Ronald Dworkin is probably the most prominent living liberal political philosopher in the United States. Unsurprisingly, he favors a national system of universal healthcare. But at a philosophical level, Dworkin also very clearly holds exactly the same position a lot of viewers seem to regard as not simply wrong, but self evidently monstrous when it was ascribed to Ron Paul (or at least Republicans in the audience) after the recent Tea Party debate. That is, Dworkin believes that if someone enjoys a fair share of social wealth and resources, and makes a free and informed choice about the level of health coverage and care they wish to purchase, then justice is satisfied when they receive the care they have chosen to pay for (either directly or by way of insurance). If it turns out that someone then needs care beyond what they chose to purchase under these conditions, it is not morally incumbent on society to provide that care. If you want to be melodramatic about it: Society (or at least the government) should “let him die.”
You don’t have to take my word for it, of course: Go read chapter 8 of Sovereign Virtue, Dworkin’s major work of political (as opposed to legal) philosophy. As he makes clear there, he believes government should provide some level of universal coverage under conditions where wealth and genetic luck are unjustly distributed, and the difficulty of becoming properly informed about the state of medical care and relevant statistics is so great. But he also reasonably he rejects a general “rescue principle” for healthcare—the principle that society must never “let someone die” or go without care if there is money in the public coffers to intervene—as “useless,” “preposterous,” and one that “no sane society” would adopt. The correct standard for what kind of coverage a society should provide, he argues, is given by trying to figure out what kind of health insurance policy and coverage most members of a particular society would choose if they were well informed and had whatever fair share of social resources is specified by general principles of economic justice. (Those principles might specify that people just born with unlucky ailments are independently entitled to a larger share; Dworkin is mostly thinking here about people who begin life reasonably healthy and will require different levels and types of care over time owing to the vagaries of life.)
Most people, Dworkin acknowledges, would reasonably forgo coverage for many types of risks or treatments, preferring lower premiums and greater present consumption. He suggests, for instance, that most reasonable people under his idealized conditions would not find it worthwhile to purchase coverage that would support their indefinite sustenance in a persistent vegetative state, or heroic and expensive interventions likely to extend life by a few months in old age.
In a society where Dworkin’s background conditions are met:
[H]owever health care is distributed in that society is just for that society: justice would not require providing health care for anyone that he or his family had not purchased. These claims follow directly from an extremely appealing assumption: that a just distribution is one that well-informed people create for themselves by individual choices, provided that the economic system and the distribution of wealth in the community in which these choices are made are themselves just.
Now, again, Dworkin’s premise all along in this argument is precisely that our society does not meet his background conditions, requiring government to supply care as a kind of second best. In our far-from-ideal world, he writes, the government should simply “construct a mandatory coverage scheme on the basis of assumptions about what all but a small number of people could think appropriate, allowing those few who would be willing to spend more on special care to do so, if they can afford it, through supplemental insurance.” In Dworkin’s view, then, if someone needs medical care that the modal informed consumer would not have chosen to cover under conditions of economic justice, that patient should get that treatment if and only if he has chosen to purchase supplemental insurance. If he has not chosen to purchase that coverage, there is no moral requirement for the public to provide it. Or again, if you still want to be melodramatic, society should “let him die.”
In a society that did satisfy Dworkin’s background ideal of economic justice—a society not perfectly egalitarian, but clearly far more so than our own—it follows from his argument that someone who made a free and informed choice to purchase less coverage than most also need not be provided by society with additional care. Our own society, of course, does not meet Dworkin’s background conditions. But Wolf Blitzer’s thought experiment at least arguably does satisfy them, if we take the liberty of reading his stipulation that the imagined patient “makes a good living” to imply that the person enjoys an economically just share of social resources, and has made the choice to forgo coverage after informed deliberation.
So under appropriate conditions—clearly not satisfied for very many poor Americans, but at least arguably satisfied within parameters of Blitzer’s hypothetical—the most prominent living liberal philosopher gives pretty much the same answer as Ron Paul: People should bear the consequences of their freely assumed risks, and “society”—or at least the government—should let them.
“But,” I hear the indignant cry, “Dworkin still advocates universal healthcare as a matter of public policy!” Well, yes. But you don’t pose stripped down, idealized, and unrealistic hypotheticals about single individuals to answer complicated public policy questions. You use them to get at very elementary moral principles. If the question is really about what kind of complex institutions should be established by statute in light of all we know about healthcare markets, reducing it to a single decision about how to respond to one imaginary person is obtuse. If the point is to reveal underlying principles, then those are valid or invalid independently of how they interact with other moral or political principles, or empirical considerations, to generate a real-world policy view.
