OP-ED

The Libertarian Mind

“It is an eternal obligation toward the human being not to let him suffer from hunger when one has a chance of coming to his assistance.” –Simone Weil

Libertarianism is much in the news these days, as the political divide in the U.S. seems to widen almost before our eyes. Before providing a rough, notional definition of “libertarianism”, I should offer readers some caveats. First, I am not a political scientist, professional philosopher, or economist, though scholars in these fields have offered many pointed critiques of what is loosely called libertarianism (see references). Furthermore, as a psychiatrist, I am trained to diagnose individuals whom I have professionally examined. I am not in the habit of “diagnosing” movements, ideologies, or political groups; indeed, the idea of doing so is clearly outside the purview of medical or psychiatric practice.

Nonetheless, as a lecturer on bioethics and humanities, it is impossible for me to read the platform and proclamations of the Libertarian Party without drawing some tentative conclusions as regards the nature of this movement; its psychological underpinnings; and its ethical implications for the poorest and sickest among us—those sometimes referred to as “the destitute sick.”

I do not propose to “psychoanalyze” particular individuals, or to speculate on the motives of political figures who figure prominently in American politics. And, because the term “libertarian” has such a wide range of meanings, I will focus my attention on the official platform of the Libertarian party, which is very lucidly spelled out in a publicly-available venue (http://www.lp.org/platform). For the most part, I will deal with the Libertarian party’s position on health care and social support systems, while offering some tentative impressions on the “psychology” of libertarian theory.

I do not pretend to offer an “objective” analysis of these issues. As a psychiatric physician and bioethicist, I am committed to certain ethical principles which put me squarely and starkly at odds with certain libertarian positions. This is not to say that psychiatrists are of one opinion on these matters—far from it. Moreover, I recognize that physicians and ethicists of good will may support the very positions I will castigate. I also recognize that, whatever the ethical failings of the Libertarian party’s views, there are undoubtedly many self-identified libertarians whose ethical impulses are humane and compassionate. Nonetheless, I will argue that this is simply not true of the Libertarian party’s position on health care and social support systems. At the same time, as a psychiatrist, I recognize that some positive elements of libertarianism—such as its emphasis on personal autonomy, personal responsibility, and self-discipline—are in accord with general principles of mental health and with the goals of many schools of psychotherapy.

The varying definitions of “libertarianism”

It is a mistake to consider libertarianism a monolithic entity or ideology. Indeed, some strains of libertarianism seem to contradict the basic tenets of other strains. As the philosopher Prof. Peter Vallentyne has noted, libertarianism is neither a “right wing” nor a “left wing” philosophy, but varies according to the particular issue in question. For example, as Vallentyne notes, “…on social—rather than economic—issues, libertarianism tends to be “left-wing”…” whereas many libertarian views on taxation, health care, and the economy gravitate toward “the right”.

For purposes of my argument, the preamble from the Libertarian Party website adequately describes the libertarian philosophy, as follows:

“We hold that all individuals have the right to exercise sole dominion over their own lives, and have the right to live in whatever manner they choose, so long as they do not forcibly interfere with the equal right of others to live in whatever manner they choose… Governments throughout history have regularly operated on the opposite principle, that the State has the right to dispose of the lives of individuals and the fruits of their labor. Even within the United States, all political parties other than our own grant to government the right to regulate the lives of individuals and seize the fruits of their labor without their consent. We, on the contrary, deny the right of any government to do these things, and hold that where governments exist, they must not violate the rights of any individual…”

The Libertarian Party Platform on Healthcare and Social Support Programs

The Libertarian Party platform states,

“We favor restoring and reviving a free market health care system. We recognize the freedom of individuals to determine the level of health insurance they want, the level of health care they want, the care providers they want, the medicines and treatments they will use and all other aspects of their medical care, including end-of-life decisions. People should be free to purchase health insurance across state lines.” [italics added]

Similarly, with respect to retirement and “income security”, the Libertarian party position states,

