This is my reply to Jeff Hammond’s recent blog post, part of our ongoing discussion of healthcare ethics. Enjoy!
After reading Jeff’s latest posts, I feel some need to address his concerns about the problematic rhetoric he detected in my recent comments. Jeff indicated that my last blog post had him feeling that I was “spreading” him, collegiate debate style. This is not my intent. “Spreading” is a rhetorical strategy in which one side aims to overwhelm the other with so many arguments that the other side cannot begin to address everything. I am not a fan of the strategy; it impedes serious discussion. While my last few posts have been lengthy, I’ve tried to avoid developing large numbers of independent, unrelated arguments. It is true that I have been posting more frequently than Jeff, and this may well be contributing to Jeff’s perception. To remedy this my plan going forward is to avoid posting more than a single post between Jeff’s replies. I’m hopeful that this will remedy Jeff’s feeling.
Jeff also took exception to my use of the word “incoherent” to describe his position, deeming this uncharitable, perhaps even uncivil. I regret that Jeff took my description this way, and I apologize to him for how this came across. It was not my intent to disparage him. The word seemed appropriate to me to describe an argument that embraces internal contradictions (i.e. claims that do not “cohere” on their face). Jeff would prefer that I simply say that I think his position is wrong. To be honest, I’m still trying to figure out what Jeff believes about forced transactions, so I’m not yet in a place where I’m entirely comfortable saying that he is “wrong,” at least on this topic. However, my aim here is not to inflame but to discuss ideas. Maybe a better way to describe Jeff’s argument is that it is “fraught with tension,” or “wrestling with a commitment to competing values in an imperfect world.” This is certainly more charitable, and it also is much closer to the language that Jeff himself uses to describe our problem: we are wrestling with policy questions that admit no easy answers. In short, Jeff, I’ll avoid the offending term going forward and look forward to the ongoing dialogue.
Having said this, I’m not convinced that Jeff’s last blog post does his argument any favors. Our discussion at present has focused primarily on the moral premises behind what Jeff calls “forced transactions.” In principle Jeff claims to be opposed to forced transactions. However, as I noted in my previous post, this principled objection to forced transactions breaks down for Jeff (Note: Jeff is not alone here. This breakdown is common for many conservative critics of Obamacare). I want to summarize what I hear Jeff saying with respect to each of the forced transactions that have figured in this conversation. I’ll list each transaction and then offer my own summary of Jeff’s argument based on what he has said so far, inviting Jeff to clarify if I am misunderstanding him:
Forced Transactions that Jeff Supports
(1) Universal Police/Fire Protection and Military Defense: This is what government is for, and there is a longstanding consensus among us that giving up some of our liberty for the greater protection of liberty (e.g. protecting our private property rights) is justifiable. If we didn’t do this then we would have no government at all, and we are okay with having government.
(2) Public Education: This is different than (1), above. We could still have a government without state-subsidized public schools. However, none of us would want to live in the community that would result from us turning our backs on compulsory public education. We’re okay with tax-funded public schools because it is a good thing for all of us that kids are educated with the skills and habits that are essential for them to become good citizens. And even if we have tax-funded public schools, our community also creates ample space for citizens to pursue private alternatives.
(3) EMTALA: It would be indecent for us to let people die on the streets. Forcing hospitals to provide healthcare that they realize they will not be fully compensated for is preferable to allowing hospitals to deny care.
While Jeff supports all of these forced transactions, he objects to the ACA individual insurance mandate:
Forced Transaction that Jeff Does Not Support
The ACA Individual Mandate: Health insurance is different than all of the forced transactions above. The ACA mandates that I purchase a product that benefits me. Yes, you might argue that my refusal to purchase insurance burdens the larger public, but what of it? I’m not a consequentialist; I don’t evaluate policies based on whether the consequences are good for society as a whole. I evaluate them on the basis of whether or not they conserve individual liberty. The individual mandate does not do this. It infringes on my liberty by forcing me to buy a product without my consent.