Anyone who thinks Ron Paul’s answer to the hypothetical is appalling and outrageous, then, should direct some appalled outrage at Dworkin, because he gives exactly the same answer within its artificial, stipulated parameters. If Paul is a ghoul but Dworkin’s cool in virtue of their different policy positions outside the conditions of the hypothetical, then those who see Paul’s view as appalling should acknowledge that the reaction to the Blitzer thought experiment is an irrelevant red herring, and what matters is (say) Paul’s awful views on economic justice, where he pretty clearly does differ from Dworkin. Then at least everyone can work up a righteous lather about the correct issue.
25 responses so far ↓
1 Chuchundra // Sep 21, 2011 at 9:40 pm
The difference is that Paul’s position on this issue is a real opinion about real people who might really die and he’s OK with that. Dworkin’s is an extreme hypothetical thought experiment based on conditions that have very little chance of coming to exist.
It’s like asking people if they would shoot their mother in the face with a shotgun. Person A says, “Yah, my Mom really pisses me off some times. I could see myself doing it” and person B says “If there was a zombie apocalypse and she got bitten, then I’d guess I’d have to”. You can’t just tick off “would shoot mother in the face” for each of them and call it equivalent.
2 Julian Sanchez // Sep 21, 2011 at 11:13 pm
Not true in the least. As Dworkin himself observes, his principle implies that very many people now being provided with expensive coverage under Medicare should NOT be provided with such coverage.
3 ascholl // Sep 22, 2011 at 12:06 am
“But at a philosophical level, Dworkin also very clearly holds exactly the same position a lot of viewers seem to regard as not simply wrong, but self evidently monstrous when it was ascribed to Ron Paul (or at least Republicans in the audience) after the recent Tea Party debate. That is, Dworkin believes that if someone enjoys a fair share of social wealth and resources, and makes a free and informed choice about the level of health coverage and care they wish to purchase, then justice is satisfied when they receive the care they have chosen to pay for (either directly or by way of insurance).”
But that’s emphatically not the position Paul takes — or if it is, his notion about what entails a ‘fair share’ and ‘free & informed choice’ are wildly different from Dworkin. It seems pretty safe to believe that the thought experiment presented at the debate was supposed to take place within a system that we could imagine (however unlikely it is) Paul establishing in our existing real world. Imagining it likely that Blitzer’s hypothetical was meant to satisfy conditions under which Dworkin would support a laissez-faire health care market is utterly contrary to occam’s razor.
Also: it’s not especially relevant for this particular scenario, but in the passage you cite, Dwarkin requires three adjustments to reality before entering into a free market system: equitable resource distribution, sophisticated individual understanding of health risks and technology — better understanding of risk than many doctors possess, actually — and that insurers not adjust rates based on individual risk. Not immediately relevant in this scenario, but an awfully big thing to leave out in your synopsis.
No doubt many people objecting to Paul’s comments believe that every effort should be made in every situation to ‘save life’, no matter the cost or likelihood. I doubt most are so dim, though, and pretending that folks objecting to ‘let him die’ must necessarily think this way does them a disservice.
4 jeannine // Sep 22, 2011 at 3:40 pm
One of the differences between Pauls position and Dworkins is the Fairness and Justice issues.
For example; I pay 20 grand a year with very high deductables.for my healthcare plan for my self and 2 kids.My son and I have asthma so our premiums have risen substantially in the last decade.We are forced to pay these outragous charges because the fear of not being covered and losing everything we worked so hard in one felled swoop if we had an emergency situation is a cruel reality,as it is for all americans. Believe me if we didnt have the assets and could get out from under this form of extortion we would.So I understand someone who may “have the money” to afford health” insurance” not wanting to be robbed by these unreasonable for profit insurance companies.
So if all things being “equal ” and americans had a fair equitable system for acheivement and attainment {which we dont by a long shot} then presumably all americans would have at least minimum coverage {single payer system?} where those who can afford more are able to purchase a more “premium” plan with their fairly earned higher wages.So those people who can afford the more premium package are making an informed “choice” to forgo special treatment they could have purchased.Those people would be making an “informed ” choice.{ Although I might add until someone has either been sick or injured or around someone who is thinking that might happen to oneself ,especially when young ,they might think…I dont need to be covered for THAT…and made an “informed ” choice not to pay for that type of coverage.Most especially the young.
