Tag Archives: Health Care

Damasio, Spinoza and our Current Confusion about Cause and Effect, by Charles M. Saunders

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Portrait of Baruch de Spinoza (1632-1677), ca. 1665, by an unknown artist

In this article, Charles M. Saunders considers Looking for Spinoza: Joy, Sorrow, and the Feeling Brain by Antonio Damasio
(Houghton Mifflin Harcourt Publishing, N.Y., 2003)

In 2003, one of our most capable and respected neuroscientists went searching for Spinoza. What Antonio Damasio found is both enlightening and alarming. It is laudable that an empirical scientist had the interest, care, and capability to analyze the sequencing and behaviors associated with what Spinoza terms ‘the Emotions.’ This is clearly a positive development. When our neuroscientist friend recognized that something about emotional response is measurable, he made strides for the entire scientific community. But by focusing his analysis only on chapters 3 and 4 of “The Ethics”, Damasio sidetracks Spinoza’s metaphysics, chapters 1 and 2 while presenting Spinoza as some sort of intuitive materialist. The alarming part in all of this is that chapters 3 and 4 are linked inexorably to 1 and 2 wherein Spinoza insists that our thoughts are as real as our experience. As notable as Damasio’s respect for Spinoza’s psychology may be there is a tremendous distance from his awakening to the import and physical reality of the emotions to an adequate understanding of the full impact of Spinoza’s discovery, that the human mind has the ability to form replications of objects so accurate that these ideas are essentially the same thing as the objects they represent.

This is an astounding claim that Spinoza makes and to this day, it has been overlooked or dismissed in light of the advances in contemporary science and its ability to “reduce” everything in its purview through observation and measurement. But cause and effect are not observable within the same time and space.

Brain illustration from The Principles and Practice of Medicine...' by W Osler, 1904, public domain via Wikimedia Commons

Brain illustration from The Principles and Practice of Medicine…’ by W Osler, 1904, public domain via Wikimedia Commons

When the neuroscientist-researcher connects electrodes to a patient to monitor brainwaves there is no question that the observable patterns that emerge are exciting and are indicators of some brain activity related to behaviors that correspond to the patient’s emotional state and mood changes But to conclude from this that the patterns and their location in the brain somehow indicates the cause of the thinking process is a leap that indicates faulty reasoning and bad science. To draw a conclusion about the source of the thinking process from an electroencephalogram is akin to a person who while standing atop the tallest building in a large city before dawn observes the pattern of traffic lights below and concludes that the pattern of lights is the cause of the flow of traffic. No matter how many thousands of lights make up the discernable pattern of the flow of traffic, the actual cause of the traffic is not observable. The cause of the traffic resides elsewhere. It originates in the reasons that each individual driver leaves home and enters the flow: going to work, driving a friend to the hospital, making deliveries, police responding to emergencies and countless other actions are the actual cause of the traffic and they are entirely disconnected from one another. There is no common cause to be observed and reported on here.
This analogy demonstrates the confusion inherent in the empirical process. There is no argument about what the scientist sees during the study. But there is a strong argument against what he claims to have observed. If this mistaken insistence that causality must be observable resided solely in speculative neurobiology the harm might not be that negligible. Unfortunately for us, this curious misunderstanding of cause and effect permeates most of our scientific theory and practice, including applications in healthcare diagnosis and treatment.

Perhaps one of the most debilitating misapplications of the empirical process lies within the field of genetics and the supposed causal link observable in DNA. Crick and Watson never assigned any causal agency to their brilliant discovery. They clearly understood DNA for what it is; a marker not a cause. Assigning cause to DNA strands came later after arrogance and the same faulty reasoning process employed by Damasio came into play. Whether a person suffers from cancer or obesity or a predilection towards baldness, DNA is not the cause of the affliction it merely marks the presence of the condition. To carry the traffic lights/scientific research analogy a bit further, just as we can clearly understand that no matter how complicated or advanced the light pattern and system flow technology might be it cannot be said to be the cause of the traffic. That flow can only be understood by seeing the individual actions and behaviors that are the actual cause. So with DNA, it is a marker that notes the presence not the cause of disease.

The upshot of all this is that our current empirical/materialist science system that has brought about some of the most significant advances for humans in medicine and other sophisticated technologies contains a seriously flawed view of cause and effect. But by insisting on a research focus only on the world of external experience it ignores the rich world of experience’s counterpart and co-equivalent, the Human Mind. This now outmoded way of explaining our planet and our relationship to it must give way to a more sophisticated view. This view will credit the mind as the source and wellspring of any scientific achievement that we’ve ever accomplished and that it is the mind which provides us with the most magnificent tool at our disposal for unraveling Nature’s mysteries.

