Williams on equality Notes for September 17

Main points

Williams argues for the relevance of facts about human equality and the nature of goods to egalitarian political programs. As I presented it in the handout, his article falls into two parts: one concerns cases where the idea of equality requires equal treatment and the other involves cases where it requires unequal treatment.

The particular case we were interested in was health care. Williams argued for a proposition about the nature of health care: it is for curing ill-health. He derived a conclusion about politics from this proposition: that is irrational to distribute health care according to anything but need. In particular, it is irrational to make wealth a necessary condition for having health care.

How much?

One thread that ran through our discussion concerned the level of health care that ought to be provided to people regardless of wealth. This was the idea behind Michael’s first remark, Ramy’s observation that the US implicitly has a public health system, and Kari’s point that the public health system that we have isn’t very good at providing health.** That was the point of Ramy’s example of the San Francisco program too.

I think this is the right question to ask for two reasons. First, a guaranteed minimum is the only plausible alternative for our society. Strict equality is not on the table. Second, we can always spend more on health care since there are always ways of dying that we could cure or ameliorate. If we aren’t going to let bodily health consume everything else, we’re going to have to decide on how much we think we have to spend and, perhaps, how much beyond that we want to spend.

We are going to go into that sort of question in the third part of the course. In order to answer it, we’re going to draw on what we learn in the second part.

Hey, this stuff all fits together, eventually!

The undeserving sick

Jenn pointed out a problem that all insurance schemes face: moral hazard. Roughly, if you’re insured against an outcome, you will be less likely to take the steps that you could take to avoid the outcome. Her example involved public health care and smoking. After class, Alex mentioned organ transplants and alcohol abuse.

Is it irrational to exclude people who could avoid getting sick from receiving public care? They’re sick, after all. And is there any such thing as “deserving” to live? I can understand deserving to win a race or a prize, but living?

On the other hand, is it fair to those who lose the scarce resources, such as available liver transplants? And shouldn’t a public system manage its costs in ways that normal insurance plans do?

Perhaps there are ways of avoiding some of these questions. Greg pointed out that many bad health habits are not a matter of individual fault. Suppose there are neighborhoods where fresh fruit isn’t available. That would mean that it would be wrong to hold the residents responsible for the ill-health effects of not eating fresh fruit. There are probably lots of social causes of bad health like that.

There are some great questions here, any one of which would make an excellent thesis project (hint, hint).

One thing I wanted to point out is that it’s possible that smokers are net contributors. It’s true that there are bad health effects of smoking and that smokers would take more out of a under a publicly financed health system than non-smokers, other things being equal.

But smokers die after their years of highest productivity and before they draw on the retirement system. That is, they pay into society and programs like Social Security, but they don’t receive the benefits.

It’s quite possible that their net contributions are positive even if we counted the costs they impose. There’s an argument to that effect in one of the chapters of the Menzel book, Strong Medicine.

Universal health care and specialists†† The last two sections were added on September 18.

I disputed Lindsay’s characterization of universal health care as offering less access to specialists. My source is Jonathan Cohn, a reporter for the New Republic whose new book, Sick, is about health care. I saw Cohn address a health care policy crowd this summer and he knocked ‘em dead (so to speak). So I look to his stuff first. Anyway, checking the book, I see I exaggerated some points but got others pretty much right.

My exaggeration concerns France. Cohn is quite positive about France’s health system and thinks that we should regard it as a model of what universal health care could be like. But he concedes that France has not been extensively studied by those who comment on the American system. I think I was more confident in saying that the French have access to specialists than I should have been: I don’t know.

I was on the money concerning Britain and Japan. According to Cohn, the British spend less than half as much as the Americans do on their health system. Spending less on health care means, well, less health care. But you can still spend a lot less than Americans do and get a lot more stuff. Cohn claims that Japan spends about 60% as much as the US, I assume proportionately. But Japan “leads the world in the availability of technology such as CT scanners and MRI machines” (Cohn, Sick, p. 226).

The comparison with Britain can produce all sorts of misleading results. For example, the survival rate for cancer patients is much worse in Britain than it is in the US. But it would be hasty to jump to conclusions about universal health care. In many countries with universal health care, cancer survival rates are pretty much the same as they are in the US. So watch out when Britain is used to stand in for universal health care coverage.‡‡ This paragraph was added on September 30.

Incidentally, Cohn’s book opens with the story of Cynthia Kline. She died of a heart attack after her ambulance was diverted from an emergency room that could perform the emergency procedure she needed to one that could not. Why? The first ER was full.

That’s another way that our current way of guaranteeing health care is a failure. As Ramy and Kari noted, using emergency rooms for what should be routine care is a bad way of giving care to those who receive it. But it also hurts those who have, you know, emergencies.

Merit and higher education

Jenn said she had read an article over the summer that fit with Williams’s point about the tension between respect and meritocracy. I suspect that she read this piece by one of Pomona College’s most accomplished graduates: Louis Menand. Here’s a longer essay he wrote on similar themes concerning college admissions.

President Oxtoby is no slouch, despite not having had the benefit of a Pomona education. (It was probably the Berkeley PhD). He had a debate with the Washington Post’s education reporter over what he sees as the overuse of AP tests. (By the way, the Washington Post’s education reporter sent his daughter to Pomona. That says something, I would think).

This page was written by Eleanor Brown and Michael Green for Freedom, Markets, and Well-Being, PPE 160, Fall 2007.
Freedom, Markets, and Well-Being