Mortality, Money and Other People

The data might not be this clear-cut, but clearly the US is an outlier.

How much is your life, or your health, actually worth? I'm sure you'd put a pretty big number on it. If, for example, you needed to borrow $100,000 to cure a chronic, life-altering disease, I would bet you would do so. Where you place your personal cutoff point when health care is no longer worth the money will vary, but at some point almost everyone will decide that it is better to accept your mortality than to expend your family's wealth in pursuit of life-extending care.

But what if I re-phrased the question? What if I asked how much your life and your health should be worth to some third party who is obligated to pay for your care? It is much less likely you would say, "you know, the government/insurance company has wasted enough money on me, it's time to let go." No, if you are entitled to care from someone else, you will want as much of it as you can get.

I think the above chart (which, in updates to the blog posts where I originally saw this now point out, is a display of GOVERNMENT spending, and may have other inaccuracies) is showing what happens when that psychological truth is given free reign. In the other countries shown, there is an understanding that the government will impose limits on what will be paid for in the interest of fairness and frugality. In the US, by contrast, there are very few limits. This leads Matthew Yglesias to argue that the much-maligned death panels are actually just what we need. As he puts it:

The "death panels" charge was a potent one for a reason. But not only is this health care spending on the elderly the key issue in the federal budget, our disproportionate allocation of health care dollars to old people surely accounts for the remarkable lack of apparent cost effectiveness of the American health care system. When the patient is already over 80, the simple fact of the matter is that no amount of treatment is going to work miracles in terms of life expectancy or quality of life.

To clarify, again, Yglesias was writing when he thought the chart captured ALL healthcare spending in each country, but surely adding in non-government spending on elderly patients would not invalidate his general point. Namely, that the decisions other countries make about what care is economically justifiable, which we would call "death panels", are the only way to constrain the growth in healthcare spending when the government is footing the bill.

But the reason the death panel argument is so potent is that we in the US understand healthcare as an entitlement, full stop. Politicians have sold Medicare, Medicaid and now Obamacare as a guarantee of full care. Think about this statement by President Obama: "I'm running because I believe that in America no one should go bankrupt because they get sick." That is a pretty remarkable statement, when you stop and think about it, because healthcare is enormously expensive. And as a practical matter, he doesn't mean it: someone who opts for experimental procedures, who tries a costly drug to tread a disease for which it is not indicated, or even someone who chooses a doctor outside of their insurance plan can all still go bankrupt. What he really means is that no one who follows the rules and limits the government imposes on healthcare will go bankrupt because they get sick, but that's not what most people hear. And so when the government tries to impose or extend those limits, people get very angry. And, as has been noted extensively in political commentary, older people vote.

There isn't a happy ending to this story, because people don't like giving up something they think they've been promised. But the only way out of the healthcare mess we're in is to make people feel they're making a financial tradeoff when they consume healthcare. One simple suggestion: the government could give tax credits (or even cash awards) to seniors who are among the lowest consumers of Medicare. Eventually, we could seek to establish a lifetime dollar target for an individual's government health benefits. People who die under that number would pass on some percentage of the difference to their estates. Or, we could provide an annual grant to seniors to buy coverage, and they pocket the difference if they find a cheaper option. (This is essentially Paul Ryan's Medicare reform proposal.) 

None of these changes would be painless, and there is a large contingency that wants to maintain the status quo no matter the costs. But a system that pretends there are no limits on what we can afford to cover, and implies there are no limits on how much care it is even rational to get, encourages people to seek out the maximum amount of care instead of the care that makes sense for them, their families, and their finances.

I know, in writing this, that I might be thought cruel. In other words, that I'm saying we should let people die if they're poor. But I'm not: what I'm saying is by creating a system that encourages the view that you should do everything possible to stave off death, no matter the financial or personal toll, we've driven people to disbelieve in their own mortality and have outsized expectations for what medicine can do. In contrast, I would recommend this piece on how doctors die: people who truly understand medicine, health and the human body are much less inclined to seek end-of-life care.

There is dignity in accepting when our life has run its course. One of the under-discussed benefits of giving more control of our health decisions back to us is that we will more clearly make our own decisions about when to keep fighting and when to let go. With no death panels required.