Charles M. Saunders

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Civil Rights and Healthcare: Remembering Simkins v. Cone (1963), by Ezelle Sanford III

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Dr. George Simkins, Jr.

Dr. George Simkins, Jr.

Upon her release from L. Richardson Memorial Hospital’s maternity ward in Greensboro, North Carolina, my grandmother, Ann Wilson Scales, walked a few short steps to her mother’s home with a small baby in hand. She had just given birth to my mother, La Tanya Wilson Sanford, in the city’s Black hospital. It was 1965. Unbeknownst to either of them, a small group of L. Richardson’s physicians, dentists, and patients had waged a quiet war against segregation two years earlier. The city was the site of arguably one of the more consequential yet little-known civil rights battles in American history. No, it was not the beginning of the student sit-in movement initiated by North Carolina A&T students in 1960. Rather, this small contingent fought in district and circuit courts to desegregate U.S. healthcare. At issue was where medical professionals could practice and where patients could access care: in the older, segregated L. Richardson Hospital, or in the newer, more modern (and better funded) Moses H. Cone Memorial Hospital.

In 1962, dentist George Simkins, Jr. unsuccessfully attempted to admit a patient to Moses H. Cone Memorial Hospital, one of two private white hospitals in the city supported by tax dollars. Combining his role as community dentist and President of the Greensboro chapter of the NAACP, Simkins initiated a class-action lawsuit against both Moses Cone and Wesley Long Community Hospitals. The NAACP’s Legal Defense Fund assisted in litigating the test case. Not only were African American patients barred from these institutions, Black physicians were barred from practicing there, even as both institutions received state and federal funds provided by the 1946 Hill-Burton Hospital Survey and Construction Act. Hill-Burton emerged from President Harry Truman’s failed healthcare reform and promised to rebuild and modernize the U.S. healthcare infrastructure. However, this program included a loophole where states that engaged in de jure racial segregation could use the money to build segregated facilities. Cone and Long Hospitals both benefitted from this program and its segregation loophole. This is not to say that segregated hospitals did not exist before the Hill-Burton Program, however; historian Vanessa Gamble chronicles the movement to establish Black hospitals from 1920–1945.

Initially, the district court of North Carolina sided with the defendant hospitals; however, the Fourth Circuit Court of Appeals (and later the United States Supreme Court, which refused to hear the case) deemed that the two hospitals’ policies of racial discrimination for both patient admissions and visiting physician staff privileges violated the fifth and fourteenth amendments of the Constitution.

Last September, the CEO of Cone Health Network, of which Moses Cone Memorial Hospital and Wesley Long Hospitals are now a part, issued a public apology to the last surviving plaintiff of the historic court ruling. Dr. Alvin Blount, 94, graciously accepted the long overdue apology from the health system, initiating local reflections on racial discrimination in healthcare. This is not the first apology issued to acknowledge the long-strained history of race and racism associated with medicine and healthcare. In May 1997, former President Bill Clinton formally apologized for the United States Public Health Service’s “Tuskegee Study of Untreated Syphilis in the Negro Male” (1932–1972). In 2008, the American Medical Association (AMA) officially apologized for its exclusion of Black physicians from membership, an important acknowledgment given that AMA membership became increasingly important for hospital admitting privileges, licensure, and broader steps in professional development. As historian Thomas Ward notes, until the AMA desegregated in 1968, Black physicians were barred from white hospitals and denied opportunities for continuing medical education, thereby justifying their own professional societies and medical schools. All of these apologies were too little, too late, and their legacies continue to influence healthcare to date.

Historical marker for landmark decision of Simkin v. Cone, 1963

Historical marker for landmark decision of Simkin v. Cone, 1963

Cone Health commemorated the legacy of the Simkins decision by allocating $250,000 in scholarship funds for students pursuing healthcare professions. Guilford County commemorated the case by placing a marker outside Cone Hospital and a bronze statue of George Simkins on the grounds of the Guilford County Courthouse. These symbolic gestures speak to the case’s broad importance, defining Simkins not only as a significant battle for civil rights in medicine, but also as a touchstone moment in a much larger movement for freedom and liberation. Simkins was decided only months before the Civil Rights Act of 1964 was ratified; the Title VI of this act and Medicare funding forced the desegregation of healthcare facilities almost overnight, as historian David Barton Smith argues. In a short documentary produced by Cone Health, Dr. Blount recalled that the Simkins case “ended ‘separate but equal’ forever.”

