The High Price of Being Shot
In the naivety of my youth, I believed that people would not be charged for medical treatment resulting from being wounded by criminals. After all, my younger self reasoned, their injuries were the fault of someone else and it would be unjust to expect them to pay for the misdeeds of another. Learning that this was not the case was just one of the many disappointments when it came to the matter of justice and ethics. As such, I was not surprised when I learned that shooting victims were presented with the bills for their treatment. However, I was somewhat surprised by the high cost of being shot.
Dr. Joseph Sakran, who had been shot in his youth, co-authored a study of what shooting victims are charged for their treatment. Since gunshot wounds range from relatively minor grazing wounds to massive internal damage, the costs vary considerably. While the average is $5,000 the cost can go up to $100,000. These costs are generally covered by insurance, but victims who lack proper coverage become victims once again: they must either pay for the treatment or pass on the cost as part of the uncompensated care. When the cost is passed on, the patient can suffer from severely damaged credit and, of course, the cost is passed on others in the form of premium increases. There can be costs beyond the initial medical bills, such as ongoing medical bills, the loss of income, and the psychological harm.
In addition to medical expenses of those who are shot, there are also the costs of the police response, the impact on employers, and the dollar value of those who are killed rather than wounded (and do not forget that dying in the hospital obviously does not automatically clear the bill). While estimating the exact cost is difficult, a mass shooting like the Pulse Nightclub shooting will probably end up costing almost $400 million. While mass shootings, such as the recent one in Las Vegas, get the attention of the media, gunshot wounds are a regular occurrence in the United States with an estimated cost of $600 million per day. While some will dispute the exact numbers, what is indisputable is that getting shot is expensive for the victim and society. As such, it would be rational to try to reduce the number of shootings and to address the high cost of being shot.
While the rational approach to such a massive health crisis would be to undertake a scientific study to find solutions, the 1996 Dickey Amendment bans the use of federal funding for gun research. There is also very little good data about gun injuries and deaths—and this is quite intentional. Efforts to improve the collection of data are dealt with by such things as the Dickey Amendment. Efforts to impose more gun control, even when there is overwhelming public support for such things as universal background checks, are routinely blocked. While this serves as a beautiful object lesson in how much say the people have in this democracy, it also shows that trying to address the high cost of getting shot by reducing shootings is a noble fool’s errand. As such, the only practical options involve finding ways to offset the medical costs of victims. Naturally, victims can bring civil suits—but this is not a reliable and effective way to ensure that the medical expenses are covered. After all, mass shooters are rarely wealthy enough to pay all the bills and often perish in their attack.
Some victims have attempted to address their medical bills in the same way others who lack insurance have tried—by setting up GoFundMe pages to get donations. While this option is problematic in many ways, the main problem is that it is not very reliable. This, of course, lays aside the moral problem of having people begging so they can pay for being victims of a shooting. To address this problem, I will make two modest proposals.
My first proposal is that gun owners be required to purchase a modestly priced insurance policy that is analogous to vehicle insurance. In the United States, people are generally required to have insurance to cover the damage they might inflict while operating a dangerous piece of machinery. This helps pool the risk (as insurance is supposed to do) and puts the cost on the operators of the machines rather than on those who they might harm. The same should apply to guns—they are dangerous machines that can do considerable harm and it makes sense that the owners should bear the cost of the insurance. Naturally, as with vehicles, owners can also be victims.
It could be objected that owning a firearm is a right and hence the state has no right to impose such a requirement. The easy and obvious reply is that the right to keep and bear arms is a negative right rather than a positive right. A positive right is one in which a person is entitled to be provided with the means to use that right (such as how people are provided with free ballots when they go to vote). A negative right means the person must provide the means of exercising their right, but it is (generally) wrong to prevent them from exercising that right. So, just as the state is not required to ensure that people get free guns and ammunition, it is not required to allow gun ownership without insurance—provided that the requirement does not impose an unreasonable infringement on the right.
Another easy and obvious reply is that rights do not free a person from responsibility. In the case of speech, people cannot simply say anything without consequence. In the case of the gun insurance, people would be acting in a responsible manner—they would be balancing their right with a rational amount of responsibility. To refuse to have such insurance is to insist on rights without responsibility—something conservatives normally rail against. As such, both liberals and conservatives should approve of this idea.
My second proposal, which is consistent with the first, is that there be a modest state fee added to the cost of each firearm, accessory and ammunition box. This money would go into a state pool to help pay the medical expenses of the uninsured who are injured in shootings. Yes, I know that this money would probably be misused by most states, probably to bankroll the re-election of incumbents. The justification is, of course, that the people who buy the guns that could hurt people should bear the cost for the medical expenses of those who are hurt. People already pay sales taxes on such items, this would merely earmark some money to help offset the cost of people exercising their second amendment rights. To go back to the vehicle analogy, it makes perfect sense to add a fee onto the cost of gas to pay for roads and other infrastructure—that way the people who are using it are helping to pay for it. Likewise for guns.
