By Jake Lehrle-Frye
The Ethics of Universal Healthcare
Alex Rajczi, Oxford University Press, 2019
Setting Health-Care Priorities: What Ethical Theories Tell Us
Torbjörn Tännsjö, Oxford University Press, 2019
Our health and the health of those around us are often at the forefront of our minds – it is after all a genuine example of something that is frequently life or death. Why is it, then, that in a country as rich as the United States, people still do not get adequate health coverage? Two political theorists have recently grappled with this question. Alex Rajczi considers whether there is a convincing case for the prevention of universal health care, or indeed any other health care system. Meanwhile, Torbjörn Tännsjö examines which medical conditions require our funding priorities. Put together, the two authors demonstrate how political theorists can intervene helpfully and forcefully into the healthcare debate. Translating philosophical principles into genuinely actionable policy, Rajczi and Tännsjö demonstrate how, in the realm of health where so much is at stake, we simply cannot allow poor reasoning to reign supreme any longer.
Tännsjö first draws our attention to an often overlooked aspect of healthcare systems: the complete lack of adequate funding for mental health, even in wealthy countries. Despite the severity and magnitude of the problem, mental health is often overlooked in favour of more visible physical ailments. If what we care about is individual welfare, however, then mental healthcare should be far higher on our list of priorities. Furthermore, paying attention to mental health on a systematic level would likely cost less than we might think. Indeed, as Tannsjo shows us, mental health spending represents a very efficient investment in terms of both happiness and public funds. Poor mental health, like poor physical health, negatively affects our ability to work efficiently, if at all. And if returning to the work force is one way of making back public finds (through additional income tax), then treating mental ailments should be as important a priority as physical ones.
Aside from the added tax revenue from those who can return to work, where else should we find funding for mental health? Tännsjö argues that one solution might be to reduce our spending on life-extending treatments for the elderly. These treatments are simply not ‘efficient’ in creating the most happiness. Here, Tännsjö’s attempts to examine our intuitions with the rigour of a philosopher might come across as too impersonal. The argument is clear: the elderly will live a few more years, potentially in pain, while eating up funding that could allow younger persons to get rid of their ailments, and enjoy the benefits of these treatments for far longer. From the perspective of maximizing overall happiness, the funds would be better used by the young than the old. At times, these blunt, and impersonal approaches to healthcare highlights the differential concerns of philosophers and politicians.
Nevertheless, Tännsjö makes his most important contribution in the area of mental health. If our interest is in individual welfare, then temporal measures of pain may belie the actual severity of the problem. Time may be perceived differently depending on one’s age and/ or their current health. He calls this ‘relative-time’. Tännsjö suggests that those with mental health issues are not just suffering but suffering for periods of time that feel longer than they actually are. This makes their problems even more important to resolve. Additionally, Tännsjö notes that it is not unreasonable to view the same numerical period of time as being of differing importance depending on the person's age. The implications of this notion, if taken seriously, would be deeply significant for the way in which public spending is allocated in healthcare.
While the argument for relative time pops up throughout the book occasionally, it is not focused on nearly enough. In reality, the effects of relative time have vast implications with respect to healthcare spending, as Tännsjö notes, but also on distributive justice as a whole. If it is true that, when in pain or misery, time passes more slowly, and thus the pain is more significant, then this presumably has implications for all areas we associate with pain or misery. To pick an obvious example it seems as though the claims of those in poverty are only further enhanced. The same is true for age-based time periods, if we give more emphasis to younger time periods in our lives then does this have quite radical implications for voting rights for the young, and/ or weighted votes for the young and old at the ballot box? These non-healthcare implications are, understandably, not explored within the book but are a prime example of the usefulness of political theory in giving argumentative heft to common intuitions like those of relative time.