Yet, the Simkins decision does not figure prominently in many popular renditions of civil rights history.1 Contrary to the aforementioned Clinton and AMA apologies, which received national attention, the Simkins apology did not move beyond the local media. In many of these local reflections, the Simkins case was likened to the historic 1954 Brown v. Board ruling. Though both cases ostensibly achieved similar ends, eliminating separate but equal institutions in education and healthcare, respectively, the comparison obscures more than it reveals. Even I am guilty of this shorthand, an easy way to communicate the gravity and significance of this decision. But this shorthand has the unintended effect of perpetuating Simkins’ invisibility.

History plays a role in why Brown lives on in the popular imaginary and Simkins does not. A majority of Americans interacted with both systems as they each cared for the nation’s most vulnerable: children and the infirm. Desegregating American education, however, was a very public battle, as images and video captured the Little Rock Nine or Dorothy Counts (who integrated my high school, Harding University High School in Charlotte, North Carolina) confronting inflamed white mobs. Brown was not simply waged in court; debates around school segregation seeped into American homes and into popular discourse. On the other hand, Dr. Blount remembered that the Simkins plaintiffs wanted to engage in a quiet challenge to segregated healthcare.2Although their fiscal independence allowed some physicians, like T. R. M. Howard, to jump to the fore of a broader movement, others sought to challenge their exclusion from the medical establishment in a more dignified manner.

While the Supreme Court heard Brown, it did not take the Simkins case. Until the Civil Rights Act months later, the lower Circuit Court’s ruling stood as jurisprudence only in the Fourth Circuit’s Mid-Atlantic region. Moreover, the two cases had distinct legal questions at their heart; Brown questioned the separate but equal doctrine established in 1896, while Simkins questioned whether public funding of private institutions counted as “state action.” Undoubtedly, Brown was an essential step leading to the Simkins decision. Without its challenge to the separate but equal doctrine, Simkins may have failed. Finally, the speed by which institutions in the fields of education and healthcare were desegregated differed dramatically. In the words of Chief Justice Earl Warren, school desegregation was ordered with “all deliberate speed,” while the Simkins case, combined with the Civil Rights Act and Medicare legislation, helped to desegregate many hospitals rather quickly. Political scientist and historian David Smith’s The Power to Heal: Civil Rights Medicare, and the Struggle to Transform America’s Healthcare System (2016) recovers this connection and situates health policy implementation in the broader movement for equality, employment, and rights.

Though the Simkins case is lauded for bringing about a swift end to segregation in healthcare, among other things, it led to the decline of Black community hospitals. While some, like Grady Memorial in Atlanta, successfully negotiated the new terrain of race relations, federal monies, power, and increased opportunities for Black medical students and doctors elsewhere, others like Homer G. Phillips Hospital of St. Louis and L. Richardson Hospital shuddered under the burden of increasing medical costs, lack of staff, and changing ideas around the importance of these institutions. In effect, Black hospitals were an anachronism in the post-Simkins era. Where some Black patients could, like my grandmother, walk to and from their community hospitals, such an action is almost inconceivable today given the large, distant campuses of many contemporary urban hospitals and medical centers.

Cone Health’s apology, though overdue, came at just the right moment. Dr. Alvin Blount passed away earlier this year, only months after his former legal foe recognized and applauded his pioneering work. The silences around the Simkins decision demonstrate that more work still needs to be done on our understanding of the history and legacy of Black liberation. Specifically, the nexus between civil rights and health remains fertile ground for scholarly inquiry. We must heed the warning of W. Montague Cobb, physician, anthropologist, editor, activist, and intellectual, “lest we forget.”

This piece was originally published at The African American Intellectual History Society (AAIHS) blog

Ezelle Sanford III is a fourth-year graduate student at Princeton University in the Department of History, Program in the History of Science. He is currently a Visiting Scholar in the Center for Humanities at Washington University in St. Louis working on his dissertation project, “A Source of Pride, a Vision of Progress: The Homer G. Phillips Hospital of St. Louis, MO.” (Bio credit: AAIHS)

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*All views and opinions expressed by guest writers are their own and do not necessarily reflect those of Ordinary Philosophy’s editors and publishers

O.P. Recommends: ‘Capitalism’s Crisis of Care’ – Sarah Leonard interviews Nancy Fraser for Dissent Magazine

