Timed with the current national release of Michael Moore’s Sicko, I have a (fairly) honest question: why do political libertarians reject the idea of state-financed universal health care? Now I know why they say they do: it would interfere with our individual liberty to do what we like with the products of our labor. Taxing me to provide health benefits for other citizens simply forces me to work X amount of hours for a distribution of those goods I didn’t (or wouldn’t) choose, in the same way federal arts funding forces me to work for other people’s enjoyment of art and opera that I myself might never want to indulge in. Nevertheless, there seems a simple bootstrapping argument available to the fans of universal health care, and I don’t quite see why libertarians would resist it. Perhaps you can help.
The argument simply expands on a foundational tenet of libertarianism: the state’s only function is to protect its citizens from external or internal threats to their life and liberty. What this is taken to mean is that there should be state-run military and police forces (and perhaps state-run fire departments and court systems), but nothing else. Taxation for such services is (justified by a complicated argument, usually) to be universal, so that everyone gets equal protection for their (mandatory) equal payments. But of course some threats to my life and liberty aren’t susceptible to protection by the military or the police. Instead, some of these threats are truly internal, coming from diseases and other bodily breakdowns. So the question is this: why wouldn’t libertarians also want to insist on a state-run system of universal health care to protect against, correct, or assuage the pain of, these threats to life and liberty?
One immediate thought is that the threats dealt with by the military and police are due to agency, so the government needs to be there to protect me from the nasty aims of other people, either from within or without the country. But why should the source of the threat matter? Surely I need protection equally from that missile heading our way if it was caused by a push from Putin’s finger or by Putin’s dog’s wagging tail whacking the button or if it simply shorted out and fired on its own. What matters is that my life and liberty be protected, not that it be protected only from certain sorts of (agential) threats.
On the other hand, not all non-agential threats are created equal. For surely there is something to the libertarian complaint about my having to pay for someone’s else’s lung cancer if it were caused by that person’s free choice to smoke, or having to pay for someone’s bacon-related heart attack to be treated. But there remain a great many kinds of diseases and ailments that are incurred through no choice of the subject at all. And while it could be very difficult to distinguish between those diseases that are incurred through choice versus those that aren’t, that epistemic difficulty wouldn’t undermine the general principle established placing the (theoretical) obligation for certain forms of health care squarely in the hands of the state. And at the very least, this would justify state-run preventive care, involving education about healthy lifestyles and free check-ups and screenings (which, when taken advantage of, significantly reduce later long-term hospital stays and costs). (Notice, though, that there’s no similar libertarian distinction, when it comes to military and police protection, between those threats that are primarily one’s fault and those that aren’t – the cops still have to come when the guy at the bar slugs me, even though I’d been taunting him mercilessly about his mother all evening long.)
As I said, this is an honest question. This isn’t my field of research, so there may be a lot written on this topic already of which I’m ignorant, or there may be a breathtakingly simple answer, in which case I’ll quietly retreat in shame. But I thought I’d throw open the PEA portals on this one on a curious whim.
I don’t know is my simple answer. But I think it may relate to the idea of holding to rules and what I like to call…ontology…a set of stipulated ways of dealing with issues to avoid “cognitive dissonance.”
Doesn’t make sense though. Libertarianism is in something of a local decline. A lot of people are starting to realize that the costs of unbridled or minimally bridled choice is higher than we at first believed. I call that “unintended consequences.” Global warming is an obvious example, but there are many others.
Passing the cost of one’s externalities to your community is getting harder–even with great social inequalities. The opposite extreme, state socialism, seems equally silly.
A Brad DeLong-like program of non-state providers and mandatory coverages seems, to me, to be inevitable.
Consequentialist libertarians would doubtless appeal to both the negative effects caused by governmental intervention in market processes (caused by granting the government a de facto [if not de jure] monopoly over the distribution of the relevant goods) as well as the dangers of establishing a legal precedent that legitimates a greater scope of governmental power/authority.
But I think the more fundamental issue is that your above argument seems to equivocate between two senses of the word “threat” with respect to the rights of life and liberty. The threats countered by the minimal state (or something like it) are those which are the products of physical coercion, in one form or another. That is, the police and military are there to prevent the initiation of violence by one party against another (and thereby prevent or attempt to correct for a rights-violation). Again, there are libertarians who do not argue from a rights-based perspective, but the general antipathy toward the initiation of force is a general feature of libertarian thought. The word “threat” as you use it (with respect to all things that may harm one’s life) does not necessarily involve the initiation of force between two individuals in society. Therefore, the things that fall into the term’s extension are dramatically different from those which fall into the extension of the libertarian sense of the word. A threat – within the libertarian politics – is generally taken to be something which is necessarily social… something that involves two parties with differing interests. Given that “internal threats” are not social in nature, they fall outside the province of governmental authority (at least within the libertarian scheme).
Hope that helps!
David,
Not sure exactly what the libertarian view on universal health care is, but I do think the source of the threat would matter on their view. The fundamental tenet of libertarianism (to my understanding, at least) is that we own our persons and have rights to property such that that others may not interfere with that property. When other people cause us harm, that right is violated. When microbes do, it isn’t, no more than my property rights are violated if my house is set on fire by a lightning strike. Of course, libertarianism doesn’t preclude prudent individuals from banding together to create an insurance scheme to protect themselves from microbes and lightning strikes. But it is permissible neither for the state to compel me to protect myself from such contingencies nor for the state to compel me to help others protect themselves against them.
This view might be silly or irrational for the reasons you suggest: I fear others’ harming me no less than natural contingencies harming me, so I may want the state to figure out a way to minimize the probability or costs of such harms.
As for your point about preventive care: Paternalism is relevant here, I think. Wouldn’t libertarians say it’s all well and good that people should not harm others with their unhealthy behaviors (e.g., smoking in public)– and in much the same way that the state may permissibly interfere with the pollution I create that harms others, the state can’t make a claim on my time, person, etc., by compelling me to receive preventive care on the grounds that it’s good for me?
