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On a Certain Blindness in Healthcare Policy
A fairer allocation of our abundant healthcare resources would take into account the needs of different moral communities
By Michael Brodrick
William James, the famous American philosopher and psychologist, was nothing if not perspicacious. On one occasion, however, James discovered within himself an alarming moral blindness. The scion of an elite family whose childhood environs included New York City, Geneva and Paris, James was traveling in the mountainous countryside of North Carolina where, in the years just prior to the turn of the century, ordinary folks eked out a scant living from the land. Smaller trees had been razed and centuries-old giants girdled. Charred stumps, dead trees left standing and scattered clumps of Indian corn had taken the place of lush foliage. Crude log cabins littered the bare landscape. The author of the monumental “Principles of Psychology” instinctively shrank from what he saw. To James, the settlement was “a sort of ulcer, without a single element of artificial grace to make up for the loss of Nature’s beauty.”
But James’ driver happened to be one of the locals, and the garrulous James couldn’t resist asking him what sort of people lived in this place. The reply came swiftly: They were the sort that finds fulfillment in homesteading. James instantly knew he had missed the point. He had been blind to the values of those unlike himself. What to James was “a mere ugly picture on the retina,” to the settlers was a livelihood, an ideal of success, a home for themselves and their families. Human flourishing, James realized, comes in all shapes and sizes.
James later wrote in his famous essay, “On a Certain Blindness in Human Beings,” that one shouldn’t be quick to dismiss how others choose to live. The discovery of our moral blindness “commands us to tolerate, respect, and indulge those whom we see harmlessly interested and happy in their own ways, however unintelligible these may be to us.”
Those involved in shaping healthcare policy should take the spirit of James’ admonition to heart. Yet bioethicists and healthcare policymakers also are often blind, in this case proceeding as if moral diversity doesn’t exist. The bioethics literature, for instance, boasts a wide range of books each purporting to unveil the canonical account of justice in healthcare policy. The unspoken assumption is that experts can simply disclose the right way to balance safety and risk, to trade off equality against freedom or to resolve moral disagreements about such controversial matters as commercial surrogacy, assisted suicide or the meaning of human sexuality. In each case, we are asked to believe that one size fits all.
The appeal of the “one-size” assumption is understandable, for each of us belongs to a moral community whose vision of the good life we find deeply familiar and intuitively correct. To see the intrinsic value of another requires Herculean efforts of moral imagination.
But irreducible moral diversity does exist. No amount of principled debate can decide once and for all whether one should choose to practice medicine for profit, raise a child with severe congenital defects or suffer through the final stages of a terminal illness, rather than opting for physician-assisted suicide. One can make such decisions only by reference to particular visions of the good life embodied in particular moral communities. As the philosopher and bioethicist H. Tristram Engelhardt has observed, those visions are irreconcilable if only because the communities involved recognize different moral authorities and follow different rules of evidence and inference. Divine revelation doesn’t count as evidence in a secular community. Catholics can’t turn to Buddhist authorities when in doubt about moral matters. The boundaries of these distinct visions of the good life set sharp limits to the moral authority of insiders to require those outside their community to comply with their vision.
The historian David M. Potter once characterized Americans as a “people of plenty.” Economic abundance, he averred, had shaped the character of Americans as a people. One could add that it has left its mark on U.S. healthcare policy, as well. According to the Peter G. Peterson Foundation, the U.S. in 2022 spent some $12,555 per capita on healthcare—more than any other OECD country. Costs are too high, and the poor are not well served, but U.S. healthcare is nothing if not abundant in terms of the sheer magnitude of economic resources brought to bear. Perhaps unsurprisingly, the policy challenges that typically grab headlines are directly related to economic growth or the fair distribution of material abundance, yet these fit hand in glove with the challenges—relatively unsung, but no less important—of accommodating abundant moral diversity.
Healthcare policies blind to moral diversity lead us down a perilous path. Whether public or private, any arrangement that creates positive rights to healthcare sets in motion a particular morality. Some treatments will be available, others off limits. Providers will have certain duties. Some patient groups will receive benefits that others do not. These inevitable policy decisions reflect explicit and implicit moral judgments about right and wrong, about what is more and less valuable. But making such decisions with eyes wide shut to moral diversity risks requiring peaceful dissenters to conform to a moral vision they reject in the absence of any moral authority to do so.
How can diverse liberal societies better organize healthcare delivery to accommodate moral differences? An admirable egalitarianism reinforces the “one-size” assumption, but awareness of moral diversity should inform what egalitarianism means in practice. We can spend common resources to provide a decent minimum of healthcare, for example, without imposing a particular moral vision on peaceful dissenters. As Engelhardt suggests, this argues for the freedom to organize healthcare delivery in a variety of ways.
Within particular moral communities where members agree on a vision of the good life, common resources can be deployed to provide a decent minimum of healthcare consistent with that vision. Catholic communities will be free to withhold their common resources from funding abortion, physician-assisted suicide and euthanasia, while secular humanists will remain equally free to fund those interventions within their own communities.
Higher barriers exist when reaching across different moral communities. Policymakers aware of moral diversity will be unable to simply disclose the correct meaning of a decent minimum. Instead, its meaning will have to be created through inclusive democratic dialogue. An example of Medicaid reform in Oregon suggests how this could be done. In 1989, Oregon created a Health Services Commission with the goal of extending Medicaid to all persons below the federal poverty line, while still controlling costs. The commission was charged with establishing priorities to decide which medical treatments the state would fund. Crucially, those priorities were established with extensive input from Oregonians themselves. Focus groups held in nearly every county in the state, public hearings and surveys helped the commission ascertain Oregonians’ actual healthcare preferences, understand how they experienced the impact of illness and discover where consensus existed. This process, although imperfect, shows that healthcare delivery can be organized across different moral communities while respecting moral diversity.
Finally, taking moral diversity seriously requires robust economic freedom. Individuals should be free to dissent from the prevailing public morality by paying out of pocket for healthcare services, joining the healthcare labor force without facing unduly restrictive licensing barriers or starting a business venture that delivers healthcare in alternative ways. The Surgery Center of Oklahoma (SCO) is a case in point. SCO is a physician-owned and -managed enterprise. Many of the patients it serves are uninsured. Unlike most U.S. surgery centers, SCO can offer high-quality care at lower, transparent prices, better serving the least well off. Their business model empowers them to cut overhead costs and eliminate wasteful practices that insurance companies and hospitals may have no incentive to curtail. By taking advantage of economic freedom, SCO can deliver surgical services in a manner consonant with a distinct moral vision of patient care.
Government entities directly control more than half of healthcare spending in the U.S. today, according to Liam Sigaud at the Mercatus Center’s Open Health Project. Meanwhile, “the shrinking share of resources controlled by the private sector is subject to vast, ever-multiplying federal, state and local restrictions, mandates, subsidies, taxes, and other regulations.” In this environment, one could reasonably worry that healthcare policy in the U.S. too easily substitutes the moral visions of political actors, elite experts and organized interests for the respectful tolerance of moral diversity that should govern relations between communities in a liberal society. Good healthcare policies should give us sustainable economic abundance justly allocated, but with the very meaning of justice at issue as between different moral communities, such policies cannot be formulated without careful consideration of abundant moral diversity. We can do better by calling to mind the lesson of James’ experience in Appalachia: Let’s keep our hands off, and let others enjoy the freedom to live by their own lights.