This is what I hear Jeff saying in his last post (and once again, Jeff is not alone. He is echoing a standard trope in conservative circles). He summarizes my argument on forced transactions as saying something like this: “If for these (i.e.. police/fire/military protection, education), then why not for that?” Jeff is basically correct, but it will help clarify my critique of Jeff’s argument if we restate the question in the opposite way: “If not for this (i.e. the individual mandate), then why for these (i.e. police/fire protection, education)?” Jeff’s objection to the ACA mandate is simply a reassertion of the moral claim that forced transactions are unjust because they infringe on individual liberty. But if this is the basis for objecting to the mandate, then on what grounds can a liberty-loving conservative affirm the justness of the other forced transactions that Jeff clearly supports? If liberty is fundamental to Jeff’s assessment of forced transactions, it’s unclear why this commitment to liberty recedes to the background when we are talking about police and fire protection, education, and EMTALA.
Let me clarify this point. It is important. With respect to police/fire protection and military defense, Jeff’s response to my argument–the reason why he is okay violating individual liberty with respect to these services–can be boiled down to this: these forced transactions are permissible because most of us agree that they are. Jeff argues that forcing people to pay for these services are the “venerable, longstanding bases” of the “American social contract.” I agree with him. However, I find it surprising that Jeff finds a mere appeal to our widely shared consensus sufficient grounds for him to part company with his own deeply held convictions about individual liberty. If liberty is so important, and if forced transactions violate my liberty, why not embrace this wholesale? Why not argue for the elimination of states altogether? Why not simply allow the market to work its magic, with individuals freely contracting with defense firms competing with one another to serve their clients? If Jeff were to make this argument, he would not be alone. Anarcho libertarians like Murray Rothbard have offered forceful, unflagging arguments against the very forced transactions that Jeff himself has affirmed in this discussion. I’m trying to understand why Jeff doesn’t find anarcho libertarianism persuasive. Jeff asserts that without state-sponsored military defense there would be no government. Yes. That’s true. So what of it? Why do you think that would be a bad thing?
On education, I agree with Jeff that education is different than police/fire protection and military defense. For one, the consensus about public education is not as venerable as is the consensus about military defense. The American public education system emerged only in the 19th century due to the efforts of educational reformers like Horace Mann. Prior to this education was informally organized, and access to education in many American communities was premised either on a family’s ability to pay a tutor or provide home-based instruction for their children, or on whether or not a community had a local benefactor who could fund charity-based alternatives for the poor. Jeff is also correct that it is technically possible for a government to operate without guaranteeing access to primary schools for all children. But Jeff is still okay with forcing individuals to pay for public schools. He argues that “it is a good thing to have a minimally competent, generally educated citizenry and workforce.” In this respect, Jeff is echoing the argument of 19th century education reformers like Mann who were convinced that the haphazard patchwork of 18th century American education was falling short of achieving this goal. Jeff also notes that ensuring universal access to education enables children to “better participate in our system of self-government.” Thus, while education is different than police/fire protection and military defense, once again Jeff is affirming a forced transaction that raises a difficult question: how do you claim to uphold individual liberty while at the same time mandating that some people pay for the education of other people’s children? As with military defense there is an anarcho-libertarian alternative to this forced transaction, defended by Thomas Woods in his recent book Education Without the State.
In short, Jeff’s argument is fraught with tension. His last blog post actually heightens this tension. Consider the range of criticisms that he levels at my argument:
- Jeff implies that when I appeal to the public effects of an individual’s refusal to purchase insurance as justification for the mandate that I am being a consequentialist. Jeff insists that he is not a consequentialist. But if this is so then what are we to make of Jeff’s own argument in support of EMTALA? What is Jeff appealing to in his considered advocacy of coercing healthcare providers to provide emergency care if not the (indecent) consequences of simply allowing hospitals to deny care?
