I’ve recently had a number of conversations about evil men and their evil deeds. As I’ve listened to the judgments cast on these men, I found myself silently disagreeing. Not with the badness of the men, but on the judgment of them. So I’ve had to reflect on why I disagreed.
Firstly, I think I disagree because of my view on what evil is. Evil committed by men is a mis-ordering of goods. Success in business is a very good thing; but you are greedy when you overemphasis on this success. You do indeed have great value as a human being; but you are guilty of being prideful when you value yourself more highly than you should. I believe every sin or evil deed is like that.
Men do what is right in their own eyes. Nobody does evil simply for the sake of doing evil. We can pick out unrealistic bad guys easily by their pure desire to do evil. Even sadists don’t do harm for the sake of harm; they do harm for the sake of pleasure, which, by itself, is a good thing. A person may do wrong knowing it is wrong, but it is because of some other good thing that is overvalued. An adulterer knows that adultery is wrong, but counts the pleasure greater (or gratified desires, or rebellion, or relieved boredom) than the value of lost faithfulness.
When considering bad people, I realized that the greatest evils don’t come from selfishness, but from foolishness. It comes from men who do not well think and pray through their motivations and actions. It came from bad philosophy (“love of wisdom”; philosophy in the Platonic sense). Nazis wanted a good thing: a strong Germany. Some of it was misplaced priorities (a strong Germany was more important than a strong France). But the most vile part of it was strong and good ambitions mixed with very bad philosophy. In this case, Social Darwinism and Anti-Semitism inspired the Holocaust and good German ambitions were driven to very evil ends.
Similarly with Colonialism, it was originally motivated by a desire for richness for friends, family members and countrymen. Later, it morphed into badly-executed altruism. Kipling’s infamous poem, “White Man’s Burden,” relates this altruistic desire: “Take up the White Man’s Burden/ Send forth the best ye breed--/Go bind your sons to exile/To serve your captives' need.” But in the case of the Colonialists, even those with the good ambition “To serve [their] captives’ need,” were thwarted by racism (i.e. viewing the colonized as “captives”), and the result has been the Pandoric post-colonial world. It is their fault that I get asked a hundred thousand times by children in Kenya, using the only English phrase they know, “Give me money.”
As a result, I think it’s possible that men who have good hearts do harmful things. I think there were many benevolent men who were also colonizers. Some good men who destroyed continents may only be guilty of foolishness, if indeed they acted by benevolence. In fact, I myself may be one of them; men may look back in a century on development workers and show the terrors that were made possibly by our work. But I believe I will be judged good; my motivations are benevolent, though it may turn out that I am guilty of some foolishness.
So what does that mean for “evil men”? I face “evil men” on a daily basis. But how different are these men from me? How often do I mis-prioritize Goods? And how much of my goodness was just a historical and social accident? I was raised in a good time and by a good family. Would these men have been the way they are if they had my advantages? Moreover, is what I’m doing even Good in the long run? These questions cannot be answered by mortal minds. And I suppose this is why we are told “Judge not, lest ye be judged.”
An old Christian-ism is when watching and evil person to say, “There, but for the grace of God, go I.” No person is special. No one is immune from the risks of sin and evil. And we cannot judge one another because we are all guilty of sin. Though sins do have different gravities, we as sinners do not have different categories. I am in exactly the same moral situation as the “worst of sinners;” even the best of sinners is still a sinner. All of us mis-prioritize.
I can (and should) look at actions and call them evil or good. But I cannot be certain, so I should not judge another; the proclamation of damnation and salvation is not my domain. We certainly need to make judgments on actions; we need to aspire to the good and fight the bad as best we are able. But for the purposes of ranking humans above or below myself, I can see neither the heart which produces an action nor the action’s ultimate outcome. I cannot look into the future to show what will come of his action. I cannot look at a man and presume to know his heart. Even if I could, I think I would be horrified by the lack of diversity in shades of black.
Note: I think I am totally ripping off C.S. Lewis with this essay. His ideas have so inspired my own I cannot identify which were originally planted by him.
“And all God’s people said, ‘Amen,’” said the tall, thin Pastor James.
“Amen!” the congregation replied. And with that, yet another Sunday’s obligation was met.
The emaciated congregation exited the church, completely without emotion except for the children who knew no greater joy than this salvation from boredom.
After his flock was led out, his heart overpowered his mind in controlling his face. His thin lips which had formed a calm smile turned to a deep frown. His dark brows furrowed, and tears flowed from his dark eyes down his sharp face. His congregation had been dwindling and their passion was growing cold. He was a young pastor leading an old congregation. Many of his members had joined a new megachurch nearby and he was having trouble paying the bills.
The pastor went over to the altar, knelt and prayed, “Dear Lord, I pray for this congregation. I ask you to give me wisdom to lead these people, and for guidance. Most of all, Lord, I pray for exhortation. I pray that I would be guided to do what I must for these people, regardless of how hard it may be.”
He spent the rest of the day in his office, reading his Bible hoping to find some guidance. The search was in vain. An unintelligible vision of discs in Ezekiel caused him to flip ahead to Zecheriah, only to discover an unintelligible prophecy of chariots. Going ahead to Matthew, he was confused by five of the seven kingdom parables. He read the letters to Timothy, hoping for new insight, but the words were stale. He prayed, but his prayers were forced and uninspiring. As the sun set, he put his things away, tidied up the church and then went to lock up the church.
As he walked out, a disheveled man was laying out a blanket on the threshold of the church. The opening of the door startled him and he looked like he had been caught. He was a fat man, with a mess of hair that was mostly black, but whitening in streaks. His clothes were dirty, and his pants and jacket were denim.
It would rain tonight. It was the Oregon, so it rained every night. It was particularly chilly, so James was feeling compassionate.
“You can sleep here tonight. I won’t call the police,” said James.
“Thank you,” said the man in a gruff voice, “The Darkness is growing.”
“It is getting dark out. Have a good night!” said James with the awkward voice of a man who only rarely has conversation with people wearing tennis shoes.
“Ha. Yeah, that too,” the man chuckled.
“What do you mean?” asked the pastor.
“I mean that the Darkness is growing. You’re a pastor. You should understand what Darkness is. Or at least you should know what the Bible says about it,” replied the man.
“I guess you’re right. Secularism is on the rise.”
“Are you stupid or something? Darkness, as in ‘this present darkness;’ ‘the powers of darkness of this age;’ or ‘the prince of Darkness.’” The man spoke slowly, saying each word deliberately, “The – Darkness – Is – Growing.”
The pastor looked concerned.
The man sighed, and looked the pastor dead in the eye, “Do you believe in demons?”
“Yes. In Christ’s time, He cast out many demons,” responded James with the proper catechized response.
The man wasn’t satisfied. He asked, “Do you believe in demons today?”
“Well, I suppose in theory,” James responded as he looked down.
“Screw theory. Do – You – Believe – In – Demons – Today?” asked the man, saying it slowly and loudly as if speaking to a foreigner.
“Not really, I guess. I’ve never seen one,” admitted James.
The man relaxed, “Praise God for that. That means I’m doing my job. Praise God that you are ignorant of the creatures who stalk your flock like wolves, lusting for the opportunity to devour their bodies and souls. This town has no idea the debt it owes you; if those monsters weren’t restrained by this church...” the man shook his head. “It seems to please God that I fight the powers of darkness directly so you and your flock can have peace; you can spend your time focusing on God without having to be distracted.”
