The conservation of health … is without doubt the primary good and the foundation of all other goods of this life.
If government’s purpose isn’t to improve the health and longevity of its citizens, I don’t know what its purpose is.
On its surface, the political life of the United States cannot help but strike us as impossibly complicated. At any given time, we confront an astonishingly diverse array of public policy problems. Each of these “issues,” as we have come to call them, seems almost impenetrably convoluted in itself and largely disconnected from all of the others. Who could simultaneously understand the intricacies of our tax code, the inefficiencies of our entitlement system, the inadequacies of our transportation system, the moral challenges presented by the abortion or marriage debates, and the ins and outs of the dozens of other prominent public questions demanding our attention all the time? And if we are not competent to think about all of these problems in detail, how can we expect to govern ourselves?
This sense of helplessness before the sheer density of our dilemmas leads many of our fellow citizens to resign themselves to leaving the task of governing to others. But it is rooted in a misimpression. Our public challenges are not arbitrary and unconnected technical problems. They did not fall upon us at random, like snowflakes on the prairie. Rather, they arose out of the ways in which we live and the ways in which we govern ourselves.
Our weaknesses and problems, no less than our strengths and advantages, are reflections of the sort of society we are, and so to understand them we would do well to reflect upon the question of just what sort of society that is. In other words, we must understand our challenges in the context of our history and of our social and political thought. In that context, they are far better connected than they seem on the surface. They are, to paraphrase James Madison, the diseases most incident to our kind of liberal democracy. Understanding our prominent public problems as symptoms of such deeper difficulties can help us to approach them from an unfamiliar angle, and so maybe to better grasp and address them.
Two of the most prominent debates of the past decade may illuminate this point, and might in turn be illuminated by it. These two debates — the first over embryonic stem cell research and the second over reforming our health care system — will both be very familiar to readers of this journal. Both touch on science and society in different ways, and indeed both have had a place within the broad bounds of bioethics in recent years. But these debates have been largely disconnected from one another. The stem cell debates have been fought as an extension of arguments about the beginnings of human life and the proper limits of science. The debates over our system of health care financing have been seen as an extension of our larger economic debates — be they arguments about inequality, or about the future of our entitlement programs and the federal budget.
These are valid and appropriate ways to think about these two public problems, but they take up symptoms while ignoring deeper causes. The debates over stem cell research and health care are in fact profoundly linked by an old and very complicated problem for our kind of liberal democracy: our inability to properly rank health in relation to other public goods. This is a problem with roots deep in the historical and philosophical foundations of modern liberal thought, and with implications that cut to the heart of our politics today.
It is of course just one of a number of characteristic liberal-democratic maladies — dark sides of our otherwise extraordinarily successful, just, and admirable kind of society. We should not overstate the degree to which this one problem shapes our politics. But considering this one example and its implications can help us to think more deeply about many of the rest of our public debates, and what might lie beneath them.
Simply put, both modern science and modern political philosophy have put the avoidance of pain and the prevention of death at the forefront of our public life.
The earliest fathers of modern science were moved by a sense of frustration with the absence of practical applications of the natural sciences as they inherited them from the ancient world. The old ways of Aristotle, in Francis Bacon’s words, “bring upon the stage the characters of master and scholar, not those of an inventor and one capable of adding some excellence to his inventions.” One of the other great founders of modern philosophy and science, René Descartes, argued that the methods of logic, handed down from Aristotle, “are useful to others in explaining the things one knows or even … in speaking without judgment of those one does not know, rather than in learning them.” They do not allow us to know or to do new things, and so to solve practical problems, which is what the new science was really after. By beginning from novel empirical foundations, that new science would set out to empower human beings over nature, and so over their greatest challenges.
And these fathers of science had a fairly clear idea of what those greatest challenges were. Descartes argued that the greatest promise of his new way of thinking was its potential to provide human beings with power over nature, and especially, as he put it in the Discourse on Method (1637), the power to enable “the conservation of health, which is without doubt the primary good and the foundation of all other goods of this life.”
This is no modest claim, especially for the notoriously doubtful Descartes. It asserts for health a place at the very top of the heap of human goods. And it is a view that sits at the heart of the modern turn in philosophy: A form of it is evident in our political thought almost as clearly as in the thinking underlying modern science. Modern politics, too, sees the preservation and protection of life and of health as the primary functions of society.
