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Egoism and the right to health care

English: Barack Obama signing the Patient Prot...

English: Barack Obama signing the Patient Protection and Affordable Care Act at the White House (Photo credit: Wikipedia)

Recent events have put Obamacare at the front and center of American political consciousness–and in doing so, focused attention directly on the right to health care. Objectivists and libertarians are deeply frustrated at the acquiescience with which Americans have greeted both things–Obamacare and the right to health care. But I think this frustration conceals something from view that Objectivists in particular have failed to grasp, and need to grapple with. Americans’ acquiescence in Obamacare, and the right to health care, is explainable in large part by an unresolved tension within Objectivism itself. I don’t mean that this tension is unresolvable or inevitable. I simply mean that it’s there. Until it’s resolved, we should all brace for frustration and political failure.

Objectivism endorses all four of the following propositions:

(1) All moral agents ought (qua moral) to act in their rational self-interest.

(2) There are no conflicts of interest among rational agents acting rationally.

(3) Rights have to be understood in such a way as to allow us, in emergencies, to take actions that would be rights-violative in non-emergencies.

(4) There is no positive right to health care, i.e., no right to be provided health care by unconsenting others.

I suppose one could quarrel or quibble with whether or not Objectivism endorses this or that claim, but I think it’s clear that it endorses all four.

Suppose that I endorse (1) and (2). Then my adoption of (4) must be conditioned on my justified belief that (1), (2), and (4) are consistent. Put another way: in endorsing (1) and (2), I must be justified in my belief that the rejection of a positive right to health care is compatible not only with my pursuing my self-interest, but with anyone’s pursuing his or her self-interest at the same time. Suppose now that I am either extremely ill, or suffer a significant injury, or rationally fear the high probability of either becoming extremely ill or suffering a significant injury. I must then be justified in believing that my adoption of (4) is compatible with my medical condition and/or my fear of such a condition. I must justifiedly believe that, all things considered, I benefit by foregoing a right to be provided with precisely that health care that would relieve my illness, my injury, or my justified fear of both.

If, for example, I have cancer, then if I endorse (1) and (2), it must be demonstrable that in adopting (4), I promote my interests. There must be some benefit, such that, even if I have cancer, my rejection of the right to be provided with cancer treatment is in my interests, whereas my adoption of such a right is not. I must somehow benefit via the willingness to forego this “right” and lose out by the willingness to adopt it. This must be the case even if, in my case, the willingness to adopt the right might make it more likely that I receive cancer treatment (and live to old age), and the willingness to forego might make it more likely that I don’t (and die prematurely). And so on, across the entire breadth of illnesses, injuries, and rationally-justified fears. (I don’t mean that the person in question must actually be persuaded by the demonstration, but that the demonstration must succeed as a rational justification of the relevant claims.)

Suppose, once again, that I have cancer. Suppose that I endorse (1) and (2), but find (4) implausible. So I reject (4) in the name of (3): I have a right to health care (I tell myself) because my medical situation is an emergency. While there is, generally speaking, no right to health care–this reasoning goes–there is one in cases of life or death, i.e., where the failure to be provided with assistance would lead (in a relatively direct causal way) to premature death.

One problem here is that the parenthetical in the last sentence is vague. A second problem is that the conception of  “emergency” just invoked isn’t the one Rand defended in “The Ethics of Emergencies”; her definition is much narrower, and explicitly excludes things like illness. So if the reasoning of the preceding paragraph is right, Rand’s definition of an emergency is wrong; whereas if Rand’s definition is right, then (4) cannot be rejected or modified in the name of (3). One or the other thing (or some third thing) must be the case. Either we adopt Rand’s definition of emergency, and foreclose the idea of justifying a right to health care in cases that fall outside of that definition; or we broaden the definition, and justify a narrow right to health care in cases that fall within the broadened definition; or some other option. But the stated options are exclusive.

What Objectivism needs is a full, comprehensive resolution of the apparent tension between (1)-(4). We need an account, for cases like serious medical conditions, of how it is that the rejection of a positive right to the resolution of the condition promotes the agent’s interests, whereas acceptance of such a right does not promote them.

My point is not to claim that such an account is impossible, or even implausible, but to insist that it does not yet exist. I’ve read the entirety of the existing Objectivist literature on the subject. Even the best effort on the subject–David Kelley‘s A Life of One’s Own–falls short of doing what needs to be done. (This is not to criticize the book at all, but simply to observe that it doesn’t deal with the issue I’ve described here.) If I’m right about that, no Objectivist can be justified in insisting on (4) while abstracting from its relation to (1)-(3). On the Objectivist view, insistence on (4) presupposes an adequate defense of (1)-(3).