While discussing mental health, it is worth noting, as an aside, Tännsjö’s admirable view on disability. In a similar way to mental health, Tannsjo point out the difficulty of empathising with people with disabilities for those whose lives are not touched by anything similar. Nevertheless, many theorists who deal with issues of healthcare and disability have tried to speculate about the ways in which disabilities affect a person’s life and what should be done about it. This has, in turn, spurred persons in disabled communities (notable examples here are those in the dwarfism or deaf communities) to come out and say that their disabilities do not make their lives worse in any way, indeed some of the benefits of being in this community make their lives better than if they had been born without a disability. This ongoing dispute is one that is frequent throughout the literature on the philosophy of health. Tännsjö takes a strong stance on this issue and argues that it is entirely up to those who are disabled to outline whether the disability has a negative effect on their lives, and it is only after a disabled person has said so that we should presume they need help.
Reading Tännsjö’s work, the reader finds themselves constantly challenging their own priorities in health. So at this point it is wise to assess our priorities with respect to the biggest healthcare debate there is – universal health care. This topic is certainly amongst the biggest political debates in the United States, one of the most powerful nations on earth.
Rajczi sets out to assess three criticisms commonly put forward by those sceptical of universal health care: that it is too fiscally risky; that it represents too much of a personal cost for each individual; and that it is inefficient. In respect to the fiscal risks of universal healthcare, Rajczi quickly allays these fears with a mountain of statistical evidence to prove otherwise. Statistics are not a traditional tenant of political theory, but Rajczi uses them well to back up his theoretical points. Hopefully such an approach will help to convince readers of the usefulness of political theory not only in providing sound arguments but also having the space to include hard empirical facts in its discussion of issues.
Another central consideration in the debate about universal healthcare is the argument that a universal healthcare scheme would most likely be more costly than beneficial to each individual. Rajczi first notes that such arguments are often used in discourse to hide more selfish motives – it is not uncommon for the privileged few with good health insurance to deride universal health care on the basis of an increase in tax with no real benefit for themselves. Instead of laying bare these selfish motives, these arguments are often made in a way that tries to appeal to the less privileged by saying it will cost them more than its worth.
Rajczi goes on to argue that in order for a personal cost argument to be even moderately plausible we must give disproportionate weight to the well-being of those paying, versus those who may benefit. Strikingly, Rajczi, of his own admission, does not frame this debate in terms of individual liberty. In political theory, issues to do with taxation are most often treated as trade-offs between personal liberty, as being free from coercive measures such as taxation, and some other value, in this case, the possibility of universal healthcare. Choosing to ignore this framework seems to be a tactical choice for Rajczi both in respect to brevity, as engaging in such issues is complicated and long, but also in terms of his desire to make such a book accessible and useful for the general public. He does, however, present a convincing argument that shows this version of the personal cost objection to be easily overcome by showing that the benefits to us and others in society vastly outweigh the personal costs.
The final argument Rajczi engages with at length is one of efficacy. Concerns about reductions in medical innovation and concerns about increased waiting lists are proven to rely on assumptions that don’t hold when submitted to rigorous empirical examination, and are, furthermore, philosophically specious. A theme that often occurs throughout the book is the assumption that the United States turning to universal healthcare would entail adopting the same spending habits and figures that countries with universal healthcare already do. Rajczi points out that this fear is largely unfounded and that, actually, concerns about wait lists, amongst other things, are largely the result of funding troubles rather than a symptom of universal healthcare. Here, we can see one contribution of political theory: the identification of unfounded arguments. Rajczi helps to break apart an often-parroted suggestion – that public health care means long waiting lists – by showing that this relies on equating two wholly different things: universal health care and funding problems.
The two authors offer a number of thought-provoking arguments, less sophisticated versions of which often worm their way into our political discourse; arguments surrounding financial problems, logistical niggles and intergenerational conflicts all feature throughout the books and all are given discerning theoretical shake-downs. The authors go to great lengths to ensure their books remain thorough and devoid of political point-scoring or baseless claims. One of the ways they do this is the methodological approaches both authors take. Neither author tries especially hard to make distinct positive arguments about exactly what we should do in regards to health and healthcare. While Tännsjö makes clear his own views, he is careful not to entirely rule out other theories of health justice. He explains where these other theories may lead to unintuitive conclusions in the area of health, but notes that some may not view these issues as catastrophic and may be happy to simply ‘bite the bullet’ (to be forced to accept an unintuitive conclusion).