I think the previous two comments have it right: libertarians are concerned with force (or perhaps force and fraud), not threats or harms that come from other sources. Of course, then the question is why think that only force and fraud give rise to reasons for state intervention. I’ve always thought this was a rather arbitrary position and some of the observations about the possible libertarian arguments against universal healthcare help to reveal this.
There’s also the “small government is more efficient” argument, which would apply to a number of issues, but this would be one of them.
I certainly can’t speak for other libertarians. But to me the distinction that Valerie suggests is arbitrary doesn’t seem that way at all. I take it to be a commonplace that we distinguish between the harms that come to us through intentional and deliberate acts of human agency and harms that come to us by other means. It is a tragedy to lose a loved one through (say) a house fire, and something else to have them shot by a rampaging school shooter. To me, the moral significance of this difference is quite marked.
One element of libertarian thought treats this distinction as indicating something quite generally about the moral significance of relations between human agents, and sees those relations as implemented in the authority of state agencies as itself morally relevant. That doesn’t get you to libertarian conclusions all by itself, of course, but it should at least make it intelligible why libertarians would see the coercive relationships characteristic of state agency as morally problematic in a way that would be different than threats of harm arising from other sources.
Another element of libertarian thought takes seriously the line suggested by B.T. and Ryan. Police and national defense services are justified (if they are; by no means do all libertarians agree on this) because they are public goods which will be undersupplied in a free market, since those who do not pay for them cannot be excluded from enjoying their benefits. The same is not true of health care. On the contrary: one significant element of the libertarian emphasis on private property rights is the attempt to internalize externalities of just the sort Ryan worries about. The fact that problems like global warming are implications of some folks shoving off the costs of their actions onto others represents a failure to capture such costs in enforceable rights to property; whether or how that can best be remedied in particular cases is left an open question, but that is the libertarian diagnosis of the problem. And one form of libertarian objection to policies like universal health care is that they do exactly that: they export the costs of people’s decisions about their own health and risk-taking onto others, thereby offering incentives for costly behavior (or at least removing the disincentives for such behavior).
As I said, I can’t speak for all, but I think those are the main lines many libertarians would take.
David,
The libertarian (at least Gauthier style) can justify taxation for the sake of public goods (e.g. road repair, lighthouses, bridges, general security, and the like) for which there is no free market mechanism to prevent free riders. In the absence of taxation or some other market mechanism to absorb costs, there is no way to prevent free riders from taking advantage of road repair or lighthouses, the military, etc. at no cost to themselves, which are there for everyone’s use. But there is a free market mechanism to prevent people from taking advantage of health care: if you do not pay individually, it presents an obvious cost to you (and not to us generally) in health. You can’t ride free. You can’t ride free since, assuming libertarianism, we would not have to provide the resources to care for you.
Just to be painfully clear: I am not a libertarian. I just play one on Pea Soup.
Valerie Tiberius remarked that she though that it was arbitrary that force and fraud would constitute the only acceptable justification for state intervention. I’d like to hint at why this is not arbitrary. Rights, as principles defining, sanctioning, or constraining one’s actions vis-a-vis other individuals, are needed to allow for peaceful co-existence of individuals within society, leaving each individual the freedom to engage in his own life projects. In this context, the primary political concern is that one will act in a manner that interrupts this peaceful co-existence and thereby prevent or hamper individuals’ activities. It is only by initiating or threatening force that one can break the peace: only force prevents one from engaging in his projects peaceably or in acting as he sees best. Thus, argues the libertarian, government is (only) justified to prevent and punish the initiation or threat of force. I’ve hardly established that this is the case in this short comment, but it does point to why force (and by extension fraud) are not arbitrarily picked out as the only acceptable justification for state intervention.
I’m thinking that the justification may depend on the libertarian. Nozick uses a principle that allows us to create protective monopolies if we compensate those whose right to protect themselves we abridge, if abridging those rights makes us safer and if the compensation is appropriate. That’s how he gets from lots of private protective associations to one with a monopoly on the use of legitimate force. The idea is that those in the monopoly association are safer because there are no rivals and this is a great good for them and hence a way of protecting themselves. And those whose private associations are put out of business can get the value of what they lose if the monopoly association protects them at least as well as their private association did, and for less cost. Or that’s how I remember the argument.
If that’s his argument (and I’m working from an increasingly foggy memory), it is very reasonable to ask whether a parallel argument can be made about health care. If going to a monopoly provider (single payer) benefits me (there are at least plausible arguments that this would be a net gain for most people), and I compensate those who would have used another provider for their loss by covering their health care needs with my monopoly provider, why is that not appropriate too? The answer that I expect he’d try is that I can get the same benefits I’d get from a monopoly provider in some other way which does not require forcing others to use the same provider.
Given his emphasis on rights (including rights to defend oneself) as side constraints, it never seemed to me that his idea that we can abridge a right so long as we compensate if important benefits accrue was a plausible thing for him to stand on if he also wanted to resist further uses of such principles in ways he would not sanction. But then I’ve never been that sympathetic to ASU or libertarian arguments generally. It always seems to me that there is a point at which they engage in funny bookkeeping.
I agree with the concern about the complications introduced by the strategy of compensation rather than respect for rights. But even so I’m not sure Nozick’s argument can be pushed in the direction you suggest, Mark. What gets the gears grinding in the protective association case isn’t just economies of scale or the like (benefits which might (however plausibly) be claimed for the universal provider case. It’s that the services provided by the various associations are themselves in conflict. Each claims to resolve disputes, and it is this relational feature of their services (one relation is between clients and other litigants, the other is in their relation to other protective associations) which doesn’t, so far as I can see, have any counterpart in the health care case, nor indeed in most others that I can think of. There are wrinkles to ca monopolistic claim to be able to initiate and deploy coercive force legitimately that don’t seem to hold for most services.
Very nice discussion, folks. Thanks.
