Adam Smith Meets the Rich Young Ruler: Health Care and the Common Good

by LaVonne Neff 10-14-2009

For more than sixty years American presidents have tried to reform our health-care system, to no avail. In the same time period, all other developed nations have set up systems that insure all their citizens, that spend less per capita than we do, and that have better outcomes in almost all categories. Why are Americans still lagging behind?

Ethicist Daniel Callahan diagnoses our problem in the most recent issue of Commonweal magazine and comes to this conclusion: we suffer from “the absence in this country of a solid common-good tradition.”

In his thoughtful article “America’s Blind Spot: Health Care & the Common Good,” Callahan points out that the absence of a common-good tradition is not ideologically based — it is felt at all points on the political spectrum. “In their opposition to liberal reform efforts,” Callahan writes, “conservatives invoke freedom, choice, and competition as their leading values. Liberals — and the Obama administration in particular — have no agreed-upon set of countervailing values.”

Instead of the common good, says Callahan, liberals have appealed to rights, obligations, and justice — fine concepts, but without much curb appeal. Conservatives invoke radical individualism, even though one of their heroes, Adam Smith,

believed that markets could not flourish without a strong underlying moral culture. Smith believed that such a culture is animated by empathy and fellow-feeling, by our ability to understand our common bond as human beings and to recognize the needs of others.

And all of us argue about the bottom line.

Sunday’s gospel reading was about a man who asked Jesus what he needed to do to inherit eternal life. Jesus told him to sell his possessions and give them to the poor. “At that statement his face fell, and he went away sad, for he had many possessions” (Mark 10:22).

I confess: I don’t want the poor to take any more of my possessions. I pay taxes. I give to charities. In the wake of the recession, our income has taken a serious hit, and a tax increase would hurt. I would much rather offer the poor someone else’s possessions. Why not help them, as many European countries do, by restricting doctors’ income and insurers’ profits?

Strangely, my cardiologist’s office doesn’t want to lose any of its possessions either. A recent mailing urges patients to oppose health-care reform and Medicare changes, warning that their lives may be endangered if cardiologists are prevented from making big bucks from overusing expensive diagnostic equipment (this is not, of course, how they phrase it).

Oddly enough, insurance companies would like to hang on to their possessions too (though almost everybody in the U.S. thinks Aetna’s CEO probably doesn’t need every cent of the more than $24 million he made in 2008). No wonder they are doing their best to scare us into keeping the present system.

Without a shared belief in the common good, who among us will go first? Or will we do nothing, hang on to our possessions, and go away sad, leaving health care unreformed and the poor uncared for?

Here is how Callahan concludes his fine analysis:

Suffering, disease, and death are our common lot. They ought to be dealt with as our common problem. It is a shame that the kind of empathy and mutual support that Adam Smith understood to be a requirement of morality have not, in our culture, been extended to health care — extended to one another in the recognition that we all have bodies that go awry and fail. Instead we are offered a consumer model, a national Walmart of medical choice where we are all sharp-eyed purchasers getting the best possible deal for ourselves. A construal of the common good as the freedom of consumers to get what they want, indifferent to the fate of others, is a cheap substitute for the real thing.

Callahan expertly diagnoses our problem, but he does not offer a solution. National revival comes to mind, but America already has a much higher percentage of church-going Christians than the countries that take care of all their poor and suffering. Maybe we won’t really care about the common good until more of us Americans experience poverty and suffering first hand.

portrait-lavonne-neff LaVonne Neff is an amateur theologian and cook; lover of language and travel; wife, mother, grandmother, godmother, dogmother; perpetual student, constant reader, and Christian contrarian. She blogs at Lively Dust.

Categories: Economics, Health

xfree9

A handful of judges who disagree does not change the meaning of the intention of the original authors.

carlcopas

Plain and clear to you, perhaps, but fortunately for the Republic not so plain to John Marshall and the other justices who signed McCulloch vs. Maryland.

xfree9

What do you mean it doesn't have to be specifically enumerated? What on earth would the tenth amendment mean? "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."

