Obama's Strategy for Health Care Reform

Thus far the Obama administration has been letting Congress take the lead in framing legislation to bring about fundamental change in the way Americans get their health care paid for. The bills being developed in Congress currently feature a "public option" that would create a government run and financed health insurance fund that would compete with the big private health insurers, like Blue Cross/Blue Shield, Aetna, Kaiser Permanente, and the other for profit health insurance companies. These companies, as well as the for profit hospitals, the manufacturers of medical equipment and supplies, the big pharmaceutical companies are now launching a massively funded public relations campaign designed to get rid of the public option idea and go on with "business as usual" for another few decades.

At the same time, the Obama plan has ticked off progressives because he and his democratic allies in Congress have decided at the outset to take a "single-payer" option off the table. There was a good discussion of this on Amy Goodman's Democracy Now show the other day with Bernie Sanders and the President of the California Nurses Union, Rose Ann DeMoro in which they both expressed frustration and anger about Congress not taking the single-payer option seriously. The single-payer option is the only possible plan that offers significant cost savings while also ensuring universal coverage. It has been empirically tested and refined in Canada and other countries that have long ago accepted the proposition that health care is a human right, to another opportunity to make a killing in the market. There is a well-developed proposal for a system of national health insurance (see PNHP)

There is no good reason for Congress not to even consider a single-payer option. But perhaps this is a calculated political strategy. The insurance industry and their Republican allies in the Congress are already lining up to oppose the "public option" that they claim will eventually threaten the private insurance business. The public option plan does not have the advantages of the single-payer system in terms of cost saving and administratiive simplicity nor in terms of universality. But it does allow the private health insurance business to stay in existence to compete with a government financed insurance program. But the private insurers and their allies are already whining that by offerring the public a lower cost option for health insurance, the public option will eventually take over the market and price private companies out of the competition.

I believe that this argument is total bullshit -- did all private schools and colleges go out of business when state governments started funding schools? But in any case, what Obama ought to say to this argument is: "OK, if you guys won't let us have the public option which may eventually drive some of your insurance companies out of business, then we are putting the single-payer option back on the table and that is what we will be pushing through Congress this year." Your choice is between accepting a proposal that may put some of insurance companies out of business eventually, or one in which they will all be put out of business immediately. Your choice."

It is likely that if the Democrats in Congress and the President play this particular brand of political hard ball the Republicans will walk and refuse to vote for any plan. But once Al Franken gets seated, the Democrats have enough votes to pass it anyway, without any Republican support. If they avoid the 60 vote threshold by means of reconciliation they will need only 50 votes to pass it in the Senate, and they should be able to do that even if convervative Democrats such as Arlen Spector and Ben Nelson vote with the Republicans.

If the Republicans start screaming bloody murder about employing this tactic to get a long overdue national health insurance bill passed, I suggest that President Obama dispatch Rahm Emanuel to Capitol Hill to convey to them the immortal words that Vice President Dick Cheney said to Senator Patrick Leahy --- "You can go fuck yourselves".

Killing Abortion Doctors vs. "Killing Babies"

The murder of Dr. George Tiller is another demonstration (as if we needed one) why it is a mistake to allow idiots access to handguns. It also illustrates the illogical nature of the anti-abortionist argument that equates performing abortions with "killing children". Before he was murdered, allegedly by a right-wing extremist by the name of Scott Roeder, Dr. Tiller's name often came up on the Fox channel's show The O'Reilly Factor, where he was referred to as "Tiller the Baby Killer."

The term "baby" is used to refer to offspring of a certain age. I was my mother's baby at one point in my life, then I was her child, then her teenage son, and now I am her adult son. I am now called "middle-aged" a euphemism for "old". The terms "ovum", "embryo", "fetus" refer to mammalian offspring during gestation, that is, before they are born. The term "infant" refers to a newborn who is unable to speak. We use "toddler" for very young children who are just beginning to walk.