An obvious objection is that this fee would be paid by people who will never engage in gun crime. This is a reasonable concern, analogous to other concerns about paying into anything that one is not directly responsible for. There are two reasonable replies. One is that the funds generated could cover medical expenses involving any firearm crime or accident and anyone can have an accident with a gun. Another is the responsibility argument: while I, as a gun owner, will probably never engage in a gun crime, being able to exercise my right to own guns allows people who will engage in gun crimes to engage in those crimes. For example, the Las Vegas shooter was operating under the protection of the same gun rights that protect me up until the moment he started firing. This fee would be my share of the responsibility for allowing the threat of gun violence to endanger everyone in the United States. Such a modest fee would be a very small price to pay for having such a dangerous right. Otherwise, I would be selfishly expecting everyone else to bear the cost of my right, which would not be right. So, to appeal to principled conservatives, this would be a way for taking responsibility for one’s rights. As people love to say, freedom isn’t free.
Emergency Rooms & Obamacare
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On the face of it, the idea seems reasonable enough: if a person has health insurance, then she is less likely to use the emergency room. To expand on this a bit, what seems sensible is that a person with health insurance will be more likely to use primary care and thus less likely to need to use the emergency room. It also seems to make sense that a person with insurance would get more preventative care and thus be less likely to need a trip to the emergency room.
Intuitively, reducing emergency room visits would be a good thing. One reason is that emergency room care is rather expensive and reducing it would save money—which is good for patients and also good for those who have to pay the bills for the uninsured. Another reason is that the emergency room should be for emergencies—reducing the number of visits can help free up resources and lower waiting times.
As such, extending insurance coverage to everyone should be a good thing: it would reduce emergency room visits and this is good. However, it turns out that extending insurance might actually increase emergency room visits. In what seems to be an excellent study, insurance coverage actually results in more emergency room visits.
One obvious explanation is that people who are insured would be more likely to use medical services for the same reason that insured motorists are likely to use the service of mechanics: they are more likely to be able to pay the bills for repairs.
On the face of it, this would not be so bad. After all, if people can afford to go to the emergency room and be treated because they have insurance, that is certainly better than having people suffer simply because they lack insurance or the money to pay for care. However, what is most interesting about the study is that the expansion of Medicaid coverage resulted in an increase in emergency room visits for treatments that would have been more suitable in a primary care environment. That is, people decided to go to the emergency room for non-emergencies. The increase in emergency use was significant—about 40%. The study was large enough that this is statistically significant.
Given that Obamacare aims to both expand Medicaid and ensure that everyone is insured, it is certainly worth being concerned about the impact of these changes on the emergency room situation. Especially since one key claim has been that these changes would reduce costs by reducing emergency room visits.
One possibility is that the results from the Medicaid study will hold true across the country and will also apply to the insurance expansion. If so, there would be a significant increase in emergency room visits and this would certainly not results in a reduction of health care costs—especially if people go to the expensive emergency room rather than the less costly primary care options. Given the size and nature of the study, this concern is certainly legitimate in regards to the Medicaid expansion.
The general insurance expansion might not result in significantly more non-necessary emergency room visits. The reason is that private insurance companies often try to deter emergency room visits by imposing higher payments for patients. In contrast, Medicaid does not impose this higher cost. Thus, those with private insurance will tend to have a financial incentive to avoid the emergency room while those on Medicaid will not. While it would be wrong to impose a draconian penalty for going to the emergency room, one obvious solution is to impose a financial penalty for emergency room visits—preferably tied to using the emergency room for services that can be provided by primary care facilities. This can be quite reasonable, given that emergency room treatment is more expensive than comparable primary care treatment. In my own case, I know that the emergency room costs me more than visiting my primary care doctor—which gives me yet another good reason to avoid the emergency room.
There is also some reason to think that people use emergency rooms rather than primary care because they do not know their options. That is, if more people were better educated about their medical options, they would chose primary care options over the emergency room when they did not need the emergency room services. Given that going to the emergency room is generally stressful and typically involves a long wait (especially for non-emergencies) people are likely to elect for primary care when they know they have that option. This is not to say education will be a cure-all, but it is likely to help reduce unnecessary emergency room visits. Which is certainly a worthwhile objective.
Is the Emergency Room a Viable Alternative?
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As Obamacare marches onward, its opponents are still endeavoring to stop its advance and send it packing. Of course, the opponents need to provide an alternative system. Interestingly, certain Republicans such as Rick Perry and Jim DeMint have claimed that uninsured Americans are better off relying on the emergency room for treatment. While the battle over Obamacare is largely ideological, the viability of using the emergency room would seem to be an objective matter.
On the positive side, anyone can go to the emergency room and hospitals cannot refuse to treat people with legitimate medical needs—even people who lack insurance or cannot pay.
However, there are numerous problems with the uninsured (or even the insured) relying on the emergency room. The first is the matter of cost. The emergency room is generally more expensive than the non-emergency options. It is certainly more expensive that routine preventative care that can keep a person out of the emergency room. The high costs are problematic because of the burden on the uninsured (medical bills is a leading cause of bankruptcy in America) and also because when the uninsured cannot pay, the cost is passed on to the rest of us (most often in the form of higher health insurance premiums). Thus, relying on the emergency room to treat the uninsured places a heavy burden on everyone and is actually a form of highly inefficient socialism in which those with insurance pay for needlessly expensive treatment for the uninsured. From a purely economic standpoint, if we are going to have medical socialism, we should at least go with the more economically efficient version.
The second is the matter of preventative medicine and ongoing treatments, such as routine checkups and dialysis. The emergency room hardly seems to be set for these medical matters, although people who are unable to avail themselves of them stand a significant chance of ending up in the emergency room, thus taking us back to the first problem. As such, the emergency room option does not seem to be a viable alternative to Obamacare. This is not to say that Obamacare is the only option or even a good option—just that it is better than the emergency-room-for-the-uninsured option.