"If design govern in a thing so small"

According to my wife (later confirmed by some Internet research) what you are looking at in the picture to the left is a cicada wasp. I was attempting to repair the bare spots in my lawn yesterday when I heard a loud buzzing, and turned around to see the tiny drama of the wasp dragging its prey back to the nest, where apparently the dead cicada would serve as the first meal for a soon-to-be-hatched baby wasp.

While I'm not generally a squeamish person, something about the scene repulsed me, and I found I was deeply disturbed by the notion that such a thing was happening right in front of me. I felt like the wasp should be ashamed of what it was doing. And suddenly I had a flashback to Providence College, and Dr. Barbour's 20th Century American Poetry class. In particular, I recalled the last line of Robert Frost's great poem, Design, which the poet wrote after watching a spider consume a similarly grisly meal. It ends:

What had that flower to do with being white,
The wayside blue and innocent heal-all?
What brought the kindred spider to that height,
Then steered the white moth thither in the night?
What but design of darkness to appall?--
If design govern in a thing so small.

This is, as so many of Frost's poems are, much more than a bit of acute observation. In those last two lines, he is calling into question whether someone can believe the universe is designed, if it has order or meaning, when confronted even with this small-scale carnage. To put it more bluntly, why God would allow the cicada or the moth to fall victim to such ruthless predators. Frost lays out a choice: either there is evil design in allowing it to happen, or all is randomness, because the notion of a benevolent designer seems like a sick joke when confronted with the cold reality of death in nature. I have to confess that watching that scene play out on my front lawn, it seemed impossible to reconcile the death of that cicada with a merciful God.

Upon reflection, I have tried to tell myself that the physical world requires balance, and that the predator is needed to balance the prey so that the system as a whole can continue. And a part of me can accept that. But another part of me was compelled to grab my garden hose and drown the wasp in its nest, and still feels now that the punishment was fitting.

Harry Potter Is Not Escapism

Ha, you like that? I just wrote a flagrantly untrue title. Of COURSE you escape into books like the Harry Potter series. If you didn't, it would be darned hard to read through 4,000 plus pages in seven books. (And, if you've reached my level of geekdom, to do it more than once.) But I just read an article that seemed to imply that escapism was, especially for adult readers, the primary purpose of reading young adult fantasy novels. Here's the offending passage:

Young adult fiction offers a promise to all of us that there is no suffering that's not worth it, no agony that goes unrewarded down the line. If you're a teenager, those promises might be false, but they're a temporary balm. And if you're an adult, too old to believe that the balance of life comes out even, you can suspend your disappointments as long as you're immersed in a story that promises something different.

There is so much disdain hidden within that third sentence. Adult readers of fantasy novels have been beaten down by life, and so need some escape to a world where life is fair, where things "come out even". ARE YOU BLEEPING KIDDING ME? What remotely astute reader could think that Harry Potter's fictional life comes out even? Yes, he wins the battle and goes on to have a family, but he never gets to know his parents, his friends and surrogate family members are picked off one by one, and he has to willingly march to his own death before he can be victorious. His life is profoundly unfair, in a way that would make a mockery of any other person's suffering if he were, you know, real.

We are drawn to Harry Potter's story (and Ender Wiggin's story, and Frodo Baggin's story) not because we're happy to see everything turn out fairly for them, but because we see that the characters choose a path that leads to suffering because they believe following that path is the right thing to do, and then they carry on despite complications, losses, and many moments where they could give up with little shame. Our escape is to believe that, were we presented with a similar choice, we too would take the moral path. But it is not merely escape, it is also instruction, because as we encourage a (probably over-optimistic) belief that we have the will to be righteous, we perhaps give ourselves a slightly better chance to behave with honor when we are presented with our moment.

The best writers of fantasy, then, are both entertainers and moral educators. If we are too quick to dismiss adult readers of young adult fantasy as beaten down drones looking to retreat to a more appealing universe, we ignore the reality that readers are living vicariously through the characters' trials, and promising themselves to imitate the fortitude their literary heroes demonstrate.

