Tuesday, April 28, 2009

To Promote the General Welfare

Or Why Utilitarianism works better than Kantianism in Government [4]

The classic story goes like this. Jim is in Venezuela on vacation. He come to a village where there are twenty villagers tied up and standing against a wall. An armed man in camouflage approaches him and introduces himself as Pedro. He tells Jim that the villagers are being rebellious and these twenty would be executed to punish the town for its political leanings (for the sake of argument, they’re pro-Democratic). But, he’d let nineteen of them go if Jim would himself do one execution (to prove that even America doesn’t support this ‘rebellion’). What should Jim do?

The Kantian answer is that he should not kill the one and let the twenty die. Jim should follow a universal maxim like “You ought not murder innocent people,” regardless of the circumstances. The Utilitarian reasons that 1 dead < style="font-style: italic;">because of the circumstances. The Kantian’s concern is the soul; the Utilitarian’s concern is the body.

Kantian morality is very appealing when absolute rules are available. This is usually when it’s a matter of individual decision. For example, I believe that the following is universal maxim: “A man ought not sleep with a woman he is not married to.” I obey this and, if I violate this maxim, I believe I have done wrong. But the question gets much harder when it goes from a question of conduct (relating to oneself) to a question of governance (relating to others). Even if it is absolutely morally wrong for me to have sex with my (theoretical) girlfriend, it does not follow that the best thing is for such an act to be illegal in a free society. Moral maxims don’t translate well to governments. “Governments ought to pass laws forbidding men to sleep with women not their wives,” isn’t a self evident universal maxim.

Part of the problem is that governments are not themselves the same kind of moral entity that men are. Another serious problem is the inefficacy of such a proposal. It’s very difficult to compromise about Kantian morality (a thing very important in government). Also it’s nearly impossible to, in political discourse, change another’s worldview upon which these moral laws are founded.

For questions of governance (where moral absolutes are elusive), Utilitarianism makes more sense. How do we maximize the good? Should we pass Law A or not? Principles of justice and equity certainly shouldn’t be violated, but it’s dangerous to put a political discussion in moral terms when there are two good ends. Certainly there are things which governments do which are truly evils (e.g. genocide, taxation without representation); but most governmental decisions aren’t so clear. Entitlement programs have the good ambition to give to the poor, but they also unfairly (in the strictest sense of the word) take from the rich. “Is Kindness more important than Justice?” is not practically answerable. However, “How do we optimize real GDP growth and provision for the poor?” is. We may disagree on the relative importance of the two, but at least we’re having a meaningful discussion. We can compromise on real GDP growth; we can’t compromise on Justice.

But we (particularly in medicine) have drifted back to Kantian, moral language in politics and policy. We say, “Do no harm” as a Kantian and Universal good. We repeat it as a mantra, as if to ward off the spectres of labor in thinking. When asked, “Is it just?” we reply, “Do no harm!”; when questioned, “Isn’t that harming someone?” we just shout “Do no harm!” louder[6]. We assert things like “Nothing but the highest quality,” and “Healthcare is a Right,” and we insist on “Evidence Based Medicine” and trust that (without even evaluating them) they are unquestionable, objective and universal truths. These things do indeed sound great, but we skip right over their cost. [5] [Ironic and Very Tangential Note]

When we say “Nothing but the highest quality” we also mandate “Nothing but the highest cost” and thus violate our second universal law by depriving the poor of healthcare (as a side note, Kant said these things were actually supposed to work together; direct contradictions are a bad sign). We insist on billion-dollar experiments (this is literally the cost of some of the bigger ones) to prove that our medicine works (we call it “evidence based medicine”; we want “highest quality,” after all). But when we get the bill for these (those of us who can afford them, that is) we’re outraged by the abuses of Big Pharma which we, by our demands for “evidence based medicine,” have created. We hop on our “Healthcare is a Right” soapbox and accuse the drug companies of greed (which is probably true) and oppressing the poor (which is probably true), forgetting that it was actually our own greed for perfect drugs which actually deprived the poor of their use.