Dworkins and Paul would agree we spend too much on extreem interventionalist care for the elderly and disabled.Terry Shaivo is a perfect example.One could easily say we prolong suffering with many of our “treatments” and with a for profit system there is no disadvantage to that.
The biggest difference is Im pretty certain no liberals would have cheer at the thought of someone dying in the streets or would have shouted “Let him DIE” with the glee and gusto of the teabaggers.Even if it was his “choice”.
5 Brandon // Sep 22, 2011 at 4:31 pm
“The biggest difference is Im pretty certain no liberals would have cheer at the thought of someone dying in the streets or would have shouted “Let him DIE” with the glee and gusto of the teabaggers.Even if it was his “choice”.
I suspect this speaks to the “melodramatic” line.
6 Brandon // Sep 22, 2011 at 4:38 pm
@ascholl “Imagining it likely that Blitzer’s hypothetical was meant to satisfy conditions under which Dworkin would support a laissez-faire health care market is utterly contrary to occam’s razor.”
Blitzer’s question was formulated *specifically* to satisfy these conditions. He could not have made it clearer that the question was: “if someone WITH THE MEANS (monetary and otherwise) to purchase health insurance comfortably CHOOSES not to, should we let him/her die rather than pony up?” I cannot imagine any other interpretation of Blitzer’s question.
7 JeffS // Sep 22, 2011 at 4:39 pm
The issue wasn’t really the position that Paul took in that debate, it was the reaction from the audience at the idea of letting the hypothetical patient die. That’s what people have jumped on, and it’s obviously the polar opposite of any reaction that Dworkin would ever have. So, OK, you can argue that people weren’t really cheering for people’s needless deaths, they were cheering for the (Paulian?) idea that America as we actually know it now already meets something like Dworkin’s conditions for equality and fairness, and therefore the deaths of the uninsured are choices, not tragedies. But that observation doesn’t excuse them a whole lot, because it just means they’re either really stupid or willfully blind to evidence.
8 jeannine // Sep 22, 2011 at 4:46 pm
Brandon,
FYI…
Teabaggers cheer Executions and torture too.
9 Robert // Sep 22, 2011 at 4:53 pm
Paul’s position is not that people should die. His position is that the government does not have the constitutional authority or competence to guarantee good healthcare for all. He would have the government get out of the way completely and let the free market allow true competition to lower prices.
One can argue that free market solutions would not lower healthcare premiums and that government has no authority for healthcare, but let’s be clear that Ron Paul was not advocating for people to die.
10 Jason // Sep 22, 2011 at 5:05 pm
Having a familiarity with Dworkin, although not with that chapter, I’m not sure your reading of his healthcare policies is justly rendering his position, particularly in the “follows from his argument” section in your fourth-to-last paragraph.
I take Dworkin’s position on the ability of an individual to optout of care to be as follows: Assume for a second that a just society would provide a certain somewhat-advanced procedure to all of its members (say, cardiac stints, as a random example), because most members of society would choose to provide cardiac stints if they were well informed and had whatever fair share of social resources is specified by general principles of economic justice. I agree that, in a dialogue, we could probably get Dworkin to agree that under some set of imaginable background assumptions (which we’d spend a long time trying to identify) about a society in which health care was purchased by individuals in advance of sickness, a well-informed educated individual who was not means-limited could decide to opt-out of cardiac stint coverage to save money. And if that individual later needed a cardiac stint, it would not be unjust for society to refuse to provide him one free of charge.
One distinction between this position that Dworkin would reach and Paul’s position, as cited by JeffS, is that Dworkin would view this situation as perhaps just but clearly unfortunate for society as a whole, as society clearly recognizes in this example that we’d all be better off if everyone got cardiac stints when needed. Paul seems to think the denial of the stint is a benefit to society, which is crazy and completely ignores the value to society of the unfortunate individual who is about to die.
But more importantly, I suspect Dworkin’s actual position for our society and every reasonably-imaginable society is that some base level of background care (say, childhood vaccination or basic palliative care for the dying) ought to be provided to all members, and that Dworkin believes people should be able to at most opt-out of more advanced care, but not able to opt-out of ALL care. Whereas Paul (and the shouting individuals in the audience) seems to believe that individuals who choose not to buy health insurance should be entirely bereft of care and left, somewhat figuaratively, out in the streets to die. Dworkin would not think this just under any circumstances.