Three Cups of Tea, Branding and Our Desire to Believe

Why are we so quick to believe liars and fabricators? We are plagued by journalists who invent facts and sources, by politicians scurrying to bury scandal, and by memoirists who find their lives are best seasoned by liberal doses of fiction. Into this last bucket place Greg Mortenson, author of Three Cups of Tea, founder of a charity intended to build schools in central Asia, and--as 60 Minutes revealed in a recent expose--a fabulist and a crook.

What is amazing, as this post by Bruce Bawer makes clear, is that the improbability of his story should have been apparent to even a casual observer:

[Mortenson] was the star of his own story. The whole point of his talk was how much one brave, selfless individual can accomplish in this world even against the most formidable of odds. And that individual was him. The premise of his spiel was that he’s a miracle worker, pacifying belligerent jihadist types by sitting down with them over three cups of tea and listening to their concerns. Yet the egomaniac I saw that day was somebody you couldn’t picture listening to anybody else for more than thirty seconds. Mortenson’s shameless self-celebration in Three Cups of Tea left me speechless. As Oscar Wilde observed of Little Nell’s death in The Old Curiosity Shop, how could any sensitive reader react to such nonsense with anything but derisive laughter?

Bawer continues by showing how callously Mortenson turned on those who had been kind to him to bolster his own reputation:

Then there’s Mortenson’s lie about having been kidnapped by the Taliban. He stuck a picture in his book of him and some Afghani acquaintances — who had treated him kindly — and identified them in the caption as his kidnappers

When we hear stories of people using others this way to bolster their own stories, we are rightfully disgusted. When we hear, as in Mortenson's case, that he was doing it in large part to enrich himself, and use his charity to support a lavish lifestyle, we howl for blood. But why do we buy in to begin with? It is easy to say, "We want to believe," but why? Wouldn't it make more sense for us to be exceptionally skeptical, and to disbelieve even true stories to protect ourselves from fraud and disappointment? Why, in other words, are humans so quick to trust?

Part of the answer, as David Brooks and Mark Earls and many others have pointed out, is that we are social creatures. We essentially outsource some of our decision-making to others. So if enough people tell you Greg Mortenson is a hero, you may not evaluate that claim very critically yourself before you, too, are singing his praises.

But I think it goes beyond that. People don't just have their small social groups, they love to organize themselves into big, abstract teams, teams that are defined by a series of positions its members are either for or against. Successfully aligning with these positions is the key to popularity for both brands and people.

Look, for example, at how Microsoft and Apple fostered opposing tribes of believers on the basis of different operating systems and technical specs. Mortenson did the same thing by aligning with deep-held beliefs in non-violence, in the power of the individual to make a difference, in multiculturalism. He pushes against the idea of cynicism (or what some would call realism or humility) and an us-versus-them mentality.

This places him squarely on the liberal-idealist team, which has many players in academia, in government, and in Western urban culture more generally. Many of these people struggle to solve the seemingly intractable problems in society, and are understandably inspired by someone who seems to be taking on big challenges with verve and success. Mortenson's story reflects their beliefs and aspirations so perfectly, they were desperate for it to be true. (Similarly, eight years ago who took what was commonly called the 'neocon' worldview really wanted to believe the Iraqi people were going to "greet us as liberators.")

We should remember that people (and brands) are not perfect. So if their stories are perfect, it should set off our BS warning sirens. The lesson is that we can't just investigate our enemies and be skeptical about those we don't agree with. To avoid our natural tendency to believe, to accept social decisions, and to take sides, we need to bring a critical eye even to those we want to love.

Greed, Sex and Public Morality

Republicans, according to stereotype, are overly concerned with what other people do with their bodies, while Democrats are overly concerned with what other people do with their money. So it was interesting, and unexpected, to read an article encouraging a renewed aversion to greed in the latest issue of First Things magazine, which decidedly falls on the conservative side of the spectrum. It forced me to reconsider some basic assumptions I have made about wealth, capitalism, and morality.