I did indeed have in mind something like Mark vR’s Nozickian extension, where abridging the rights of people to protect themselves would make us all safer (and so some compensation would be necessary for those whose rights were abridged). If Nozick were to reply, as vR anticipates, that one might be able to get equal or greater benefits from retaining the non-monopolistic system, one might reply with worries about unequal quality of care spread across a population as breeding greater risks to public health — lack of basic vaccinations or easily treatable contagious diseases from some providers might suffice as supporting examples. These might also be the sorts of examples that would provide the relevant sort of conflict to address the LeBar rejoinder, although I have to think about this some more.
The main response thus far, though, has been to offer distinctions between types of threats to life and liberty, insisting (as I thought would occur) that agential threats are distinct from other threats (like diseases) insofar as the former — involving the initiation of force — are rights violations, while the latter aren’t. The following, from Shawn and Michael Cholbi respectively, were rather typical:
Now I guess I meant to allow that there was indeed a distinction between the two forms of threat, but my question was about the reasonableness of that distinction. I don’t yet see why that’s so. Thus, to engage directly with Shawn, I don’t see why it’s the case that “only [agential] force prevents one from engaging in his projects peaceably or in acting as he sees best.” Surely the same interference and prevention occurs when I’m crippled by disease or injury. Similarly, to Michael, if it’s self-ownership that’s key here, then while I agree that only other people can violate my rights to my body and the products thereof, that remains only one source of interference with my doing as I see fit with my self. Another is disease, and if the point is to protect my relation with my self, then again, I don’t see that whether or not some threat has intentions is relevant.
In a different sort of move, Mark L. suggests that “One element of libertarian thought treats this distinction as indicating something quite generally about the moral significance of relations between human agents, and sees those relations as implemented in the authority of state agencies as itself morally relevant.” I’d like to hear more about this. For one thing, it’s not clear to me why the moral relations between individuals are to be the only relations implemented in the authority of the state (as opposed to relations between me and various viruses and bacteria, say, which while not necessarily moral, are certainly of the life-threatening kind).
Sorry: in the penultimate paragraph I meant to say that my question was about the reasonableness of the distinction for purposes of state coercive power
Engelhardt seems to be the exemplar of the libertarian position on this.[1][2]
His view is basically as several commentators have already mentioned above. He argues that we can be held culpable only for unfairness we have caused. He draws a distinction between situations which are unfair (where one person has been disadvantaged by another) and situations which are unfortunate (where one person’s misfortune is not the result of another’s actions). Thus the seemingly ‘unfair’ differences between people resulting from chance do not create duties on us to give up our resources to aid the less fortunate in Engelhardt’s view. The upshot of this is no universal health care system since no one has the obligation to aid others… Unless it is they who have done the harming. (He does concede that public health care for some groups like those who were exposed to chemicals during service in the military should be provided)
An interesting counter argument to this which I am not aware of in the literature is given the social science evidence that seems to show that greater financial inequalities in groups seem to cause poor health outcomes (The Whitehall study for example), perhaps having a free market does cause some of that ill health.
In response to Jeremy’s point:
“There’s also the “small government is more efficient” argument, which would apply to a number of issues, but this would be one of them.”
I would have thought given the vast amount spent on health care in the US, and its inefficiency in terms of outcomes compared to countries with socialised health care systems that this cuts the other way.
Cheers
David
Refs:
1. Engelhardt, H. T., Jr., “Health Care Allocations: Responses to the Unjust, the Unfortunate, and the Undesirable”, in Justice and Health Care, ed. Shelp, Boston: Kluwer, 1981.
2. Engelhardt, H. T. Jr. “Infinite Expectations and Finite Resources.” Allocating Scarce Medical Resources (2002): 3-18.
3. Wilkinson, R G. The Impact of Inequality: How to Make Sick Societies Healthier. Routledge; 2005
I think it’s important to bear in mind that libertarianism is a doctrine focused on processes rather than end-states. [1,2] It’s also important to bear in mind that libertarianism is a theory about justice, or as they are often wont to put it, about the proper use of violence [3], and not a theory about value. So take a person who’s sick. The goodness or badness of this state of affairs might hold independently of the causal history that produced it, but the justice of it, and hence the legitimacy of state violence in response, does not.
Violence, according to libertarians, can be used only for retaliation. Retaliation here means in response to a rights-violation. A person’s getting sick through a non-agential process does not involve a rights-violation, and thus does not warrant a state response. Things are different if an agent is involved [e.g. you stick me with a needle; you move your infected self on to my property in violation of my wishes and get me sick, etc].
So there are several ways of understanding Shoemaker’s question about the reasonableness of the libertarian approach. One is whether it is reasonable to have a historical or process theory of justice rather than an end-state one. I think the answer here is probably yes. If one is concerned about desert, then history matters. And in a world of imperfect information and efficiency, history even makes sense to as a way of manipulating incentives or as a proxy for other relevant information. Now, whether the *particular* historical elements picked out by the libertarian are relevant is a more difficult question. But I think that the theory is at least a starter, especially if the theory of rights is buttressed by consequentialist considerations about the effectiveness of state vs. market action and the like.
[1] Robert Nozick, Anarchy State and Utopia
[2] Brian Barry, On Classical Liberalism and Libertarianism
[3] See, e.g., various statements of this point by Murray Rothbard, such as The Ethics of Liberty, chapter 5.
David wrote: “Thus, to engage directly with Shawn, I don’t see why it’s the case that “only [agential] force prevents one from engaging in his projects peaceably or in acting as he sees best.” Surely the same interference and prevention occurs when I’m crippled by disease or injury.” Disease, injury, and the like could certainly prevent some one from acting as they determine best, but this can’t sensibly be called force (possibly coercion makes the point clearer?). We don’t think of cancer coercing an individual, do we? That seems to stretch the concept beyond normal bounds. The main point is that rights exist solely as a function of living with others and serve to define the political relationship between individuals. Thus, it is only other individuals that can act in ways that violate these rights.