“By Demons?” asked a bewildered pastor skeptically.
“Yeah, by demons, jackass,” the man replied. “Have you ever tried sleeping near demons? With your spiritual guard down, they can burrow into your mind and cause horrors which make nightmares seem like fantasies. Or have you ever been hanging out with friends, joking around, and a possessed comes over shouting and foaming at the mouth? It really ruins the mood. Or trying to hear the voice of God in His Word over choirs of demonic shrieking? Or trying to get time alone with God and having to keep watching your back? Fighting them is really goddam distracting to living a normal life.”
The pastor’s eye twitched.
“God damn it. I forgot you pastor types can’t bear swearing,” sighed the man.
“Umm,” started the pastor with a failed attempt at bravery. “Surely you know the Third Commandment.” His voice wavered, “Thou shalt not take the name of the Lord in vain.”
The gruff man looked him dead in the eye, as if waiting for the punch-line. A few beats passed and he said, “You’re kidding, right?”
“I do not joke about the Law of God,” responded the pastor with unwavering piety.
“Well you should,” said the man with disapproval. “You hold it in such high esteem you’re not even holding it anymore. Maybe if you laughed once in a while you might read your Bible more than one time in a goddam week. The Third Commandment isn’t about vocabulary. It’s about ambassadorship. Do not take the name of the Lord, unless you mean it. Don’t call yourself by His name, unless you’re goddam serious. I’ve got a foul mouth; but I sure as shit take my role as Christ’s messenger seriously.”
He paused, scratched at his crotch, and continued, “We’re getting distracted. I came here with a message from God. ‘Pray unceasingly’. You normally have prayer meetings on Thursdays, and cancelled it last week.”
The pastor looked surprised, “It was just me, brother Ron and sister Gladys. And they both fell asleep! I didn’t think there was a point. But how did you know that?”
“Because there was a shitstorm out there on Thursday!” shouted the man, “I got my ass handed to me! You’re the only church in fifty miles so I knew it was you who did some dumbass thing.”
“There’s a hundred churches in this town. What are you talking about?” asked the pastor.
“I don’t know much about theology or leading churches. But what I do know is that I can sleep without harassment here and nowhere else in this town,” the man said.
He continued, “My message is simple. Please keep having prayer meetings. For the love of God! I don’t care if it’s just you and Gladys! I can only do so much. The shit is gonna start spilling over if you don’t keep doing your job.”
“What does this have to do with demons?” asked James.
“You don’t understand. Do you think God tells you to pray for shits and giggles? Do you think He’s a big jokester, handing down commandments for fun? That shit’s for a reason!”
“You’re telling me that Gladys and I are holding back demons?”
“Yes. That’s what I’m saying. There is a goddam reason! So please, do me a favor: keep praying.”
“OK. I’ll do that.”
“A City on a Hill cannot be hidden. This whole town is in a deep darkness. Your very presence is drawing their souls to Christ and driving the demons away. Since you came, they’ve hated it here. No matter what happens or how depressed you get, you are the Light of the World.”
“Alright. And thank you. I prayed that God would send you. Are you an angel?”
“Do I look like a goddam angel? Do these look like shining garments to you?”
“Well if you’re not an angel, can I get your name?”
“My name is Mike,” said Mike.
“It’s a pleasure to meet you, Mike. Mike like the archangel?”
“Sure. He’s cool: strong and glorious. But I think I’m closer to Mike like Tyson: strong and viscous.”
So the pastor got in his car and drove home, wondering at the things he had seen and heard, swearing to God that he would never again cancel another prayer meeting.
We 'lose' consciousness for eight hours (hopefully) every day. But our consciousness isn't lost strictly speaking. It's still present. We usually don't have control over it and we often don't remember it. But our conscious goes places and does things. With no sensory input, we (our consciousnesses) have dramatic experiences, do bold (and cowardly) deeds, and live wildly different lives from our waking selves. And we take these nightly vivid hallucinations in stride.
It seems when we don't sleep enough, our waking consciousness is diminished. I felt today, sleep deprived but forced awake chemically by caffeine, much like Bilbo. As he describes, being pulled toward the realm of shadow by the Ring,"I feel all….thin, sort of stretched, if you know what I mean: like butterthat’s been scraped over toomuchbread. I need a change, or something."
Why? There is certainly physical fatigue, but this is not mental. There is also mental drowsiness, but this is countered directly by caffeine; after coffee I have no more difficulty staying awake in class. Though I am not as "present," as I would be well slept and uncaffeinated with an identical level of physiologic 'drowsiness'. What is the difference? There must be some other axis of wakefulness that can only be 'charged' by leaving the physical world.
And not just leaving it. Sleeping 8 hours but preventing stage IV ("REM") sleep, the phase in which we are said to dream, is not restorative of this new sleeping axis. It seems necessary for us that we go somewhere, and the only way we can is through a phase of sleep associated with dreaming. Some postulate that this is simply the random firing of neurons. But if that were true, then using hallucinogens would be as restorative as REM sleep. By all accounts, this is not the case.
More importantly, dreams are not chaotic; they are orderly. It is not a series of flashing lights and sounds. Dreams are a narrative. Certainly the 'rules' of the universe as we understand them are a bit different. Creatures exist there which we do not believe exist here. "Impossible" things like flying and laser vision occur (at least in my dreams). But they are not random in any sense. We recognize our friends, we interact with our families, we fight our enemies.
What happens when we don't sleep? Well, we do sleep. If we try to stay awake, we draw whatever place we go in dreaming to the wakeful world. When you keep someone awake for days at a time, hallucinations and all manner of craziness set in.
All these things seem to point to sleep being a non-chemical thing. But if it is non-chemical, what is it? Here is how a materialst must explain these observations:
Unknown chemicals act by unknown pathways to achieve a state (dreaming) which, though it can be imitated by chemicals (hallucinogens), cannot produce the effects of that same state. When this state is not achieved, fatigue sets in, all the effects of which can be antagonized chemically (sympathetic agonists, caffeine) save for 'wakefulness.' To put it another way, the one conscious effect which cannot be chemically countered (wakefullness) is the result lacking from the element of conscious experience which cannot be chemically induced (dreaming). This lack of any evidence for a chemical connection to this fundamental aspect of the human experience indicates it is a ripe area for research; we ought to search out which chemicals it is exactly that cause wakefullness and dreaming.
A materialist is forced by his faith (or to put it more euphemistically, his worldview) to hold to the baseless claim that all of dreaming and wakefullness is chemical. But, as with all faith, evidence (or lack thereof) does not affect the firmness of one's conviction. Nevertheless, I hope that fairminded people will have the sense to consider, perhaps, that we are not chemical robots, and that there is something higher than chemicals and deeper than Scientism.
Mar 4:10 And when he was alone, they that were about him with the twelve asked of him the parable. 11 And he said unto them, Unto you it is given to know the mystery of the kingdom of God: but unto them that are without, all [these] things are done in parables: 12 That seeing they may see, and not perceive; and hearing they may hear, and not understand; lest at any time they should be converted, and [their] sins should be forgiven them.
Lest? What do you mean “Lest…their sins should be forgiven them”? Doesn’t He want their sins to be forgiven. Jesus seems to be saying something very not-PC in Mark: that He doesn’t make parables clear for the purpose of people not believing in Him. The blow is softened in Luke’s account (so most Christians just skip over Mark’s “lest” and go on to a more comfortable Luke).