- Jeff accuses me of being a collectivist who has a hard time understanding or acceding to an individual’s prerogative to use his property as he wants. Jeff asserts that he is not a collectivist. But if this is so, then what are we to make of Jeff’s own argument in support of tax-funded police, fire protection, and military defense? What is Jeff’s argument in support of forced taxation for these services if not an argument that allows the state to supersede my prerogative to use my property as I want?
- Jeff argues that liberals like me rely on vague notions of the common good as grounds for justifying infringements of individual liberty. Not Jeff. He is all about defending liberty. But if this is so, then what are we to make of Jeff’s own argument in support of public education in which he appeals to the creation of “a minimally competent, generally educated citizenry and workforce” as grounds for forcing taxpayers to fund schools that their children don’t attend? What is this argument if not one that assumes some notion of a common good as grounds for justifying a forced transaction?
Fraught with tension indeed. Jeff, like many conservatives, wants to frame our healthcare debate as if it is a debate between liberty-loving people like him and bleeding heart collectivists like me. It’s not difficult to see why such a frame appeals to conservatives. But here is the point, the reason why discussing police and fire protection, military defense, and public education is relevant to a debate about healthcare: these examples illustrate that the common frame that conservatives employ in healthcare debates–the frame that Jeff returns to as if by default at the conclusion of his last post–doesn’t accurately reflect our identities in this debate. This is not a debate between liberty-loving conservatives and collectivists liberals. Conservatives are collectivists too, willing to appeal to consequences and to pay homage to the common good when this reflects their moral intuitions about justice. All of us, liberal and conservative, are collectivist/consequentialist/advocates-for-the-common-good about some things. The question is whether or not these impulses, this concern for the effects of public policy on the larger community, this desire to protect this thing we call the common good, should inform the conclusions that we reach about healthcare policy too.
Jeff suggested that I “bedazzle” readers by focusing more of my time doing “theological ethics” for them. I found that request humorous when I first read it. After reading Jeff’s post my first instinct was to simply lift the entirety of Jeff’s paragraph on public education as an example of what it looks like for a Christian to appeal to the common good when supporting coercive public policy. But that would distract us from the primary topic of this discussion: healthcare. Elshtain does not speak directly to the topic of healthcare and the common good in her book, so instead I’ll take steps to respond to Jeff’s desire for a more substantive discussion of a theology of the common good by quoting at length from the January 18, 2017 letter from the US Congress of Catholic Bishops to Congress, a “Letter to Congress on the Affordable Care Act.”The letter was written by the Most Reverend Frank J. Dewane on behalf of the bishops. It states in an eloquent way what it looks like for Christians to appeal to the ideal of the common good as a basis for moral conclusions about healthcare policy. Appeals of this sort are not idiosyncratic, nor are they outside the mainstream of the Christian theological tradition, as Jeff well knows:
As you begin the 115th Congress, I urge you to work in a bipartisan fashion to protect vulnerable Americans and preserve important gains in health care coverage and access. The Catholic bishops of the United States have consistently advocated for access to decent health care that safeguards and affirms human life and dignity from conception until natural death. In a 2009 letter to Congress, my predecessor as Chairman of the USCCB Committee on Domestic Justice and Human Development, Bishop William Murphy, wrote: “All people need and should have access to comprehensive, quality health care that they can afford, and it should not depend on their stage of life, where or whether they or their parents work, how much they earn, where they live, or where they were born. The Bishops’ Conference believes health care reform should be truly universal and it should be genuinely affordable.”
Every person is made in the image of God and possesses inherent dignity. A just community strives to see and address the needs of those who struggle on its margins, and each segment of society is called to build toward a common good that creates and maintains conditions aimed at true human flourishing. In our country’s policies toward that end, we must not see health care as a luxury, but as a necessary building block to help individuals and families thrive and contribute to the good of the community and the nation.