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‘Capitalism’s Crisis of Care‘ is a discussion between Sarah Leonard of Dissent magazine and critical theorist and feminist Nancy Fraser, which focuses on Fraser’s concept of today’s ‘crisis of care’, which, as she explains, is a product of capitalism. In capitalist societies, ‘social reproduction’, the social and family bonds necessary for raising families and caring for the elderly, have ‘no monetized value. They are taken for granted, treated as free and infinitely available “gifts,” which require no attention or replenishment’ and which, like nature itself, is ‘an infinite reservoir from which we can take as much as we want and into which we can dump any amount of waste.’ Capitalism, unjustifiably and artificially, splits ‘economic production off from social reproduction, treating them as two separate things, located in two distinct institutions and coordinated in two different ways.’ This leaves us with this crisis of care, in which working people are stretched to the breaking point, trying to make a living while trying to maintain the level of care and attention that children, the elderly, and social bonds in general need as much as ever.

Fraser outlines the history of the development of this crisis of care, ‘trac[ing] a historical path from the so-called liberal capitalism of the nineteenth century to the state-managed regime of the mid-twentieth and on to the financialized capitalism of the present day. In a nutshell: liberal capitalism privatized social reproduction; state-managed capitalism partially socialized it; financialized capitalism is increasingly commodifying it.’

If we are to resolve many of the most pressing social problems we face today, from funding health care to adequately providing for the elderly, ill, and disabled to giving working families sufficient time and resources to raise the very families society depends on, we need to start by examining our assumptions and habits with the same care and rigor Fraser reveals in her analysis.

Here’s another excerpt from this absorbing and enlightening interview:

‘Leonard: Many of the questions that you raise about social life and the family have come to seem utopian again, like some remnant of the 1960s, and not necessarily central to a socialist program. And yet, you argue that we’re actually at a crisis point—these issues must be central. The challenge of social reproduction is so fundamental to everyone’s lived day-to-day experience that it’s been surprising to me that it’s often absent in the current revival of socialism.

Fraser: I agree very strongly with that. Given the acuteness of this crisis of social reproduction, it would be utopian, in the bad sense, for the left not to be focusing on this. The idea that we could somehow bring back manufacturing, that’s what’s utopian—again, in the bad sense. Unlike the idea that you could build a society that assumes every adult is a person with primary care responsibilities, community engagements, and social commitments. That’s not utopian. It’s a vision based on what human life is really like.’… Read more

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Book Review / Summary: The Birth of the Pill

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In The Birth of the Pill, Jonathan Eig tells the fascinating story of the four people whose combined efforts, arguably more than any others, made birth control effective, affordable, widely available, and perhaps most importantly (since it makes all the others possible), socially acceptable: Margaret Sanger, Dr. Gregory Pincus, Dr. John Rock, and Katherine McCormick.

At the time the contraceptive pill was being developed, human reproduction was still very poorly understood. Prudish attitudes and obscenity laws hampered scientific research, discouraged and in many cases prevented doctors from educating their patients, and kept women from having any significant degree of control over their own bodies or the decision to become pregnant. It took a few independent-minded, morally driven people of unusual character to achieve change in the arena of reproductive rights.

Two of these four had spent years caring for people whose unchecked fertility threatened their own life and health, and the well-being of their families. Women, especially poor women, found themselves pregnant again and again before their bodies had recovered from earlier pregnancies, had medical conditions caused or exacerbated by pregnancy and childbirth, or could not afford adequate food, clothing, shelter, and health care for their rapidly growing families. Many women also found too many pregnancies burdensome, as they were prevented from pursuing an education or a career, or suffered from exhaustion, depression, and feelings of hopelessness as they found themselves caring for more children than they could cope with.

Margaret Sanger and Dr. John Rock encountered all of these problems up close and personal; their birth control activism was the direct result of their experiences as reproductive health care providers. Sanger worked for many years as a nurse caring for the poorest people in the slums and tenements of New York City. She was so moved by the plight of these women that she risked fines and imprisonment to open the first ‘birth control’ clinic (as she coined the term). Countless poor women, who had often already fled starvation, poverty, and disease in their home countries, found themselves unable to escape the cycle of repeated pregnancies and deepening poverty as their own bodies weakened and their meager resources were stretched ever thinner in the face of anti-immigrant bias, pittance wages, and filthy, overcrowded, and dangerous living and working conditions. This was also an era when women had no right of refusal of sex to their husbands. They faced the awful choice of risking another pregnancy, injury or death by self-performed abortion, or being abandoned when few jobs were available to women, and few jobs paid women enough to live on themselves, let alone support a family. And charity organizations, try as they might, could not keep up with even a fraction of the demand for assistance. Despite repeated arrests and fines, Sanger continued to provide birth control devices and information to the who women flocked to her clinic, pouring out their life stories in person and in letters like this one (original spelling):

‘… I am thirty years old have been married 14 years and have 11 children… I have kidney and heart disease, and every one of my children is defictived and we are very poor. Now Miss Sanger can you please help me… I am so worred and and I have cryed my self sick …I know I will go like my poor sister she went insane and died. …the doctor won’t do anything for me … if I could tell you all the terrible things that I have been through with my babys and children you would know why I would rather die than have another one. Please no one will ever know and I will be so happy and I will do anything in this world for you and your good work …Doctors are men and have not had a baby so they have no pitty for a poor sick Mother. You are a Mother and you know so please pitty me and help me. Please Please.’