That's pretty plain and clear.

carlcopas

For many, grace is reserved for Sunday morning, between the hours of 9 and 12, and the holidays of Thanksgiving and Christmas, when baskets of food are distributed to the needy.

carlcopas

It doesn't have to be specifically enumerated because, contrary to what you assert, "general welfare" was not prescribed specifically.

Supreme Court Chief Justice said as much in McCulloch vs. Maryland: "We admit, as all must admit, that the powers of the Government are limited, and that its limits are not to be transcended. But we think the sound construction of the Constitution must allow to the national legislature that discretion with respect to the means by which the powers it confers are to be carried into execution which will enable that body to perform the high duties assigned to it in the manner most beneficial to the people. Let the end be legitimate, let it be within the scope of the Constitution, and all means which are appropriate, which are plainly adapted to that end, which are not prohibited, but consistent with the letter and spirit of the Constitution, are constitutional."

Judi Heppner Daly

I'm Canadian, and as someone who benefits substantially from our health care system I have always been amazed by Americans who are against a health care system. I can understand the big insurance companies that make millions being opposed, but I've never understood how more regular men and women rail against an idea that could see their lives be more secure. How nice would it be to not die of cancer because your insurance company won't pay for the drug that could save you?

I once asked two American email buddies about their thoughts. I found the results fascinating. To put it in a nutshell:
Person A wanted a health care system because people who deserve health care might not get it the way things are presently.
Person B did not want a health care system because people who don't deserve health care might get it in the new system.

I wonder if there is a strong perception in America that if you are poor, marginalized, on drugs, you are solely there because of poor moral choices and you don't deserve to have nice things. Where is grace?

xfree9

Yeah, I pretty much agree with your assessment near the end. I'm not quite so sure I'd believe that a war made an economy "stable," even if it did guarantee jobs. Wars only destroy productive assets, because eve the assets created in our nation were used only to destroy. I'm not sure that should be acceptable to the economic calculation of any Christian.

MoTres

While the actions identified are not recoveries when evaluated in isolation, one must acknowledge their contribution to what we now view as the recovery. Because if one identifies things like, going into debt as a nation and government contracting as non-participatory in the recovery, the challenge will become, defending the idea that we as a nation ever recovered. Furthermore, when soldiers returned from the second World War, flushed with the success on the battlefield, and the pay and promises of the grateful nation, the war became a force in the market, which contributed to financial stability in the US.

But most importantly, identifying WWII as an economic boost in the United States was an incidental part of the argument from which it was taken. The post was not militaristic, it merely identified the power of mass focus and feared that there is insufficient motivation to defuse the inertia that is more than sixty years building.

The most basic idea of an organization like Sojourners is that the more people speaking up, firmly united by a common interest, the harder it will be for a small group of hyper-powerful individuals to control the turning of the world.

Very few people would view the simple majority as an inherently just body or assert that "the people" are necessarily right. De Tocqueville wrote extensively about the risks inherent in the majority rule. But the hope is that as people's urgency builds, we will begin to pull back the curtain and expose the wizard for what he is. And I believe that this is a hope that we share.

irish_annie

good point. i note that Jesus appealed to the rich young ruler. he didn't chase him down and pick his pockets. 'charitable' giving, by definition, should be voluntary, from a heart of love. let us follow the example set by our heavenly Father, who refuses to do with force what he has chosen to accomplish through loving patience.

irish_annie

sorry, the author speaks of what she knows not. one cut being currently implemented (ahead of HR 1032) is 40% cut in reimbursement for echocardiograms for medicare patients... but it's not being implemented across the board. only those echoes performed in your dr's office will be penalized. medicare will still pay 100% for the ones performed at the hospital... i smell special interests...
this will put people out of work (the echo techs in the dr's office). it will make it more difficult for elderly patients who could formerly receive the (much-needed btw) service at their dr's office and now must navigate hospitals which are often inconvenient and confusing, adding stress and strain, fatigue, to one who is already ill. heartless.

xfree9

I think that's a total misreading of the Constitution. In Federalist #41, James Madison wrote, "For what purpose could the enumeration of particular powers be inserted, if these and all others were meant to be included in the preceding general power? Nothing is more natural nor common than first to use a general phrase, and then to explain and qualify it by a recital of particulars. But the idea of an enumeration of particulars which neither explain nor qualify the general meaning, and can have no other effect than to confound and mislead, is an absurdity."