David also wrote: “it’s not clear to me why the moral relations between individuals are to be the only relations implemented in the authority of the state (as opposed to relations between me and various viruses and bacteria, say, which while not necessarily moral, are certainly of the life-threatening kind).” If, as is the case with libertarianism, one’s argument is that the state is only justifiable as the protector of individual rights, then it can only be on that basis that the state has any (legitimate) authority. The state is understood within libertarianism as an institution within in a given geographical area that has the power to prevent and retaliate for the use of force/coercion. The state is justified (and required) because the protection of individual rights needs such an institution to make sure that individuals do not initiate force and to punish those who do. This activity needs strict and clear rules in order to proceed and must be based in the context of protecting individual rights. Moving beyond this context, moves the state into exercising its power in ways that actually violates individuals’ rights; thus, undermining the very justification for the state in the first place.
Admittedly there are many steps here that need to be filled out, but it gives us a sense of where the authority of the state comes from and what that authority is. Now we can answer David’s question. Viruses and bacteria can surely be life-threatening. The state, however, is only justifiable under libertarianism to protect individuals from other individuals, not from just anything that is life-threatening. Moreover, the state’s power is the exercise of force (either to prevent or retaliate). This does not seem to do a whole lot of good against viruses and bacteria. What is needed for the protection from viruses and bacteria are doctors, medicine, and knowledge. And what these need are institutions and sets of rules that make sure that individuals are free in order that they can learn, develop, and practice medical skills and knowledge. This also possibly makes clear why libertarians see socialized health care as a violation of individual rights. The state has no power over viruses and bacteria, but it can use that power on individuals and interfere in their lives and choices.
Incidentally, it’s worth noting that David’s challenge could be, and has been, taken to push in the opposite direction. David notes that libertarians favor taking money from A to provide protection to B against thieves and murderers, but not against bacteria, and concludes that the state should expand its redistributive and protective services. Anarcho-capitalists like Rothbard, on the other hand, conclude that even the first sort of redistributive protection is rights-violating, and that the state should get out of the business of even that (and hence, get out of business altogether).
I like the Rothbardian way of pressing the case in the other direction, as Matt notes. I’d toyed with the idea of presenting it in this way as well, setting up a kind of dilemma: either go the Rothbardian route, which constitutes (to my mind) a reductio, or go in the more expansive state route. At any rate, thanks for making that route explicit, Matt.
As to your original point about libertarianism as a historical, process-based doctrine, I don’t yet see why that’s not also compatible with the incorporation of state-run health insurance. One could, for example, think that redress for past diseases and injuries (not directly due to or foreseen by one’s autonomous choices, say) could be due, just as one thinks that redress for force or fraud could be due. The system of health care, then, could operate akin to a system of reparations, the only difference being that the former redresses threats to life or liberty that are non-agential in nature.
To Shawn: You had explicitly said that “only [agential] force prevents one from engaging in his projects peaceably or in acting as he sees best,” and I was disputing the “only” portion, suggesting that there are other things in life as well that may prevent one from acting as one sees best, namely, injury and disease. That it can’t be called “force,” then seems to me irrelevant. True, it’s not a violation of rights — I fully admit that — but my point is just that the motivation for the state’s protecting rights — that doing so enables individual citizens to exercise autonomy unhindered, say — also ought to incorporate protection against other such autonomy-undermining threats such as disease and injury. If the state can violate (or perhaps just slightly infringe?) property rights via taxation for police and military in order to establish the very preconditions for rights in the first place, why not violate/infringe a bit more to establish and buttress those same preconditions with respect to the diseases and injuries that could also hinder the exercise of one’s rights?
David S mentioned vaccinations and the like leading to public health benefits that might be much harder to obtain without universal coverage. And David H makes similar points. That actually feeds into a response to the idea that defense from other protective associations is somehow different from rationales for limiting liberty based on wanting to accrue greater health benefits.
I take it that the root libertarian idea is that rights defend us from the actions of others and that one legitimate function of government is to make sure that others don’t violate our rights by creating harmful externalities which we bear. Defense against aggression is just a special case of this sort.
But then when you actually look at lots of health problems, it turns out that they are social. One aspect of that is the aspect raised by several people above that inequality can itself cause people to be less healthy. That’s an important point, but there is more. Even in a society which was otherwise equal the decisions of others can have health consequences for me. Pollution is hard to contain and makes people sick. If may be cheapest for me to counteract those effects by forcing others into a single payer health system and compensating them for their loss of liberty for being so forced by giving them health care, it does not look fundamentally different from the defense case.
Now you might think that Nozick could respond that there were other ways to get the same benefits. But that’s true in the defense case too. I could probably get around the inconvenience of lots of little free lance protective association by paying to make mine the biggest baddest private PA around. But this is very expensive. So Nozick allows us to do the cheaper thing and force a monopoly.
So in response to Mark L, the parallel is between the cases is as follows. First we get some private associative mechanisms for dealing with externalities – in the one case the harms from aggression in the other the harms of polution (and other things). These associations might pay their way both by charging their beneficiaries and by collecting fines from those who have created the externalities (and N would have to allow that as fair given that those fined did something to harm others by shifting the costs of their actions to these others). But this leads to both inefficiency and conflict in both cases. (In fact, it might lead to conflict between PAs and Health Associations who collect fines from polluters, and non-vaccinators, and non-hand washers, and . . .) There is then a chance to make things more efficient and make most everyone better off by consolidating into one system. And better yet, if we consolidate both functions into one system we get even more efficiency. And this is efficiency at the thing libertarians think we have a right to try to do – protect ourselves from harm caused by others.
Given that Nozick thinks it is OK to override the right to do this for oneself so long as the people whose rights are overridden are compensated I don’t see a distinction.
I have always thought that the most plausible version of libertarianism is the sort of consequentialist libertarianism that comes through in the writings of Milton Friedman. On this approach, the answer to David’s question is fairly straightforward.
We all want to live autonomous and well-off lives. Criminals represent one sort of threat to individual autonomy and well-being. Coercion, initiatied by a state that has monopolistic power over the initiation of force, is the only practical way to deal with criminals.