The third is the matter of compassion. While hospitals cannot deny people necessary medical care, such care is certainly not charity: either the patient must pay or the cost is passed on to the rest of us. As such, relying on the emergency room as a matter of social policy is essentially saying to people that they can get treatment, provided that it is an emergency and that either the patient can pay or the cost can be passed on to everyone else. It is generally agreed that we should collectively protect each other from terrorism, foreign enemies, and our own criminals. This same concern should also extend to protecting each other from disease and injury. After all, whether Sally is dead because of cancer, a criminal’s bullet or a terrorist’s bomb, she is still dead. So, if we can have a huge collective defense against these other threats, we surely can have a developed collective defense against medical threats—one that is better than the emergency room.
Adjuncts & the Affordable Care Act
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The Affordable Care Act imposes fines on large employers (defined as those employing 51+ people full time) that fail to offer affordable insurance coverage to their full-time employees. As might be imagined, this has created some concerns for such employers and their employees.
While I do believe that the act has some positive aspects, I tend to agree with those who think that health insurance should be split from employment. That is, it should be something people can select from a competitive market regardless of who they are working for. Properly done, this would be a considerable benefit to businesses and individuals. However, my main concern here is with the likely impact of the Act on adjuncts and others in a similar plight.
Adjuncts are, in many ways, the temp workers of academics. They are typically hired from semester to semester to teach a few classes at relatively low pay ($1,500-3,000 per class being typical) and generally have no benefits or job security. Adjuncts are usually classified as part-time employees, primarily because they often teach less than what is considered a full class load and typically do not have the other duties (such as committee work or advising) of full-time faculty. They are also typically classified as part-time so as to avoid the need to provide them with the benefits of full-time employees.
The Affordable Care Act defines a full-time employee as one who is employed an average of thirty hours a week. Currently, there is not a clear definition of how the part-time status of adjuncts should be determined, since adjuncts typically work in terms of credit hours taught rather than in terms of hours on the clock.
As might be suspected, colleges, universities and businesses have varied definitions of what counts as being part-time and not all of these match the Affordable Care Act definition. In response, some colleges and universities are already taking steps to address this matter. A common responses has been to cut the hours of adjuncts and other part-time workers to 29 hours or less to avoid having to provide affordable insurance or paying the fine. In the case of adjuncts, some schools have cut the number of courses and adjunct can teach, despite the fact that the matter of what counts as full time faculty under the act has not been sorted out.
As might be guessed, the reduction in hours is an unintended consequence of the act. However, it is obviously not good for the adjuncts and other part-time employees who are typically struggling to get as much work as they can. As it stands, adjuncts often have to teach classes at multiple colleges in order to get by and other part-time workers often have to hold multiple jobs. If employers start reducing the hours of part-time workers, they will need to find additional jobs to make up for the lost income, which will be at least inconvenient.
On the one hand, it is easy to blame the Affordable Care Act (or, to avoid the fallacy of reification, the people who passed the act). After all, the “big” employers are being forced into a trilemma: provide affordable health care or pay fines or cut employee hours down to 29 hours a week or less. Since the first two options cost money, the obvious choice is the third one. No doubt employers would prefer to keep things as they are, but the act forces them to make the employees pay the price for the act.
On the other hand, it could be argued that the employers deserve some of the blame, especially in the case of colleges and universities. After all, adjuncts are exploited by universities and do not even get the insurance coverage that is offered to students (I had better benefits as a grad student than as an adjunct). Adjuncts could be provided with affordable health care (as students are) it is just the case that employers are choosing not to do so in order to save some money. That is, it is just another case of the working people being screwed over by those with vastly larger salaries and plenty of benefits. It is not surprising that many of the same folks who weep over the rich being forced to pay marginally more taxes are also outraged that businesses would have to provide affordable health insurance to employees. There is also a certain meanness in the attitude that is essentially this: “What, we have to provide full-time employees with affordable health insurance or pay fines!? In that case, we’ll just fire people or cut their hours!”
My own view is that this illustrates the important of separating health insurance from employment. This would allow employers to hire people without worrying about the costs of providing insurance (or paying fines) and would allow individuals to get insurance apart from being employed. Of course, this would require serious revisions to the health insurance industry to make health care actually affordable for individuals, especially those working low-paying part time jobs. Naturally, employers could continue to offer health insurance, but this would not be mandatory. However, no matter what is done, someone obviously has to pay the bills.
Weather Defense Initiative
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Humans have always faced off against the impersonal power of the weather, sometimes winning and sometimes not. In many ways, humans are at war with the weather of our world and the damage inflicted by weather can be comparable to that which we inflict on each other. But, while some might attribute an intelligent design behind the ravages of the weather, it seems most reasonable to hold that the climate does not wage intentional war against us. Rather, the world simply does as it does and sometimes this kills us and destroys our cities. However, destructive weather, as it has historically done, does raise questions about the alleged benevolence of our alleged creator.
Sticking with the war metaphor, there are clearly times in which the conflict is more damaging than others. In recent years, the damage has stepped up considerably. The September 2012 edition of National Geographic featured “Extreme Weather” by Peter Miller discussed, as might be imagined, the recent extreme weather that has impacted the world. The article was, obviously, written before Sandy hit the United States. However, Sandy was, in some ways, just another example of extreme weather.