I can only imagine what Sanger felt as she read this letter as she worked with so many women struggling under these same burdens, while social mores and the law opposed her efforts to help them.

Dr. John Rock was an obstetrician and fertility specialist. While one of his main focuses was on helping women with fertility problems become pregnant, he also worked with many other women for whom pregnancy, childbirth, and child care was detrimental to their physical and mental health, for various reasons. He became a staunch activist for birth control, and worked to convince the public and the Catholic church, of which he was a committed member, that effectively planning families and regulating childbirth is not only practical, but of the highest moral worth, since it promotes bodily and spiritual health, and a loving family life in which all children can be well cared for. He thought he could convince the church hierarchy that the hormonal method of birth control is consistent with Catholic teaching, since it’s simply an extension of the natural cycle that occurs in a woman’s body, rather than a barrier method with was doctrinally forbidden; his rhythm-method clinic taught the only form of birth control other than abstinence that was sanctioned by his religion, but as he observed, neither worked very well. His efforts to help women control their rates of pregnancy would eventually prove effective, but his efforts to convince the Church, until this day, have been in vain.

Yet birth control was not only linked to beliefs in reproductive rights and health: it was linked to a change in sexual mores. Sanger, Pincus, Rock, and McCormick all held what we’d now call ‘sex-positive’ beliefs: they thought sex could and should be a wonderful thing, among the most joyous, intimate, and healthy means by which humans connect with one another. In a time when sex was often regarded as shameful, depraved, and for the sake of men (I would argue that while it’s re-branded, it still is, as ‘liberated’, ‘powerful’ women painfully squeeze themselves into bustiers and stilettos and straighten, curl, bleach, and cut their hair and bodies to fit into a few stereotypical male fantasy body types as possible, in our crudely sex-obsessed, tabloid, misogynistic culture — yes, I’m talking about you too, Beyonce), they thought it could and should be a loving, freeing, and transcendent experience for both partners.

Dr. Gregory Pincus, the scientist who would ultimately formulate the first effective, FDA-approved birth control pill, was an unusually independent-minded, freethinking, colorful personality from an early age. As a young researcher at Harvard, he was widely publicized for his frank and unapologetic views on the benefits of revolutionizing human reproduction through scientific intervention. The sensationalist, brave-new-world ‘news’ stories led to Harvard’s kicking him out of their faculty and their labs, as a reputation-defense measure. Pincus went on to found his own research institute,. where he continued his research into hormones and their effects in reproduction. Arguably, it was this very political and financial independence from any large mainstream establishment that enabled him to succeed in his goal to produce the first birth control pill.

It also took money, and lots of it, as it does with any new pharmaceutical. Planned Parenthood could only provide limited funding for Pincus’s work, so it dragged on slowly, until Katherine McCormick, wealthy heiress, came along. She had discovered, shortly after she married, that her new husband suffered from severe mental illness. McCormick was well-educated, an MIT graduate at the time of her marriage, and was fascinated by all things science. When she learned of her husband’s mental illness, she poured time, money, and research into finding a cure, especially in the fields of hormonal research and heritability. She was also dedicated to women’s rights causes, and by the time of her husband’s death, her interests and fields of study and activism led to her single-minded determination to aid in the cause of making birth control effective and widely accessible. It was she, more than any other, who provided Pincus the funds to pursue more lab research, and for he and Rock to conduct more clinical trials.