Disease and infirmity represent another sort of threat to individual autonomy and well-being. But what is the best way to deal with this threat? If some economists are correct to portray the single-payer health system as (a) financially inefficient, (b) insensitive to the particular situations of particular patients, (c) unattractive to the best medical talent, and (d) a worse-than-the-DMV bureaucracy that will spawn an array of fiefdoms where all the incentives are incentives of power and control, then the best way to deal with disease, for the vast majority of people, will probably be something other than the single-payer health system. “Free” care isn’t worth very much – certainly it is not worth giving up your own liberty to choose another service provider – if the care isn’t very good!
The deeper philosophical point – and what makes this form of consequentialism a form of libertarianism – is that this is not an accident. Across the board, things run better for the vast majority of people when they are in control of their productive and financial lives, choosing to whom they give their money and for what purpose. The only domain, on this view, in which this fails to be true is the domain that deals with protection from agential threats of force and fraud. It is these empirical facts that ground the libertarian definition of a political right and the libertarian theory of how rights can be violated. On Friedman’s consequentialist view, that account is not an analytic or a priori truth, but a summation of the empirical facts. (This pragmatic account of rights contrasts with various neo-Kantian accounts, found in writers like Nozick.)
If there is a positive duty of charity or benevolence to those who are badly off, this could still be fulfilled in a number of ways that would be fundamentally compatible with a free-market system: voluntary contributions to charities that provide medical care, or even compulsory taxation to support a (private- or state-sponsored) system of Medicare that has the narrow goal of helping the indigent.
David, This libertarian is opposed to universal health care for several of the reasons mentioned, but mainly because I believe it will lead people to get much worse health care than in other feasible institutional arrangements. The argument that a well-functioning system of freely moving prices within a context of market competition tends to produce higher quality services at a lower price applies as strongly to medical services as to any other kind. I think the empirical evidence for this general claim is so overwhelming strong that defenders of government provision face an immense uphill battle (intellectually, if not politically).
There was a good debate late last year between libertarians and universal care advocates at Cato Unbound, which I edit, here, which should give you a good taste of some of the arguments.
I think it’s necessary to be careful to acknowledge that the status quo health care system is very far from what a libertarian would argue for. For example, there is no libertarian justification for the guild-like regime of medical licensing. There is no justification for prohibiting access to experimental drugs. Etc. Here’s a blog post I wrote a while back laying out what a much more classical liberal health care system might look like. (But not really super-libertarian, since you’ll see both mandatory insurance and a government rationing program for the uninsurable.) You’ll notice right away that it looks radically different from the current dispensation.
Jason and Will: Thanks for these comments. I took myself to be aiming at the kind of neo-Kantian political libertarianism of someone like Nozick, so I don’t really have much to say to the consequentialist version of the view, other than to voice the need for (and expectation of) empirical disconfirmation, which, as a philosopher, is not within my domain or even skill set. [Insert clever wink-wink icon here.]
Nevertheless, I think Mark vR has provided a really nice articulation of the challenge to Nozickian libertarians that I’m obviously sympathetic to, and I wonder if it also doesn’t include a whiff of consequentialism itself, at least insofar as it points out costs and benefits that would have to be incorporated into any more straightforwardly consequentialist libertarianism.
MvR, you write,
Pollution is hard to contain and makes people sick. If may be cheapest for me to counteract those effects by forcing others into a single payer health system and compensating them for their loss of liberty for being so forced by giving them health care, it does not look fundamentally different from the defense case.
It is hard to contain. But why isn’t the cheapest way to counteract those effects to get the polluters–those who are imposing the costs and riding free–to pay for what they are costing others? Since those costs are no doubt exorbitant, we have an incredibly strong incentive not to pollute that is consistent with libertarianism (or, as I say, consistent with at least Gauthier’s libertarianism).
Regarding Mark’s comments:
First, I think the general consensus (and certainly the general consensus among libertarians) is that Nozick’s compensation argument for the minimal state fails. Norman Barry’s book has a good summary of many of the problems with this argument. Many of the anarcho-capitalist criticisms can be found in Vol. 1 No. 1 of The Journal of Libertarian Studies.
Second, even if it is successful, I still don’t see how it can be extended to justify government provision of health care in general. Certain public health measures might pass muster, and I think some libertarians have argued as much. So one could make a reasonable argument on libertarian grounds, I think, for quarantining individuals with highly contagious and dangerous diseases. But I suspect a lot of libertarians would want to argue that this particular kind of move would be rights-violating (as they are not truly ‘retaliatory’ force) and unnecessary (as the same effect could be achieved in a regime of full private property by contract (CC&Rs, etc). Leftover damages would be taken care of by tort and liability law.
At any rate, this doesn’t seem to get us anywhere near a single-payer system since a) a lot of medical conditions aren’t caused by anyone else’s wrongful actions, and b) even those medical conditions which are so caused do not require such a system to either prevent the conditions from being caused/transmitted in the first place or to provide compensation afterwards.
Regarding David’s response to my last post:
You write that you don’t see why we shouldn’t “think that redress for past diseases and injuries (not directly due to or foreseen by one’s autonomous choices, say) could be due, just as one thinks that redress for force or fraud could be due.” But due from whom? In the case of force and fraud, there is a wrongdoer to whom the state can turn for redress. Not so in the case of many medical conditions. What would be the moral principle here? That the state owes compensation to anyone to whom anything bad happens? If I’m beset by the difficulties of aging, is this something which gives me a legitimate claim against others? Providing compensation through coercive taxation is prima facie a violation of individuals’ rights. So if anything is going to justify it, it had better be something of equal moral seriousness – i.e. a violation of rights. Or, to put it in more Nozickian terms, if the prima facie rights violation of taxation is to be justified, you had better show how the non-governmental method of dealing with the problem is actually rights-violating (by, say, imposing unjustified risk), and hence how the prohibition of such activity by the state is permissible, assuming that compensation is provided.