I don’t think there is such a defense right now. That is the basic problem I have with almost all Objectivist polemics on this subject. Such polemics begin in midstream, insisting on derivative political claims while leaving the fundamental ethical ones basically undiscussed and undefended. That, it seems to me, is what explains the peculiar hysteria that seems expressed in such polemics. The more loudly its exponents insist on their claims, the more they seem to become conscious of the tension within them–and on the need to downplay that tension in the heat of argument. But that is not a sustainable strategy for political success. It’s a recipe for self-marginalization, and ultimately, self-deception.

My practical suggestion to Objectivists would be to redirect their effort and resources away from celebrations of the government shut-down (and outrage over Obamacare) and toward offering a more defensible version of the Objectivist argument with respect to (1)-(4). Virtually every political frustration we face can be traced, in some way, to our failure to do that.

Feel free to resent the coercion in Obamacare, to criticize it, and to resist it. But ask yourself all the while how much is gained by an approach to politics that demands on the one hand that we insist on egoism, and then seems to turn around and demand what look and sound like acts of self-sacrifice in the name of liberty. If we have nothing to say in answer to the question, “What’s in it for me?” we have no way of winning any argument on our own terms. It is one thing to say that a cancer patient gains by foregoing a right to health care. It is another thing entirely to say that a cancer patient’s self-interest doesn’t matter because liberty matters more. If we cannot get this distinction right, we cannot get politics right. What absolutely cannot be done is to blur the two options into one indiscernible polemical blob.

Honesty should tell us that we lack an account reconciling the Objectivist conception of egoism with the Objectivist conception of liberty. Justice tells us that we owe such an account to our interlocutors regardless of their state of physical health. Pride should dissuade us from settling for a less ambitious approach to politics. Productiveness should get us started on the job.

Irfan

(Thanks to Kate Herrick and Michael Young for valuable discussion on this topic. Neither Kate nor Michael should necessarily be taken to agree with anything I’ve written here.)

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5 Comments

  1. Matt Faherty says:

    I don’t see how the issue you raised is crucial to the Objectivist position on heath care. The vast majority of Americans and voters are not cancer patients or suffering from an immediate disease. They are ordinary customers of a completely irrational pseudo-insurance system who fear they might one day become sick. For such people, the normal libertarian/Objectivist arguments are adequate: The current healthcare system and Obamacare violate individual rights, raise costs, destroy quality, doesn’t make actuarial sense, etc.

    Your argument is a sub-set of a common anti-liberty argument which I think can be broadly refereed to as the “political prudent predator” argument. Why get rid of state intervention if I happen to be the beneficiary at the given moment. Off the top of my head, my counter arguments are:
    – it is psychologically damaging to live as a dependent of the state, at the expense of others
    – you may be a beneficiary of state action at the moment, but in the future, when a new gang or sub-group of looters takes power, you may get the short end of the stick
    – your family and friends are probably being harmed by the system.

    Admittedly, the effectiveness of these arguments might be lessened for an individual who is in a “loose” emergency, but I still think they basically apply, accept the second argument if the individual dies.

  2. irfankhawaja says:

    I’m not actually endorsing any anti-liberty argument; I’m explaining the correct burden of proof for the pro-liberty argument. My point is that the burden of proof is higher than Objectivists realize, not that the pro-liberty argument cannot successfully be made. But fair enough: I can elaborate on why it’s crucial to set the burden of proof higher than most Objectivists realize.

    One implication of the non-conflicts-of-interest principle is that the best social system requires no sacrifice of interests for anyone. That implies that it requires no sacrifice of interests for the ill, the injured, as well as those who rationally expect the possibility of either outcome. “The ill, the injured and those rationally expect the possibility of either outcome” includes everyone, not just the majority. I used cancer just as an example, but you can change the example to just about anything. You could include those who rationally fear the possibility of getting cancer, or those who rationally fear the possibility of _____________, where the blank is any serious injury/illness. Rationally speaking, everyone must have this fear and (somehow) plan around it. I haven’t specified how. All I’ve said is: whatever the answer to “somehow,” it has to promote every beneficiary’s interests better than all of the other available options. If there is no such option, fine; but we’d have to prove that.

    I’m not disagreeing with anything you say in criticism of Obamacare or a nationalized system. I’m saying it it doesn’t add up to a conclusive case. Its lack of conclusiveness is why millions of people reject it on the basis of other considerations they regard as more important, and why we have Obamacare in the first place.

    Matt: Obamacare violates rights? Opponent: it’s not in my interest to respect rights.

    Matt: Obamacare raises costs. Opponent: well, I don’t have insurance now and have no access to health care, so if the costs are redistributed, it’s in my interest to get better access than I have.

    Matt: Obamacare destroys quality. Opponent: But the redistribution of quantity compensates for that.