The author of the piece, Edward Skidelsky, argues that our elites have lost the traditional, still-popular view that there is something wrong with being greedy, that it is an essentially disordered, wicked activity. This notion, which your average modern economist might dismiss as juvenile, has a rich heritage. As Skidelsky puts it:

Explanation of this point requires a brief excursus into Aquinas’ theory of acts and ends. An act, for Aquinas, has two ends: one “proximate,” which is what makes it the kind of act it is, the other “ultimate,” which is what the agent aims at in acting. If either end is bad, the act as a whole is bad. A good ultimate end cannot redeem a bad proximate end; thieving to help the poor is still thieving.

He goes on to say that most thinkers in western history, up until the Enlightenment, took it as a given that trying to accumulate more money or things than you needed is wrong, no matter if it leads to good things happening. But one of the views of the Enlightenment was the economic view of man, the belief that our wealth-building activities enhance human progress as a whole. Skidelsky notes:

This transformation of attitudes to wealth creation cleared the ground for the new science of political economy. Having been demoralized, so to speak, economic acts became open to analysis and assessment in terms of their effects, intended or otherwise. They could enter into a calculus. It now made sense to ask, for instance, whether it might not be more beneficial in the long run to let corn prices fluctuate freely, even in a famine, than to regulate them—a question that could not have been decently posed when the duty to feed the poor was regarded as absolute. Without this prior demoralization of economic activity, [Adam] Smith’s enterprise would have been unthinkable. Aquinas, for instance, would have regarded it as akin to an earnest discussion of the benefits of cutting up a hospital patient and distributing his organs among others.

Now, I have accepted uncritically that the best way to improve the well-being of all is to allow individuals to pursue their own self-interest. And I don't see how you can renounce that principle without setting some group (whether the command-and-control planners of the Soviet Union or the divine-rights kings of old Europe or some body of clerics) as the arbiters of what is allowed and what is forbidden. But do we need to promote the idea of material success as a complete good? is there room for guilt about greed in a capitalistic society?

I struggled with these thoughts for a little while, but then was absorbed in another First Things article, I began another, this time "Religion, Reason and Same-Sex Marriage" by Matthew J Franck. In this piece, Franck expands on an earlier article where he argued that anti-gay marriage arguments are not based solely on irrational bias and have a place in the public debate. I have outlined my position on gay marriage on the blog in the past: namely, that we have gone so far away from the traditional sense of marriage already, and it makes so little sense for the state to license romantic companionship, that we ought to eliminate civil marriage entirely. Franck, as you might imagine, takes a different view:

Yet another danger may await us in the event that traditional views of sexual morality are overthrown and same-sex marriage is established. We see a sign of it in the driving of Catholic Charities out of adoption services in Massachusetts. The freedom to participate fully in civic life, to offer oneself to others in civil society, conscientiously on one’s own terms as a religious person professing one’s beliefs, may be jeopardized by this new dispensation.

Franck, along with many other observers, thinks the adoption of gay marriage and the host of cultural assumptions that go along with it will push Christians out of public life. This may be possible in the long term, though it is unlikely to happen any time soon in a majority-Christian nation.

So, to recap: we have two articles. One is about the ubiquity of greed in our society and of the need to curtail it, and one is a reaction to the legal advance of gay marriage. What do they have in common? In my view, both authors commit the fallacy of equating laws and government action with public morality as a whole. Look at this quote from Skidelsky:

Democratic states use economic incentives all the time to encourage motives and ways of life considered to be civilized. They limit hours of work, restrict or forbid Sunday trading, regulate where and how advertisers may operate. In a utilitarian political culture, such legislation is usually justified on grounds of economic efficiency or “health and safety,” but its unacknowledged motive is ethical. These states wish to erect safeguards against the powerful human tendency to rapacity.

If we acknowledged the legitimacy of such motives, we might think of many further ways in which the power of the state could be harnessed to discourage avarice. Of course, such proposals will encounter the objection of “paternalism,” but there is nothing inherently paternalistic about a citizen body collectively deciding to encourage certain forms of life and discourage others.

It's true that society's laws are an important benchmark of what is acceptable and what isn't, but they are far from the only ones. The culture of a society can be an equally powerful force in shaping behavior, and yet both Skidelsky and Franck are primarily concerned with whether the law advances or challenges their beliefs about the well-ordered life.

