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Living High and Letting Die

September 19th, 2011 · 16 Comments

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?

Tags: Moral Philosophy



16 responses so far ↓

  • 1 Mugen // Sep 19, 2011 at 6:48 pm

    I dream of paying 200 or 300 dollars a month for insurance. There are an unfortunately larger-than-commonly-known number of us who spend quite literally 25% of our income on health insurance alone, let alone the other associated (and uncovered) costs of health care. To make matters worse, I’m not overpaying by having chosen the “wrong” plan, there is no optional available for people in my position to pay less. Period.

    I wonder what Ron Paul would have *me* do?

  • 2 Matt D // Sep 19, 2011 at 7:17 pm

    1) We do already prohibit various dangerous activities or at least try to mitigate their risk.

    2) Seems like you glossed over the relative certainty of each case – a 99% chance of death from lack of medical care would rightly compel us to act more than would a 10% chance of death due to, say, drunken swimming. Your hypothetical presumes certainty in both cases but the reality is we’re dealing with probabilities.

    3) There’s nothing really inconsistent about being willing to pay (via universal health care) for our freedom to engage in risky behavior with the benefit of a safety net.

  • 3 Julian Sanchez // Sep 19, 2011 at 7:22 pm

    Well, we don’t have to wonder: He’d argue that the high cost is substantially a function of excessive government intervention under the status quo. I can’t accurately assess how much truth there is to that claim, but he alleged as much during the same debate.

    Also, as I say at the outset, I think we can consider these questions separately. One question is what “we” (communities, state governments, the federal government) ought to do for people for whom insurance is an unreasonably burdensome cost, or even effectively unavailable.

    The separate question is what we ought to do for people who purchase less insurance than they CAN reasonably afford, and then find themselves with an uncovered ailment. Support for subsidies or regulatory intervention aimed at making some level of insurance reasonably affordable to everyone is, at least on face, perfectly compatible with the view that there’s no *further* obligation to provide care beyond whatever level people then choose to purchase.

  • 4 Julian Sanchez // Sep 19, 2011 at 7:29 pm

    We do, to some extent, try to limit hazardous behavior—though much more aggressively when there’s some question about how truly “voluntary” it is. We still permit quite a lot of voluntary risktaking—though perhaps less than I think we should. And probabilities at the individual level are (near) certainties at the collective level. The probability that any individual swimmer will drown during a given swim is very low. The probability that more than 2,000 people will die by drowning this year is more like 99%—we just don’t know which 2,000.

  • 5 Watoosh // Sep 19, 2011 at 7:29 pm

    @Mugen: die in a ditch, obviously. At least if you believe the horror stories liberals tell about libertarians and especially Ron Paul.

    If you understand the plumbline libertarian position, though, you’ll see that the question is framed very oddly. The onus is not on you to do anything differently, but on society (meaning any voluntarily cooperating network of people, not the government) to help you, and the government to stop propping up Big Medicine/Insurance by patents, licensing fees, regulatory cartels and other interventions that drive up costs and restrict choice.

    I’ll admit, though, that the way Ron Paul phrased his answer was flawed – he made it seem as if the status quo was a free market in which people without coverage are willingly so and should just suck it up. Then he added, as an afterthought, that corporatist policies are what make the system so unbearable. Roderick Long commented on this on Bleeding Heart Libertarians.

  • 6 Glen // Sep 19, 2011 at 7:42 pm

    “in effect by repeating one horn of a dilemma more loudly”

    I wish you had said “blowing one horn of a dilemma” instead.

  • 7 Julian Sanchez // Sep 19, 2011 at 7:54 pm

    Ooh. I’m going to steal that!

  • 8 Nathan T. Freeman // Sep 19, 2011 at 9:58 pm

    Julian, how would you condense all this into an answer that fits into 30 or 60 seconds? As usual, I find myself nodding and smiling at your words, but I also find myself trying to imagine how Rep. Paul might have been able to deliver this answer as a response during the debate.