For those that do exposit this verse, it is generally taken to mean that Jesus is creating an insider group, separating those who would believe from those who would not. This has been taken as a verse in support of a Calvinist view of the world where those who are inside were predestined to be there and that’s the way God wants it; parables may even be a way of limiting the accountability of those who are going to be damned anyways. And though Calvinism is always tough to swallow, expositionally it’s usually a safe bet (and the side of the argument I usually find myself on).
Today in my Bible study, we went back and looked at where Jesus was quoting from:
Isa 6:9 And he said, Go, and tell this people, Hear ye indeed, but understand not; and see ye indeed, but perceive not. 10 Make the heart of this people fat, and make their ears heavy, and shut their eyes; lest they see with their eyes, and hear with their ears, and understand with their heart, and convert, and be healed.
Pretty much the same thing (once you pass it through the Septuagint). First note the context: this is the first message given to Isaiah, immediately after his commissioning.[1] So the context makes this into a pretty important message. And what’s the message? Israel will not listen. But Isaiah isn’t satisfied with his commission. He asks God, “Lord, how long?” (Isa 6:11)[2]. And God tells him, “Until the cities be wasted without inhabitant…” and then goes on to describe exile and a remnant.
When did that happen? From the writing of Isaiah to the present, the desolation of the cities of Israel was either by Nebuchadnezzar (586BCE) or by Vespasian (70CE … :P Just fooling. Anno Domini 70 [3]). But if you look at Jesus’ words, He seems to be applying God’s words to the present situation; He seems to be claiming His parables are the fulfillment of the first part (“lest they see…and hear”). It would follow that the prophecy of desolation is Vespasian’s.
Look closely at the Isaiah passage. The word that caught my attention was: “until”. The implication of ‘until’ is that this blindness is only temporary. Where do we hear about “blindness until…”? A BLB search yields one result:
Rom 11:25 For I would not, brethren, that ye should be ignorant of this mystery, lest ye should be wise in your own conceits; that blindness in part is happened to Israel, until the fulness of the Gentiles be come in. 26 And so all Israel shall be saved…
In this part of Romans, Paul is talking about Israel’s role in God’s plan. Here he describes how Israel’s disbelief benefits the Gentiles: “…through their fall salvation [is come] unto the Gentiles…” (Rom 11:11). In other words, if Israel did not fall, the Gentiles would not have had the chance for salvation. If the Jews would have accepted Jesus as King, they would have set up His throne in Jerusalem and kicked off the Millennium in 32AD; His crown would not have been of thorns and the fealty paid by the Romans would not have been in jest. But Eternity would have been empty save for a few million Jews, peppered with Gentiles like Melchizedek and Rahab.
Why doesn’t Jesus want them to be forgiven in Mark 4? Because if the Jews to whom he preached believed, then multitudes of Gentiles would not be saved. It wasn’t that Jesus didn’t want the Jews to believe in Him; He didn’t want them to believe in him yet. By keeping the Kingdom of God a secret, by encoding it in parables and telling only His closest disciples, Christ was preparing the way for His own crucifixion. By keeping His identity a secret from those people who he loved most, by allowing his beloved ones to suffer from blindness, he made salvation possible for billions. His secrecy made possible a world where He would pay for the sins of the world, and a world where those few disciples to whom he told these secrets would then go out and preach Salvation to all tribes, tongues, peoples and nations.
What sounds like an elitist Jew speaking secrets to an inner circle, actually is a daring and heroic plan to save the world.
[1] In my book, Isaiah in this scene wins the “Best possible direct response to God” award: When God asks in His throne room (filled with recently-described super angels screaming to each other "Holy, Holy, Holy") “Whom shall I send?” Isaiah has the balls (faith) to shout “Here am I; send me.”
[2]This, by the way, is also pretty insightful/ballsy
God: “I’m going to crush them.”
Isaiah: “Yeah I know you’re saying that, but, come on, they’re your people. I know you won’t forever. So, how ‘bout it? When are you going to give up and bless them again like you always do?”
[3] I think I’m going to start saying the full translated phrase from now on. “When were you born?” “In the year of our Lord 1985.”
A dollar spent in the US buys orders of magnitude less health than one spent abroad. It turns out that for most questions, the equitable and the efficient are often the same. Kenya has a lower life expectancy and a lower GDP (it’s more equitable) AND a dollar spent there will save so many more Disability Adjusted Life Years (DALYs[3]) than a dollar spent in Japan. So to a first order approximation, this ethical dilemma is only theoretical.
As a second consideration which must be addressed before the question directly. Serving the poorest has more broad-reaching effects than simply an increase in DALYs (which is usually optimized in cost effectiveness analysis or CEA). An intervention that allows a poor person to escape poverty had long-reaching effects on that person, their children and their society. Saving a man from premature death by AIDS does more than help him, it allows him to contribute to his community. Getting people onto the proverbial ladder of development, putting them in a position where they could begin to climb up and improve their situation, is an important consideration beyond strict CEA.
Nevertheless, there are times and places where you can help people more effectively who are better off, or you can less effectively those who are worse off. All other things being equal (particularly the Development value discussed above), I value efficiency over equity.
There is certainly an argument to be made for serving the poor. You have to try really hard to find a philosopher or religious teacher who teaches against this (perhaps Ayn Rand, but I think even she may see the value of Global Health as a piece of International Development). To most (including myself), it seems to be a Good which is self-evident. But in much of global health, everybody’s poor. If I could bring 10 years of added life to 1000 people making $2/day or to 500 people making $1/day, I’d choose to help the richer and so save more people.
As I’ve written elsewhere[1], where Kantian ethical statements are satisfied, (i.e. One ought to help the poor), Utilitarian ones should pervade (“Greatest good for the greatest many”). I disagree with the argument that is made that achieving ultimate equality in income is a moral imperative (this argument is frequently attributed to John Rawls, though I admit I’ve only had secondary exposure to him). I reject a morality whose end is the homogenization of income; I disagree that the lack of equality (e.g. Capitalism) is inherently bad, and I do not think that the logical end of this, Communism, is even a good place to be (see Harrison Bergeron[2]). I fail to see equity as an independent axis of the Good; it certainly correlates to the Good. Often those who are poorest are most oppressed. Those who are weak are enslaved. So I agree that injustice is committed against the poor, but as we all know, correlation is not causation. The badness is in the injustice, not the disequilibrium of money.
Truly it is moral to serve the poor for reasons of mercy and compassion. Suffering is indeed evil that should be fought against. But I cannot see a universal moral reason why some people can’t drive Hondas and others Acuras.
Fortunately, this theoretical situation is not that big a problem. It’s clearly moral to help the poor. And the poorest and the easiest to help are often the same people. When they’re not, most of those remaining could be helped in escaping povery by Global Health. When they can’t be, we should consider showing the greatest good that we are capable of. We can discuss these minor points of philosophy (and really should), but it’s not where we, as a society, are failing. I hope that one day we’re having this very debate broadly: “Should we save the really really poor? Or just the really poor?” Unfortunately, we’re still at the, “Should I buy a third car? Or a new TV?” phase.
[2] One of my favorite short stories and a powerful argument against the ethics of Equality. It opens thus, “THE YEAR WAS 2081, and everybody was finally equal. They weren’t only equal before God and the law. They were equal every which way.” Vonnogut, Kurt. “Harrison Bergeron.” 1961. http://instruct.westvalley.edu/lafave/hb.html
“Why Helping Working People Keep Working Is Really Important” · The costs of missing work for treatment and because of illness should be considered.