In the ancient view of politics, as expounded by Aristotle, political communities were necessary for the fulfillment of man’s nature, to seek justice through reason and speech. Man’s ultimate purpose was the virtuous life, and politics was necessary for the pursuit of that end. But Machiavelli launched the modern period in political thought by aiming lower. Human beings gather together, he argued, because communities and polities are “more advantageous to live in and easier to defend.” The goals that motivate most people are safety and power, and men and women are therefore best understood not by what they strive for but by what they strive against — against danger, against death, against pain and discomfort.
The earliest authors of our liberal political thought agreed. For Thomas Hobbes, relief from the constant threat of death was the primary purpose of politics, and in some sense of life itself. John Locke saw the state as a protector of rights and an arbiter of disputes, with an eye to avoiding violence and protecting life and limb. The most basic law of nature, which must be given force by the state, Locke wrote, is that “no one ought to harm another in his life, health, liberty, or possessions.” It is above all to protect these that societies are organized.
This lowering of aims — in both scientific and political thought — derived in large part from a new and different way of thinking about nature. Aristotle saw in nature a repository of examples of every living thing in the process of becoming what it was meant to be. This teleology — the understanding of things by their ultimate purposes — shaped his anthropology and his political thinking as well: He understood mankind by the heights toward which we seemed to be reaching. The early moderns, by contrast, saw in nature a merciless oppressor of the innocent, always burdening and constraining mankind. This inspired them to aim first and foremost for relief from nature’s tyranny. If nature is above all the source not of a desire for excellence but of a desire for relief, then society must be directed to relief first and foremost — relief from danger, fear, and pain. In that way freedom, another word for relief, became the aim of politics, while power and health became the goals of the great scientific enterprise.
The preservation of life — and not just any life but a healthy life as free as possible from pain and suffering — is thus at least implicitly taken to be the primary good and the foundation of all other goods by our kind of society. We have accepted Descartes’s premise and acted on it, even if we rarely consider it explicitly. (As Alexis de Tocqueville observed of our republic in a different context in the 1830s, “America is the one country in the world where the precepts of Descartes are least studied and best followed.”)
The moral consequences of this preeminence of health and relief are quite profound, if not always obvious. A society in pursuit of health is not necessarily a society that neglects other important goods. On the contrary, the hunger for relief from pain and misery tends to encourage charity and sympathy, and to reinforce the drive to equality, fairness, and fellow-feeling. Modern societies have been uniquely protective of the basic dignity and inalienable rights of individuals, and of human liberty.
But in our time, more than any other in the modern period, we have begun to see the darker consequences of the preeminence of health. The founders of the modern scientific project may have been focused on health, but in some respects modern science had been on an extended and very fruitful detour until roughly the middle of the twentieth century — a detour through physics and chemistry necessary to make the age of biotechnology possible. In practical terms, medicine has not had all that much to offer until relatively recently, and so our political thought has emphasized other ways of pursuing relief, and the question of health in a liberal society has not generally risen to the surface.
Over the past century, however, the dreams of Bacon and Descartes have been growing increasingly relevant again. We have been living through a golden age of modern medicine, an age overflowing with glorious advances that make it possible to avert suffering, preserve health, and extend life to a degree never before imagined. But these advances are not without cost, and so this is also an age that increasingly forces us to contemplate those costs, and to balance the pursuit of health against the pursuit of other goods — a balance that our kind of society is uniquely ill-suited to strike because we value health and relief so very highly. It is an age in which asserting that health is the primary good and the foundation of all other goods has some very practical consequences.
The pursuit of health does not necessarily conflict with other goods and obligations, but in those cases when it does conflict with them it tends to overcome them. And so when the pursuit of health through science and medicine conflicts with even our deepest commitments — to equality, to the protection of the weak, or to responsible self-government — science and medicine typically carry the day. This is a peculiar and largely unexamined facet of our modern modes of thinking, but it is one that increasingly asserts itself in the life of our country. And the debates over both stem cell research and health care policy arise precisely from that difficulty, and are linked by it in surprising ways.