“Retirement and Income Security Retirement planning is the responsibility of the individual, not the government. Libertarians would phase out the current government-sponsored Social Security system and transition to a private voluntary system. The proper and most effective source of help for the poor is the voluntary efforts of private groups and individuals. We believe members of society will become more charitable and civil society will be strengthened as government reduces its activity in this realm.[italics added]

The same basic stance is taken in the Libertarian position on what they term “the social welfare system”:

“We should eliminate the entire social welfare system. This includes eliminating AFDC, food stamps, subsidized housing, and all the rest. Individuals who are unable to fully support themselves and their families through the job market must, once again, learn to rely on supportive family, church, community, or private charity to bridge the gap.” [italics added]

It is striking that no empirical evidence is proffered to support the claim that the “most effective” source of help for the poor is the “voluntary efforts of private groups and individuals”; much less that society “will become more charitable and civil” as government reduces its activity in this realm. It is probably difficult for the Libertarian party to cite empirical case examples, since no industrialized nation has ever adopted a strictly libertarian position on retirement and income security—or, for that matter, on health care delivery.

Indeed, the research of economist Prof. Jeffrey Sachs argues against the libertarian position on health care and social supports, albeit indirectly. Sachs compared  a group of “…relatively free-market economies that have low to moderate rates of taxation and social outlays with a group of social-welfare states that have high rates of taxation and social outlays.”  He refers to the first group (including the U.S., U.K, Canada and Ireland) as the “Anglo-Saxon countries,”  and the second group (including Denmark, Finland, Norway and Sweden) as “the Nordic countries.” Sachs notes that  “…budgetary outlays for social purposes average around 27 percent of gross domestic product (GDP) in the Nordic countries and just 17 percent of GDP in the English-speaking countries.” Sachs’s research found that

“On average, the Nordic countries outperform the Anglo-Saxon ones on most measures of economic performance. Poverty rates are much lower there, and national income per working-age population is on average higher. .. [Furthermore]…the results for the households at the bottom of the income distribution are astoundingly good, especially in contrast to the mean-spirited neglect that now passes for American social policy. The U.S. spends less than almost all rich countries on social services for the poor and disabled, and it gets what it pays for: the highest poverty rate among the rich countries and an exploding prison population. Actually, by shunning public spending on health, the U.S. gets much less than it pays for, because its dependence on private health care has led to a ramshackle system that yields mediocre results at very high costs.”

And even within the so-called “Anglo-Saxon” countries, the U.S. health care system compares unfavorably, in several respects, with that of Canada. In what is arguably the definitive study of US/Canadian administrative health care costs, published in the New England Journal of Medicine, Woolhandler et al (2003) analyzed the costs of insurers, employers, doctors,  hospitals, nursing homes and home-care agencies in both the U.S. and Canada. They found that administration consumes 31.0 percent of U.S. health spending, double the proportion of Canada (16.7 percent).Average overhead among private U.S. insurers was 11.7 percent, compared with 1.3 percent for Canada’s single-payer system and 3.6 percent for Medicare.  Furthermore, the authors concluded that “…excess administrative overhead can be attributed to the highly complex private health insurance system in the United States.”

Woolhandler  et al argued that, if streamlined to Canadian levels, enough administrative waste could be saved in the U.S. to provide comprehensive health insurance to all Americans. The website of Physicians for a National Health Program  (http://www.pnhp.org) makes a comprehensive case for a publicly-funded, single-payer insurance plan.

Moral Implications of the Libertarian Stance

For those among the destitute sick who have been unable to afford any health insurance at all, it will be of small consolation that the Libertarian party wants them to have the “freedom” to “determine” the level of health insurance and to purchase it across state lines. If these were even remotely practicable ideas, it would follow that all who wanted full health insurance coverage for serious chronic illness would have the “freedom” to obtain it. Of course, this is simply not possible in the real world, much less in our present economic environment.  Indeed, the libertarian’s position is a bit like strongly supporting the individual’s “freedom” to flap his arms and fly.