Instead of trying to guess at universal truths of governance[2], we ought to come up with practical, goals. We cannot all agree that “Healthcare is a human right”; we can agree on “It’s good for everyone to have healthcare.” Instead of asking “How do we guarantee healthcare for all?” we can rally around the question “How do we optimize the distribution of healthcare?”
It is very important to note that the two questions usually have different answers. According to one of my professors, settling for nothing less than “Primary healthcare for all” is leading to “Primary healthcare for none.” Instead of focusing on what could practically be done with available resources (my professor’s goal was to “eradicate Polio,” a goal we are approaching), some people’s zealous attachment to an ideal has actually led to more human suffering. Instead of spending limited money on vaccines to help a million children, they build clinics for a lucky hundreds while thousands die of polio which could have been prevented. And if you really believe that it’s a universal truth that “All people ought to be provided primary healthcare,” you should praise those people. Those people, whose actions ended in the deaths of children by Polio, were Good with a capital ‘G’. They did what was Right. The consequences (dead children) should be irrelevant.

But we don’t really believe that. Kantian ideals and absolutes are wonderful for a podium, but not for real governance. “We ought to fight the Axis of Evil!” as a moral imperative is a lot more motivating than, “It would be in the world’s best interest, including our own and that of the Iraqi people, to war with Saddam Hussein.” And if the Iraq War cost $1,000 and the only casualty was a hangnail, nobody would complain. When it really comes down to it, we’re political utilitarians deep down; we all compare costs and benefits. Internationally, we praise a government that saves children much more than one that nobly tries and fails to provide universal healthcare.

Centuries ago, the wisest of men once assembled to answer this very question: What should a government do? They did not put it in moral terms [3], but practical ones:
…form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity…[1]
Let us follow their example. So let’s drop the moral language and get to work. The ends we are seeking are common. Rather than fighting over what is the moral thing for a government to do, let us seek to do things like “promote the general Welfare.” Let us agree on a set of things that we can all strive together for: Humanists, Christians, Buddhists, Hindus, Jews, Muslims; Democrats, Republicans, Independents; Atheists, Deists and Theists alike. Let us set out for ourselves what things we would like to accomplish tangibly and find ways to do. Let us together war against suffering; let us not each die defending an ideological hill from the other.

Now if only we in the US had a set of things we agreed to strive for…

[1] Preamble to the Constitution of the United States.

[2] By the way, it’s really hard to come up with Universal Truths without actually thinking about it… guessing usually doesn’t work. Crafters of Universal Truths should at least try to visit the philosophy department every now and again.

[3] These men were certainly extremely Kantian when it came to personal duty. But this did not seem to translate to the Government itself, at least not in the Constitution. In the Declaration they make it clear that, regarding oppressed men, “it is their right, it is their duty, to throw off such Government” and in the process they were, “appealing to the Supreme Judge of the world for the rectitude of our intentions.” They, as men, believed they had clear and strong moral obligations. In contrast, a government has pragmatic aims. I have not developed this theory fully; it may be worth another post.

[4] How did I end up on this side of the argument?

[5] Ironic and Very Tangential Note: I cannot miss the chance to point out a great irony. These arguments for universal truths on what government ought to do are being made by people who are almost universally self described “Moral Relativists.” The same people who bemoan the close-minded Christians who ‘impose their views’ about sexuality or abortion on others are imposing their own views on healthcare. When I’ve pointed this out to people, they tell me that the great difference between “Everyone a right to life” and “Everyone has a right to healthcare” is that the latter is not based on religion. In other words, the only valid arguments are ones made from the Humanist perspective; the Christian one is invalid for governance (Christianity should only apply to Christians; Humanism should apply to Humanists and Christians). So the difference is that “Everyone has a right to healthcare” is actually True (so should be imposed, though the word ‘imposed’ is always heavily euphemized) and “Everyone has a right to life” is a religiously motivated opinion which should be disregarded. I've even talked to multiple educated people who believe it should be illegal and have said, "Any law motivated by religion should be ruled unconstitutional as a violation of the separation of church and state."

[6] Not-defining ‘harm’ is a hard enough problem to avoid; our brains might explode if we actually had to answer “Why is ‘Do no harm’ the only and overriding thing a doctor ought not do? On what basis ought you 'Do no harm'? And why define your profession on not doing something? Wouldn't it be better to say 'Do heal' instead?”

P.S. I can lie about the post time. But, being a Kantian in my personal ethics, I won't. The time is 1:50am and staying up late is a birthday present to myself.

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