· Pneumonia sucks and worsens life by 27.9%.
· It is important to have the right perspective in addressing health problems and if our goal is development, we should approach problems with the good of the whole community in mind.
· Doing an analysis from a societal perspective suggests that we should prioritize working adults in pneumonia treatment.
Note: This also is technical. Sorry to my non-nerd readers if you do not find this interesting.
The following thought just occurred to me in thinking about my previous article: opportunity cost has been ignored. When we normally think about the ‘cost’ we think about it in terms of dollars spent on treatment, and the ‘benefit’ as being years of quality life lived[1]. In my own analysis, I didn’t discuss the difference in opportunity cost. This will be especially important to development.
If we want a society to develop, a large part of that must be in improving income generation. Any health care analysis cannot ignore the impact it is having on the ability of people to generate income. Ultimately ‘sustainable’ means that people can earn enough money themselves to not need outsiders.
Pneumonia Sucks [9]
So let’s return to our question. Pneumonia (my new favorite developing world illness) has some pretty serious complications. The World Health Organization rates diseases based on how much they suck[2]. And pneumonia sucks pretty hard. The DALY weight is 0.279[3], putting it equal to having an amputated arm or being deaf over the period that you have pneumonia. Another way to put this is that it’s better to live three years without pneumonia than four years with it. That’s how bad it sucks.
The burden of disease (roughly “how bad it sucks”) is not the same thing as the cost. It is essential to determine who is spending the money when considering in the cost. In my previous analysis, I was incorrectly considering the patient perspective.
In my previous (conceptual) analysis, I ignored the cost of visiting the doctor and loss of productivity at work. This will be a huge driver of the overall cost, particularly when considering disease in working-age adults. Not being able to breathe sucks for a child, but it doesn’t affect as directly the income generation of the family. And this is a critical consideration in development. Health, at least at this stage of development, should be a means to the end of self-sufficiency. Time is extremely valuable, especially when a person’s time is worth $1 a day.
Simplified, Make-Believe Analysis
Warning: Math approaching. For those who have had severe allergic reactions to math in the past, it is recommended that you skip to the “Discussion” section. But it shouldn’t be all that bad. There's nothing but the four basic operations[11].
Let’s get back to pneumonia. Imagine Abasi, a 30 year old Kenyan man with a wife and a 5 year old daughter named Sakina, coming down with pneumonia. He’s sick and he’ll stay sick until he gets treatment which costs $4.00 (and we’ll assume that it’s perfectly effective). Abasi will die five years after getting pneumonia if it remains untreated. Let’s also say that he’s only able to work at 75% capacity because of his difficulty breathing. The clinic is far away, so it takes a full day to walk to the clinic, get treatment and walk home. In that day, he loses $1.00 worth of productivity. But every day, he’s losing $0.25 because he can’t work. Healthy, Abasi can look forward to 33 more years[4]. Sick, he only has 5 (and that with a lowered productivity). The ICER can be calculated as follows:
This means it is cost-saving. In the long-run, Abasi saves money by getting treatment. This is superb. In a sense, it is literally an investment ($5 initial investment to save $312 which is a 6200% increase in 5 years; that’s what I call an ROI).
If the analysis were repeated from the perspective normally taken (the “provider” perspective), it comes out costing money. Repeating the analysis above from a provider perspective (ignoring ignoring the value of Abasi’s time and lost wages), it comes out to costing $0.14/DALY.
Now imagine his daughter, Sakina, comes down with pneumonia. She should be able to look forward to 56 more years of life and has the same five years to live if she doesn’t get treatment[4]. The difference here is that she doesn’t help generate income for Abasi, so the major economic impact on Abasi drops out of the equation. He still has to take the day to travel to the doctor, pay the same amount for the medication, and (for the sake of this simplified analysis[5]) have the same discounted DALYs. From Abasi’s perspective, the ICER for his daughter is:
Note that this is now positive; when Abasi spends money to save his daughter, it is not cost-saving. Nevertheless, if Abasi values a year of his daughter’s life at something more than $0.10, he should buy the medications. The provider perspective (which doesn’t care that Abasi took a day to travel) is $0.08/DALY.
One more exercise. Imagine we took the societal perspective, concerning ourselves with the overall wellbeing and costs to society. And imagine we were concerned about only a five-year window rather than the lifetime of Abasi and Sakina. With smaller windows, long-term goods are washed out, but it’s a conservative assumption that is verifiable. Would this be cost effective for Abasi’s pneumonia? Sakina’s? Repeating the analysis from a 5-year societal perspective shows that it is cost-saving for Abasi and cost-effective for Sakina ($3.57/DALY) [7].
Perspective
Abasi
Sakina
Payer
Cost saving
$0.10
Provider
$0.14
$0.08
5-year Societal[10]
Cost saving
$3.57
So as you can see, the only perspective where treatment of Sakina is more cost-effective is in the provider perspective. Which helps explain why we are so concerned about saving the children: from our perspective (that is, one only concerned with health and not development), it’s a better idea to treat kids before adults. But if you are Abasi, or if you care about the immediate development of the society he lives in, then you ought to prioritize him.
Discussion
What’s my point? First, these numbers should wake us up: 8 cents for a year of healthy life[8]. I don’t bother to stop and pick dimes up off the street. And yet it is for want of this that people like Sakina are dying[6].
Secondly, these numbers should be translated from Imagination Land to reality. I made all this up out of thin air. I think in this easy case (pneumonia treatment), I’m probably right in recommending emphasis on treatment of Abasi. But there are many questions which are not so easy. Most treatments are not extremely cheap, extremely effective and most diseases do not have the morbidity profile of Pneumonia. Even in Pneumonia, if treatment was not close to 100% effective as I assumed, or if there were significant side effects, or the costs were more than $4.00 (which is certainly possible), these conclusions do not stand. Most work in this area is either not applicable; treatment costs and regiments in the developed world are perfectly irrelevant to the developing world. It would be quite useful to compare the cost effectiveness of various developing world interventions from a societal perspective, side-by-side, using local prices. If such a model were constructed well, the details could be adjusted (i.e. Penicillin here costs $3 instead of $1.50 in Kenya) and the conclusions, recalculated.
Finally, it is very important to consider our perspective and our goal. If we don’t care about development and our goal is simply to extend life, then paying for Sakina is the best idea. But if we are concerned about the societal costs, more emphasis should be placed on Abasi; his pneumonia will cost society more than Sakinas in the short term. If we are concerned about development, we cannot just look at saving Sakina. She is truly the future of Kenya, but Abasi is the present. And it is he who must build the future. He must have an income to support Sakina, pay for her school, and tear off the shackles of poverty. And health interventions ought to aid him.
Conclusion
This analysis shows that it is extremely important to care for those who are the ones developing. Mercy compels us to care first for Sakina; prudence reminds us to care for Abasi first. It is the same thing that they tell you on airplane safety videos. While mercy compels us to put the oxygen mask on our children first, prudence (and the video) reminds us to put it on ourselves first so that we can be able to help our children. Let it be so in Kenya.
If our goal is five-year development, the healthcare should focus on Abasi. But I pray to God that we can find the eight cents to save Sakina.