In his encyclical, Pacem in Terris, Saint John XXIII wrote: “We must speak of man’s rights. Man has the right to live. He has the right to bodily integrity and to the means necessary for the proper development of life, particularly food, clothing, shelter, medical care, rest, and, finally, the necessary social services.” (no. 11). Like his predecessors, Pope Francis continues to echo this teaching, recently saying, “Health, indeed, is not a consumer good, but a universal right which means that access to healthcare services cannot be a privilege” (Address to “Doctors with Africa-CUAMM,” May 7, 2016)
I suspect that there is a fair bit here that Jeff will have some sympathy for: the appeal to the inherent dignity of every person created in the image of God and the desire for communities that promote human flourishing. This letter well reflects the heart of Catholic social teaching. There is a longstanding commitment in the Catholic tradition to this ideal that we call “the common good,” reflected in foundational encyclicals of contemporary Catholic social doctrine like Rerum Novarum (1891), Pacem in Terris (1963), and Laudato si’ (2015). Jeff may see this facet of Catholic social teaching as a prime example of what he accuses liberals like me of offering up, a “vague notion of social solidarity and the common good.” But isn’t one of the purposes of discussions like this to take these vague notions and to discern how we embody them in public policy? That’s what the Catholic bishops are doing in their letter. They are suggesting that in a public debate about the future of healthcare in America that access to medical care should be viewed as a right, not a privilege. They are arguing that access to comprehensive healthcare is a natural extension of a commitment to human dignity and human flourishing. They are saying that ensuring access to healthcare to all members of the community is in keeping with the Christian commitment to the common good. What do you think, Jeff? Are you not bedazzled?
I’ll conclude by pointing to one final tension in Jeff’s latest post and then point to one thing I’m hoping Jeff will do in a future post. The genesis of this online debate was a Facebook thread that I started shortly after the November 2016 election. Distraught over the results of the election, I realized that the future demanded that I reassess my own thinking about healthcare reform. With a Trump presidency looming, it was clear that the ACA was in jeopardy. Jeff is a conservative who is quite well versed on the topic of healthcare policy, certainly more than me. I reached out to Jeff and told him I was eager to learn what a conservative like him envisions as an ideal future for the American healthcare system. I’m still seeking an answer to this question. If the ACA is a disaster in conservatives’ eyes, what are they hoping for? What would a healthcare system that embodies the commitments of conservative intellectuals like Jeff look like? I want to listen and learn. I’m open to considering conservative alternatives to Obamacare.
Jeff has not yet outlined for us the contours of what he hopes for, though there are places where his comments suggest some hints of what he actually wants. Jeff’s last post, however, muddied the waters for me. Remember, Jeff’s first contribution to this discussion was his well-stated summary and defense of EMTALA. In that post, and once again in his recent post, Jeff indicates that he is not okay with people dying in the streets. This is why he supports EMTALA. But if this is so, I can’t begin to make sense of the conclusion of Jeff’s latest blog post, where Jeff discusses the logical implications of the position he embraces in a way that lead him to precisely the opposite conclusion:
[M]y first inclination is toward the freedom of the individual, because ultimately the individual is the sovereign chooser. In large part, what makes human life worthwhile is the ability to direct it myself. If I don’t want it (the health insurance), I don’t want it. I shouldn’t be made to buy it. But, at the same time, I shouldn’t get the benefits of having bought it, if, in fact, I never buy it. I should be stuck with the consequences of my decision. I should, in essence, be allowed to die in the streets. It was my decision.
Perhaps Jeff is still trying to work out in his own mind how to reconcile a commitment to liberty with the indecency he so forcefully argued against in his initial foray into this discussion. This is another one of those “fraught-with-tension” moments that needs to be resolved. To be clear, I don’t think that one can argue that we should not let people die on the streets while saying at the same time that we should. In the end, these tensions raise the question that I keep wanting Jeff to answer in our debate about the ACA: what is your alternative?