Alot depends here on the way in which libertarian rights are grounded. You seemed to assume, in one of your posts above, that the grounding of libertarian rights is teleological in some way – they promote positive freedom, or autonomy, or some other good state of affairs. And some libertarians do ground rights in these ways. But Nozick pretty clearly doesn’t. So I don’t see an inconsistency in his position. Figuring out whether there is in the other libertarian positions is going to require us to be a bit more careful in identifying which particular kind of libertarianism we’re talking about, and what exactly their grounds for libertarian rights are. My own hunch is that libertarians’ denial of the legitimacy of universal health care isn’t internally inconsistent, even if it is all-things-considered implausible.
Mike, you write:
But why isn’t the cheapest way to counteract those effects to get the polluters–those who are imposing the costs and riding free–to pay for what they are costing others?
That’s an empirical question, as is the question of whether the same strategy for other kinds of defense would not be cheaper. I have my suspicions as to the answers in both cases and my guess is that the answer partially turns on how secure you are trying to get. But I’m no expert on the relevant empirical data. The arguments I see that it would be cheaper to go the libertarian route are as often as not a priori, so I think I’m entitled to my skepticism.
But in any event (and to partly respond to Matt as well), I’m not claiming that we can provide a good libertarian justification for national health insurance. I don’t in fact think we can provide a good libertarian justification of anything. I’m just claiming there is no principled difference between defense where it concerns attack and defense where it concerns and unintended consequence of other activities.
I suppose I should qualify that claim to this extent – libertarian arguments may generate differential treatment of illness depending on how it is caused so that the government system would not fix diseases without a social component without charge. But then in principle, the same argument would apply against using the National Guard in times of tornado, flood, or other natural disaster.
That looks like a reductio of the Libertarian position to me. One efficient way to deal with national defence is to fund public hospitals which can do double duty against other disasters as well (as opposed say to invading countries that have not attacked one’s own).
Finally, I don’t think that anything I said in spelling out a Nozick-inspired argument for single payer health care was teleological, except perhaps to the extent that some of what Nozick himself says about situations in which we can override a right if we compensate is teleological or similar in spirit.
Will, while I appreciate David S’s duck and cover in regards to the empirical question I thought I would engage in it a little with you.
You say:
“The argument that a well-functioning system of freely moving prices within a context of market competition tends to produce higher quality services at a lower price applies as strongly to medical services as to any other kind. I think the empirical evidence for this general claim is so overwhelming strong that defenders of government provision face an immense uphill battle (intellectually, if not politically).”
For the general claim yes of course the market is often an efficient way of providing goods. For the specific claim in regards to health care, I would take it as a counter example rather than a place where the market does a good job. How else do you explain the appalling health outcomes in the US when combined with the high amount of GDP expended on health care in the US. I don’t have the stats to hand, but as far as I was aware every country with a socialised health care system both has better outcomes on most measures and spends less. That to me sounds more efficient.
Now fair enough perhaps the US market isn’t libertarian enough, but it is a darn sight closer to a libertarian approach than those countries with socialised health care. So doesn’t it seem odd it has worse health outcomes?
I would have thought given the vast amount spent on health care in the US, and its inefficiency in terms of outcomes compared to countries with socialised health care systems that this cuts the other way.
At the risk of repeating what Will said, the key assumption in the quoted sentence is that the US health care system is not socialized, when in fact it (mostly) is. The US health care system has a few specific features which contrast greatly with European-style systems, some desirable and some not, but all too often this contrast is taken to mean that the US health care system is somehow libertarian or free market, which it assuredly is not.
I don’t have the stats to hand, but as far as I was aware every country with a socialised health care system both has better outcomes on most measures and spends less.
I don’t have comprehensive stats to hand either, but my understanding is that that result holds only for very general measures, in particular life expectancy, which is influenced mostly by factors other than the health care system. (For example, if one cherry picks various US states, one can find better health outcomes than for European countries, just because of differences in diet, exercise, crime rate, and poverty rate.) Some other measures are influenced by differences in criteria; for example the U.S. calculates infant mortality differently (and more liberally) than European countries do, thus the U.S. appears to have a higher rate.
However, when the set of measures is expanded to include outcomes related to specific diseases, such as liver cancer, colon cancer, etc., the results for the U.S. are dramatically better than those in socialized health systems. See, for example, this BBC report that compares colon and breast cancer survival rates across the U.S. and Europe, and note that the U.S. has higher survival rates than any European country for both diseases by large margins. This quote from the report suggests the result is broader as well: “In the US, the survival rate is as high as 60%, and death rate in the US was lower than for any of the European countries in all cancers except skin cancer.”
Matt: Regarding the “redress” point, I was thinking of “redress” in the “to be made right” sense, not in the “the wrongdoer is to make it right” sense. In other words, to have one’s wrongful injury made right under the law will just involve the police tossing the wrongdoer in jail. It’s not as if the criminal makes things right with me; rather, the state of affairs in which he’s thrown in prison “makes things right” insofar as it restores some kind of societal balance. I’ve just been saying that if the wrongness he committed consisted in his violation of my rights to life and liberty, where it’s just life and liberty we (as a society) want to preserve, then by the same token we should empower the state to provide health care as well. The “redress” for disease, then, would consist in the state “making things right,” as in “restoring the natural healthy balance,” or some such. As I’ve said all along, though, this wouldn’t necessarily mean that the state compensates me for anything bad that happens. Likely what would be justified would simply be some sort of universal preventive care network (akin to a military emphasis on deterrence), as well as treatment for diseases and injuries not directly dependent on my autonomous choices.
This leads to your next point, though, and I fully admit that getting clear on the type of libertarianism at issue is essential. If anything, what this discussion has brought out (and reminded me of) are the many variations on libertarianism that are out there.
Thanks everyone for your enlightening contributions. Peace out.
Thanks to Mark vR, David, and others for pushing objections to the libertarian line here. It is striking how quickly more consequentialist and rights-based rationales for libertarianism can begin to diverge in responding to these sorts of problems.