We can play semantic games with these words, for instance, we can say to a pouty teenager that they are "Acting like a baby," which will generally be taken as an insult. Calling a teenager a baby is misusing the language: if we take these terms in their literal and precise meaning, a teenager is not a baby. Similarly, calling a fetus a child is misusing the language. But here there is an obvious point that people are trying to make when they misuse the language in this way -- they are saying that they believe that fetuses (and perhaps ova and embryos) have the same moral status as babies.

Rather than playing these semantic games, why not just address this question frankly? The reason is is that once one does so it becomes clear that it is not at all obvious that it is true that fetuses have the same moral status as children. Simply calling fetuses children begs the central question in the debate over abortion. Unfortunately, however, some people seem to believe that begging this question is a way of answering it. That is, they believe that if one repeats the mantra "Abortion is killing babies." often enough with enough sincere conviction, it becomes true.

There is no similar problem for the sentence "Killing doctors who perform abortions is murder." This is quite literally and obviously true because no one in their right mind doubt that doctors who perform abortions are persons who have certain moral and legal rights which are violated when they are deliberately killed. This is a settled question of ethics and law.

There are, however, some people who seem to believe that it is morally justifiable to murder doctors who perform abortions in order to save the lives of "babies", by which they mean fetuses. Here is where the misuse of the language leads to moral confusion and error, not to mentioned incitement to hatred and violence.

It is not a settled question as to whether fetuses are persons who have certain moral or legal rights which are violated when the women who are gestating them decide to end their pregnancies. It is a hotly contested question subject to intense debate. To describe the fetuses who die as the result of abortions as "babies" or "children" treats that debate as though it were settled, when in fact it is not.

What is settled as a matter of law is that it is legal in the United States of America for women to seek and have abortions. One may not like this law, or agree with it, but it is in fact the law. Wishing the law were different than it is does not change the law. Calling fetuses "babies" and calling abortion "murder" does not change the law. It only serves to mislead people and to incite hatred against women who seek abortions and doctors who provide them with these medical services.

The murder of Dr. Tiller illustrates that words can be harmful. From what I can gather from press reports, the person accused of his murder believed that abortion was "baby-killing" and therefore that Dr. Tiller was literally a "murderer". Since the law was not going to punish him for his crimes or prevent him from committing similar ones in the future, the murderer decided to become a vigilante and give Dr. Tiller what he deserved himself, namely that he deserved to die for performing abortions. Nor was this the first time Dr. Tiller was targeted by members of the "pro-life" movement. Nor was he the only abortion doctor to have been murdered --David Gunn was gunned down in Florida in 1993 --and Barnett Slepian was slain in 1998. These killings reveal a pattern: the reasoning that allows some people to reach the conclusion that it is permissible to murder abortion providers is a trifecta of moral errors.

First, as I already noted, it is wrong to simply assume that abortions are murder. Second, it is wrong to take the law into ones own hands. And third, it is wrong to suppose that death is an appropriate and ethical punishment for murder.

When one commits murder one violates another person's right to life. To deter and punish murder by having a private individual or state deliberately kill the offender is another violation of the right to life. I don't have time to argue the case for this here (see my "Death Penalty and the Forfeiture Thesis" in the Journal of Human Rights), but even murderers do not "forfeit" their right to life, and no one, neither private individuals nor states, have the rightful authority to cause that right to be forfeited. In particular, vigilantes like Scott Roeder do not have this power.

I do hope that if Roeder is convicted of this heinous crime that he is severely punished, for instance, that he spend the rest of his life in prison. But I am glad that he will not be subject to the death penalty under Kansas law.

I suppose that this makes me "pro-life".

The Golden Rule

There is…one rule that lies at the heart of every religion – that we do unto others as we would have them do unto us. This truth transcends nations and peoples – a belief that isn’t new; that isn’t black or white or brown; that isn’t Christian, or Muslim or Jew. It’s a belief that pulsed in the cradle of civilization, and that still beats in the heart of billions. It’s a faith in other people, and it’s what brought me here today.

