This post is a submission to the Hastings Center’s Values and Health Reform Connection, a new group blog on American values and why they matter in health reform.
In a previous post, I used Paul Menzel’s provocative contribution to the Hastings Center’s Values and Health Reform Connection as a touchstone for getting clearer on what implication the values of fairness and equality of opportunity might have for health care reform. Since that post was mostly critical in nature (I argued that they do not have the implication Menzel describes), I wanted to offer a constructive suggestion that, while not novel, might provide some reason to think that seemingly conflicting strands in contemporary political philosophy can provide mutually supportive grounds for a government guarantee of affordable access to adequate health insurance.
One thing I tried to argue in that first post was that the Rawlsian ideal of equality of opportunity does not provide the momentous rationale for justice in health care that some, including Menzel, think it does. Although Rawls is a well-credentialed liberal, he deliberately avoided the question of health justice, and it is not clear which, if any, plank of his theory could be broadened or reinterpreted to yield the pro-reform conclusions that Menzel and I stand together in endorsing.
There may, however, be a characteristic of Rawls’s view that could provide the germ of a constructive expansion. Although Menzel characterizes as “libertarian” the view that duties of justice are largely grounded in the features and consequences of special relationships, I explained in the earlier post how Rawls’s liberal interpretation of equality of opportunity stresses the ways in which features of one’s situation are the man-made result of collective decision-making by one’s society. So the distinctive features of the citizen relationship are also central to Rawls’s account. But Rawls departs from libertarianism insofar as he recognizes that the myriad social and economic choices we as a society make have such profound effects on others that they often generate strong duties of fair sharing, compensation, and fraternity. Thus even if Menzel’s conception of equality of opportunity is not itself a basic component of justice, perhaps many of its demands can be vindicated—both philosophically and, eventually, politically—in light of the special ways citizens’ lives are influenced and shaped by prevailing social and economic institutions.
Ironically, the path to such a vindication can be illuminated by none other than the most important philosophical defender of libertarianism, Robert Nozick. To be sure, Nozick is widely remembered for his bold claim that “taxation…is on par with forced labor.” But in a brief discussion of polluting activities—i.e. activities that impose “negative effects on other people’s property such as their houses, clothing, and lungs”—Nozick says that the proper response to unintentional pollution may be to “spread the cost [of addressing the negative effects] throughout society,” or, if feasible, to “place [the costs] on those who benefit from the activity.”
At this point we can follow Merrill Goozner’s lead and refer to the “vast literature on the social determinants of health” that describes the “real and enduring determinants of ill-health in our society—poverty, income inequality, social insecurity, and status anxiety.” If what the epidemiologists say is true, that is, if a central cause of poor health and health disparities is the pattern of social and economic choices made by society at large (and not by individuals on their own), then there is an argument, potentially compelling to the liberal and the libertarian alike, for coercive social measures that spread the costs of addressing consequent ill health throughout society.
We can now see that the objection on the part of the well-off to subsidizing the premiums of the poor or the care of the ill might have a conclusive rebuttal. If economic arrangements that generate inequalities also contribute significantly to the poor health of those who are ill, then it seems reasonable to require those who have benefited most from these arrangements to contribute to health care of those who benefit least and who turn out to be actively harmed by those same arrangements. In the search for rationales that might win wide consensus, then, there is some reason to hope that empirically informed arguments that are good enough for both Rawls and Nozick could be good enough for the American people.
Unfortunately, a recent study soon to be published in the American Journal of Public Health gives us reason to believe that cogent arguments will not be enough by themselves. The study finds that when presented with news stories explaining that individuals’ Type 2 diabetes is genetically caused, both Republicans and Democrats respond with some willingness to use public funds to address the medical problem. But, when presented with news stories explaining that social and neighborhood factors beyond an individual’s control cause diabetes, Republican—but not Democratic—support for public intervention wanes. So a person’s political leanings seem to have an effect on his or her receptiveness to normative arguments that should be resonant with both left-leaning and right-leaning political philosophies.
Does this mean that we philosophers must go back to the drawing board, normatively speaking? It does not. It does mean that we should be mindful that philosophy isn’t politics or advertising, and that some well-meaning advocacy campaigns may have unintended consequences. But this is likely true for virtually any cogent argument strong enough to justify robust government action where it was previously lacking and where some adamantly believe it should not exist. Fortunately, some of the very social scientists that first taught us about the social determinants of health have already begun to think systematically about how to design messaging strategies to educate the population about the many social causes of ill health. This confirms that whatever happens during this current round of reforms, it will be absolutely essential that philosophers and social scientists strengthen and extend their cooperation. Neither group can succeed without the other, but with a little luck we can together translate the rather ecumenical case for progressive health reform into political action supported by those whose values comport with this case, but who were nonetheless previously reluctant to support it.