While there are some who are skeptical about climate change, it is possible to discuss the matter by ignoring the alleged causes of the extreme weather and focusing on the damage done by weather incidents.
Weather disasters have been rather costly financially in the United States and the damage done has increased significantly. From 1980-1995 there were 46 disasters causing $1 billion or more damage. In 1996-2011 there were 87 disasters causing that amount of damage. Insurance companies reported insured losses of $36 billion in 2011, which is 50% greater than the average for the past decade.
Part of this can be attributed to the fact that Americans increasingly live in areas that are subject to destructive weather, such as the coastal regions of the United States. Part of this can also be attributed to the greater value of the structures being built, especially in risky areas. After all, the destruction of a beach mansion costs more than the sweeping away of a beach cabin. However, even taking into account such factors (and the obvious factor of inflation) the damage being done has increased.
There is also the cost human life. The 2003 heat wave in Europe killed about 35,000. In 1970 Tropical storms killed 500,000 in Bangladesh. There are, of course, many other sad examples of humans being killed in large numbers by weather events.
While the exact costs in deaths, suffering, property loss and economic damage can be debated, it is clear that weather events cost us dearly. If the damage inflicted by the weather was done by a human attacker, there would be screams for war, defense and retaliation. Look, for example, how the United States responded to 9/11.
Naturally, retaliation against the weather would be absurd—there is no intelligent agent to seek vengeance against (except, perhaps, God) or deter. However, it does make sense to establish a developed defense against the damage of weather.
People are, of course, establishing defenses against weather events. For example, France took steps, such as building air conditioned shelters, and cut the heat deaths in 2006 by two thirds. While storms still tear through Bangladesh, the construction of shelters and warning systems has reduced the death toll from hundreds of thousands to thousands. These are still heavy losses for humanity, but an improvement over the old system.
While these defenses have shown some effectiveness, our response has been largely reactive (we tend to slap together a response to the last disaster rather than preparing for the next one properly) and piecemeal.
So what I propose is a worldwide weather defense initiative (WDI—yes, this is blatantly stolen from SDI) to address the damagers presented by our planet. Many steps, such as large scale tsunami warning systems, are in place. However, most of our cities are woefully underprepared and our defenses are very limited. Meanwhile, we waste and squander resources making war on each other. I contend that at least some of these resources would be better spent (morally and practically) on defense against the weather rather than against each other. Such spending would, of course, allow for the profits and political dealings that defense spending now involves. However, at least the results would probably be more positive in terms of lives saved. I am not, of course, proposing that military defense be neglected—after all, I know us and I know that we are obviously not to be trusted unless guns are pointing at us. Even then we should probably not be trusted.
The Individual Mandate
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The United States Supreme Court is considering the constitutionality of the Affordable Care Act and this has created quite a political stir. One of the main points of concern is the individual mandate. The gist of this is that individuals are required to buy health insurance. Those who fail to do so will be fined.
Setting aside the rabid rhetoric, the main philosophical issue seems to be whether or not the state has a legitimate right to impose this mandate. Or, as opponents of the mandate put it, whether or not the state has the right to require people to buy a private product.
On the face of it, I am inclined to agree that the state does not have a general right to compel citizens to buy products even when it would be wise and good to do so. As critics have noted, while broccoli is good for people, the state would seem to have no legitimate right to compel people to buy it. This sort of reasoning is consistent with my own view of liberty, which is roughly based on that of John Stuart Mill’s view. The general idea is that people only have a moral right to compel people when the actions in question can cause unwarranted harm to others. Even if doing something would be good or wise, society has no right to compel an individual into doing (or not doing something) when it is not their legitimate concern (that is, involves harm to others).
Because of my adherence to this view of liberty, I would be against the state compelling people to buy broccoli, to exercise or to quit smoking. After all, in such matters the individual is sovereign. Since I endeavor to be consistent in my principles, I also oppose the illegality of recreational drugs as well as any law that would ban same-sex marriage. After all, if it would violate liberty to force someone to buy broccoli because it is good for them, it would also seem to violate liberty to force someone to forgo marijuana because it is bad for them or to forgo same sex marriage because some people do not like it. Not surprisingly, some folks are not quite consistent in these matters: they scream for freedom when an individual mandate is on the line but are quite happy to impose on others when the issue turns to same-sex marriage.
Given my view on a broccoli mandate it might be suspected I would oppose the individual mandate. However, this is not the case-I actually support it. Naturally, some folks might accuse me of supporting it from blind liberalism. However, my reasons for supporting it are classic conservatism. This should not be at all shocking since the individual mandate actually has a fine conservative pedigree.
Given its origin, it might be tempting to argue that the conservative assault on the mandate is misguided. However, to claim that something is good (or bad) based on its origin would be an error (specifically the genetic fallacy). It might also be tempting to argue that the conservatives are being inconsistent in attacking the mandate given that it was supported by conservatives in the past. However, this would be a mere ad hominem tu quoque. However, it is certainly interesting to note that the conservative opposition to the mandate seems to be driven by their opposition to Obama rather than the result of a reasoned repudiation of the conservative arguments in favor of the mandate. As such, one might suspect that the rejection of the mandate is motivated in part by an ad homimen attack amounting to “Obama and the Democrats are for it, so it must be bad.” However, my goal is not to consider the history and psychology of the matter, but to present conservative arguments for the mandate.