Eig’s book is not a simple hero story: he reveals the history and personalities of each with their complex set of motivations, warts and all. Sanger was a eugenicist, for example. It was not uncommon for progressives, scientists, and those in the medical field to subscribe to the principles of eugenics at that time; many thought (mistakenly, as it turned out) that it was the only way science could really ‘cure’ disability and disease once and for all. Medical science, humanitarian groups, and governments had not yet offered systematic or effective solutions to the dangers of pregnancy and childbirth, diseases caused by overcrowding and malnourishment, and mental health issues, and were simply unable to keep up with the demands of the humanitarian crisis in affected communities. Eugenics, on the other had, seemed to offer the only sure and straightforward solution, until the application of its principles by fascist governments revealed how faulty a ‘science’ (really a pseudoscience) it was. Sanger was also a neglectful mother, unsuited by personality to the stay-at-home role mothers were restricted to in her time. Pincus was a media hound, and conducted some of his trials in what today would be considered an unethical manner. Rock was willing to mislead some of his patients when he found that public attitudes made most women unwilling to participate in contraceptive studies, if presented as such. And McCormick, like Sanger, had a marked tendency to elitism.

Yet the contributions of these four unusual, passionate, driven crusaders towards improving women’s health and social and legal emancipation can hardly be stressed enough. Women can now have as many children as they choose when they choose, and are not subject to the whims of men when it comes reproductive issues (still mostly true despite discouraging recent regrettable, retrograde legal decisions, for example, regarding the mandate that insurance companies pay for full reproductive health care). Sanger’s, Pincus’s, Rock’s, and McCormick’s belief that birth control would ultimately improve and save the lives of women, and improve the standard of living for families, have been vindicated over the years. For example, women on the pill live longer, on average, than other women, and the results of decades of study leads the World Health Organization to promote birth control as an important means of improving health and relieving poverty around the world.