The elevation of health as a primary good has been powerfully evident in the stem cell debates of the last decade. The conceptual outlines of these debates are familiar enough: Opponents of destroying embryos for research have argued that the embryos, which are developing human beings, should not be treated as raw materials for experimentation. Supporters of the research have countered that the embryos could not be considered human persons, and therefore that concerns about their fate should not stand in the way of promising medical research.
But that is not really how the debate has been fought out in practice. By far the most prominent line of argument has not been about the ethical issues at the heart of the debate, but about the potential utility of the embryos in question, and the horrors they might help to overcome. Proponents of the research have often made their case using patients suffering from terrible diseases, appealing to our keen sensitivity to mankind’s helplessness before nature’s wrath, and to the terrible injustice of disease.
The potential of embryonic stem cell research to advance the cause of health has been grossly exaggerated by these advocates — Pennsylvania Senator Arlen Specter’s assertion in 2007 that embryonic stem cells had “the potential to conquer … all the maladies we know” was only a particularly egregious instance of that common vice. To call such baseless contentions overstatements would be a gross understatement, since the research has so far not even come close to conquering any known malady, let alone all. But implicit in the propaganda campaign for federal funding of embryonic stem cell research was the assumption that a sufficiently impressive assertion of the potential biomedical promise of the research would be enough to overcome any ethical objections to it. If the pursuit of embryonic stem cell research could in fact significantly advance the preservation of health, surely nothing could stand in its way. Every objection to the means involved in the research could be answered on the grounds that the struggle for the preservation of health demands it, and the struggle is paramount: It is the primary good.
By this logic, to stand in the way of the struggle for health, for whatever reason, is to become complicit in nature’s iniquity. As Stanford University stem cell scientist Irving L. Weissman told a Senate subcommittee in 2004, “Those in a position of advice or authority who participate in the banning or enforced delays of biomedical research that could lead to the saving of lives and the amelioration of suffering are directly and morally responsible for the lives made worse or lost due to the ban.” Weissman was effectively telling the Senators that preferring anything over the pursuit of health would be a moral outrage. Lives are at stake, after all, and there is action we can take to protect them: this is a time to act, not a time for moralizing.
But of course, the tragic fact is that the struggle for survival will always rage. People are always dying, and they always have been and always will be. If that means that there can never be a time for moralizing, then we are in trouble. And the tenor of our debates over the limits of medical science does suggest that, to many, that is indeed what the facts of disease and of death are taken to mean.
Any argument for limits on our pursuit of health which is not itself grounded in the protection of health or life has little chance of getting heard under such circumstances. The argument against destroying embryos for research is, of course, grounded in precisely that case for the protection of life — though it requires a working out of the case at a rather high level of abstraction. The champions of embryo-destructive research argue that this process of working out the case is itself a needless distraction from the pursuit of health. They even argue that concern for the life of a human being who cannot feel pain is misguided — insisting that the avoidance of pain and the preservation of health must be our highest priority, even at the cost of our commitment to the equality of all.
The opponents of embryo research have often tacitly accepted the logic of that objection. They often choose to just quibble with the case for the medical potential of embryonic stem cells — arguing that such cells are not really as promising as some scientists claim, or that other kinds of therapies will work better. Both sides have tended to make their most energetic cases not about the definition of personhood or the details of embryology but about the potential for medical advances. That potential has almost always been the subject of the argument, and the source of the urgency and force of the debate. To insist that our commitment to basic human equality should place restraints even on the pursuit of a genuinely promising avenue of medical research is to challenge the preeminence of health in our political thought, and it has proven to be a difficult challenge to mount.
In the end, then, the embryo debate is an argument between two camps of defenders of life who implicitly accept the primacy of health in our political thought. But what happens when we need to rank health against other important goods — when the question isn’t life against life but life against other crucial commitments?
As we are poised to find out in the coming decades, what happens may well be national bankruptcy. The world’s liberal democracies stand poised to go broke trying to pay for medicine. We could hardly ask for a clearer example of the implications of the primacy of health in our political thought than the health care debate in which our country is now engaged.
The health care debate — which is really a debate about how to pay for health insurance — has raged in America for decades, and has been especially prominent in the last few years. That debate has two facets, each of which is both economic and moral. First, there are the 50 million Americans who are today without health insurance, and therefore potentially without access to routine and chronic care. To be sure, some of them have chosen not to buy insurance, though they could afford it. Some are in the United States illegally, and so do not qualify for programs that otherwise assist the poor. But several tens of millions are simply unable to afford coverage. They are not poor — the poor are insured by the Medicaid program. They are not elderly — the old are insured through Medicare. They are, for the most part, lower-middle-class people who do not receive insurance through an employer (as most American families do) and cannot afford to buy it on their own. And their numbers have grown in recent years because the cost of insurance has been growing far faster than wages.