One stock conservative principle is that people should take responsibility for themselves. This principle is often taken to entail more specific principles, such as the one that people should pay for what they receive and the one that the state should always endeavor to avoid providing welfare and its ilk.
These principles seem eminently reasonable. After all, if I fail to take responsibility and because of this I get aid from the state that I have not paid for, it would seem reasonable to regard me as a thief. To use a specific example, if I decide that I am tired of working and quit my job to go on welfare, then I would seem to be stealing from my fellows. After all, I could support myself and merely would have chosen not to do so. To use another example, if my company gets subsidies from the state when it is profitable on its own, I would thus seem to be robbing my fellows. After all, my company can easily support itself without sponging off the taxpayers.
At this point, one might be wondering what these principles have to do with the individual mandate. After all, it has been cast as the state imposing on liberty by forcing people to buy a product. However, this is not the proper way to see the mandate. To see that this is the case, consider the following.
Back in 1986 the United States Congress passed the Emergency Medical Treatment and Labor Act. This act mandates that hospitals cannot turn away or transfer a patient unnecessarily when there is an emergency condition. While hospitals can ask about the patient’s ability to pay, they cannot delay or refuse treatment based on a lack of ability to pay. Hospitals can, of course, refuse to provide treatment or examination in non-emergency situations. Hospitals that violate the law can be fined as can doctors who are complicit in declaring a patient’s condition to be a non-emergency when it actually was.
Since people know that hospitals cannot turn away emergency cases, people who do not have insurance often turn to emergency rooms for medical treatment. In some cases, they do so even for routine care on the assumption that the medical personnel will provide at least some care even in the case of non-emergencies. While there has been some dispute over the exact numbers, this has been a problem in many hospitals for quite some time.
Obviously enough, when a hospital provides “free” medical care to the uninsured, it still must be paid for. After all, medical personnel do not work for free nor do the supplies and equipment needed for treatment come free. While hospitals do try to collect from the uninsured patients, this often does not cover the bill. After all, most people who are uninsured are without insurance because they cannot afford it rather than as a matter of choosing to forgo it. As such, the costs must be passed on to those who have insurance as well as on to the state. It is estimated that covering the bills of the uninsured adds $1500 to a family’s insurance premiums and about $500 to that of an individual.
As such, under the current system hospitals are required to provide services to those who cannot pay and the insured and the taxpayers are compelled to pay the bill. Thus, some people are not taking responsibility by paying for what they receive and others are left to pick up the tab-including the state. This is exactly the sort of situation that one would expect a conservative to rail against. After all, it involves people getting something for nothing as well as other people being compelled to pay more. And, of course, it also involves the state in providing “handouts.”
In this situation, there seem to be two main legitimate conservative options. The first is to ensure an end to the free ride and the government handouts by compelling people to get insurance. This way they would be paying for what they received and not being free riders. This, coupled with the Affordable Care Act, would also have the benefit of allowing people affordable access to non-emergency preventative care which would be better for their health and also reduce the strain on emergency rooms. There is, however, a second option.
A second way to address this problem is to repeal the part of the Emergency Medical Treatment and Labor Act that requires hospitals to provide emergency care to people who cannot pay. If those without insurance or money were not treated, then there would be no extra cost to pass on to the insured or to the state, thus solving the problem at hand.
Obviously, while the second solution would save some people money, it would not come without a price. It would require accepting that people should be left to die if they lack the financial resources to pay for vastly overpriced medical care. I would certainly hope that this is not a value that my fellow Americans would endorse, but perhaps this is not the case. Perhaps we should be free of the burden of caring for others and they should be free to die on the curb of a hospital because the job creators did not create an adequate job for them.
Health Care & Compulsion
President Barack Obama's signature on the health insurance reform bill at the White House, March 23, 2010. The President signed the bill with 22 different pens. (Photo credit: Wikipedia)
The United States Supreme Court will soon be ruling on the constitutionality of the Affordable Care Act. This ruling will, of course, settle the legality of the matter-at least until it is challenged. While the constitutionality (or lack thereof) of the act is certainly interesting, my main interest as a philosopher is the ethics of the matter.
While the law is 2,400 pages long, I will just focus on the ethics of a key part, namely that the law requires people to purchase health care insurance. Opponents of the law assert that this is the first federal law that requires citizens to purchase a product and they typically assert that this goes beyond the legitimate power of the state. Proponents of the law retort by arguing that the state is acting legitimately. As such, a key moral issue is whether or not the state has the right to compel citizens to buy a product in general and insurance in particular.
On the face of it, the idea that the state has a right to compel people to buy a product seems to be absurd-even when such a purchase would be a good idea. After all, buying and consuming fresh fruits and vegetables is a good idea, yet one would be hard pressed to present an argument in favor of compelling this by law (the Broccoli and Orange Act, perhaps).