In other words, "general welfare" was prescribed specifically in the Constitution. If that were not the case, our nation wouldn't be a nation of laws, but a nation led by politicians who write laws that suit whatever they believe "general welfare" meant for the day.

You may be able to argue for universal health care as a "common good," but the Constitution has specific enumerated powers it grants to the federal government, and that is not one of them.

WaveTossed

"The government's only method of action is violence, even if it is padded by all sorts of other things. Privately-held companies, if they are not already protected by the government, would truly be accountable to "the people" because they would simply go out of business if they do not provide a good or service that the people wanted."

That used to be true. However, with the development of what Eisenhower so aptly named, "the military-industrial complex," government has handed over the force option to certain cartels of enterprises that are supposed to be private. We have had Blackwater and other similar companies -- and also the oil companies -- determining foreign policy and using troops and mercenaries.

Fast-fowarding to today: I just found out on a TV show last night that health insurance companies are exempt from any of the anti-trust provisions of law. So it's perfectly legal for health insurance companies to form a monopoly cartel and fix the prices. With this system of a health insurance monpoly cartel, there is no free market, there is no competition -- and therefore, no capitalism. I've heard talk about legislation to revoke the anti-trust exemption for health insurance companies. I wonder if this legislation would go any further than the proposed legislation to revoke major league baseball's anti-trust exemption.

There is also the more recent concept of companies "too big to fail" so they have to be bailed out by taxpayer money. Were health insurance companies made exempt from anti-trust laws because of this concept?

The free market works if we have a free market. Which we don't in this day and age.

carlcopas

The so-called "elastic clauses" are wide enough to drive a truck through. "General welfare," which is another way of stating "common good," is defined by Congress at any given time. If Congress decides that health care is necessary for the general welfare, then it has every right to provide for it.

Section 8: The Congress shall have power
To lay and collect taxes, duties, imposts and excises, to pay the debts and provide for the common defence and GENERAL WELFARE of the United States; but all duties, imposts and excises shall be uniform throughout the United States;

To make all laws which shall be NECESSARY AND PROPER for carrying into execution the foregoing powers, and all other powers vested by this Constitution in the government of the United States, or in any department or officer thereof.

WaveTossed

One of the factors that the article doesn't deal with is the issue of voluntary acts for the common good. Many Americans don't feel that the government, with all of its rules and regulations, will be the best institution to act for the common good. My first instinct is to want to contribute to my church, or to other private institutions to act or provide for the common good. I don't have a feeling of "I've got mine, screw the others!" Instead, I have a feeling that if my taxes get raised, I'll have little if any control over how my raised taxes get spent.

Much of this reluctance has to deal with the endless war-making that our government (both during Repub and Dem administraions) has been engaging in. France, England, Canada, Switzerland, and other countries don't pour thousands of troops and munitions into overseas wars. I don't want my taxes raised only to see most of the money go for overseas military ventures. If the U.S. weren't so engaged in trying to perform as the Morality Thought Police of the World, we could put into place a health plan that would insure that no one would go without health care due to lack of funds. Either we could lower taxes to such an extent taht people could afford health care, or else we could keep taxes the same but spend the revenue on health care rather than on sending troops and munitions overseas.

