"You shall know the truth, and the truth shall make you odd." ~Flannery O'Connor

Saturday, July 25, 2009

Health care: getting clear on the premises

For the past several days, I've watched the debate at What's Wrong with the World about Obamacare in particular, and the economics of health care in general, with growing frustration. I am frustrated because, to my mind, there's little use in debating such questions without achieving some clarity about what the pertinent moral premises ought to be. So much is, or ought to be, obvious; and many of the participants have indeed expressed their moral premises. But I see no agreement on what it would take to resolve the disagreements at that level, or even an awareness that reaching such an agreement is important. Since I believe it is important, I shall suggest a way of reaching, or attempting to reach, such an agreement.

To that end, the point of departure is the question is how we would reach agreement about formulating the goal of a national health-care policy. Personally, I see the goal as ensuring quality health-care for everyone at a cost the nation can both afford and accept. But making that our goal makes sense only if some level of health care must be treated as a politically enforceable right, not just as a market-priced commodity. Libertarians would not agree that health care should be treated as such a right at all, and non-libertarians do not agree on the extent to which health care should be treated as such a right. So the next question to be addressed is how resolve such disagreements.

I believe that question can and ought to be resolved in contemporary America. To that end, there are two points to consider: what citizens in general actually believe, and how their beliefs need to be modified in order to make possible a political resolution.

Americans in general believe that nobody should be forced, just by their inability to pay, to go without the health care they need for living life with a modicum of human dignity. Both our political policies and our private practices reflect that belief. It follows that Americans in general agree that health care should be treated as a right to some extent. So the libertarians have already lost the debate. The main point of contention is just how that extent can be defined and respected in a manner consistent with what I claimed is the goal: "quality health-care for everyone at a cost the nation can both afford and accept." That is largely a question of politics and economics: specifically, what politically feasible means of delivery would best attain the stated goal. Like most conservatives, I believe that Obamacare would fail miserably on that score, even aside from such intractable moral issues as abortion and euthanasia. But more importantly, not even conservatives can answer the main question without first gaining more clarity about our moral premises.

To that end, the chief moral question is what it means to "live life with a modicum of human dignity." That in turn requires that we get clear about our philosophical anthropology; for we cannot resolve major disagreements about what "a modicum of human dignity" entails without a clear, self-consistent answer to two other questions: what is the human person, and what is the human person for? In a blog post, of course, nobody can answer such questions to the satisfaction of all. What I suggest for general consideration, however, is the proposition that the principles of solidarity and subsidiarity, as expounded in Catholic social teaching, are those best suited to addressing the health-care debate in contemporary America as well as many other domestic-policy debates.

I say so because most Americans would agree that both principles are valid and mutually compatible. I say "would" agree because most Americans are unfamiliar with the terms, and still fewer know the philosophical and theological background for the corresponding concepts, but nonetheless hold beliefs that are fairly close to each. Accordingly, I suggest that the empirical debate about the economics of health care be conducted as a debate about how to balance solidarity and subsidiarity in heath-care provision. What I propose thus far is of course a framework for the debate, not a particular resolution of the debate.

I also propose clarifying that framework in one crucial respect: the morality of rationing. In a world of finite resources, any system of health-care delivery—be it purely market-oriented, socialized, or some hybrid of the two—is going to allocate health-care resources in such a way that some people get less care than they believe they need for living life with a modicum of human dignity. So the rationing question boils down to the question on what basis some people will have to get what they believe to be "the shaft." This seems to be the most morally and politically contentious question in the health-care debate.

Consider the fact that, under the current system, Medicare is variously estimated to spend 40-60%—i.e., roughly half—of its budget on care for people in their last three months of life. No doubt some of that expense is justified; but there should also be no doubt that some of it is not. Much of it is driven by the unwillingness of elderly patients and/or their families to accept the impending fact of death. Unless and until that attitude changes, no large-scale reform of our national health-care system will be both attainable and affordable. People who can afford to buy a bit of time for themselves or their loved ones, however wretched that time may be, should of course have every right to do so. But should their fellow citizens be forced to subsidize such choices? If we're going to achieve national health-care reform at all, the answer has to be no. That is not only a self-consistent but an inevitable way of balancing solidarity and subsidiarity.

This suggests that our national health-care policy should be a hybrid: socialized care for those who cannot pay for what they truly need "for living life with a modicum of human dignity," and free-market solutions for those who can. It is at that point, and only at that point, that debating economics becomes central. But we will not be able to reach that point unless the reality and necessity of rationing is generally accepted. And no such acceptance will become general unless we get our philosophical anthropology—i.e., the basis for solidarity and subsidiarity—straighter than we've got it.

Cross-posted at What's Wrong with the World.
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