I’ve seen plenty of outraged online discussion over past week concerning this exchange—and especially the audience reaction to it—from the recent Tea Party debate:
“A healthy, 30-year-old young man has a good job, makes a good living, but decides: You know what? I’m not going to spend 200 or 300 dollars a month for health insurance, because I’m healthy; I don’t need it,” [moderator Wolf] Blitzer said. “But you know, something terrible happens; all of a sudden, he needs it. Who’s going to pay for it, if he goes into a coma, for example? Who pays for that?
“In a society that you accept welfarism and socialism, he expects the government to take care of him,” [Ron] Paul replied. Blitzer asked what Paul would prefer to having government deal with the sick man.
“What he should do is whatever he wants to do, and assume responsibility for himself,” Paul said. ”My advice to him would have a major medical policy, but not before —”
“But he doesn’t have that,” Blitzer said. “He doesn’t have it and he’s — and he needs — he needs intensive care for six months. Who pays?”
“That’s what freedom is all about: taking your own risks.,” Paul said, repeating the standard libertarian view as some in the audience cheered.
“But congressman, are you saying that society should just let him die,” Blitzer asked.
“Yeah,” came the shout from the audience.
I don’t have very strong or well-formed views about the appropriate shape of American health care policy, and I’m generally pretty happy to live in a society where someone who collapses in the street gets care without the need for a credit check first. At the same time, I doubt these kinds of stripped-down thought experiments, useful though they often are for clarifying principles or moral intuitions, are especially illuminating on questions of public policy.
Some very roughly predictable number of people will die each year from skiing accidents or drowning in natural bodies of water. Should “society” just “let these people die”? Obviously anyone who happens to be present when someone is drowning ought to intervene to save them, if they can, and we’d call anyone who just sat on the beach watching a ghoul. But some people will, predictably, die because nobody is around to save them. So “society” (meaning, in this case, state governments or the federal government) could try to prohibit anyone from engaging in these risky activities, or fence off most bodies of water, and post lifeguards at all the others. We don’t intervene before the fact—by prohibiting unsupervised swimming and similar risky activities—in part because even if we thought it were enforceable, we think people should be free to take risks. We don’t post lifeguards everywhere, partly because it would be costly and infeasible, but also partly because it seems unreasonable to force everyone to foot the bill for risks others have chosen. (Some people, of course, do not really “choose” to go without insurance in a meaningful sense, and we could have a separate argument about what “society” owes those people, but the person in Blitzer’s example pretty clearly doesn’t fall into that category.)
The fact that people aren’t intuitively horrified by “letting die” in this situation is almost entirely a function of how the question is framed. If we ask whether to prohibit everyone, collectively, from unsupervised risk-taking before we know who will be fine and who will be harmed or killed, the intuition that adults ought to be allowed to take risks usually seems to win out. When we ask what we ought to do about a particular individual, where “society” is effectively put in the role of the bystander at the lake, a principle of rescue usually seems to win out: Of course you shouldn’t sit idle! For the kinds of ethical dilemmas we face as individuals, that’s fine, but when it’s posed at a policy level, we effectively face both situations simultaneously, and so need to reconcile conflicting intuitions that didn’t appear to conflict when we considered them at the level of individual choice and obligation.
A lot of people seem to think that just triggering the “bystander” intuition provides some kind of moral clarity, because again, what sort of ghoul doesn’t share that intuition? But this is just a way of ignoring a real moral tension between intuitions, in effect by blowing one horn of a dilemma more loudly, not a serious attempt to grapple with it. From the synoptic perspective of policy, whenever we are committed to affording adults the freedom to take serious risks, we are effectively committed to “letting” some people die. Almost nobody is actually prepared to endorse the level of compulsion or precautionary supervision (which avoids direct coercive prohibition by socializing the cost of chosen risk) that would eliminate such cases, which means now we’re just haggling price. We’re all prepared to “let people die” in a huge number of cases; the interesting question is which ones and why, not whether.
Slightly tangentially, even if we stick to the example of the 30-year-old needing medical treatment—I note that very few people are quite as vocally outraged that we routinely let people in even this precise situation die, so long as they’re people in other countries. So if our 30-year-old is in Utah, and neither his friends, nor his family, nor the government of Utah are prepared to foot the bill for his treatment, we’re supposed to regard it as just obviously morally monstrous that the federal government would not step up to the plate. From California to Maine, it’s our responsibility because he’s one of us. But if he’s in Mexico, or Kenya? We might think it’s awful, or hope someone will volunteer their assistance, but most of us don’t seem to think it’s just obviously our collective political obligation to intervene.
There are a lot of obvious practical considerations one might invoke to explain why we treat the cases differently, but if you think the fundamental moral issues are illuminated with optimal clarity by thought experiments where we just zoom in on these individual cases, then there’s no getting around the fact that (American) society is “letting people die” in huge numbers, provided they had the misfortune to be born on the wrong side of a border. Whatever the practical relevance of those people’s nationality, it has no bearing whatever on their basic moral status. If we insist on framing the question as a “bystander problem,” then the nationality of the fellow drowning in the lake should be morally irrelevant. The only salient facts are that we could do something, and whatever other players might be capable of acting aren’t, in fact, doing so.
One respectable and consistent way to deal with this is to infer that we ought to be spending vastly more money on foreign aid to billions of people around the globe who are vastly worse off than almost all of our fellow citizens. Another is to conclude that the “bystander” frame is not actually that helpful when evaluating questions of public policy or collective action.
Finally, and I know I’ve harped on this before, but I think discourse about issues of public health would be immensely improved if we just ditched the misleading phrase “saving lives,” which grossly oversimplifies the actual choices and problems we really face. Death is non-negotiable, so no lives are ever really “saved”: Our actual choice is typically whether to take an action which, at cost C, has probability P of increasing lifespan by time T with quality Q, relative to all the other actions we could take. Until we have infinite resources, then for some array of values for those variables, the federal government is going to have to determine that the expected value of the intervention doesn’t justify obligating the public to bear its cost—though a particular patient’s state or family or friends or church might weigh things differently and decide to foot the bill themselves. What sets describe the morally acceptable ranges for C, P, T, and Q? And how far outside the “correct” ranges do you have to fall to be a moral monster?