The Libertarian party platform seems quite content to claim that if the government pulls back from aiding the poor, “society” will somehow take up the slack—while carefully avoiding any implication that each of us, including members of the Libertarian party, has an affirmative  moral duty to aid the poor. And, predictably, the platform is silent on what the sick and destitute are to do if “the voluntary efforts of private groups and individuals” fail to materialize.

Libertarians aver that “A compassionate society will find other ways to help people who need temporary assistance.” (http://www.lp.org/platform) Yes–and if we lived in a reliably “compassionate” society, the libertarian agenda might work out quite well. Unfortunately, in hard economic times, the ability of private charities and philanthropic organizations to help the needy is drastically reduced.  For example, in 2008, the Rocky Mountain News reported that

“Wall Street’s troubles and the faltering economy are delivering a one-two punch to Colorado’s food banks, animal shelters and other nonprofits such as the Salvation Army and the American Red Cross. These organizations are experiencing greater demand for their services from people in need. But the increased demand is coming just as these groups are bracing for a cutback in financial contributions from their donors – if the cutbacks haven’t already occurred because of the economy. (http://www.rockymountainnews.com/news/2008/oct/09/donations-to-charities-decline/)

More recently, according to the Oct. 18, 2010, Charlotte Observer,

“A new ranking of the nation’s 400 biggest charities shows donations dropped by 11 percent overall last year as the recession ended – the worst decline in 20 years since the Chronicle of Philanthropy began keeping a tally… An earlier report by the Giving USA Foundation found overall charitable giving declined 3.6 percent last year. That report included giving to private foundations and to smaller charities, while the Chronicle’s survey only includes top charities raising money from the public.”

(http://www.charlotteobserver.com/2010/10/18/1769542/charity-donations-fall-11-the.html)

Notice that in the Libertarian platform, there is little or nothing as regards the moral responsibilities of anyone in particular, such as members of the Libertarian party.  (One exception: libertarians must abjure the violent coercion of others). The task of aiding the sick and destitute is left, nebulously, to “society” which, in the worldview of libertarianism, will naturally and inevitably produce a sufficient number of “compassionate” members.  To be sure: some libertarian proposals for improving access to health care are worth considering, such as establishing tax-free medical savings accounts, or making health care expenditures fully tax-deductible. But these would benefit primarily those steadily employed and able to put money aside on a regular basis—not those who have been unemployed for months or years, much less the homeless or destitute.

Perhaps members of the Libertarian party are afraid that if they dare invoke the moral responsibilities of their own membership in assisting the destitute poor, busy-body “liberals” will inevitably turn this into a legal obligation to help others, which is clearly anathema to libertarians. For my part, it is hard to read the Libertarian party’s philosophy of health care and social welfare without feeling the icy wind of indifference to the destitute sick.

Libertarianism as Inverted Narcissism

In psychological terms, narcissism may be either “healthy” or “pathological” in nature and degree. A certain amount of positive self-regard is essential for self-preservation and the pursuit of one’s prudential interests. But beyond a certain point, self-regard can become a kind of grandiose self-worship, characterized by an inordinate sense of “entitlement.” It may seem paradoxical, even perverse, to accuse libertarians of an overweening sense of entitlement. After all, isn’t the cardinal tenet of libertarianism the claim that individuals must stand on their own two feet, without expecting “handouts” from the government? Indeed, a libertarian might well object that, “It’s the liberals and socialists who have an exaggerated sense of entitlement! They are the ones who are constantly demanding that the government take care of them, furnish them with health care, retirement income, and social welfare programs.”

It is true that the narcissism of the libertarian movement is not always evident on first inspection of its claims. The sense of entitlement among libertarians is not straightforward, and appears in some curiously “inverted” forms. And yet, the grandiosity of the libertarian position is hard to miss. In effect, the libertarian proclaims, “I’m such a tough, self-reliant hombre—not like you simpering, teat-sucking wimps!—that I don’t need or expect any help from anybody, and the rest of you should live the same way I do, no matter what your capabilities or disabilities, and no matter how poor or sick you may be.” Indeed, as Robert Locke has put it,

“Libertarianism itself is based on the conviction that it is the one true political philosophy and all others are false. It entails imposing a certain kind of society, with all its attendant pluses and minuses, which the inhabitants thereof will not be free to opt out of except by leaving.”