--President Barack Obama, speaking in Cairo Egypt, June 4, 2009

The Golden Rule (GR): Do unto others as you would have them do unto you, is widely accepted as a valid moral rule. However, it is fairly easy to show that it yields incorrect and inadequate moral guidance in many cases. But there are reasons why it has been so widely accepted and continues to be taught, and these reasons have to do with its very incompleteness as a principle of ethics, and its connection with the idea of reciprocity.

The GR can be stated in either a positive or a negative manner:

GR+: Do unto others as you would have them to do unto you.

GR-: Do not do unto others as you would not have done unto you.

In the first version it states a principle of positive duty while in the second it states one of negative duty. However, it is possible to state the GR in a way that is neutral between acts and omissions:

GR0: Treat others as you would have others treat you (where "treatment" can be understood as involving both acts and omissions).

By employing the subjunctive "would" the GR is quite different in its implications than the principle:

GR%: Treat others as they have treated you.

The GR% is a principle of pure reciprocity. Using it prescribes returning kindness for kindness and cruelty for cruelty, presumably in the same proportions as they are received from others. One might regard the GR% as "fair" in that it would rule out repaying a kindness with cruelty, and also, repaying cruelty with kindness. But unless you have already been acted upon by others in some way, there is no way to interpret the GR%. The change to talking about how one would want to be treated, obviates this problem, but as we shall see, creates other problems.

Also by way of preliminary clarification, one should understand the GR as having implicit universal quantifiers:

GRQ: Everyone should always treat all others as they themselves would wish to be treated.

Making the quantifiers explicit allows us to see more clearly why GR provides incorrect moral guidance in many cases.

Consider the rich man who does not wish to be given money as charity in order to feed his children (because he doesn't need it) who reasons that since he does not want to be treated as a recipient of charity, others, who might be much poorer than he, should not either. Or consider a case from my own experience. I would like my wife to attend my lectures because I would want to get her honest opinions on how I did. She, on the other hand, has repeatedly told me that she does not want me to attend her lectures since she thinks I would distract her and make her more nervous. If I followed the GR I would attend her lectures and if she followed the GR she would not attend my lectures. But this is clearly wrong: the right thing to do is for me not to attend her lectures and for her to attend my lectures.

In order to be successfully applied the GR assumes that there is a symmetry in the conceptions of the good between the agent and the patient, that others would want to be treated as oneself wants to be treated, but this is obviously untrue in many cases.

But, it will be objected, the cases I have chosen to illustrate a problem with the GR are framed at the wrong level of abstraction. Rather than framing the application in terms of specific types of actions (giving charity or attending lectures) the GR should be understood as recommending that one treat other persons in accordance with their own conception of their good. Since I would want others to respect my own conception of my good I should assume that others would likewise want that I respect their conceptions of their own good.

So then we might restate the GR as: "Everyone ought always treat all others in accordance with their own conceptions of their own good" or more succinctly:

GR*: Treat others as they want to be treated.

GR* is an improvement over GR because rather than assuming that the agent's own preferences are automatically a good guide to the patient's preferences, it asks us to consider the patient's preferences directly. But one immediately sees there is another problem with this formulation. What if the moral patient involved has a mistaken view of what their own good consists in?

Suppose Janine has a fifteen year old son, call him Oscar, who thinks it is in his best interest to drop out of high school and get a job as a gas station attendant. Janine, as Oscar's parent, would be acting irresponsibly to simply agree to this idea. Oscar has a mistaken view of what his good consists in and his own wishes in this case ought to be set aside in favor of Janine's more adequate conception of her son's good.

The problem with GR* is that in some cases one ought to treat people in ways that those people should ideally wish to be treated rather than in the ways they actually do wish to be treated. So we need to revise the GR once again:

GR*I: Treat others as they should ideally want to be treated.