Notes
[1] I’m sure this thought has occurred to someone; it may actually be taken into account in the calculation of DALYs. In a brief review of DALY definition (Drummond, et al “Methods for the Economic Evaluation of Health Care Programmes” Third Ed. p 187), it did not seem to include lost wages. I’m fairly sure that ‘cost’ of lost work should be counted separately. This does need outside confirmation, however as I’m not certain.
[2] http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_part3.pdf
[3] I have found this table at long last! WHO did not make it easy. http://www.who.int/healthinfo/global_burden_disease/GBD2004_DisabilityWeights.pdf
[4] Life Tables, Kenya. http://www.who.int/whosis/database/life_tables/life_tables.cfm
[5] As another simplifying assumption, I assumed 0% discounting.
[6] To cover my bases, we can’t just spend $0.14 cents and save someone practically. Health and social systems have conspired against their getting healthy.
[7] The actual numbers are -$219.64/DALY for Abasi and $3.57/QALY for Sakina. The interpretation of the larger magnitude Abasi number is confusing so wasn’t displayed in the text; this sort of analysis isn’t usually used to evaluate methods of saving money. The most important feature is that it is negative.
[8] When I say ‘we’, I mean the developed world. We’re usually in the perspective of the NGO provider.
[9] I have looked for data like I present here many but to no avail. I am very happy about finding it.
[10] Why did I not calculate the 25 year societal perspective? Because I’m fairly sure I need to learn how to discount money (I’ve forgotten how to properly do this) to answer the question even close to correctly. Also I do not know how to compare negative ICERs. Maybe I could model it like an investment?
[11] And if you're really nerdy, you could snicker that there is never more than some combination of the four basic operations. After all, what is integration but an infinite number of additions?
Health plans designed for the poor (“Appropriate Healthcare”) should be cheap, accessible and should address the major causes of morbidity and mortality.
The top seven health problems in Kenya, making up more than 65% of the mortality, are malaria, lower respiratory infections (e.g. pneumonia), HIV, prenatal problems, nutrition, TB, diarrheal disease.
Cost effectiveness is a helpful way to think about allocating healthcare when resources are limited, particularly in the developing world.
Health fairs and local health workers could be two ways to address these major health issues in a cost-effective manner.
An appropriate Kenyan health plan should focus on the most cost-effective ways to address the seven major Kenyan health problems.
Note: this is far too long (and probably too technical) for a blog. I apologize in advance to my normal reader.
Introduction
“Health Insurance” as it is modernly conceived serves two major functions. Firstly, as the name implies, to insure that you’re taken care of if something really bad happens. The more recent (and perhaps important) part is health maintenance. Health insurance pays for annual checkups, screening exams, and (increasingly) over the counter meds like allergy meds. So it’s not really health insurance. And this is what the public health people love: prevention. In the developed world, these two things are bundled together because we’re really rich and don’t really care. We need ‘em both, so why bother paying for health maintenance and health insurance separately? This is likely why no market for stand-alone health maintenance programs has emerged. Also, the kinds of death we want to afford when we buy health insurance require expensive hospitalizations, chemotherapy, and bypass surgeries. So, because these things are ridiculously expensive, so is the whole package of American “Health Insurance.”
But when we think about appropriate goods and services, which I’ll define as, “goods and services useful and affordable to poor people,” we need to think about economy. While we cannot forget that people in the developing world are dying of cancer and heart disease, traditional Coronary Artery Bypass Grafts aren’t even close to appropriate for those earning a dollar a day. If we were picking apples from a tree, we shouldn’t have a “Top branch or bust” strategy. There is plenty of fruit that we can reach while we’re still on the ground.
There are things people are dying and suffering from (we cannot forget what is called ‘morbidity’ in our consideration; that is, suffering short of death) which are easily prevented and cured. We want to take care of the easy stuff first.
If a healthcare plan were to be designed for the poor, it would have to meet these criteria
· It must be cheap, cheap, cheap
· It must be accessible
· It must addresses major causes of mortality and morbidity
We want to avoid the hospital. That’s where things get really expensive. In fact, we want to avoid the clinic if it’s at all possible. And transportation. And waiting. And we need to make sure we pay for the important stuff. We need to beware good intentions: we do not want a comprehensive plan covering everything but nobody.
Kenyan Problems
In considering this question, I’m going to look at some data from Kenya (believe it or not, “Africa” isn’t a country). Here’s some data from the World Health Organization from Kenya on the top five causes of overall mortality (compiled in 2002).[6]
Condition
Mortality (thousands)
%
#1 HIV/AIDS
144
38
#2 Lower respiratory infections
37
10
#3 Diarrheal diseases
24
7
#4 Tuberculosis
19
5
#5 Malaria
18
5
Cost EffectivenessAnalysis
The cost effectiveness analysis perspective will be very useful here. It contradicts the (probably true) belief that human life is invaluable and says essentially, “The reality is that we have limited resources; how can we do the greatest good with them?” Here’s a super-simplified example.
You go to the doctor and the doctor, after running some tests, comes in and tells you, “I have some good news and some bad news. The bad news is you have Really Deadly Disease (RDD) which, if untreated, will kill you tomorrow.”
You, having nerves of steel, are cool and collected. You ask flatly, “What’s the good news?”
“The good news is that there’s a cure! Well, it’s not really a cure. It’s a drug you have to take for the rest of your life. As long as you take it, you’ll be healthy. The day you stop taking it, you’ll die. And the drug costs $45,000 per year.”
In this example, someone (your insurance, hopefully) has to pay $45,000 for every year of life you enjoy. This is usually adjusted for quality and so we usually say Quality Adjusted Life Years or QALYs (you would discount life lived in a sub-optimal state; you might count 1 year as a paraplegic as 0.5 QALYs). Compared to the alternative (instant death, which costs nothing), you have an incremental cost of effectiveness of $45,000/QALY. That is something we can pay in the developed world, and because of such expensive treatments, is why our health insurance costs what it does.
QALYs and Development
In thinking about the developing world, we have extremely limited resources. We’re not talking about whether the line should be at $45,000 or $46,000/QALY. This kind of analysis has a much more powerful impact on developing countries. If a health-minded NGO wanted to do an intervention, are anti-malarial bed nets, antibiotics, or AIDS treatments more cost effective? Can more life be saved with one over the other?
In Kenya, healthcare spending is $105 per capita in 2006 (by PPP, not by exchange rate). Only a fraction of that has been by the government: $586 million (2% of $29.3 billion GDP) [1]. So even assuming we have $105 to work with (it’s very likely that most of that is a lot of spending by the richest in Kenya), what is more cost effective? Treating Malaria or Malaria bed nets? And whatever of those is better, is that more cost effective than treating HIV? And is HIV treatment better than antibiotics for pneumonia?
If I was an NGO who had $1 million and I wanted to do handouts, what should I spend money on? Should I fight AIDS and invest in HAART (Highly Active Anti Retroviral Therapy)? Or should I buy ITNs (Incecticide Treated Nets)? For HAART, it’s $1000 to save a life year[3]; for ITN, it’s $86. In other words, I could save over 11,000 people from Malaria for a year (assuming $4/net I’d have to buy 250,000 nets to do this), or I could save 1,000 people from HIV for a year. Of course there’s more people suffering from HIV, but with limited resources (as all NGOs have), the focus should probably be on addressing Malaria first. But then again, vaccinations against Pneumonia (Hib) are even more cost-effective ($62/year saved). And what about treatment for Pneumonia?