To present a more substantial argument, I will begin by noting that I favor a a presumption in favor of liberty. That is, the burden of proof is upon the state to show that the intrusion on liberty is legitimately warranted. While spelling out the various conditions under which intrusion would be warranted goes beyond the scope of this essay, one obvious justification is that the intrusion prevents an individual or group from inflicting unjust harm onto others. Thus, the restrictions on murder, theft and defective products are warranted. Intrusion that are done merely for the good of a person would not be justified, at least if we follow John Stuart Mill’s classic arguments regarding liberty. After all, if I am sovereign over my self, then the state (and others) have no moral right to intrude on my actions when they impact only me. As such, while the state can justly prevent me from selling tainted broccoli, it would not seem warranted in compelling me to eat broccoli-despite the fact that doing so would be good for me. This line of reasoning, interestingly enough, would also forbid the state from making the use of marijuana illegal and would also make laws forbidding same sex marriage morally wrong since they impose on liberty solely to impose a specific religious/moral view rather than to prevent people from harming one another. In fact, the principle that the state cannot compel except to prevent harm would entail a host of libertarian positions on various issues-something that should be duly considered when using such a principle.
Of course, it could be argued that while the state has a right to compel people to not do various things even when they are not harmful to others, it does not have the right to compel people to take positive action. That is, the state can be justified in telling me what not to do, but it has no legitimate right to tell me what to do. As might be imagined, this approach is often taken by folks who want the state to compel people to not do various things (like smoke marijuana or marry someone of the same sex) but who are against this specific act.
While justifying specific acts of compulsion can be challenging, this approach does seem consistent. After all, the principle is that the state cannot compel taking action and can only compel people to not do things. As such, while the state can, for example, forbid abortion, it cannot morally compel people to buy health insurance.
Naturally, if this principle is used to argue that forcing people to buy insurance is wrong, it must be applied consistently-namely that the state is wrong to compel action and it can only forbid. This would entail that compelling young men to sign up for selective service is wrong. It would also entail that compelling people to pay taxes is wrong. Forcing automakers to include seat belts, air bags, and brakes would also be wrong. Forcing women to undergo an ultrasound before getting an abortion would be wrong. So would forcing children to attend school. Compelling people to serve on a jury would also be wrong. And so on. Naturally, this might have considerable appeal to some people, but this path would seem to take us into the realm of the absurd (although some, such as the anarchists, would say we are already there and doing this would take us out of the absurd).
The obvious counter is to insist on narrowing the principle from “the state has no moral right to compel” to “the state has no moral right to compel people to buy a specific product.” The challenge, of course, lies in justifying this principle. As might be imagined, the reply that “the state has not done this before, so doing it is wrong” is not a good argument. After all, the mere fact that something has not been done before is no indication of whether it is good, bad or indifferent. This sort of “reasoning” could be seen as a variant on the appeal to tradition fallacy, in that the idea is not that something is good because it is a tradition but that something is bad because it is not.
What, then, is needed is something that shows that the state lacks the legitimate authority to morally compel people to have health insurance while it does possess a right to compel people to do things. The challenge is to show a relevant difference between the insurance case and the other cases in which state compulsion is (allegedly) morally acceptable. The obvious thing to point to is that the state would be forcing people to buy a product. However, the mere fact that this is different does not entail that it is a relevant difference that make this specific compulsion wrong. After all, the state does compel us to pay for Medicare, Medicaid and Social Security and is thus compelling us to buy what amounts to health and retirement insurance.
Naturally, it could be argued (as some have) that the state should not do this-that being forced to pay for Medicare, Medicaid and Social Security involves an unjust compulsion and thus the state should not do this. This view would allow someone to consistently oppose the Affordable Health Care Act’s compulsion to buy health insurance but at an obvious price-namely the need to be opposed to these three things. As such, those who do not want to be rid of these things will need another line of attack.
The most fruitful one is that the the health care coverage is a private product rather than a state product. This, of course, does provide a significant difference between the state’s “products” and health care coverage. Of course, it does not provide an argument against the state compelling people to pay into a national health care insurance (as it does with the current national health care insurances, Medicare and Medicaid). As such, focusing on the fact that the product is a private one would seem to help shore up the view that the state should instead compel people to buy national health care-after all, this seems to be well within the legitimate power of the state (at least as it is currently conceived).
Nations other than the United States do, of course, have national health care. Of course, this sort of thing is presented as a worse demon than forcing people to buy private insurance. But this is a matter for another time.
Contraception, Again.
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It seems a bit odd arguing about contraception in 2012. After all, the matter seemed to have been large resolved some time ago. While it is tempting to say that Contraception 2012 is a manufactured conflict, there do seem to be some points worth addressing in this context.
One talking point that has been presented by some folks, such as mainstream American media personality Rush Limbaugh, is that insurance coverage of contraception is the same thing as paying someone to have sex.
In the case of people who are prescribed contraceptives because of medical conditions (such as ovarian cysts), this is obviously not the case. In cases in which the person is simply using the contraception as contraception, she is still not being paid to have sex any more than the coverage of Viagra and comparable medicine for men is paying men to have sex. At most, what is being paid for is the means to have sex (Viagra) and the means to avoid getting pregnant (contraception). True, these are connected to sex, but covering either is not the same thing as paying people to have sex.
Another common talking point is that the plan to cover contraception will be “using people’s money” to pay for something they do not approve of.
One obvious reply to this is that for most folks insurance coverage is either paid for by the individual or as part of a benefit package for a job. Either way, the person is earning her coverage. To use an analogy, my insurance covered my quadriceps tendon repair (mostly). This was not using some other people’s money since I pay for my insurance. Likewise, if a woman get contraception covered by her insurance, she is paying for that (either directly or by getting benefits as part of her compensation).
It might be countered that some women get coverage from the state, so tax dollars could go to pay for birth control. Since some folks are against contraception or do not want to pay for it, this should not be done.