Relative to the rights-based approach (which I prefer), Mark vR’s arguments from the problem of the negative externalities of inadequate care remind me of a really thought-provoking paper on this topic by Daniel Polsby (“Regulation of Food and Drugs and Libertarian Ideals,” Social Philosophy and Policy, vol. 15, 1998). For me, what the argument shows is how crucial it is how we construe the notion of harm: if we construe it broadly enough, then the wave of negative externalities will swamp just about everything in its path, since, as human beings, we are so sub-optimal in just about everything we think and do. (Of course, how such sub-optimal beings can hope to improve their lot through coercive political institutions is another question, but leave that aside.) Intuitively, what we want (what I want, anyway) is a conception of harm that can distinguish between the harm you cause me by failing to wash your hands and the harm you cause me by discharging a bazooka pointed at me. That’s a cartoon, obviously: in between is the harm you cause me by boarding my plane knowing you carry an infectious and drug-resistant form of TB, and it’s not a trivial matter to decide which of the other cases that is more like.
So maybe at this point the best rights-based libertarian contribution is methodological (the consequentialist or economic libertarian arguments may have more to offer): the best solutions we can arrive at for dealing with these touchy cases are likely to come from considering where we draw some theoretical line on the harms (or losses in welfare, or etc.) that we may justifiably resist and which we just have to suck it up and accept as part of the cost of living in a shared world. The libertarian version of that line of thought is that we do that by deciding where to draw property lines so as to enable peaceful resolutions of the inevitable conflicts. That’s messy, but that’s probably about as the problem requires.
A couple of people early on responded to my remark that restricting state intervention to protection from force and fraud is arbitrary. I wanted to clarify: my thought was not that there aren’t any arguments for this restriction, rather, I should have said that I don’t see the moral basis for these arguments. In this I take myself to be in agreement with David S:
“Now I guess I meant to allow that there was indeed a distinction between the two forms of threat, but my question was about the reasonableness of that distinction.”
It seems to me that the best way to think about justified infringements of liberty is along the lines of a contract. And if you think about people contracting into civil society, I can’t see why they would regard threats from other people (who want to beat them up or steal their stuff) as the only important threats. Granted, getting beaten to a pulp by another person is different from getting beaten to a pulp by a hailstorm, and having your car swept away by a tornado is different from having it stolen. But I’m not persuaded that that is a difference that would matter to people who are wondering what infringements of their liberty it makes sense to accept. Maybe I’m just too much a Rawlsian about these matters to see the other side!
I also have a couple of specific questions for the libertarians out there. First, I don’t really see how the existence of free-riders helps to provide a justification for state intervention. If you benefit from my private security force, how does this harm me in a way that libertarians recognize as harm?
Second, where do prohibitions against fraud come from for libertarians? I can see how they are justified in the context of a consequentialist defense of a free market, but what about rights-based arguments? I suppose what I’m wondering is how prohibitions on fraud derive from theories that give pride of place to property rights.
Last, I remember (a very long time ago) reading an argument that the libertarian (and, also liberal — if my shaky memory serves me) conception of harm is a conception of harm that makes sense from a position of privilege. For those who have nothing, property crime doesn’t look like the worst thing (or something like that). Does this ring a bell with anyone?
Valerie,
I’m (obviously) not a libertarian but I do have some sympathy for a relatively stringent duty not to harm. I think that the notion of harm is baseline relative – I harm you if I do something (initiate a process?) that makes you less well off relative to some baseline or other. But whether that speaks against or in favor of some sort of prohibition or prima facie duty not to harm depends on what you think the baseline is. Libertarians often just pick a baseline of full (I want to say Lockean, but it isn’t clear to me that Locke really had the view in full starkness) property rights in things as they happen to be currently distributed and argue from there. That’s not too attractive if you don’t have anything. But I think there are other plausible baselines for determining harm and that these might well be attractive even to those who start out with little or nothing. In fact I think being left in a position where you have to ask other people permission to use some part of the world’s resources for your own well-being can constitute harm. But that requires an argument.
I also want to join in the chorus of folks thanking one another for an interesting discussion here.
Valerie asks, “Where do prohibitions against fraud come from for [rights-based] libertarians? … I suppose what I’m wondering is how prohibitions on fraud derive from theories that give pride of place to property rights.”
Although I have more sympathy with the consequentialist form of libertarianism, I think I know the answer to this.
First, I think most rights-based libertarians give pride of place to autonomy — the ability to make life-defining choices for oneself, free from physical coercion — not to property rights. Property rights are merely seen as rights without which the exercise of autonomy would be impossible and/or meaningless.
There is a long tradition, going back through Kant to earlier jurists (and even, in my opinion, to some comments made by Augustine in De Mendacio) that treats fraud as closely related to the threat of physical coercion. If I tell Richard, “Give me your wallet, or I’ll beat you up,” I gain his consent by by-passing his judgment as to what it is best for him (on the whole) to do. If I withhold some sort of important information from Richard, and thereby gain his consent or cooperation, (e.g., “Give me your wallet, and I’ll examine it to see if you qualify for a free restitching”) I have by-passed his judgment in a similar way.
And if I say, give me your wallet or I won’t pull you out of the quicksand?
Sounds like it might be a good deal. 🙂
But your point is taken: there are more valuable things in the world than deontological-style libertarian autonomy.
Or the shopkeeper says, give me £1 or I won’t give you a loaf of bread?
Or: teach my philosophy courses or I won’t pay you a salary? The interesting question isn’t: are there conditions under which we can see choices as coerced? Obviously there are. But it’s not clear how coercing more people, more of the time, is any sort of solution to that problem.
It also seems to me that there are two questions or possible objections here which it is worthwhile to distinguish: (1) Given the badness of coerced choices, what can we do to avoid them? and (2) Given the badness of being in exigent need, how can we avoid having people be in such need? I think there are good libertarian responses to both, but they are not the same answer. Though they point to the same institutions the rationales are different.