This is the sort of analysis which must be done as this work progresses. Any fool can shout about how big a problem is. It takes a wise man to find a solution. This is the mindset with which the remainder of this paper was written. Though there is not the data to do a numerical analysis, the things which have been chosen are gross approximations of what may be actually cost-effective.
An Overlooked Problem (A Ripe and Low-Hanging Fruit)
Why haven’t we ever heard about the #2 killer in Kenya (and from what I’ve heard, much of Africa)? We hear about AIDS all the time. And diarrheal disease all the time. And TB and Malaria. But why don’t people talk about “Lower respiratory infections”? And yet according to Kenya’s Ministry of Health, 1 in 37 Kenyans goes to a clinic for Pneumonia each year [9].
Here’s the ironic thing: they’re the easiest one on that list to treat. Everything else (with the possible exception of diarrheal disease) requires rather extensive measures. But Lower Respiratory Infections (aka “pneumonias”[8]) are usually easy to diagnose and easy to treat (certainly by comparison). X-rays are nice, but they’re usually just to confirm what the doctor can find out from getting a good history and physical. Stethoscopes aren’t that expensive[7]. And neither is first-line pneumonia treatment: Amoxicillin w/ clavulanate (“Augmentin”) [5] which can be gotten for $1.34 in Kenya[4].
That’s what you call affordable. For someone living on $1 a day, a $4 ITN with long-term (but no short term) benefits is a hard sale. A $1.34 drug which lets a person get back to work/play/school/home in a few days is a much easier sell. But there is presently no cheap way to get at it without spending a day to go to the clinic, paying for transport, waiting for a doctor, paying for the visit, get diagnosed and then hope they have the medication you need. The out of pocket cost is too high, not to mention the opportunity cost (instead of earning money, time was spent going to the doctor).
Idea One – Local Health Workers
How do we make it easier to treat pneumonia? Train local health care workers. Buy them stethoscopes (or loan them the money for stethoscopes and let them pay them off by working) and let them sell their services to their neighbors. It would be their job to purchase a small amount of pharmaceuticals and sell them to those who need them. If disease tracking was a concern of the local dispensary, they could require the worker document each case and only sell a new batch of drugs with the delivery of patient records. The patient form could require a signature and include the price of the drug (to limit health worker corruption), and describe the level of training of the worker. Or if we really want to be fancy, we could use SMS to communicate in real time to the dispensary.
The bottom line is that a person with pneumonia for, say, $0.25 can get a diagnosis and accordingly be offered treatment: “Yes, this is Pneumonia; I’ll sell you the drug for $1.32” or “No, this is not Pneumonia; I won’t sell you the drug.” This would provide broad and easy access to pneumonia treatment, and reduce mortality and morbidity of the #2 killer in Kenya, in addition to providing supplemental income for the health care workers.
Idea Two – Health Fairs
As transportation seems to be a major issue, bring the clinic to the people. This is what well-intentioned white doctors do all the time, and are able to help hundreds or thousands of people on a single day.
The organizers would stock up on common meds (“common” will quickly be defined after the first of these; likely antibiotics, de-worming meds and vitamins; it may be a good thing to do community surveys about before the first one). Ideally, doctors and nurses would volunteer or already be paid (by the national government); if not, their daily wage would be a part of the cost. Para-medical personnel (health representatives) would act as medical students under the doctors present, learning what they could (so as to better help people between fairs) and aiding in the streamlining of patients. Other volunteers would be needed for paperwork, administration and set up. Also, this should be done on a weekend or holiday where the opportunity cost would be lower (people don’t have to miss work/farming).
It could be discounted or (more likely) free for those on the healthcare plan; a fee would be charged for those who aren’t (reasonable, of course). All health related business could take place on a single day. Nets could be retreated. Sick people could get their meds (or at least people sick from diarrheal disease and pneumonia). Children could learn hygiene. In addition, with good record-keeping, this could be an excellent venue for tracking health statistics (a pre-interview could record recent births, deaths and illnesses in their family, relatives, friends, neighbors). These fairs could be rotating and occur as often as there was demand and funding.
Conclusion
Imagine we had a health plan which addressed the seven strategic Kenyan areas (HIV, Lower Respiratory Infection, Malaria, TB, Diarrheal disease, Neonatal/Maternal health, and Nutrition). For the expensive and well-funded diseases, it would act as a referral network, perhaps providing transportation to well-funded HIV centers. It would cover treatment by local health workers or health fairs for simple pneumonia and diarrheal disease, in addition to some simple nutritional supplementation if anemia is suspected. It would provide annual insecticide for bed nets. It would pay for a trained birth attendant. And it would pay a certain amount for emergency transport for serious illness.
By focusing on the extremely cost-effective interventions and omitting the more drastic ones (direct treatment of HIV, paying for hospitalization), healthcare may become affordable to even the poorest[13]. Much change would be necessary before this could be realized. It is certainly not possible with the present system. But it may become possible with a few intelligent changes and a community to support it.
The Challenge: To design a healthcare plan that would prevent and treat the most deadly and painful diseases accessibly and affordably; to drastically reduce the morbidity and mortality of the rural poor with $1.00 per month per person[10].
Notes
[1]Stats taken from GapMinder (which draws from reliable sources like the World Bank) http://spreadsheets.google.com/pub?key=pk7kRzzfckbzz4AmH_e3DNA&gid=3
http://spreadsheets.google.com/pub?key=phAwcNAVuyj0XOoBL_n5tAQ
[3] Technically this particular study used Disability Adjusted Life Years (DALY); it’s similar to a QALY but figured out with a slightly different method. Fundamentally it’s saying the same thing.
[4] http://www.kemsa.co.ke/datagrids/kemsa_commodity_catalogue.php Item - PHA0545. 105.25 Kenyan Shillings which, according to Google, becomes $1.34 as of 5/2/09.
[5] 96% of pneumonia should be sensitive to this treatment in the US; it may even be higher in Africa because of less antibiotic usage. Taken from “Diagnosis and Treatment of Community-Acquired Pneumonia” by the American Academy of Family Physicians. M. NAWAL LUTFIYYA, PH.D., ERIC HENLEY, M.D., M.P.H., and LINDA F. CHANG, PHARM.D., M.P.H., B.C.P.S. http://www.aafp.org/afp/20060201/442.html
[6] http://www.who.int/whosis/mort/profiles/mort_afro_ken_kenya.pdf . It is very interesting to note that in Kenya’s Ministry of Health annual report, they came to different conclusions. They talked about morbidity in the executive summary and said #1 was Malaria and #2 was respiratory infection. It seems they’re making their conclusions based on who shows up to the hospitals. If I’m right about the data source, this discrepancy probably means that HIV patients aren’t showing up to governmental healthcare facilities. Perhaps they don’t have the money for treatment. Perhaps there stigma. Perhaps they’re going to NGO sites who don’t communicate with the government. In any case, it’s a problem. Beware: it’s terribly written and goes on for a page of the Executive Summary complaining about how bad the data is and why it was that bad. For that report, check out: http://www.health.go.ke/Healthfacilities/Annual%20Report%20_%20HMIS.pdf
[7] I remember buying decent quality stethoscopes for my group at $30 each; they get down to $7 on the internet… not that I’d trust a $7 stethoscope.