The stock reply to this is that our tax dollars are routinely used to pay for things that we might not want to pay for or that we might even oppose. For example, I’d rather not have my tax dollars pay for subsidies to corporations and I certainly don’t want to be paying for other dudes’ Viagra. This is the way democracy works-provided that the spending is set up through due process, by agreeing to the legitimacy of the state we also give our consent to the spending-even for things we would rather not contribute to.
Naturally, it can be argued that we should not be required to pay for anything we oppose and this has considerable appeal (see Thoreau’s arguments about civil disobedience for an interesting look at this matter). However, if we adopt this principle for contraception, it must also apply across the board. So, for example, folks who are against war can insist that war should not be paid for using tax dollars and so on. It seems likely that for every proposed spending there will be a person who opposes it-thus the state should not spend money on anything. While this would solve the deficit problem, it would seem a rather absurd solution.
A third talking point is that contraception should not be covered because it does not treat a condition. This is most often brought up when defending the coverage of Viagra (which restores a natural function).
The easy reply to this is that some forms of contraception are used to treat medical conditions (such as ovarian cysts). As such, this use should be covered. But, of course, this would not warrant the coverage of contraception as contraception.
One reply worth considering is that the framing of the debate begs the question against women. After all, the claim is that anything that is covered must treat or prevent a harmful condition and this would exclude contraception (except in cases in which a women would be medically harmed by being pregnant). However, this framing tends to be simply assumed rather than being argued for, which is rather unfair to women in this regard. After all, the matter of pregnancy seems to be unique (and limited to women) and hence it seems questionable to insist that it must automatically fall under the framing in question. It can, of course, be argued that it does-but an argument is wanted here to show that is the case.
While some might be tempted to cast pregnancy as the harmful medical condition that is being prevented by contraception, the idea of casting pregnancy as a harmful medical condition has rather limited appeal. After all, while pregnancy puts considerable strain on the woman, it seems rather difficult to cast it as an illness that needs to be prevented or treated as if it were comparable to measles or cancer.
A more fruitful line of approach is to argue that contraception provides medical control over a woman’s quality of life. That is, it enables her to chose whether to be pregnant or not. Doing this clearly falls under the domain of medicine and women do seem to have a legitimate claim to this right. After all, much of medicine deals with maintaining a desired quality of life and women would seem to have as much right to that as men.
Naturally, it might be countered that I am treating pregnancy as a disease (which would be some major rhetorical points against me). But this is not the case. All I am claiming is that given that pregnancy can be rather challenging for a woman and, of course, a child is a major consumer of resources a women has a legitimate right to use medical means to maintain her desired quality of life-just as a man has a legitimate right to use Viagra and its ilk to maintain his desired quality of life. Just as Viaga is covered as a quality of life drug, so should contraception.
A fourth, somewhat uncommon, talking point is that contraception is on par with abortion, so covering contraception is covering abortion.
One stock reply is the obvious fact that contraception lowers the number of unwanted pregnancies and this lowers the number of abortions. As such, folks who are worried about abortion would seem to have a good reason to favor covering contraception.
Of course, some folks contend that contraception is like abortion in that it prevents a possible person from becoming an actual person. While this does have some philosophical interest, it would seem to entail that every moment I am not out and about impregnating women, I am engaged in acts comparable to abortion. After all, by not impregnating as many women as possible, I am preventing some possible people from becoming actual people. Put a bit less absurdly, if I am practicing abstinence, then I am effectively engaged in abortion since all those possible people will never become actualized.
It could be countered that this only applies to cases in which I am actually having sex (and presumably that I should only be having sex with a woman I am married to). That is, every time I have sex, there should be a roll of the dice to see whether or not the woman gets pregnant. Presumably if either of use chooses to use any method that lowers the probability of pregnancy, then this would be on par with attempting an abortion. As such, the only acceptable family planning would be to decide to have sex only when one plans on a pregnancy since intentionally preventing it would be unacceptable. I would be interested in seeing some arguments for this that do not involve an appeal to theology.
Protect Life Act
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Abortion is a matter of seemingly endless moral and political debate. In the latest round, the Republican controlled House has passed the Protect Life Act. Two of the main aspects of the act include preventing federal money from being used in health care plans that cover abortion and to allow health care workers to refuse to perform abortions. This includes cases in which an abortion is medically necessary to save a woman’s life.
The first aspect of the act seems to be at least partially a solution in search of a problem. The Affordable Care Act (known by the dysphemism “Obamacare”) already prevents public money separate from private insurance payments covering abortion. However, the is a common misconception (intentionally fueled) that “Obamacare” pays for abortions.
The act goes beyond this in an attempt to restrict coverage of abortion. The bill, if made into a law, would forbid women from buying private insurance plans including abortion coverage. This is, of course, limited to purchases made through a state health care exchange.
The main justification for this aspect of the bill is that the Republican backers claim that taxpayer dollars should not go to abortions. Of course, the bill goes beyond that and attempts to restrict women’s choices.
On the face of it, the justification has a certain appeal. After all, in a democratic (or republican) system, the taxpayers have a right to decide where their tax dollars are spent (and also to have a role in decisions in general-if only via representatives). As such, if the majority of Americans are opposed to having tax dollars go to abortion, then it would be presumably correct to not provide such funding. Majority rule and all that would serve as the moral justification. This would, of course, entail that the same principle should apply uniformly. So, for example, if the citizens did not want subsidies going to corporations or did not want to fun capital punishment, then such things should not be allowed.