As to the first: From my perspective, the virtue of a libertarian rights approach is that the alternatives are deeply coercive as a matter of institutional fact. That is, not only do they establish situations in which some (even majorities) are taken to be entitled to coerce others as a matter of routine, but those coercive institutions are supposed to earn our moral support and demand our obedience. So it doesn’t seem to me that worrying about coerced choices is the promising line to take in attacking libertarian conceptions of rights.
And this I think is the response to Valerie’s and Mark vR’s points about the response we want to threats. It’s not just that we’d like security from threats of all sorts; obviously we do. But establishing responses that institute as a matter of course relationships between moral agents that we recognize generally as reprehensible (that is, coercive relationships) is not a morally attractive solution. If we can do so via the machinery that arises out of people’s cooperating with each other freely and voluntarily, there is I think a compelling moral case to be made that we should do so. If that is right, then the argument against libertarianism turns on the concerns about “market failure” as in e.g. the national defense case and free riding. But (like others Matt indicated earlier) I’m not sure that there are such cases, and in any event I’m not interested in making a case for public provision of defense either.
On the second: As I indicated before, I think the “baseline” question is indeed the important one. But, unlike Jason, I think property rights is the right framework for thinking about answers to it. For one thing, we (arguably) have property rights in our persons and labor. One important consequence of that is the right to contract, which is obviously important for lots of things libertarians hold dear, like markets. The dicey part is how property rights are accorded in the shared physical world. And here the empirical and consequentialist arguments come to the fore. The point (a point, anyway) is not that an individual poor person is better off for having his right to his non-existent property protected. The point is that he is better off for living in a society in which they are such rights. And there are fewer such people in societies with robust protection for rights in property than in societies without such protections. If we want conditions under which people don’t find themselves limited in their choices by exigent need, robust rights in property have done more to move more people out of such conditions than any other political arrangement we’ve hit upon. Obviously nothing is perfect, but the comparison class isn’t perfection anyway but the other imperfect alternative ways of organizing our social lives.
Regarding the “give me a dollar or else…” line of argument, it’s probably worth keeping clear on the distinction between coercion and exploitation here. As I see it (although this is not entirely untcontroversial) the distinction between A’s coercing B and A’s exploiting B turns on the source of the harm that B is trying to avoid. In typical cases of coercion, the source of the harm is A. “Give me one dollar or else I’ll shoot you.” B gives the dollar to A in order to avoid a harm that would have never befallen him had A not been in the picture. In typical cases of exploitation, on the other hand, the source of the harm that B is trying to avoid is independent of A. “Hey, I see you’re in some quicksand. Give me a dollar and I’ll pull you out.”
Now, there are clearly borderline cases here, but in general I think this distinction reflects an important moral difference. And the reasons libertarians have to worry about coercion and use state force to prevent it might not be equally good as reasons to worry about and coercively prevent exploitation. [For example, I think it makes good obviously good sense to refuse to legally enforce coercive agreements. I’m not so sure it makes good sense to refuse to legally enforce exploitative ones. If I’m drowning in quicksand, and my only option is to continue to drown or to be exploitatively rescued, I’ll take the exploitative rescue]. So, anyway, I’m not sure this line of examples is very helpful in getting at the relationship between libertarianism and coercion.
There are libertarians, libertarian arguments but no libertarian states, so it seems difficult to answer David’s Shoemaker’s initial question with any integrity. What I mean by this is that most libertarians advocate for a no-holds-barred form of free-market capitalism and simultaneously restrict the government from financing something like universal health care. In a politico-historical limbo these two claims do not appear at odds with each other, yet given that absolute theoretical neutrality and god’s eye perspectives are completely untenable, libertarians find themselves supporting a free-market that is itself a recipient of mass amounts of government welfare. So, of course, what group of free capitalists would favor a state-financed health care system over the excesses of profit? But the obvious catch is that government — via the people’s tax-dollars — is necessary for a free-market not only to protect it through the use of military force, but also to finance its ever-growing (international) expansion.
Although out-of-step with what I had a chance to read in the responses, I’d be interested in hearing why libertarians would prefer to militarily protect the right to exist within a free-market, yet not the health of the consumers within it.
This is a very interesting discussion and I am glad to see libertarianism being discussed amongst a larger audience. However, I have to note that the particular point made by Matt Zwolinski -that we must first very clearly indicate which version of libertarianism we are talking about- is incredibly important.
As to the topic at hand, I think that the AnCap explanation answers this question most clearly since it sees taxation(meaning non-consented to confiscation of property) as inherently wrong. As such, the very question of which services government can and should provide is made uninteresting, since the answer is always: precisely none(so long as those services are funded by involuntary transfers of property).
The version of libertarianism in discussion all along has been minarchism and it is, as you can see, quite different. However, I certainly don´t think that the discussion above has been without merit, but the question that it would answer would be a different one in order to be truly relevant(at least in a broader libertarian context). This question would be: Which services would it be fair for the mutually agreed to society that we entered into to require those who want to be it´s new members to also support?
If you are truly interested in learning about libertarianism, this is an excellent place to start(lots of free articles, books, videos, audio clips, and a good forum):
http://www.mises.org/journals.aspx
This is a very interesting discussion and I am glad to see libertarianism being discussed amongst a larger audience. However, I have to note that the particular point made by Matt Zwolinski -that we must first very clearly indicate which version of libertarianism we are talking about- is incredibly important.
As to the topic at hand, I think that the AnCap explanation answers this question most clearly since it sees taxation(meaning non-consented to confiscation of property) as inherently wrong. As such, the very question of which services government can and should provide is made uninteresting, since the answer is always: precisely none(so long as those services are funded by involuntary transfers of property).
The version of libertarianism in discussion all along has been minarchism and it is, as you can see, quite different. However, I certainly don´t think that the discussion above has been without merit, but the question that it would answer would be a different one in order to be truly relevant(at least in a broader libertarian context). This question would be: Which services would it be fair for the mutually agreed to society that we entered into to require those who want to be it´s new members to also support?
If you are truly interested in learning about libertarianism, this is an excellent place to start(lots of free articles, books, videos, audio clips, and a good forum):
http://www.mises.org/journals.aspx