But now we can clearly see that in order to apply GR*I one needs to have a theory of the good which tells one what it is persons ideally should want for themselves. Since the GR purports to be a moral rule or principle, let's assume that the term "should want to be treated" can be understood as meaning how he or she "morally ought to be treated." On this interpretation, the GR tells us something uncontroversial but also rather unhelpful, namely that we ought to treat people the way they ought to be treated.

To avoid this tautology, those who employ the GR as a guide to moral action must have a substantive ethical theory which describes the kinds of treatment which persons are morally entitled to receive. The GR*I will thus yield rather different prescriptions depending on which moral theory the agent has. If the agent is an ethical egoist he would want to be treated in ways that maximize his self interest. As Brian Medlin points out, it is doubtful that this principle can be consistently universalized. If the agent is an act utilitarian he wound want others to treat him so as to maximize the utility of all concerned on each occasion in which he is acted upon. On this view, the agent must be prepared to accept the fact that his or her own interests may be sacrificed at the altar of utility. If the agent is a contractarian he will want that others keep their agreements with him in cases in which he keeps his agreements with them. In this case, the relationship between the GR and the principle of reciprocity comes into focus. To the extent that the rules of morality can be viewed as conventions that are chosen and followed because they are in the long run mutually beneficial, the GR functions as a way of reminding us to be faithful to these agreements and the practices they support. If you would want others to keep the promises they make to you, then you are required to keep the promises you make to others. If the agent is a Kantian he will want others to treat him as an end in himself. If he is a virtue theorist he will want others to treat him so as to promote his eudaimonia, and so forth.

Depending on the moral theory of the agents who apply the GR*I, it will yield rather different moral prescriptions, and this feature of the GR may, as Paul Weiss has observed, be the basis of its nearly universal appeal, "because it allows and even tempts as many interpretations as there are modes of self-regard and systems of ethics" (Weiss 1941, 421).

But the GR can also support quite wicked actions if only the agent is willing to be treated in a similar fashion. If my ethical theory prescribes wanton murder and mayhem, and I am willing to be the recipient of such actions myself, then the GR does not rule it out. According to Weiss's analysis, for the GR to function as a moral rule three conditions must also be met:

(a) We know what we want.

(b) What we want is identical with what we ought to desire.

(c) What is good for us is also good for the rest. (Weiss 422).

The key conditions are the second and third – that we know how ideally we should want to be treated, and this idea of the good is valid for others. But how can we prove (a) and (b)? Kant provides at least the beginning of an answer. In the Groundwork of the Metaphysics of Morals (1785) he observes:

Let it not be thought that the common "quod tibit non vis fiery, etc." could serve here as the rule or principle. For it is only a deduction from the former, though with several limitations; it cannot be a universal law, for it does not contain the principle of duties to oneself, nor of duties of benevolence to others (for many a one would gladly consent that others should not benefit him, provided only that he might be excused from showing benevolence to them), not finally that of duties of strict obligation to one another, for on this principle the criminal might argue against the judge who punishes him, and so on. (note 7)

In the Second Formulation of the Categorical Imperative he proposes a different principle, that persons (both ourselves and others) be treated as ends in themselves rather than as means only. We can then reinterpret the GR as follows:

CI2: Everyone ought always treat all other persons as ends in themselves rather than as means only.