It is probably easier to change the laws to reflect the kind of society you want than to change the culture, but I would argue that a truly Christian response to the problems of materialistic greed and sexual amorality are to build up a virtuous alternative in Christian communities, prove the superiority of that way of life and then share it with others. This may be a libertarian point of view that borders on the naive, but the law that supports our beliefs on Monday may change to oppose them by Friday. (This is, in fact, what is happening with marriage laws.) If we can encourage a truly neutral state in matters of morality and culture (which I admit is a high challenge itself) than Christians should be confident that living out their beliefs will show others a better way. Public morality should be built (and renewed) from the ground up by moral individuals, not imposed from the top down by the state.

On Condemnation

200 Years ago, the idea of slavery had many defenders: it was seen as biblically endorsed, blacks were assumed to be inferior, and it was the basis for an entrenched economic system. A combination of high and low rationales made it seem like a permanent feature of our society. Today, anyone who would endorse anything that bears the faintest resemblence to slavery would be hounded out of public life.

This evident truth occurred to me when reading a recent post by Ta-Nehisi Coates, titled, "On Improvement". He talks about some of the flaws inherent in humanity, and whether we can ever wash away the dark spots on our collective soul. He starts, innocently enough, by speculating on why we so enjoy football:

Have we created institutions which look unseemly, but actually are addressing some deeply-felt need? In relation to football, what if we--as humans--have a need to vent aggression, even if only vicariously? And what if we do this through other people who will be richly rewarded for their sacrifice, but will also suffer tremendously?

He goes on to speculate why some people persist in holding seemingly ludicrous beliefs and seeking out sources of information that reinforce them, for example those who cling to the 'Obama-is-a-Muslim' theory. He then concludes:

I confess that I have not fully worked this out, yet. I guess I'm just wondering the extent to which we've crafted our own chains. How much of this is just who we are? How much of it can be improved and reformed?

Coates doesn't touch on what I would consider the most obvious explanation: that our sinful human nature constantly tempts us down crooked paths that make us feel good, or make our lives easier, or help us avoid standing out from the crowd. To return to slavery, think about the ways that institution rewarded southern whites 200 years ago:

1) It enriched them. (we could probably stop right there, but wait, there's more!)
2) It gave them absolute power over someone else.
3) It helped them fit in, by not condemning something the richest, most important members of their community were all doing.
4) It gave them a clearly defined sense of the enemy (both the slaves and, perhaps more importantly, northern whites who were butting in.)
5) It provided a clear social hierarchy, and ensured they would never be at the bottom of it. (This is why, I'd guess, so many poor whites who owned no or few slaves were so adamantly against abolition, and explains some of the nostalgia for the Confederacy that still exists.)

I'm sure I could go on, but the point is that slavery was deeply embedded in the psyches and the relationships of the people in the southern states, and thus required major the application of powerful forces to tear it out.

Now, the interesting thing is that I could build similar lists for social causes championed today by both the left and the right. Does not abortion give the woman absolute power over the unborn child? Does not condemnation of gay marriage clearly define the enemy for conservatives? The question is whether as a society we will ever come to see abortion-on-demand or denying gay couples the right to marry in the same way we now regard slavery: that is, as a stain, something abhorrent.

One final thought. If it is true that societal ills have their root in human sinfulness, then we can expect changes in social structures, technology, and government to change what evils we tolerate, but not that some evil will be tolerated by large swaths of what we generally call decent people. An example: in the 1960's, television brought images of the civil rights struggle into every American home, making it impossible for people to ignore the plight of blacks the way they had for a century. At the same time, the contraceptive pill and improved surgical techniques made it possible, for the first time, for women to seperate sex from childbirth. Both technological changes created the impetus for major social changes: I would argue one for the better and one for the worse. One could imagine, say, a technology that allowed a fetus to develop in an artificial uterus after a few months of pregnancy, along with increased concerns about population declines in western nations, to change the societal calculus again.

A society's morals are not static, nor should we assume blindly that all changes are for the better. But we should hold out hope that we can learn an improve. Often, the sign of our progress is marked by those old practices which are now so widely condemned that (we hope) they will never curse us again.