[8] Looking at the MOH report, they seem to think “Pneumonia” and “Respiratory Disease” are two separate things (some of the charts inconsistently call it “Other Disease of the Reparatory System”… I’m assuming ‘other’ than Pneumonia). Maybe in Kenya, they call typical pneumonia “pneumonia” and atypical pneumonia “other disease of the respiratory system.” Without ever defining their terms, it is impossible for me to know what “Respiratory Disease” means, or what possibly could be hospitalizing hundreds of thousands of Kenyans that is not COPD or pneumonia. But that’s just one chart. Further down there’s another that disagrees with it, saying that Pnemonia is the most significant disease and “Other Respiratory Disease” is nowhere to be found. Being unlabeled, I can’t quite tell what each of the charts is measuring and why they’re different. Bottom line is that Pneumonia is a big problem.
[9] http://www.health.go.ke/Healthfacilities/Annual%20Report%20_%20HMIS.pdf p143. This seems way too high. I would guess two things are working together: nutritional vulnerability (immunosuppression) and misreporting. I doubt many clinics actually culture their patients. It’s probably easier to give an antibiotic than X-ray or culture sputum. So any productive cough becomes “pneumonia.” Not that I’d recommend any changes to the protocol; a good H&P should have decent enough specificity and sensitivity.
[10] Assuming $1/day x 2 adults = 2/day*30 days/month = $60/month/family. Assuming 4 children/woman, the average family has 6 members and $60. If the health plan cost $1/person/month * 6 people = $6/month, then that would come out to 10% of a family’s income, which is roughly what the rich and middle-class pay in developed countries (the poor pay a much larger percentage in developed countries). Perhaps this is still too high to be feasible, but it puts it in the right ballpark. Maybe it could be even cheaper. The right thing to do is find out (as with any product) how much people are willing to pay, and then design a plan at that price point.
[11] Though the data they present does not support them, Anemia was complained of by the MOH; this is likely prevalent and under diagnosed. I read elsewhere that protein insufficiency is a problem, especially for children. It may be (though this theory is a total stab in the dark) that this is part of why everyone gets pneumonia.
[12] There is a lot of potential synergy with these seven and other areas of development. Improving water and sanitation would prevent a large amount of diarrheal disease; improving agriculture outputs (esp. protein, vitamin A; raising chickens and eating their eggs and livers would do wonders) would improve nutrition. Of course, business development improves all areas with more money to spend on needed things.
[13] Another consideration is that without the limited ‘insurance’ side, it’s not necessary to make this a monthly ‘plan’. In essence, a health plan without insurance is simply pre-paying for health services from the buyer perspective. The primary advantage to doing so for the buyers is to help them set aside money aside regularly for services we (the provider) think they should buy. The primary advantage to the provider is that health money can be pooled and invested in the community’s health; for example, no one person could make a health fair where doctors are within walking distance and services, by virtue of massive volumes, are inexpensive. But there is a small insurance component to it: not everyone is going to need emergency transport, not everyone is going to get pneumonia, not everyone is going to come to the health fair.
Also, with a limited plan, it limits moral hazard (doing dangerous stuff because you're covered) by only providing limited treatment to diseases which aren’t preventable, and prevention to diseases which are expensive to treat (HIV, Malaria). Because services are limited, it prevents providers from feeling the incentive to do more things. They’re not paid commission on the drugs they sell, and they only have a limited number of services. This would be taking Britain’s approach to limiting healthcare spending: limit the supply of medical services (you can’t get an expensive MRI if there aren’t any near you).
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.
This is my hundredth post! In November of 2006 I started this blog because, "I enjoy writing. It may be therapeutic for me, and it may help me organize my thoughts." This has proved true.
Thank you, my reader, for supporting me with the occasional comment or email; you have no idea how encouraging it is to know that my writing is having an impact on more people than just me.
For this post, I've gone back and looked at some of my old posts and collected some of the best of them here including an excerpt from each.
Perhaps Christians ought to re-learn the language of those around them to win them for Christ. We continue evangelizing with the outdated language of reason to a culture that no longer understands or cares.
The adventure to understand and know Woman is great; it is a noble quest that demands the best of Man. With so little of manliness left today, it is no wonder why so few undertake it with the courage and dignity that it deserves.
The Body of Christ is an analogy which may be far deeper than I originally gave it credit for. I have now studied basic cell biology a second time and have realized that this metaphor could be extended a bit. There is a hint here of something deeper.
Faith is very much like science. You may be shocked by this, but look at how similar they are. Both study truth. Both use methods involving the formation and testing of theories. Both are self-critical, challenging the theories to strengthen them. Those who make a discovery in each attempt to communicate it to others.
[also see the flurry of replies on the Facebook note here; this is my most inflammatory article to date]
We have heard of the epic struggle of life, up from a single organism that struggled and strove to survive. We have heard of the grand battle of this organism and its children to overcome the odds and live and reproduce and change. This great odyssey through the eons has become the narrative of our age, the modern story of our creation.
Photography, like all art, is a portal to eternity. As the prophets who shared their glimpses of heaven causing us to yearn for its glory, I aim to make visible that which is invisible to most.
Life is loving our neighbor, and true life sometimes requires that a person not live as long. Life is not a beating heart. It is a thriving soul. Making life all about prolonging the functioning of a pump is foolish.
We consider it an obligation and an honor for a scientist to make his findings known. We look at respect on the evangelical scientist, he who tries to better the world by his revelation of truth. And this is what I aim to do: to share what I believe I understand.
There are explicit definitions for the “good news” or “the Gospel” in I Chronicles, Isaiah, Romans and I Corinthians. In my reading of the scriptures, these four definitions contain seven common elements:
He is violent and benevolent. Loving and hating. he blesses the children and curses the pharisees. He accuses Peter for using a sword and himself wields a whip. He blesses the peacemakers, but then declares He has not come to bring peace but a sword. He condemns separation through divorce, and then promises it through faith.
The trees sang their praises to God, and my smile would have grown if it were possible. My joy, ever filling, spilled over into my eyes which upturned, but even they would not be able to contain it.
The Doctor was pensive. Normally The Doctor never had time to think. Work was too busy, not a good place for thinking. And home was far too relaxing a place; also not a good place for thinking. So today was special, for he thought.
I ran out of my interview at 3:50PM, tie and blazer flapping in the wind. The girl who offered me a ride to the airport (who just happened to have as perfect a face and as enchanting eyes as ever I have seen) texted me to say she would be late.
“Welcome to the Abundant Life ALC!” the voice of the attendant was perfect. His voice was as confident and clear as an actor of old. “My name is Dante. How may I help you?” asked Dante with such a sincerity as it almost tempted Jim to feel something.
#3 Philosophy is Good in itself [Note: this turned out to be a Biblical argument when I didn’t originally intend for it to be; I eventually want to make a non-Biblical one, too. My apologies to non-Christian readers.] Philosophy, the love of wisdom, is good for its own sake. Wisdom can indeed be a means to an end (Pro 24:3 “Through wisdom is an house builded”), but this is not the main reason to pursue it.
Wisdom is valuable in herself (for wisdom is often personified). Solomon, in speaking of wisdom, says, “She [is] more precious than rubies: and all the things thou canst desire are not to be compared unto her” (Pro 3:15).