The position you outline in your fourth-to-last paragraph, that Dworkin might think it just for someone to purchase “less care,” is not the same as Paul’s position, which appears to be that its just to let people waive their right to all care. I don’t think it follows from anything you’ve cited from Dworkin that he would agree that a person should be able to decide, in advance, to opt-out of health care entirely.
11 jeannine // Sep 22, 2011 at 5:05 pm
“Paul’s position is not that people should die. His position is that the government does not have the constitutional authority or competence to guarantee good healthcare for all. He would have the government get out of the way completely and let the free market allow true competition to lower prices.”
Ah but robert it does.Just see the rest of the civilized world.We pay more and get less than any other industrialized country and with the most medical mistakes.
At least we are #1 in something other than prison populations eh?
12 Russell // Sep 22, 2011 at 5:34 pm
ascholl nails it. There is a significant difference between saying society should let people die when keeping them alive reaches the technological and financial extreme of what the informed, competent individual in our society would choose as a health plan, and letting them die simply because they cannot afford common care. The first is recognizing practical limits: we can’t put every patient suffering metastatic cancer into experimental protocols. The second has a distinctly different moral tone, say, letting someone develop metastatic disease because they can’t afford surgery on their currently benign tumor. Yes, there will be politics and difficulty in deciding where the first boundary is. And yes, it’s simpler in the second case to say, “tough, if you can’t afford it.”
13 ascholl // Sep 23, 2011 at 9:49 am
@Brandon – No. If you read the passage that Julian cites, it’s clear that the scenarios are different. Dworkin requires much more than a ‘free choice’ – he requires that (all!!) individuals be sufficiently medically knowledgeable & risk-conscious so that they would never end up in this situation. If Blitzer presented a scenario in which a well to do, healthy 30 year old decided to forgo massive payments which would fund ‘heroic’, very-low-success-rate procedures – then we’d have something like what Dworkin presents. But I think it’s pretty clear that Blitzer means to describe a situation in which the insurance-decliner was ‘imprudent’, and Dworkin stacks things so that all individuals are ‘prudent’.
In any remotely real world, of course, many people wouldn’t be. And in that world, Dworkin considers their free choice insufficiently ‘informed’, and would compel them to pay for whatever median insurance the impossible people in his thought experiment would have settled on.
14 Michele // Sep 23, 2011 at 11:22 am
I agree with the general point that Blitzer’s hypothetical does little to help us figure out the “kind of complex institutions should be established by statute in light of all we know about healthcare markets.” But I do think it highlights a fundamental difference between people on opposite sides of the debate.
For the overwhelming majority of goods and services, most of us are fine with the fact that those who cannot afford them will just have to live without them. But there is a small sliver of goods and services that, at least some of us argue, are so vital that society has a moral obligation to provide them for those who cannot provide for themselves. Examples would be food, shelter, access to education.
Blitzer’s hypothetical conjures the image of someone who is imprudent and selfish. For those who think healthcare is a luxury, rewarding those failing with guaranteed coverage is ludicrous. If private citizens or institutions choose to be so generous, fine and well, but it’s not for officials to spend taxpayer money to save people from the consequences of their own choices. I don’t think the people in the crowd were cheering the death of others, but for this principle.
For people who believe healthcare should be added to this list, the idea that denying them a vital, fundamental good that can mean the difference between life and death is appalling.
I think the reaction of some in the crowd, and the reaction to that reaction illustrate this difference perfectly.
15 Dan // Sep 23, 2011 at 1:26 pm
Paul and Dworkin have the EXACT same position but liberals are out to defend their guy. This is pathetic. It’s like when Fox News defends a Republican but trashes a Democrat for doing the same thing. Paul believes things down to a very philosophical level, that is what libertarians rely on, hypothetical situations. The people on here trying to say there is a difference are just as stupid as the Tea Tards they trash on.
16 ascholl // Sep 23, 2011 at 2:13 pm
@Dan – Shorter Paul: “A free market would produce the most just distribution of health care.” Shorter Dworkin: “A free market would produce the most just distribution of health care. If and only if resources start out distributed equitably among actors, all actors are extraordinarily knowledgeable, and the supply side of the market isn’t really ‘free’ in the normally understood sense.” Yeah, these are totally the exact some positions.
