.
Yet there are even problems inherent to this solution as well: it conjures images of banking institutions setting up shops in emergency rooms for the express purpose of extending loans with outrageous terms to patients in need of life-saving care which they can’t otherwise afford. I suppose this could simply be dismissed under Libertarian ideology as a proper and obvious function of subjective value in relationships of exchange; but how can a person under the duress of life-threatening circumstances properly and rationally place a value on a life-saving loan? Isn’t that value necessarily limitless, since in the absence of receiving the loan, the predicate to all other sources of value, i.e. life, is extinguished? The bank could charge a milllion percent interest, and it would still be rational for the indigent patient to accept the loan.
The last objection to the libertarian writer’s “gamble calculus” is that I highly doubt you will find many people, even small government conservatives, who actually believe that we should structure society in this way. Ironically, guaranteed access to emergency care provided by EMTALA is quite often offered up to me, when I discuss healthcare reform with my right-leaning peers, as proof that we don’t need universal healthcare in America. The fact that many on the right lean on this guaranteed access as an argument against government-funded universal healthcare demonstrates that there is a heavy consensus in America (and obviously in most other 1st-world countries) that a person who can’t afford life-saving care should nonetheless be provided with that care, even if it means that the rest of us end up picking up the tab somehow.
So the basic assumption on which guaranteed access to healthcare regardless of ability to pay rests, is actually held across the political spectrum, even by many who have lost little love for government over the years. This fundamental rift, then, is more likely to manifest as a discussion of how we should pay for care to those who can’t afford it, rather than whether we should pay for care for those who can’t afford it. The collectivist argument, of course, revolves around matters of efficiency and practicality (simply stopping at EMTALA-like backstops is just socialized medicine without any of the organization that makes healthcare cost-efficient or affordable). But that is an argument for another day.