With his excellent book, Eig not only compellingly tells the story of how the pill came to be, but also of the human dramas behind its invention. The history of the pill, the circumstances which gave rise to its invention, and the ideas of its creators show us how and why ready access to effective birth control is as important today as it ever was.

~~~~~~~~~~~~~~~~~~~~~~~~~~~

Sources and inspiration: 
Eig, Jonathan. The Birth of the Pill: How Four Crusaders Reinvented Sex and Launched a Revolution. W.W. Norton & Company, New York, 2014. http://books.wwnorton.com/books/The-Birth-of-the-Pill/

Kelland, Kate, Ed Jon Hemming ‘Women On the Pill Live Longer: Study’. Reuters, Mar 12 2010
http://www.reuters.com/article/2010/03/12/us-contraceptive-pill-risk-idUSTRE62B01R20100312

World Health Organization website, ‘Reproductive Health’.
http://www.who.int/topics/reproductive_health/en/

Personal Responsibility and Collective Action Problems

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In a recent essay, ‘But My Brain Made Me Do It!‘, I argue that many attempts to evade or minimize personal responsibility for one’s actions are misguided. The concept of personal responsibility exists not only to impart personal and societal meaning to human behavior, but to assign accountability. After all, if human beings can not be required to fulfill responsibilities or make retribution for harms done, societies could not function and group living would be impossible. Many attempts to evade personal responsibility only consider the reasons why one might easily have acted one way or another, and ignore two other key factors which lend weight and force to it in the first place: whether the person could have acted otherwise, and whether the person was in fact the one who performed the action. Therefore, attempts to isolate only deliberate intention, and to disregard other factors in matters of personal responsibility, undermine the nature and utility of the whole concept.

In the United States, debates about the meaning and ramifications of personal responsibility surround not only crime and punishment issues, but also public policy dealing with collective action problems, such as pollution, overpopulation, gun control, defense, law enforcement, and access to health care. These types of problems result from individual choices en masse, so that personal responsibility may be difficult to assign to any one individual. Yet, these problems would not exist unless all of those individuals choose to act they way they do. Collective action problems affect so many people, are so complex, and are so expensive, that a solution to them requires mass participation: many individuals each required to take part in solving the problem.

Yet solutions are often difficult to find because of the personal responsibility problem: how do we hold particular people responsible for solving a collective action problem when their individual choice is merely a ‘drop in the bucket’, so to speak? If personal responsibility is so narrowly conceived that one is only held responsible when there is a clear and direct link from the act in question to the entirely of the consequence, and they that they must have (mostly) understood the consequence of their action beforehand, than we must allow that no-one can be held responsible for most collective actions problems. But if we take a more robust view, that people can be held responsible for what they do and the consequences that flow from it, even if the consequences cannot be foreseen or intended, then we do have the right to call on the community to do what they can to fix the problem, be it through contributions of money or effort, through reparations, through accepting (just) punishment, or through other means.

In my ‘Brain’ essay, many of my arguments supporting a robust view of personal responsibility are consistent with a typically American conservative viewpoint, though some of my conclusions relating to particular public policies may differ. (For example, when it comes to criminal justice, I favor a reparative/restorative system over a punitive one, and restraint over zeal in enforcement of all but the most serious crimes, but those are topics for other essays.) When I apply the same arguments to collective action problems, however, the result is more consistent with a progressive approach to public policy as well as to morality.

A robust view of personal responsibility, I find, entails that individuals are morally obligated to contribute, through taxes or otherwise, to programs that preserve and promote the health, protection, and basic well-being of society as a whole. I argue this for two reasons: one, it is individual choices, be it in the aggregate, that create collective action problems (I address this issue in a past essay, in my example of the Dust Bowl crisis in mid-century United States, where the individual decisions of farmers to ‘get rich quick’ created a crisis for everyone, including those others who decided to farm more prudently and responsibly.) Therefore, members of a society should contribute to solutions or to make reparations, for the harms to others that result, directly or indirectly, as a result of their choices, Secondly, individuals, as well as society as a whole, often enjoy wealth, comfort, improved health, and other benefits that are derived from the reduced circumstances of others. A robust view of personal responsibility would also require that those who enjoy these benefits should pay their fair share for them when they have not adequately contributed for them otherwise (for example, in the marketplace).

Consider the issue of health care, and the debate over whether it should be publicly subsidized.

A typically American conservative position on this issue is that health care should be a free market commodity, because it should be a reward for honest work and its contribution to society. If one is personally responsible for their own actions, then if they do their fair share and work hard, they earn the right to access health care. The market is the mechanism, therefore, that limits the access to health care only to those people who have contributed to society through work. People who do not do their fair share, on the other had, should not get health care as a freebie, coercively paid for via taxation, by wage earners. If people feel like freely donating health care to the poor, fine and good, but they should not be forced to do so.

I sympathize with that position to a limited degree. I now work in the health care industry and see people who I have good reason to believe are gaming the system, quite often, in fact. (I address this issue in another recent essay.) If some people are cheating the system, I agree, they oftne are doing the wrong thing, but, I think, not necessarily. Consider this example: a pair of aging parents find their nest egg, carefully scrounged together through a lifetime of hard work, suddenly threatened by the wife’s recent diagnosis of breast cancer. These parents may be faced with this set of choices a) let the wife die without treatment, b) pay for the treatment, wiping out the life savings with which they would have paid for their retirement and the care of their children c) hide their assets to access free public health care assistance. These parents may feel justified making the third choice, since they feel that their primary moral duty is to save the life of their spouse and to care for their children, that their lifetime of hard work contributed enough to society to earn the moral right to this public assistance, and that they do little wrong gaming a system made corrupt and expensive by greed and political chicanery. I, for one, would find it difficult to condemn such a choice, and in some circumstances, may agree that it’s the most morally justifiable choice.

