The Numbers Game

Yesterday a friend emailed me a link to a post and its comments which strike me as somewhat endemic of a certain divide between "liberal" and "conservative" attitudes, and the moral difficulties that come with both. (Perhaps one of the few things that all of both persuasions agree on is that these terms are imprecise, yet they do evoke roughly what I'm looking for here, so I'll use them and consider all necessary provisos and qualifiers said.)

The topic is the S-CHIP legislation that made its way from congress to the president's desk, where it was vetoed. I'll admit, I haven't been following politics terribly closely the last month or two, but the basic purpose here is to federalize funding for a set of state programs to provide government paid healthcare to children in families up to twice the poverty line. You can read a pretty balanced (kudos to the NY Times) piece on the immediate debate that inspired this piece in this editorial. The thing that is causing so much controversy as of now is that the families the legislation is designed to help are decidedly middle class: Maryland has a household income cap of 55k/yr, and NY recently tried, but failed, to raise their cap to above 80k.

Now, it's true that there are certain circumstances in which even a middle or upper middle class family can have trouble getting affordable health insurance. Some friends of ours own their own fairly successful small business -- but their youngest daughter has Down Syndrome and even small business insurance refuses to cover her. They have to use a state program by which they can pay a flat amount per month (I believe around 500 dollars -- we had to look at the same possibility in our pre-corporate days because one of our daughters has a heart murmur) and get subsidized insurance for her separately.

However, given that independent estimates say that the proposed S-CHIP legislation would probably cover 6 million children, of which 30% would be children already covered by private insurance who would transfer out onto the public dole -- there are I think legitimate questions as to whether this is a good use of resources. While some underline the necessity of helping middle class families with undue burdens, others (and I would tend to fall in this camp) would tend to think that under certain circumstances it behooves you to seek out a job working for the state or federal government or for a large corporation in order to make sure that you can get the kind of insurance your family requires.

The actual question of the wisdom of the legislation, however, is not what I want to address. It seems clear to me that there are many different conclusions that reasonable people could come to in this situation.

Rather, what stikes me is a particular mode of moral thinking that seems deeply problematic. The interchange is taken from the discussion on this post. The two people talking are the author of the post (Katerina) and a commenter (Blackadder):

Katerina:
Democrats = kill the babies in the womb
Republicans = kill the children by not given them healthcare!

Blackadder:
There are approximately 1.3 million abortions in this country every year. How many children die in this country because they don’t have healthcare?

Katerina:
So you’re reducing the value of human lives to mere numbers?
Wow. What an ethic of life you have there.

Blackadder:
No, I’m not reducing the value of human lives to mere numbers. But you didn’t answer my question. How many children die in this country each year because they don’t have healthcare?

Katerina:
...I repeat it again: I don’t reduce human lives to numbers: if Democrats kill more than the Republicans and all that nonsense discussion. Even if there is only one child who has passed away because of the lack of healthcare insurance is enough for me....

Now, the blog author is very young, and so try to overlook some of the more college-activist phrasing here. That's an easy target, but that's not what I think is interesting about this exchange.

What is interesting is the modification of a very sound moral principle into an open mandate for unlimited government action. It is an oft observed principle that one may not perform a lesser evil (but still a clear evil) in order to avoid a greater one. The classic (though unlikely in any practical terms) example of this is the "If you kill this once innocent person, some great world improvement (end of hunger, peace between nations, etc.) will be achieved" illustration. Performing a "smaller" objectively evil act in order to achieve a good of a great magnitude is falling into the error of proportionalism. This is the issue we have when people argue: Sure, cloning human embyos and then killing them for their stem cells may be wrong -- but surely it's okay in the context of all the great cures we might achieve as a result.

What Katrina is doing, however, is not simply avoiding proportionalism. She's engaging in a very key shift in analysis. When she says "I don’t reduce human lives to numbers: ... Even if there is only one child who has passed away because of the lack of healthcare insurance is enough for me." she is arguing that a specific remedial action (funding $35 billion in additional government-paid healthcare) is morally necessary so long as it saves at least one human life.

In a sense, this is very similar to the argument for gun control which I was arguing against a while back, which went essentially: "So long as it is clear that some number of gun deaths, however small, will be averted by additional gun control measures -- the moral necessity of avoiding death trumps any desire some people may have to possess dangerous objects."

And yet, if one thinks about it, almost any government funded service or increased level of regulation could be justified by the claim that it must save the life of at least one person. Can it be that we are morally required to turn over all money to government programs and institute all possible safety regulations (to the point of having every person wear a padded suit and banning all means of fast transportation other than emergency vehicles) simply because that would doubtless save some number of lives? Generally speaking, I am hesitant to claim that patently absurd precepts are necessitated by moral theology. That would be to assert either that theology itself is patently absurd, or that our faculties of reason are so terribly malformed that moral necessity looks like absurdity to us. A failure to "ring true" would seem to indicate a need to look deeper.

While I don't have a neat and clear solution to this problem, a couple of principles occur:

1) While at an individual level we have a duty to perform all reasonable acts to care for and protect those around us, trying to provide or regulate such things at the governmental level results in extreme inefficiency. So for instance, when it comes to gun safely, it is my clear duty to keep my guns in locked cases, keep ammunition out of reach and out of site, never shoot at an unknown target, and never use a weapon to threaten those around me. Following all of these rules carefully, and adapting them to the needs of changing situations, it is highly unlikely that my guns will ever be a threat to anyone. However, when the government tries to assure a similar level of safety across all gun owners and potential gun owners, we end up with a huge number of regulations, which still don't succeed in restricting people enough to avoid all crimes and accidents.

Similarly, if someone in your immediate circle desperately needs help paying for medical expenses, it's a clear and straightforward process for family and parish members to step forward and collect the needed money. However, when a government program attempts to insure that every such needy person is taken care of via government paid insurance, they end up paying all medical expenses (not only emergency, but routine and affordable) and also building a wasteful bureaucracy to do so.

2) While I don't for a moment think that fundamental moral principles change due to changes in technology, we currently have a lot to sort out in that medical care has moved, in the last 100 years or so, for a personal, corporate work of mercy, to a high technology and thus potentially high expense field. Once upon a time, the need to care for the sick was pretty much a need to devote as much time and patience as necessary to nursing. It's something that is often not fun, but is intensely doable. However, in this day and age, there are at times situations where the money required to perform some exotic operation (and honestly, that's what we need insurance for, not to pay for the $70 doctors visit and the $50 anti-biotic) can be tens of thousands, hundreds or thousands or even millions of dollars. What are we to make of the call to care for the sick, when providing the maximum of care for one person can, at times, take the financial resources that could feed thousands or tens of thousands of the world's poor?

3) Is there a fundamental difference between the level of charity which individuals may be morally required to provide to each others, and the level of government mandated "charity" which can or should be rightly exacted from society and given out to those determined to be "in need"? I suspect that, given government's lack of discernment and inefficiency, and the fact that such an act is not actually charity on anyone's part, the level of moral obligation government institutions have is different from that which individuals have -- but I'm not sure how to look deeper into the question.