Meanwhile, the second facet of the problem is the immense burden that our health care entitlement programs are placing on the nation’s economic future. The numbers are depressing and staggering. A decade from now, our national debt will be larger than our entire economy — a level of debt we have not seen since the immediate wake of the Second World War — and (unlike the late 1940s) it will be on a trajectory of continuing ballooning growth. By 2035, according to the Congressional Budget Office (CBO), the debt will be twice the size of the economy and still expanding quickly. This is an utterly unprecedented, and almost certainly unsustainable, level of debt. The resulting much-diminished economic growth will cast a shadow over the prospects of the next generation, which will be unable to experience anything like the prosperity that Americans have known over the past sixty years.
Our health care entitlement programs are by far the foremost causes of this coming explosion of debt. In its latest long-term projections, published in June 2011, CBO reported that, between now and 2050, spending on the federal health care entitlements (especially Medicare and Medicaid) will nearly triple as a percentage of the economy, while all other federal spending combined (including Social Security, defense, discretionary spending, everything but interest on the debt) will actually decline as a share of the economy. The health care entitlements are, in essence, responsible for the entirety of our long-term debt problem.
These two facets of the health care debate at first seem to point in two contradictory directions. More and more Americans are uninsured, even as the cost of our existing public health-insurance programs is getting so large that it risks crushing the economy. So does the government need to do more or less to provide health insurance? Democrats in the health care debate tend to emphasize the first of these problems, and so argue that more public spending on coverage is needed, while Republicans usually focus on the second, and so devise ways to cut health-entitlement spending. But wouldn’t focusing on one problem make the other worse? Is there a way to address both at once?
To answer that question, we need to grasp the underlying economic problem that explains both facets of the issue: the exploding costs of health coverage and care. The cost of health care has been growing far faster than the general inflation rate for decades. In 2010, health care costs grew by more than 7 percent, while inflation was below 2 percent. That means that the cost of insurance premiums is rising far faster than people’s wages, leaving more and more people unable to pay for coverage. And, combined with the aging of our population, it means that the costs of our health care entitlements are growing far faster than tax revenues, leaving the government more and more in debt.
The health care debate is therefore properly understood as an argument about how to restrain the growth of health care costs. The moral dilemmas that compel us to act force upon us an economic question: what can we do to keep costs from growing so quickly without undermining the quality of care and the access people have to it? If we don’t keep those costs from growing that quickly, they will overwhelm everything else our government needs to do and they will crush our future prosperity.
Put this way, it is clear that the health care debate forces us to weigh health against other national priorities — and, as we have seen, this is something our political system and our kind of regime are exceedingly ill-suited to do. Attempts to confront this problem always seem to turn into efforts to spend yet more on health. The Patient Protection and Affordable Care Act enacted in 2010, colloquially known as Obamacare, was first sold (and perhaps genuinely intended) as a way of “bending the cost curve down,” as President Obama liked to say back then. Even as originally intended, it would have tried to do so in a way that was very unlikely to work, as it would have relied on federal regulation to induce greater efficiency in the health sector. But as it made its way through the political system, the bill became simply a means of expanding public entitlements to health coverage, and so of increasing costs rather than lowering them.
The trajectory of those costs in relation to everything else our government does makes for a case study in the difficulty our kind of society has in properly ordering its priorities. The federal government got into the business of paying for health insurance in 1965. In 1971, one year after Medicare and Medicaid reached their mature fully functional forms, spending on those two programs combined accounted for 1 percent of our gross domestic product (GDP), according to CBO. That figure doubled and doubled again, so that forty years later, by 2011, federal health spending accounted for 5.6 percent of the GDP. This astounding rate of growth has dwarfed the growth of everything else our government spends money on. Indeed, conservatives who complain about the general growth of government spending rarely consider just how thoroughly the growth of health care spending has defined the larger trend. The figure for all non-health care federal spending combined (excluding interest on the debt) was 17.1 percent of GDP in 1971 and was again 17.1 percent of GDP in 2011, according to CBO. That figure has gone up and down in that time, of course, but as it happens it was precisely the same in 2011 as it had been forty years earlier, while health spending more than quintupled. In essence, the net growth in government as a percentage of the economy in these four decades has been entirely a function of federal health spending.