Locke further points to libertarianism’s “…genius for making its followers feel like an elect unbound by the moral rules of their society.”

More charitably, the libertarian stance may be viewed as a highly rationalized variation on the “rags to riches” theme popularized by the 19th century novelist, Horatio Alger. Although there is plenty to admire in the figure of the “self-made man” who succeeds through a combination of pluck and luck, libertarianism takes the Alger mythos to cruel extremes. It exhorts the individual to “Pull yourself up by your bootstraps!” even when the unfortunate person in question has no boots–and perhaps, no feet. Thus, when libertarians insist that “Individuals who are unable to fully support themselves and their families through the job market must… learn to rely on supportive family, church, community, or private charity to bridge the gap…” they are proffering a perverse mirror-image of the infamous line popularly attributed to Marie Antoinette: “Let them eat cake!”  For the libertarian, this becomes, “Let the poor and destitute find charity somewhere!” The not-so-covert implication seems to be, “If you were fool enough to get yourself into this mess—for example, by not saving up $20,000 to pay for this year’s chemotherapy—you’ll just have to find somebody to take care of you.”

Nowhere is there any discussion of what should be done to help the sick and destitute when “supportive” family, friends, or private charities are unwilling or unable to step in.  Should the government do nothing, and let the sick and destitute die of hunger or chronic illness? The Libertarian platform is silent on this matter—for this is a troubling question, and, from my perspective, many libertarians show little interest in being troubled. For them, life would really be no problem at all, if only government would get off our backs and let the strong and the free prosper. There is a kind of adolescent naivete in this, but also a strong whiff of elitist hypocrisy. As Gabriel Winant recently wrote,

“Libertarians…are walking around with the idea that the world could just snap back to a naturally-occurring benign order if the government stopped interfering…this is the belief system of people who have been the unwitting recipients of massive government backing for their entire lives. To borrow a phrase, they were born on third base, and think they hit a triple… [furthermore]…they’re thoroughly out of touch with reality. It’s a worldview that prospers only so long as nobody tries it, and is too unreflective and self-absorbed to realize this.”

To be sure, there are positive elements within the libertarian world-view. No American who grew up reading Ralph Waldo Emerson’s essay on “self-reliance” could doubt that this is a virtue. Nor would most Americans deny the value of protecting civil liberties and the blessings of freedom. But as Robert Locke observes,

“Empirically, most people don’t actually want absolute freedom, which is why democracies don’t elect libertarian governments. Irony of ironies, people don’t choose absolute freedom. But this refutes libertarianism by its own premise, as libertarianism defines the good as the freely chosen, yet people do not choose it. Paradoxically, people exercise their freedom not to be libertarians.”

And when it comes to Libertarian party views on health care and social welfare, this physician finds only a shallow ethos of callousness, cloaked in the populist rhetoric of “freedom” and “responsibility”.  The Libertarian view on these matters seems to me little more than grandiose and jejune utopianism, masquerading as high-minded respect for individual rights. Surely, a humane society that cares about its sickest and poorest citizens must do better than that.

References

Libertarian Party Platform  http://www.lp.org/platform

Peter Vallentyne, “Libertarianism”, Stanford Encyclopedia of Philosophy, accessed at: http://plato.stanford.edu/entries/libertarianism/

Jeffrey D. Sachs, The Social Welfare State, beyond Ideology

Scientific American Magazine November 2006

Gabriel Winant, The lesson of Rand Paul: libertarianism is juvenile. Salon, accessed at http://www.salon.com/news/politics/war_room/2010/05/21/libertarianism_who_needs_it

Robert Locke, Marxism of the Right, in The American Conservative, March 14, 2005.  Accessed at: http://www.amconmag.com/article/2005/mar/14/00017/

Woolhandler S, Campbell T, Himmelstein DU.  Costs of health care administration in the United States and Canada. N Engl J Med. 2003 Aug 21;349(8):768-75.