A similar, but distinct, approach is taken by Rajczi who applies what he calls ‘other-orientated’ argumentative methodology. His argument is rarely to dismiss well-established criticisms of universal health care. Rather, he seeks to show that the concerns that are central to these arguments should in fact lead one to endorse universal health care.
While ‘other-orientated’ and ‘bullet-biting’ approaches are obviously powerful academic tools, they are perhaps most interesting when applied outside of academia. With the state of discourse across the world, and especially in the United States where Rajczi frames his debate, it has become futile to try to force others to fully give up their positions. This is unfortunately true even where arguments are near irrefutably flawed and/or misguided. Indeed, we have seen in the US senior politicians shunning verified climate science and in the UK those largely responsible for one of the most important decisions for generations suggesting that the British people ‘have had enough of experts’. Perhaps, then, at least as a temporary measure, we should take an ‘other-orientated’ approach to our current political discourse; maybe the best way to deal with those who will shout in the face of facts and reason is to show that their own arguments do not imply the conclusion they want them to. After this they are presumably faced with ‘biting the bullet’ or accepting that the implications of their arguments are not desirable. Taking an ‘other-oriented’ approach, when it comes to healthcare, may point to some hope of reconciliation between opposing sides of the debate which are rarely willing to concede the validity of moral standpoints apart from their own.
Moreover, using the methodological techniques of these two authors, we can show someone that their arguments do not lead to the conclusions they wish, and from this, one would hope that upon reflecting on their views they would be more likely to act on these conclusions. Having clearly thought about, and followed through, arguments to their logical conclusions will, in theory, make one more likely to act on these views. At the very least this is what we want political theory to do for us – make us understand why we believe what we believe, and then, if possible, to act on it.
Both books do suffer from a joint failing though: the relative lack of consideration of advantage through health. To be clear, here, I am speaking about raising persons above some level of ‘normal or average’ healthcare into the realm where they can be considered to be advantaged. Granting bionic arms that make one lift more than someone with normal functioning arms is an example of such an idea. While this was not the explicit subject of these two books, and one could write volumes on the topic of advantage through health, both books seem to miss the opportunity to really address the topic from their own viewpoints. Wherein such advantages are accessible only by the very wealthy this may present challenges to justice in health.
Between them, Tännsjö and Rajczi help members of the public and politicians alike to understand the ins and outs of commonly heard arguments surrounding health. To some readers, though, this may seem futile. Upon reading Rajczi’s arguments for universal healthcare in the United States, we might be heartened at the soundness of these arguments. Further, we might think his ‘other-orientated’ methodology and use of statistics stands a good chance of persuading more people to the side of universal healthcare. Moreover, Tännsjö’s thorough discussion of priorities in healthcare gives good guidance to politicians and theorists alike. Despite all of this, one may still conclude with the pessimistic view that certain opinions are so entrenched in the public psyche that they simply cannot be overturned. It is all well and good trying to persuade others on their own grounds that they are incorrect, or trying to mobilise those with good moral compasses into action, but the fact remains that if we fail to convince the right people then all this will be for nought.
This certainly seems to be what Tännsjö believes. He argues that despite the obvious truth of some of his arguments surrounding the elderly and those with mental health troubles the squeamishness of the public at large will prevent any real action being taken. Tännsjö suggests that perhaps the best we can do is by discouraging research spending on those conditions he argues are less important in order for this to then have a knock-on effect with resources spent elsewhere on more important conditions.
Do we need to be left with such a bittersweet conclusion? Of philosophical clarity but practical pessimism? On the contrary, philosophical clarity is the first step towards breaking through thoughts of practical pessimism and cutting through an often crowded and misguided public discourse. This is the role political theory plays in society, it allows us to question our deepest held beliefs and their role in everyday politics. These two authors masterfully achieve just this by managing to confound and question the readers assumptions in the realm of health. It is true that many people will steadfastly refuse to engage with us, but that is unfortunately true regardless of how cogent we are. Instead, we should rise above such people and consider the political theory of health as the start of an attempt to change public discourse with informed, and philosophically sound, arguments.
JAKE LEHRLE-FRYE reads Political Theory at St Cross College. He swears blind that he didn't just pick St Cross College because it said egalitarianism quite a lot in its biography.
Art by Imogen Barrett