And, if you happen to be Jewish or Christian, you are commanded to be a lover of wisdom (or in Greek, a “philosopher”): “Get wisdom … love her, and she shall keep thee” (Pro 4:5-6). The Biblical definition, though slightly different, is not that far off from what Socrates possessed. I’ve read only one chapter of The Republic, so I don’t have much to go off of. But let’s compare the wisdom of Solomon to the wisdom of Socrates and see if there’s overlap:
Solomon: The mouth of the just bringeth forth wisdom (Pro 10:31) Socrates: …the just man is like the wise and the good...justice is indeed both wisdom and virtue (350c, 351a)
Solomon: Happy [is] the man [that] findeth wisdom (Pro 3:13) Socrates: …the just man is happy (345a)
Solomon: Only by pride cometh contention: but with the well advised [is] wisdom. (Pro 13:10) Socrates: it’s injustice that produces factions, hatreds, and quarrels among themselves, and justice that produces unanimity and friendship. (351d)
I think there’s quite a bit of overlap. The point is that Wisdom is the same to Socrates and Solomon. They were describing the same thing (the latter with the help of God directly). Both were concerned with how a person should live his or her life. Both thought deeply about these matters. They both sought wisdom before wealth or production. In the case of Solomon, he sought wisdom first, and all the ‘pragmatic’ things (wealth and fame) were added to him because of it. We should aspire to be the same way.
#2 Philosophy is needed for good living What is the meaning of life? This is often posed as an unanswerable question, one that philosophers waste their time discussing. But the reality is that we all have an answer. When we get out of bed and go to school or work, it’s because we’ve answered that question in some way. But did we ever really think about it? For most, the answer is ‘no’. Most people accept the answers given to them by others who have thought about it. This is often unconscious; it diffuses into a person’s mind slowly over years. Hearing a thousand times in a thousand ways, in lecture halls, textbooks, and conversations that “God is dead,” and “Life has only the meaning you give it” you will slowly drift in that direction if unhindered. Of course, you don’t have to choose, but, in the words of Rush, “If you choose not to decide, you still have made a choice.”
We are fiercely individualistic in almost every other way. We like to believe that our thoughts are our own. We dress uniquely. We listen to unique music. And we are our own person. But we all think the same. And we resist any conversation or thought in ourselves that might expose and thus endanger this homogeneity. I often hear, “I don’t spend time talking about philosophy. I’m a practical person.” If that is you, you are an efficient slave to a master not of your choosing. Indeed, we are all slaves to some worldview or other, but why anyone would take pride in his blind obedience is baffling. We value ‘practicality,’ but fail to see that the same trench can be dug for Hitler or for the Allies; the goodness of the digger is not in his speed but in his master. If we asked a Nazi soldier, “Is Fascism a good form of government?” he could respond, “I don’t spend time talking about philosophy. I’m a practical person” as he continues digging. Should we leave our goodness in the hands of the society into which we happened to be born? We can transcend our present time and place with an ancient and mystical art: reading. If every German had challenged the assumptions of their society and read even the first chapter of The Republic, they might have realized that “…it is not the work of the just man to harm either a friend or anyone else…” (335d).
Philosophy deals strongly with living a good life. Of all the time we spend, don’t you think we should figure out what exactly a good life is? If we get that one wrong, then pretty much everything else is in vain. There are things that I would take on authority: unimportant things upon which there is much agreement. The functioning of physics. The existence of a city called Boston. I trust that I’m not being lied to. Even if I was, it wouldn’t matter that much to me (sorry Harvard). But some things are important and there is little agreement on. These are the things I don’t want to have to trust anybody about. What is Justice? What is the Good? Does God exist? How do we think about pirating music? Is the present system of education well-founded? I don’t want to entrust these answers to a social lottery of influences; I want to have reasons that I myself understand.
It is often true that being able to think about the basic elements of a thing help with planning. If one truly understands what a community is, or what a human is, or what education is, then the plans to bring about changes in those things come more easily. For easy things, knowledge of physics helps with building a bridge. But knowledge of what helps with building a government? And what is the process by which such complex things are developed? Philosophy is essential for these questions.
One more thing. If you actually think you have a good answers for important questions, share them. In the Republic, Socrates’ says of a man who wants to leave the discussion without fully sharing his opinion, “…you have no care for us and aren’t a bit concerned whether we shall live worse or better as a result of our ignorance of what you say you know” (344e).
So getting stuff done isn’t good enough to be Good. It’s what you’re doing it for that matters (a good Worldview or bad one). And that decision should be one you make, not one you are assigned. And to make a decision on these matters requires study and discussion.
I just finished book I of “The Republic” after having a very stimulating conversation on politics over dinner. (Before I go on, and before you go on, read “The Republic.” I know it sounds scary. That’s why I waited. But I was stupid and don’t want you to make the same mistake. It’s a really great book.)
Anyways, the thought I had was on how deep conversation is perceived. I am often asked after I’ve had a particularly good discussion with another person, “So, did you get anywhere?” I’ve always been annoyed by this question, but kept it to myself because I assumed my questioner was right: philosophy doesn’t ‘progress’ in a straight line like most other fields. Often the conclusions of an hour of discussion land the discussants very close to where they started. I was usually embarrassed that we had not made much ‘progress’ towards solving the Problem of Governance in an hour as we would have if we were discussing a crossword puzzle (we might have even finished it).
But I do not think that way anymore. Because, as I have seen them, there are at least three good reasons why studying and discussing philosophy is a good idea. And don’t get tripped up on the word “philosophy” (“phileo” = love; “sophy” = wisdom); I mean discussing hard questions that don’t have easy answers. This covers everything from God’s existence to the wrongness of pirating music. Ultimately, what is the Good that we should pursue and the True that we should believe? These aren’t dry academic discussions about nothing for no end; they’re the essence and motivation of all our decisions. When I say ‘philosophy’ I don’t mean the class you took as a gen-ed requirement.
#1 Philosophy is good exercise Imagine a race run in a circuit. The gun goes off, and the race begins. The fastest racers stay together, neck and neck, running hard for mile after grueling mile. Two pull ahead of the rest, sweating hard. Finally one of them, in a final exertion, gets ahead and wins the race. And then from the bleachers an onlooker, empty popcorn bag in hand, snipes to the winner, “So, did you get anywhere?” Such a question should be answered by something like, “No, ***hole, I didn’t. I just ran a ****ing race.” [1] This is sometimes how I feel when that question is posed to me after a good discussion. Someone who didn’t do any work presumes that the point of the exertion was to ‘get somewhere,’ and, seeing no ‘progress,’ mocks the waste of time and sweat.
Having a philosophical discussion makes you a stronger person. I got this idea from Francis Bacon who said, “So every defect of the mind, may have a special receipt”[2]. He doesn’t see the mind as a muscle; it’s more like a body. There are multiple muscles that need exercising, and so different exercises for each. There is a part of our mind which reasons philosophically, and by exercising it, it gets stronger. Philosophical discussion about topics so big they won’t get solved are like dumbbells: not directly useful (though valuable, see #3), but weights which when lifted repeatedly, make a person strong for other, more useful endeavors (see #2).
[1] *** = ‘ant’ and **** = ‘frak’ above [2] Francis Bacon's essay "On Studies": “Bowling is good for the stone and reins; shooting for the lungs and breast… So if a man's wit be wandering, let him study the mathematics; for in demonstrations, if his wit be called away never so little, he must begin again … So every defect of the mind, may have a special receipt.” [As a side note, I love being able to remember three words in an essay I read two years ago that was written five centuries ago, typing them into Google, and then being presented with the entire essay in a matter of seconds.]