Ronald Pies, MD, is Professor of Psychiatry and Lecturer on Bioethics & Humanities, SUNY Upstate Medical University, Syracuse, NY, and Clinical Professor of Psychiatry, Tufts University School of Medicine. He is the author of several psychiatric textbooks, as well as several books on religious ethics (“Ethics of the Sages,” “Everything Has Two Handles”). His most recent book, “Becoming a Mensch”, has just been released by Hamilton Books/Rowman & Littlefield.

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Joel Hassman, MDRyanSmart LibertarianDeterminedMDRonald Pies MD Recent comment authors
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Joel Hassman, MD
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Joel Hassman, MD

There are too many people in positions of power and influence have the mind set and say outwardly, who as the Jack Nicholson Character in “A Few Good Men” tersely says: “You (the American Public) can’t handle the truth!” Libertarians, in my humble opinion, really scare the hell out of Democrats and Republicans, because this political mind set does not genuflect inherently to a political partisan cause either side of the real Republocrat party as a single entity is selling daily. Independence, really is the antithesis of what our alleged representation wants for its’ servants, er, constituents. Oh, and I… Read more »

Smart Libertarian
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It really comes down to economics, the price system, profit and loss system, and mutually beneficial exchange. I am not going to read the article because only 1 of 3 things is likely: 1. He is absolutely correct and totally understands libertarians and economics and agrees with them (not likely) 2. He thinks he understands libertarians and economics and shows you why they are wrong (likely) 3. He fully understands libertarians and economics but lives in a dream world where economics doesn’t matter and tugs on your heart strings about grandma with cancer and that if only someone were taxed… Read more »

DeterminedMD
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DeterminedMD

Dr Pies, what are you doing here? I thought this was Psych Central for a second, and then realized I was at TheHealthCareBlog after all. Let me offer you my opinion about going on at blog sites and commenting as you do. People sometimes have the unfortunate impression that someone of your stature, until proven otherwise, is a Key Opinion Leader (which you are as a psychiatrist and wrote wonderful columns at the Psychiatric Times in the past) and thus has some validity and representation of the group you mention partnership to, and that is dangerous. Dangerous, because in the… Read more »

Ronald Pies MD
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Ronald Pies MD

I appreciate THCB’s publishing my commentary on the Libertarian Party platform, and I understand that this is a complicated and emotional issue. Before any further comments come in, I’d like to state my usual policy re: “internet etiquette”. I do not respond to anonymous postings, with very rare exceptions (e.g., someone’s life or limb is endangered by giving his/her full name). My view is that if I or any of my colleagues are putting our names and reputations on the line, the same should be the case for those who respond to the posting. I will also not respond to… Read more »

John Irvine
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My favorite line:
“I am not in the habit of “diagnosing” movements, ideologies, or political groups; indeed, the idea of doing so is clearly outside the purview of medical or psychiatric practice.”
I’d be kinda of interested to read your professional take on, say, the Tea Party movement. ; )

Tim
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Tim

That was a lot of words to say that if you think charity should be only voluntary you are demented.

coyote
Guest

Hmm, well you seem intent on making sure everyone understands the core assumptions of libertarians. Lets make sure that everyone understands your core assumptions as well. The core of libertarianism is that humans should not deal with each other using force or fraud. Everything flows from that single point. So, in our example of free health care for the poor (or free anything to anyone), libertarians will say they oppose government action to achieve it because the only way to do so is through the use of force — either a doctor must provide his time for free or a… Read more »

Ryan
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Ryan

There is one fundamental flaw in your argument:

Assuming other people will not use force or fraud to get what they want.

Evidence:

Human history

Smart Libertarian
Guest

Well, most libertarians are not anarchists. Most libertarians believe that one of the few roles government should play is to protect people and markets from force and fraud. If someone commits fraud against you, you should be able to go to the government to seek justice.