    Matt: Obamacare makes no actuarial sense. Opponent: It’s not supposed to. It’s a redistributive program, not a literal insurance policy. Actuarial standards are the wrong ones to apply.

    Matt: It is psychologically damaging to live off the state. Opponent: It is more damaging not to know whether, if you have a serious health problem, you will have access to health care.

    Matt: You may be a beneficiary now, but you won’t be in the future. Opponent: Show me this in some detail. If you do, I’ll accept your case.

    The “friends and family” bit is just a repetition of the preceding issues.

    My point is not that Matt is wrong and the opponent right. My point is that Matt & Co. (I’m part of that company) have a much longer way to go than they realize in responding to the opponent. It’s in their interest in stopping and making the realization in order to re-direct their efforts, not to keep repeating the same arguments and wondering why America seems to have accepted Obamacare.

    The health care issue is an instance of the “prudent predator” issue, but in a way, that is my point. The Objectivist literature on that subject is inadequate. There are a few programmatic sketches of arguments, but nothing comprehensive enough to win the day. We have to face that fact before we try to win political battles at the national level. This is why I said elsewhere that the whole idea of an Objectivist movement is premature. If the philosophy isn’t built up, the movement isn’t going to go anywhere.

    Irfan

  3. Michael Young says:

    The problem that Objectivists have, but non-initiation-of-“force” libertarians do not, is that of obligations being defeated merely by the weight of non-moral, personal reasons (in particular, reasons of personal well-being) – and when those reasons do not concern one risking life or limb to fulfill the obligation (emergency situations). Such egoistic considerations might either support prudent predation or a system of rights according to which getting health care from non-consenting others does not constitute predation (but rather the enforcement of a moral right that is appropriately enforced by the state). This problem is especially acute because these reasons of personal well-being are precisely what Objectivism offers as the *basis* for moral rights (or “what we owe each other”) – and as the basis for the state using the threat of imprisonment (and, ultimately, of a violent confrontation that you would lose) to enforce the non-violation of certain of those moral rights (and probably other rules besides).

    Absent the burden of this (or any other) attempt an a deep explanatory-style justification, all of us have sufficient reason to believe that we owe it to others not to prey on them or treat them as mere resources. And sufficient reason to believe that there are exclusive property rights that are very similar to what we have now. We also know that there are general social conditions of benefit to all (including the condition of the do-not-steal rule being effectively enforced) that cannot be achieved without the forcible action of the state – and that are important enough to use the overwhelming threat of force by the state in order to achieve. In particular, taxation for such legitimate, public goods is justified – it is a caveat built into any principle of secure, exclusive ownership of property in a society.

    We also know that we don’t owe others charity in the sense of it being legitimate for them to demand it of us. More importantly, though we *may* owe others things via our participation in collective action that affects them (in simply living together in society, being a citizen, etc.) and having a share of the responsibility for the intended and unintended consequences of that action, what we owe most plausibly would be not *putting* people in a bad way in going about our business in society and having the state act on our behalf. But people in a bad way through no fault of their own might simply be victims of bad luck – no obvious obligation there. And people in a bad way might have simply made bad decisions that they are appropriately held accountable for (though probably still are appropriately objects of charity, though preferably of a sort that encourages more responsibility and better decisions) – again, no obvious obligation there. For the most part, society does not *put* people in a bad health care position and, to the extent that it does so, it may well do so via bad state policies. Only if the market *put* people in such a position and only if there were no permissible tweaking of the exclusive-property-rights rules and regulations that would fix it, would a forced-wealth-transfer scheme – this sort of radical departure from the exclusive-property-rights-with-taxation-caveat scheme – have strong, clear reasons of justice behind it.

    (The part of the above that goes beyond intuitions and into theoretical conjecture is the part on behalf of, and the response to, the idea of social responsibility and justice – a non-obvious idea that is not well-developed in our scheme of intuitive judgments (and that the progressive left deserves credit for bringing to the fore). What is missing, on the “right” side, is a theory that ties together the various intuitive strands of a system of requirements that largely require non-interference and protect a wide berth of morally and physically free action for each individual. I don’t think egoism is well-suited to do this work, though it is easy to why this might seem plausible. In any case, a good theory would vindicate these sorts of intuitions, allow us to prioritize them when they conflict, evaluate things like the collective-responsibility conjecture of the social justice theory, and allow for the “construction” of systems of requirement and permission that serve relevant ends in circumstances that our systems are not well-adapted to. And satisfy our curiosity about what general principles could do all this work!)

  4. irfankhawaja says:

    I think the response to all of that is very simple. If we’re going to admit intuitive judgments at the ground floor, the intuition that most Americans have is that there’s a positive right to health care, and it overrides everything you’ve said. You might call that “predation” or “using others as a resource,” but intuitively, few people would or do put things that way. The rest of what you’re saying we “know” is something that, intuitively, no one can be said to know. In asserting it, you’re begging the question against any interlocutor who believes in a right to health care.

