Utilitarianism in Health Care
The newest addition to the Atlantic’s impressive list of bloggers, Megan McArdle, an economist with strong libertarian leanings, does not approve of single payer health care systems. She makes on her argument on what she considers social justice grounds. Here is what she says:
“A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick. It does not distinguish much more finely than that between the deserving and undeserving within that class. This is why discussions of particularly deserving or undeserving people within the larger class, such as your fine old Uncle Bob who served his country in two wars before becoming a minister, are irrelevant; … almost any class we can specify will contain some very worthy members who deserve more from society than they have gotten. What we need to know is whether the class of old and sick people as a whole are much more deserving than the class of young and healthy people; whether our transfers do more good than harm.Single payer advocates seem to invariably assume that the answer is yes. This is a natural reaction; the old and sick inspire our sympathy. But I am not sure that, as a group, they should also summon our sense of social injustice. How do we decide which class is more “deserving”? Our intuitions offer dozens of ways, but I think these are the major metrics: (1) They are needy. The class we propose to benefit has greater need for the money than the class from whom we propose to take. (2) It’s not fair. The class we propose to benefit has been unluckier than the class from whom we propose to take. (3) They are responsible. The class from whom we propose to take has in some way contributed to the problems we are trying to rectify.”
On all three grounds, she argues that social justice considerations do not support a transfer from the young and healthy to the old and sick on social justice grounds. As I read this, I felt there was something very wrong with her reasoning. Personally, I am in favor of single payers systems, and on the record as saying so. But I’m the first to admit that there are valid Catholic arguments against single payer systems. There is nothing intrinsically evil about choosing to fund health care in a different manner.
But still, at least from a Catholic perspective, there is something fundamentally flawed in McArdles’s reasoning. Here is the problem: it treats social justice not from the point of view of the common good, but from an individualist ethic ultimately derived from utilitarianism. Like all teleological philosophies, it is only outcomes that matter, and these outcomes are defined in terms of maximum utility, or happiness (utilitarianism is of course, a special application of consequentialism). The main problem, of course, is that it takes no account of whether an act is inherently right or wrong, irrespective of consequences. This kind of thinking arose directly from the Enlightenment, and a flawed concept of rationality based on what can be demonstrated empirically. As Pope Benedict noted, in a world based on calculations, it is the calculation of consequences that determines what should be considered moral and immoral.
I think this manner of thinking owes as much to Thomas Hobbes as it does to classic utilitarians like Bentham. It was Hobbes who, more than anybody else, led to the idea of social contracts overtaking the common good as the object of policy. Hobbes did not see humanity as an organic community underpinned by the common good; he saw instead a collection of individuals all seeking mastery over each other, necessitating some form of “social contract” to keep the peace. The individual is everything, the community, nothing. It follows naturally that social justice flows from the aggregation of individual happiness, rather than an organic conception of the common good. But the common good stems from the dignity, unity and equality of all people, not some mechanical calculation. It refers to “the sum total of social conditions which allow people, either as groups or as individuals, to reach their fulfilment more fully and more easily”. It is the social and community dimension of the moral good. While it is underpinned by the dignity of the human person, it is not an individualist ethic; rather, it recognizes that there is no fulfilment if the individual does not recognize that he or she exists “with” others and “for” others.
To see the bankruptcy of the contracts approach to justice, consider abortion. Clearly, the unborn are not agents that can participate in a social contract. Clearly, their welfare must therefore be discounted, and subjugated to the welfare of others, who are proper contracting agents. It is this notion that underpins the pro-abortion position today, and it stems from a failure to understand the encompassing and organic nature of the common good.
Back to health care. McArdle engages in a classic utilitarian calculus to argue that social welfare is not increased by a transfer from the young and healthy to the old and sick. It’s all about individuals, and “welfare” is limited to wealth. Whereas the right to health care is regarded by the Church as basic to the common good, the utilitarian approach instead sees only a collection of individuals out for themselves, and therefore largely responsible for their own health care. Within this individualist ethic, a social contract can indeed justify redistribution, but this is based on extremely limited characteristics, such as luck and personal worthiness. Nowhere in sight is the core principle of solidarity, a “a firm and persevering determination to commit oneself to the common good”. Nowhere is the idea that our interdependence coupled with the right to health care may call for the young and healthy to look after the needs of the old and infirm, irrespective of circumstances. And that is what troubled me most about McArdle’s reasoning.