In my work in the medical office as well as in my years in the work force, I’ve seen far more examples of situations that bear a closer resemblance to the hypothetical situation I presented (closely inspired by a real life one) than to simple cheating out of greed or laziness. I work for a good doctor, who is the only local one in his specialty to see low-income patients on public health care assistance. (The reimbursement rates from many public health care assistance programs are very, very low, and physician’s offices have a hard time keeping their doors open at all if they accept many patients with that insurance.) Therefore, our office cares for many of the working poor as well as the suspected cheaters. Every day, I see elderly people who carry the signs of their past lifetime of hard work as well as people who currently work long, hard hours for little pay, whose health care is paid for through taxation because they can’t afford it otherwise. And I think: that’s how it should be.

That’s because all of us enjoy the benefits that come from the hard work of so many low-income people. We get to eat plentiful, cheap food because other people toil long hours with little pay in fields, restaurants, and factories. We get to wear comfortable, well-made clothing and stuff our wardrobes to a degree that no-one but the wealthiest of aristocrats used to enjoy, again, because others work in miserable, boring, depressing conditions working practically for nothing. I live in Oakland’s Chinatown, where I am surrounded by the hardest-working people I’ve seen in my life, other than the (largely immigrant and children of immigrant) people I worked with in the food industry, and these people, too, receive pitiful remuneration for the vast contributions they make to your life and mine.

When you and I pay a few cents for an apple, or a few bucks for a shirt, or a couple hundred for a computer, we do not pay our fair share, to my mind. The market may have driven prices and wages down, but when we’ve purchased those things, we’ve only fulfilled our part of the bargain between the buyer and the seller. We have not, however, fulfilled our personal responsibility towards all those other people who made our wealth possible. We have paid for our own life of comparative wealth and ease in an exchange that buys a life of privation for another.

So when you and I buy that cheap apple, that cheap shirt, that cheap computer, our decision to do so creates an economic situation in which many other people earn poor wages. And those poor wages, in turn, mean that people can’t afford to buy health care, or indeed, enjoy those benefits of society that their work makes possible in the first place. In the long run, it’s our fault, even if indirectly, that other people can’t buy health care, because this situation arises as a consequence of our own choices, our own actions. And this is only one example in which individual actions cause collective action problems. Other examples are pollution, overpopulation, natural resource depletion, systematic racism, traffic jams…. The list goes on and on.

So here’s a question with which I would challenge those who don’t like to feel responsible, or to hold other people responsible, for such collective action problems, including so many American conservatives: why is it that you should be personally responsible for your economic well-being by choosing to do your part and work hard, but you should not be held personally responsible for the consequences of your choices in the marketplace for others who work hard? As an example we’ve already considered shows, we can follow the chain of consequences readily from our own market choices to their collective impact on the lives of others. People, out of self-interest, choose to pay less for food if they can, usually without questioning why it’s cheap. But for food to be cheap, it’s generally because wages are low (in combination with improved technology, which can increase efficiency; but sometimes, new technology means workers have to compete with it, again lowering wages). Individual choices to buy cheaper produce cause wages to be low: they benefit from the reduced circumstances of others. And healthcare, even in more efficient, less corrupt systems than ours, tends to be expensive, because of the high cost of the education of doctors and of research and development, and because it’s labor intensive (each doctor’s visit often requires a significant input of time to be effective), so low wage earners usually cannot afford adequate health care. Therefore, our personal decision to buy cheap produce causes many others not to be able to afford health care. Why, then, would we not be held to any level of responsibility for the consequences of our actions when it comes to access to health care?

We already accept the idea of personal responsibility for individual contributions to collective action problems in many other areas of life. In order to enjoy the legal right to drive, for example, we’re required to purchase driver’s insurance. That’s because our own decision to drive can have debilitating and fatal consequences for others, even if they are entirely accidental. Almost no-one intends to maim or kill another when getting behind the wheel, yet we accept that when we choose to drive, we are still personally responsible, in one way or another, for what happens as a consequence. We also accept that since we desire and enjoy such benefits and freedoms as the right to go our way unmolested by other people, to vote, to travel on public roads and bridges, and so on and so forth, we are responsible for contributing to those institutions that solve collective action problems, and contribute to the maintenance of the military, the police, infrastructure, legal system, and so forth, thorough our tax contributions and otherwise.

As intelligent social creatures, human beings have conceived and developed societies organized according to and supported by robust conceptions of personal responsibility, demonstrated by such human products as morality and law. Instead of operating primarily from a ‘me and mine’ outlook, the most successful and long-lasting, and I argue, the happiest persons and societies operate from a predominantly ‘us and ours’ mentality, with the ‘me and mine’ enjoying even greater benefits than pure self-interest could produce. (The earliest Christian communities adopted this influential philosophy and practice, with great success and to their great credit; consider the tale of Ananias, who, out of greed, did not contribute the same percentage as others towards the welfare of all. Contrast this with the later incarnations of the Church, which retained the rhetoric and abandoned the practice of equal personal responsibility for, and equals enjoyment of, the public good.)

In sum, a robust view of personal responsibility leads us to act more responsibly in our day to day actions and, in turn, to generally behave in such a way that has the best outcomes. We come to act as Immanuel Kant’s categorical imperative would have us do, to ‘Act only according to that maxim whereby you can, at the same time, will that it should become a universal law’. When each of us realizes that our day to day actions often have not only immediate and personal but wide-reaching consequences, our behavior changes. And when we wish that the consequences of our actions are beneficial or at the least not harmful, our behavior changes for the better, our imagination expands, and the world becomes a richer and safer place for us all.

Healthcare: A Matter of Public Interest, or a Consumer Good?

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http://www.learnersdictionary.com/definition/bandage

Looks like this uneasy compromise between private moneyed interests and our national commitment to the life and health of our citizens is off to a rocky start, and I’m afraid it may fail.

I wish Obamacare was the title of a single-payer national healthcare system, or at the very least, a public option (freedom to choose!). Healthcare should be considered essential infrastructure like roads and bridges, or a national defense of the citenzenry like the military, not a mere consumer or luxury good. This is because it is the hyper-social, cooperative side of human nature, where we band together to protect and nourish each other, that makes us a successful species. This, in turn, is what makes the other freedoms we enjoy possible. Remember, we have no freedoms when we’re dead or incapacitated. Human liberty requires human cooperation in order to exist at all.

That is, if we consider preserving human life of greater importance than the license to grab as much money as we want regardless of the harm we cause doing so.