CI2 says that one should always regard other persons as rational agents in their own right who have a good in themselves and for themselves. In the case of competent adults, this is usually understood as entailing that one respect the other person's autonomous wishes concerning themselves. So, in the case of competent adult moral agents, CI2 is equivalent to GR* -- we should treat other adults in the ways in which they autonomously wish to be treated. This reading of the GR follows on the assumption that competent adult moral agents are the best judges of what is in their own good consists in. In cases involving minors or adults with impaired judgment or mental capacity, the alternate rule would be to do what is in their best interest, which is equivalent to GR*I in that it allows a substituted judgment as to what a person's good consists in. It does not, however, automatically assume that the agent's conception of his or her own good is a reasonable approximation to the patient's good. If the patient is, say, suffering from advanced dementia, then if I am their caregiver I ought to take care of various tasks for them, such as paying their bills, but I would not consider it in my best interest to have them take care of paying my bills for me. Kant's Categorical Imperative can thus be understood as an improved version of the GR. It is an improvement because rather than relying on a subjective and perhaps idiosyncratic conception of the good which an agent may have and which the agent may or may not share with the patient, it proposes a general conception of the good for rational moral agents that could in principle be embraced by all rational moral agents.

Kant claims that the second formulation of the CI is equivalent to the first formulation: Act only on that maxim that one can at the same time will to be a universal law. So then can the GR pass the universalization test? Not, it seems in the standard version, since I would not want other people to treat me in accordance with their conception of their good in cases in which their conception was mistaken or in cases in which it disagreed with my conception of my good. Willing the standard version of the GR would result in a contradiction of my will since in cases in which my conception of my good implied A and other agent's conception of his good implied ~A, I would be willing both A & ~A by willing that both of us follow the GR. I can, however, will the GR*I without contradiction since in this case if I am a competent and autonomous moral agent I would be willing that others treat me in accordance with what I conceive to be in my own best interests, and if I am not autonomous, then I would be willing that they treat me in accordance with what I should regard as in my best interests. In both of these cases, other agents would be directed to treat me as an end in myself whose best interests are morally considerable and should be taken into account in their decisions about how to treat me.

But Kant's theory provides only a "thin" conception of the good. A utilitarian theory attempts to put some additional flesh on the bare bones of respect for persons. Utilitarians often argue that in deciding how one ought to act one ought to take into consideration the interests and preferences of other persons as well as one's own interests and preferences. They also agree that one should be impartial and give equal consideration to the interests of other persons. In these particular respects, the GR captures the notion of equality of consideration that is found in utilitarianism. GR* expresses a moral rule that is similar to the Principle of Utility (PU) as understood by a preference utilitarian. If we assume that utility can be measured in terms of preference satisfaction, the preference utilitarian version of the GR would be to "Do unto others so as to maximize aggregate preference satisfaction of all concerned, where each person's preferences should be considered to have equal weight to one's own." This is similar to GR* which advises us to treat others as they want to be treated. However, the idea that people's preferences provide an adequate conception of the good is highly doubtful for reasons already discussed.

Perhaps only a fully developed virtue ethics can provide us with an adequate conception of the personal good that would apply with equal force to oneself as well as to others. According to the virtue ethics view what we ought ideally wish for ourselves is what will make us better people; but "better" in the virtue sense, that is, what will make us more just, more courageous, more charitable, more wise, and so forth. Ideally we should all wish that we become the most virtuous people we can be. This leads to a version of GR*I which tells us that we ought to treat others in ways that will make them more virtuous persons. Ideally, everyone ought to desire that they become more virtuous persons, since on this view, the attainment of virtue is considered to be the highest good for human beings. We should aim for eudaimonia (moral virtue, flourishing, or happiness) both for ourselves as well as for others.

This then leads to another version of the GR:

GR*E: Treat others so as to promote their eudaimonia.

GR*E is more adequate than the earlier versions, but is still lacking as a practical moral rule because it is not easy to interpret and apply. The specific actions that one ought to take in order to fulfill this maxim will vary depending on both the characteristics of the agent and also those of the patients to whom the actions are directed. Rather than a guide to practical action, the GR*E can function as a way of interpreting the Golden Rule so as to fulfill Weiss's conditions (b) and (c), but applying it depends on our knowing what virtue consists in and how best to promote it.

REFERENCES

Paul Weiss. "The Golden Rule." Journal of Philosophy, Vol. 38. No. 16 (1941): 421-430.