And without major reforms of these programs, that growth will only continue. By 2020, CBO projects Medicare and Medicaid, together with the new entitlements created by the new health care law, will account for 6.9 percent of GDP. In 2030 the share will be 9.2 percent. In 2040, CBO projects it will be 11.4 percent of GDP, and by 2050 it will be almost 14 percent. On the course we are on, in other words, the federal government will become a health-insurance provider with some unusual side ventures, like an army and a navy.
We prioritize health and so our public institutions cannot regard health as just one of the goods they are charged with securing. We do not know how to keep our spending on health care in check and so health care is overwhelming everything else we want to do. We stand to leave the next generation an impossibly heavy burden of debt — shirking our duty to budget responsibly, just as in the stem cell debates we are shirking our obligation to human equality and the protection of the most vulnerable. We need to find ways to put health in perspective.
Finding those ways will be no easy feat, however, precisely because the elevation of health above other priorities runs so deep in our political imagination. Proposed solutions that fail to take account of that fact stand very little chance of success.
In May 2011, Daniel Callahan and Sherwin Nuland — two eminent and well-intentioned graybeards of American bioethics — argued in The New Republic that the way out of our troubles on the health care financing front required a fundamental reorientation of our attitude toward medicine. They recommended “a top-down, bottom-up study of the entire U.S. health system, with a view toward taking it apart and reconstructing it in a manner adapted to our nation’s needs — a multiyear, multidisciplinary project whose aim would be to change the very culture of American medicine.” They said we need a more restrained research enterprise, a more humble medical establishment, more rationing of care, and above all “substantial shifts … in the way our culture thinks about death and aging.”
If that is the only path to better ordering health among our priorities then we are in very serious trouble. Because our attitudes toward health are so deeply rooted in modern political thought, a completely different attitude toward health would simply require a completely different civilization. The kind of stoicism that Callahan and Nuland suggest might be admirable in some respects, but it is just not plausible to expect our liberal-democratic polity to produce it, and with good reason. Many of the things we most appreciate about our society — including its compassion and sympathy — are tightly bound up in our disproportionate and even reckless elevation of health.
And while stoicism about health care might be appealing in principle, in practice it will last exactly as long as it takes for someone you care about to get sick. At that point, you will want to do everything possible to make that person well again, and if you cannot see to that yourself then you will want your society and government to help.
Without a doubt, that desire must be tempered through some mediating institutions and balanced against other priorities. But these balancing mechanisms must comport with our kind of society — they cannot be rooted in foreign soil. As James Madison would remind us, we need liberal remedies for the diseases most incident to liberal regimes. That means we need solutions that are rooted in liberal institutions even if not necessarily in liberal political institutions.
In the stem cell debates, we seemed forced into an impossible choice between the sick and the defenseless. The right response to such a choice is to seek a third option — to seek a way out. Fortunately, in the stem cell debates it seems that a technological solution will be possible, in the form of new techniques for producing stem cells with the abilities of those derived from embryos but without the need to use or to harm human embryos. That researchers have found these techniques is very fortunate. That our society has sought them, however, is the more important indication, for it shows that we have a chance to moderate our inclination to put health above all, if we understand the need for doing so. The recognition of the need for perspective and balance is really the key.
In the health care debate, that need is almost as crucial, and there too the solution involves an appeal to liberal institutions. Specifically, it requires us to see that markets — properly designed and regulated — offer a far better means of ordering health among our priorities than our political institutions do.
There is of course an economic case for a more market-friendly health sector. The problem we confront is after all a problem of exploding costs caused by the immense inefficiency of our system of paying for health care — a system filled with perverse incentives for waste and higher cost. The Medicare program pays doctors based on how much they do, rather than on the results they achieve for patients, and so encourages more volume rather than more efficiency or quality. The Medicaid program allows state governments to provide increasingly generous benefits while the federal government foots most of the bills — a sure recipe for out-of-control costs. And the private insurance market is shaped by a tax exemption for employer-provided insurance, which creates a huge incentive for more costly coverage.