    “What do you mean by ‘let him die?’ Are you saying we shouldn’t allow him to go without insurance? But we let people take risks with their lives all the time. What if the same man went skydiving, or drove a motorcycle, or went swimming in a lake, or ate raw fish, or walked down a flight of stairs? Every one of these things carries risk of mortal danger, but we don’t outlaw two-story homes because of it.

    Certainly if you watched someone drowning or falling down stairs, as a human you would rush to help them, just as any person in mortal danger is helped by doctors, nurses, police officers and fireman — not by government mandate but by normal human compassion — just as I did in my own practice. But would you say that every body of water must be surrounded by fences and lifeguards or every flight of stairs must have an EMS team, simply because there is the POSSIBILITY that someone might die?! That’s ludicrous.

    Life IS risks. We cannot legislate away reality. And if an able-bodied, financially secure, 30-year old makes a bad bet… well, that is unfortunate. But it is not incumbent on the rest of the world to force him not to, anymore than we force him not to eat sushi or walk down stairs.

    And I yield the balance of my time.”

    Do you think that answer would work?

  • 9 Matt D // Sep 19, 2011 at 11:20 pm

    “And probabilities at the individual level are (near) certainties at the collective level. The probability that any individual swimmer will drown during a given swim is very low. The probability that more than 2,000 people will die by drowning this year is more like 99%—we just don’t know which 2,000.”


    Upon further reflection, I guess I don’t totally understand your original point, though.

    I mean, at some level it’s true that we’re not really talking about whether society will *let people die* because obviously there’s only so much we can do, and some are going to die no matter what. But at the same time, it’s also true that there are things we *can* do, and to not do them is in fact tantamount to letting people die. Literally prohibiting every activity with a risk of death isn’t something we can do. The scope is too broad and there’s too many variables. Providing life-saving care to someone who is already in a hospital is something we can do. The scope is narrow and the variables are few and known. That’s what people intuit and, for my part, I think they basically get it right.

  • 10 Nathan T. Freeman // Sep 19, 2011 at 11:20 pm

    I should note that the end counter-dilemma is deliberate. The suggestion is that we force him to not take risks, not that everyone else mitigate the risk. Because that makes the reply easy…

    “That’s not what I meant. We shouldn’t outlaw stairs; we should pay for it when someone falls down them.”

    “Oh? So we’re not cutting risk, we’re just subsidizing it?! Well, that’s just silly. It’s a bad idea to forbid people from walking down stairs. It’s just absurd to pay them for falling down while doing it.”

  • 11 Nathan T. Freeman // Sep 19, 2011 at 11:31 pm

    “Providing life-saving care to someone who is already in a hospital is something we can do.”

    And it’s something we *already* do. People don’t die in hospitals because they failed a credit check. They do end up in Chapter 11 because of it — and that sucks, but it isn’t death.

    I was in the ER last night with my daughter, and there was a big sign on the wall that spelled out “You CANNOT be denied care on the basis of ability-to-pay.” This is completely the norm for hospitals and medical practices around the nation.

    Julian’s point about the horns of a dilemma don’t go far enough. People don’t die because of acute trauma that they can’t pay for. It simply doesn’t happen.

    The 30-year old in Blitzer’s question wouldn’t die. He’d just be presented with an $80,000 hospital bill as a consequence of his choice. And if he didn’t pay, the hospital would send it to collections, and all the resulting financial consequences would ensue.

    Does that suck? Sure. But it sucks for the guy who’s credit score is in the tank because he didn’t pay for catastrophic medical insurance. Not because he died.

    It’s easy to curry favor with voters to say “you shouldn’t have to cover your medical bills.” But it’s also the same as saying “you have to cover everyone else’s medical bills.” Candidates like to leave that part out.

  • 12 Matt D // Sep 20, 2011 at 12:31 am

    “The 30-year old in Blitzer’s question wouldn’t die.”

    The question isn’t whether he would die under today’s regime, it’s whether he would die under the audience’s preferred regime. Given that their preferred regime is manifestly and, for that matter, definitionally one in which he does die, I’m not totally sure what point you’re making.