    So I don’t think the problem is avoided by giving up the Objectivist commitment to ethical egoism. You’ve just pushed the same problem to a different place. You’ve solved the problem of reconciling rights with egoism by insisting that the reasons of the person demanding a right to health care are somehow “non-moral” and can on “intuitive” grounds be discounted or dismissed. But “intuitively,” no left-leaning interlocutor would ever grant that. He or she would simply say: if the demands of those seeking a right to health care are not moral, nothing is. That’s a ground-floor intuition, and every other belief must be brought into reflective equilibrium with it.

    Obviously, I’m not agreeing with that interlocutor. I’m just saying: given your premises, he has a point, and probably wins the argument. At any rate, I’d give it to him on points.

    Irfan

  5. Michael Young says:

    Sure, one might insist that it is permissible for them to demand that their extreme needs be met by others. The thing is, most of us don’t believe that. Most of us believe that it is only when one is in special relationships (friendship, marriage, parent-child, etc.) that such demands are permissible. And most of us believe that we have a general moral obligation to help others (including strangers) in dire need that is not correlated with their being permitted to demand this of us – let alone their being permitted to enforce this demand through the state (if we think of obligations proper as correlated with permissible demanding, we can think of such obligations to help others in need as our having strong *pro tanto* moral reason to help others in dire need). Sure, such intuitions might be wrong. And they might be steadfastly denied, but I don’t think they are honestly denied (though one might honestly think that they are overridden or revealed to be erroneous relative to some theory).

    My response to the steadfast denier? “Wow. Do you really think that it is not only really important for being a good person to help others, but that it is okay – in some ground-level way, not as the result of some non-obvious facts about our particular circumstances of living together in society or some background theory – for people in need to simply demand that their needs be met (at least if they are dire enough) – and have that demand enforced through the state?” That would be to start a sensible conversation based on recognizing, and recognizing some substantive, ground-level intuitions about, a fundamental distinction in the structure of morality or moral reasons.

    It is plausible for the left-leaning person to point out that there is such a thing as permissible-demand-correlated obligations that society has not to treat individual people of groups of people in a way that harms them arbitrarily (or that is otherwise grossly unfair) – i.e., social obligations that each of us has to do his or her part or fair share in bringing about society not doing such things. I don’t think this point gets folks as far as they think because you need an analogy to individual action and negligence to get very far in justifying social or collective-action obligations that cover very many broadly “distributional” consequences in society. (Also not all moral reasons to alleviate the “unfairness” of bad luck or misfortune are proper, permissible-demand-correlated moral obligations; many are merely strong *pro tanto* reasons.)

    I suspect that strong general social utility arguments and weaker social justice arguments (and paternalism arguments as well) suffice to support mandatory participation in some general schemes of social insurance. But this is not because I can permissibly demand that you pay for my medical care simply because I need it (let alone permissibly have this demand enforce through the state). Any permissible demands and general obligations to do one’s part so that society does the right sorts of things are of a different sort (and many concern insisting that everyone does their part for the state to achieve its the proper ends – not the broadly distributional outcomes that constitute how society “treats” people in pursuing its proper ends). So I think that the “proper obligations of altruism” justification for rights is more a popular argument than an argument that survives minimally systematic criticism and thought. This is why Rawlsians, for example, rely so heavily on social justice type arguments (even if they are not framed quite as I just framed them, in terms of collective action and responsibility). I think that addressing this sort of popular rights-of-altruism argument publicly is quite important, however, as it is this moral idea, not so much the more-subtle social-justice idea, that has the most impact in the world. (If a signficant chunk of voters did not mix up being uncharitable or cruel with it being proper to demand, and to have the state enforce one’s demand, that others help one out, our social and political world would be much different and much better.)

    I realize that the Objectivist project, like all serious philosophical projects, seeks a deeper explanatory-style justification for *why* it is true, if it is true, that there is no general moral permission to demand that others take care of one. Completing such projects is hard. They are much harder if we do not allow for what we honestly think just seems right – our intuitions – as a defeasible part of our “foundation” for grounding a full, deep, explanatory-style knowledge. Of course, there is the ever-present danger of our intuitions being infected by pragmatic bias, in-love-with-my-conjecture bias, bad background theory, confusion, and built-in error (things that naturally strike us as true that ain’t). It is partly the necessary hazards of our having to start with and defeasibly trust our intuitions that makes the philosophical explanatory and justificatory project legitimately hard. It is a good thing that some of us – like Irfan – are super-sensitive to these dangers and urge us not to simply run with our intuitions without attempts at constructing the sort of theory that might vindicate them and explain why they are true (when they are true)…

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