Everyone agrees that this gross inefficiency is the problem. The left and the right in the health care debate are divided over how to solve that problem. The left argues for channeling more health care decisions through our political institutions — since those are geared to the public good rather than the profit motive and will better impose discipline and efficiency. The right argues for channeling more health care decisions through our economic institutions — that is, through the market — arguing that markets are uniquely well suited to creating incentives for both efficiency and quality; they give providers a reason to offer consumers what they want at lower prices.
But beyond these familiar economic arguments — and the longstanding debate about whether markets or governments are better at creating efficiency fairly — is the deeper question we have been considering: the problem of our fundamental inability to rank health among our other priorities. This deeper problem actually points to the strongest argument for a carefully regulated market approach to our health care crisis — a system in which government subsidies help those who cannot afford to participate in the market do so on the same level as others, but in which insurance options, and therefore choices made throughout every level of our health care system, are shaped by the desires of consumers in a competitive market. After all, markets don’t just make expensive goods cheaper — they are also extraordinarily effective prioritizers, allowing many individual decisions to be made close to the ground. In the case of health care, that would mean having more critical decisions about spending made by patients, by families, and by doctors, and creating a strong incentive for those decisions that have to be made by insurers to be made in ways that will be perceived as fair by their customers.
Market solutions would by no means eliminate all the grave difficulties involved in prioritizing health care. There would still be rationing, there would still be times when being out of money means you are out of options, there would still be decisions made by insurance company bureaucrats that strike patients and doctors as unjust. But there would be far fewer than under a system that assigned rationing decisions to public officials and gave patients far fewer choices and far less control.
In a properly regulated but competitive insurance market, we would have a much better chance of actually prioritizing health among the goods we value. Because while liberal political institutions are unsuited to such prioritization, we liberal citizens are often up to it. Families, which after all are not liberal institutions, can make difficult choices — balancing the needs of different generations and the importance of different needs and wants — in ways that democratic political institutions often simply cannot.
A key problem with our health care system is that too many decisions are channeled through such political institutions. We can do better, and in a way that is thoroughly in line with our liberal-democratic way of life.
These kinds of liberal remedies to the diseases most incident to liberal regimes are well within our grasp, if we are aware of the need for them. That awareness requires us to be alert to just what diseases are most incident to our free society, and to see that our public policy problems are not random technical quandaries but practical challenges with deep philosophical roots.
If we don’t make the effort to see that, and if we instead leave it to technocratic managers to deal with our problems as the unconnected administrative dilemmas they appear to be on the surface, then we would run the risk of letting our deepest and most serious challenges fester and grow, and of failing to meet our basic obligations as citizens.
This, too, is a dangerous temptation that is too often incident to our kind of regime: the temptation to fold our hands and let government officials handle things, and so to leave the most significant decisions and choices to others; the temptation to take pleasure in our lives where we can find it but to avoid responsibility and to forget about the future.
In understanding that liberal temptation, our best guide is not Descartes but Nietzsche, who described what could become of us in an age beyond responsibility, an age he believed was the inevitable destination of liberal societies. The degeneration of virtue in such societies, he argues, will atrophy our ability to plan for the future, our drive to work, and our interest in governing. In such a state, people will lack the noble aspiration to a virtuous life, setting their aims far lower, as Nietzsche writes. “One has one’s little pleasure for the day, and one’s little pleasure for the night: but one has a regard for health.”
Our regard for health, it seems, can easily coexist with a society that we would not otherwise be proud of. Unbalanced and unmoored from other goods, such regard can become a vessel for self-absorption and for decadence. It can cause us to abandon our commitment to our highest principles, and to mortgage the future to avert present pain.
It can, but it does not have to. It is not inevitable. If we do the work of coming to know ourselves and our society, and if we seek consciously to push back against our excesses and to balance our pursuit of safety, health, and comfort with our desires for justice, excellence, and responsibility, we can sustain a thriving and self-governing republic, committed to the preservation of life and of health as two among many important goods it pursues.
What we require, in other words, is the kind of balanced public life that comes from self-awareness and self-knowledge. Such a balance would help us make the most of the abundant strengths of our society while combating its weaknesses. The ancients had a word for such an edifying balance: They called it health, and so should we.
Putting Health in Perspective