17 jeannine // Sep 23, 2011 at 3:06 pm
@Dan, Paul is a Randian cult member.Ayn Rand was a damaged sociopath who’s religion is selfishness and who’s literary “hero’s were based on a real life child killer Edward Hickman she was in love with.
“A wonderful, free, light consciousness” born of the utter absence of any understanding of “the necessity, meaning, or importance of other people.”
” ‘[My hero is] very far from him, of course. The outside of Hickman, but not the inside. Much deeper and much more. A Hickman with a purpose. And without the degeneracy. It is more exact to say that the model is not Hickman, but what Hickman suggested to me.’ ”
“Other people have no right, no hold, no interest or influence on him. And this is not affected or chosen — it’s inborn, absolute, it can’t be changed, he has ‘no organ’ to be otherwise. In this respect, he has the true, innate psychology of a Superman. He can never realize and feel ‘other people.’ ”
This echoes almost word for word Rand’s later description of her character Howard Roark, the hero of her novel The Fountainhead:
“He was born without the ability to consider others.”
A classic sociopath.
So to yell out “Let Him DIE”in a crowd and not be chastised says everything you need to know about the people in that room.
The fact that Dworkin would allow a person the informed choice to not buy extra coverage doesnt mean he would want that person dying as republicans in that room seemed to have no problem with. and was viewed by millions .
See the difference?
18 Julian Sanchez // Sep 23, 2011 at 4:55 pm
“Shorter” really has become the crutch of people who have trouble with even moderately complex arguments, hasn’t it?
19 Pithlord // Sep 23, 2011 at 4:55 pm
The existence of economic scarcity implies that we inevitably let people die. It is not in the power of any society no matter how technologically advanced to do otherwise.
I’d appreciate it if you’d point this out to right-wing critics of “death panels.” No social insurance system can give unlimited coverage. That does not mean the state is murdering grandma.
BTW, the problem with the crowd reaction wasn’t that they would let the hypothetical guy die, but that they celebrated his hypothetical death.
20 Craig Burley // Sep 24, 2011 at 8:22 pm
“Paul and Dworkin have the EXACT same position…”
No they don’t. It’s not within a football field of the same position. Before he is willing to accept Paul’s position Dworkin requires people to be well-informed about their health and health outcomes (no misleading through market forces) and an equalized (or at least “fair”) share of resources between all people. That’s not even remotely Ron Paul’s position.
The transparency of the twisted hoops Julian has to contort himself through to get them to the “same” position is pathetic, and unworthy of him, but I suppose the Ron Paul hagiography must go on. Not only is Ron Paul uninterested in the prerequisites for Dworkin to consider this position legitimate, he is strongly against them. The idea of a “fair” distribution of resources (in Dworkin’s sense of that term) is frankly appalling to Ron Paul.
21 Craig Burley // Sep 24, 2011 at 8:30 pm
““Shorter” really has become the crutch of people who have trouble with even moderately complex arguments, hasn’t it?”
It has its place, and where someone is tying himself in knots to pretend that two people with entirely divergent views on the ethical distribution of medical resources have the same view, merely because he can invent a single bizarre counterfactual where the two would be similarly satisfied with an outcome.
One final point. It’s entirely clear that The Blitzer Counterfactual (worst thriller title ever) doesn’t even arguably satisfy Dworkin’s criteria since Dworkin requires informed choice, something that a for-profit insurance-based system cannot possibly deliver, since its profits grow in proportion to total medical expenses.
22 D // Sep 25, 2011 at 12:48 pm
Uh, I think the more important fact is that Dworkin is not running for president, so he doesn’t have to defend his ideas in the context of political reality.
23 ascholl // Sep 25, 2011 at 4:36 pm
“Shorter” really has become the crutch of people who have trouble with even moderately complex arguments, hasn’t it?
That stings a little, but only because it’s unkind – not because it’s accurate. Dan’s argument isn’t ‘complex’ … it’s more a simple (incorrect) assertion than anything else. And I hardly think a rebuttal requires more text than a pithy ‘shorter’.
24 Barry // Oct 21, 2011 at 9:15 am
Chuchundra
“The difference is that Paul’s position on this issue is a real opinion about real people who might really die and he’s OK with that.”
And we saw that with his fundraiser dying.
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