Come to think of it, the rationale used to send troops all over the world usually consists of "it's for the common good, to fight terrorism (or communism or fascism or whatever). It's as if many people in the U.S. don't mind having their tax money taken involuntarily from them to spend on overseas military ventures. But not for taking care of our own through some sort of universal health plan -- either private (by reducing taxes or allowing for 100% tax exempt health savings accounts of unlimited size) or public (using tax revenue to implement some sort of public health plan). Something isn't computing here.

xfree9

Wall Street certainly was responsible for its own actions. But that doesn't negate the responsibility of the government to protect the principles of sound money and banking, which it did not do.

NMRod

I know the Wall Street mantra is that they were all helpless and hopeless alcoholics who only did what they did because government forced the drinks down their throats against their will.

NMRod

"How you define the end of the Depression is key...
If you define it by unemployment, then of course the answer would be WWII; but employment is not inherently productive, and employment to destroy assets and people is certainly not productive."

This explains exactly why Wall Street is exuberant about a recovery that still has millions losing jobs, having pay reduced, and the number growing ever greater and according to the same folks won't begin to recover until 2017. This reduces their labor costs, allowing them to become more efficient at keeping more of the overall financial resources to themselves.

I was an executive at a Fortune 500 company. There was enormous waste in the various V-P's departmental capital budgets, but no one wanted to reduce it for the size of those budgets was a measure of each exec's clout. On the other hand, we sought to eliminate as many employees as we possibly could, via outsourcing and offshoring. However, the corporation's overall expenditure on pay did not decrease, because the executives all absorbed the savings into their own remuneration. Needless to say, this "Standard Operating Procedure" did not make it into the corporation's high-minded statements in employee handbooks.

Now, you can say that what moral compulsion says that employees in America are more worthy of having work than those in authoritarian countries where there are no labor standards?

There should be no moral claim that Americans are more worthy than others. But the intention of employers is not to be moral, but to treat a labor force as a mere commodity, to pay as little for as possible, realizing that in this country it's not possible to pay them as little without benefits as they can there. Of course, eventually, the workers of this country may become sufficiently desperate by being pitted against the bottom that wages here will be competitive and leveled. This certainly is not a problem that management or investors worry about at all. Quite frankly, a situation where they remain well-off while most others do not, is not something that they care about. They are for themselves and use the considerable resources available to cosset themselves in that circumstance.

I really don't care how much this is supposed to be natural; it's evil. It is really just more "Am I my brother's keeper?" avoidance of responsibility. Not caring whether others live or die, because the employment system they have become dependent upon moves opportunities to elsewhere because it's more profitable to you personally, is tantamount to having murder in your heart.

xfree9

Comparing us to Denmark is a good idea, mostly because it sheds light on the complex nature of existing in a society such as ours. I surely cannot speak for the founding fathers, but my hunch is they had a sense of where things would go because of their ethic of freedom and desire to see people immigrate (emigrate?) here. The Constitution was written so that the states would make the vast majority of the decisions about what is good for its people, therefore (theoretically) making it easier to have government do what little it can to improve society. Today, however, we have a huge federal government imposing itself into the states' business where it has no Constitutional authority. Education and health care are simply two of those areas.

xfree9

The enormous waste of unproductive activity did prolong the Great Depression, evidenced by its length during FDR's interventionist policies.

WWII was followed by an economic boom because the government brought back thousands of productive workers, and only until 1946/1947 was the country released of its wartime obligations and government control over the economy.

How you define the end of the Depression is key to answering the question as to when it ended. If you define it by unemployment, then of course the answer would be WWII; but employment is not inherently productive, and employment to destroy assets and people is certainly not productive.

In sum, when the troops came home, they went to work, produced things, and the economy recovered.

Anothernonymous

"Smith's notion of empathy and fellow feeling was one that expressed itself through private acts of charity at least as much as through government."

That's true, LV, but Smith did acknowledge that there are services that only the government was capable of providing, since it was not in the nature of the free market to supply them. These included, famously, public education. Why not public health care? Neff is absolutely correct that the situation speaks to our lack of a national belief in the common good.

It's a lot easier if you live in Denmark, where everybody is more or less Danish, to believe in the common good as something that affects us all. For all the advantages of our multi-cultural society, this is one thing we seem to have lost.