In the case of abortion, most Americans hold that it should be legal. While this does not entail that they want to fund abortions, it would seem to indicate that abortion rights are accepted by the majority of Americans. As such, attempting to restrict these rights under the guise of keeping taxpayer money from funding abortion would seem to be somewhat deceptive. After all, it is one thing to prevent public money from being used and it is quite another to forbid women from buying private insurance with their own money. It is especially ironic given the Republican mantras about the free market and individual choice.
Also, if most Americans favor the legality of abortion and the Republican backers of the bill are claiming that they are right to impose restrictions based on the fact that some people are morally opposed to abortion, then it would seem to follow that anything that is morally opposed should not be funded. This would include capital punishment, war, the drug war and so on. In fact, it seems likely that very little would be left with public funding. Naturally, it could be argued that the moral opposition would need to be significant, but even under that condition capital punishment and many other things could no longer be funded with public money. Perhaps this would be a good thing-but I am reasonable sure that neither the Democrats nor the Republicans would be willing to accept this a general principle.
Perhaps the most controversial component of the bill is that health care workers who morally oppose abortion will have the legal right to refuse to perform abortions-even when doing so is medically necessary to prevent the death of the woman. Currently hospitals are legally required to perform abortions when doing so is medically necessary to saving the life of the woman. Some Catholic hospitals have been breaking the existing law for years.
On the one hand, a strong case can be made for allowing health care workers to decline performing an abortion on moral grounds. After all, a law that compels people to perform what they regard as an immoral action (such as fighting in war or paying taxes to support a war or what they regard as an unjust system) would seem to be well worth both moral and legal scrutiny. This matter has, of course, been addressed in regards to civil disobedience and the question of what a person should do when his/her conscience conflicts with the laws of the state.
In the case of non-emergency procedures, I am certainly sympathetic to the view that health care workers with strong moral beliefs should not be forced to engage in what they regard as an immoral action (most likely murder). Likewise, I am sympathetic to people who refuse to fight in war or support the state on the grounds that they regard the killing (or murder) of human beings as immoral.
On the other hand, a strong case can be made that professionals are obligated to perform their jobs even when doing so goes against their conscience. For example, a nurse who is opposed to drug use would not seem to have the right to refuse to treat a victim of a self-inflicted drug overdose of illegal drugs. As another example, a police officer who thinks that homosexuality is an abomination would not seem to have the right to refuse to protect a homosexual who is being beaten to death.
In the case of emergency procedures, a very strong case can be made that such procedures should be performed. On utilitarian grounds, performing such procedures would seem to be right. After all, the most likely result of not performing the procedure is that the woman and the fetus both die. The procedure would at least save the life of one person, which would presumably be a good action. To use an analogy, imagine that a child has been rigged with a terrorist bomb and is running at a woman. The bomb cannot be removed in time and will detonate in seconds. A soldier or police officer is nearby and can stop the child-but only by shooting her. The woman can, of course, scream to the soldier/officer that she would rather die with her child. However, it would not seem wicked of the soldier or officer to take the shot if the woman did not forbid it.
It can, of course, be argued that this is not a utilitarian matter but a matter of the action itself being right or wrong. If it is assumed that abortion is wrong because it is killing, it would seem to follow that not helping the woman would also be wrong-after all, this would cause her death.
At this point it is natural to bring up the stock distinction between killing and letting die. In the case of the woman, the medical care provider would be letting her die rather than killing the other being (which may or may not be a person). In general, our moral intuitions tend to indicate that killing is worse than letting die, which could be taken as a point in favor of allowing health care providers to let women die rather than perform an abortion. However, since the being will also die anyway (in most cases) it would seem that refusing to save the woman would (as noted above) merely double the number of deaths rather than do something that would be morally commendable. This could even be argued on the same moral basis as triage. In this case, the act could be seen not as killing the being, but saving the mother rather than allowing two patients to die. To use an analogy, if a mother and child were brought to a hospital and both were dying and the doctor knew that her choice was between saving the mother or letting both die while she worked to futilely save the child, then the right thing to do would seem to be to save the mother. Expending pointless effort on a child that could not be saved while letting the mother die would not be noble or good. Rather it would be a wrongful decision that would kill the mother. As such, this provision is clearly immoral.
The Tree of Community
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While I was doing some touch up painting on Thursday, a storm suddenly rolled in with wind, rain and a little thunder. As I was packing up my gear, I heard a tree fall. I went out to look and saw that it had fallen across the road in my home owners’ association. While it did not block my way out it did block some of my neighbors. Naturally, I went out to move the debris.
As I was clearing the debris, two of my neighbors came out. One woman helped as best she could with the branches and the other went to find out who to call about a huge tree in the road. The boyfriend of another neighbor came out and helped until he had to go, but he said he would be back with a winch to pull the tree out of the way. Another neighbor came out and offered to help clean up things, once the storm passed. At that moment, the rain began to pour down. Since we had cleared enough debris to allow people to get by the tree, everyone retreated from the rain.
While this was just a small thing, it does show what is best about people: our ability to join together to do good-even if it is just something like clearing a path through debris so that a neighbor coming home from work can get to her house. It is easy to forget that we are bound together by ties of our shared humanity and that being there for each other, even for the little things, is an essential part of being a good person.
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