    In any case, the reason people don’t die (more often) is that many hospitals are legally required to take all comers, and even those that aren’t under legal compulsion often recognize a moral duty. In any case, there is effectively a subsidy at work, as the hospitals take a loss on these patients when they’re unable to pay.

  • 13 Nathan T. Freeman // Sep 20, 2011 at 1:16 pm

    Actually the question, since it was directed to Rep. Paul, it’s whether he would die under Paul’s preferred regime.

    “the reason people don’t die (more often) is that many hospitals are legally required to take all comers, and even those that aren’t under legal compulsion often recognize a moral duty.”

    Which is it? Because they have a legal obligation or because they recognize a moral duty? If it’s the latter, then there’s no need to legislate it. And that was Dr. Paul’s point when he followed up his answer with “I never turned away a single patient based on inability to pay.”

    Strictly speaking, there’s only a subsidy at work if the patient is never obligated to pay. If a trauma patient receives life-saving care without insurance, and then gets billed for it, it’s a standard civil matter of debt settlement, just the same as if he didn’t have car insurance and crashed into another vehicle. It’s not a matter for public policy.

  • 14 JD the elder // Sep 20, 2011 at 1:25 pm

    I’d like to point out something I’m surprised no one else touched on (maybe it was too obvious): the conflation of “society” with “government”. When the question comes up “so society should just let him die?” the best answer might be “Are we talking about _society_, or about the government? They’re not the same thing, you know.” Arguably, “society” should help the young man, but government’s got nothing to do with it.

  • 15 ascholl // Sep 20, 2011 at 4:04 pm

    I may be misreading you, but my strong intuition is that viewing the problem of healthcare as a ‘bystander problem’ is both morally & practically useful, and that a ‘bystander’ view is entirely consistent with (and greatly benefits from!) an actuarial, cost/benefit minded perspective.

    Within a given society, however you want to define a society — probably the individuals and institutions operating w/in a state — you can pretty accurately predict how many people will develop certain medical conditions in a given period of time. Among 30-35 year olds, perhaps 1000 come down w/ lung cancer, another 1000 turn schizophrenic, 5000 have serious car accidents, 3000 become diabetic, 1500 hiv+, etc. The routine or ‘reasonable’ treatment for each of these conditions will be determined by the society’s resources, technological/intellectual development, and mores. I believe that a society in which the majority of the people in each of these groups gets roughly the same treatment is a better society than one in which some people get much better or worse treatment than others. And if 80% of the HIV afflicted get effective antiretrovirals and 20% don’t, I think it’s useful and accurate to view it as the ‘society’ standing idly as the 20% die.

    I’m not very taken by your comments on geography. Health care results are the direct result of a complicated system of interacting institutions, existing largely w/in the boundaries a nation-state. If a hypothetical person in utah, with an at-the-macro-level-routine disorder is left to die, while his neighbors in equivalent conditions are left to live: yes, that’s (some level of) monstrous. Same thing for the fellow in Mexico or Kenya. As a US citizen, living in Washington state, I have immensely more say in — and responsibility for — the institutions that lead to this result than I do for institutions in Mexico or Kenya.

    A last comment, largely unrelated: I think a couple commenters deliberately misinterpret the scenario. Yes, ER care is uniquely non-deniable. If the 30 year old was in a horrible car accident, he’d probably be taken care of pretty w/o insurance. If, on the other hand, she developed some chronic condition — which is what I hear in the phrase “something terrible happens” — she would either need to come up w/ a whole lot of money or receive poor care.

  • 16 Max Marty // Sep 25, 2011 at 5:03 pm

    I’m rather surprised that Ron Paul’s answer wasn’t something along the line of :

    “The answer here is private charity. Since you, Mr. Blitzer, and many others feel that this cause is more worthy than anything else these dollars could be spent on, you would contribute to charitable organizations who would find and help individuals in this predicament. Others would feel that the most important problems are something different, perhaps helping the elderly or purchasing mosquito nets for children at risk in Africa, and they would contribute accordingly. That’s what America is all about, people helping each other, and America is great because we give people the freedom to help others in a way that is in accordance with their individual values.”

    Or something like that 🙂