“A decent provision for the poor is the true test of civilization.”
“Joe” has been on the streets now for two months. He’s 35, unmarried, and diagnosed with chronic schizophrenia since age 19. His illness is difficult to manage, even with regular medication, and Joe is subject to hallucinations telling him to “fight off the evil ones”. Like most people with psychiatric disorders, Joe has never been violent—but when his illness is not well-controlled, he can become loud and belligerent.
Despite his many tries at holding down a job, the economic downturn and his worsening psychosis have left Joe jobless and homeless. Joe’s family thinks he is “faking” his symptoms and they are “fed up” with him. They have refused to take him in or help him with his medical care. Joe has no friends willing to help him and survives on the streets by panhandling and dropping in at soup kitchens. The local shelters won’t accept Joe, because he is “too agitated.” Joe sleeps in alleyways, or, when lucky, in ATM stations. In the past month, he’s been beaten up twice by members of youth gangs. Recently, Joe was diagnosed with type 2 diabetes, requiring daily medication and monitoring. Joe says he doesn’t want “charity”, and would like to work again, but doesn’t see how he can.
“Joe” represents many patients I’ve cared for during nearly 30 years of medical practice, and typifies thousands of Americans with severe mental illness. In my previous blog entitled, “The Libertarian Mind”, I posed this question: what is the moral responsibility of federal and state government to help care for people like Joe? I argued that the Libertarian Party platform—calling for the abolition of “the entire social welfare system”, including food stamps—is neither humane nor compassionate.
And, I argued in favor of a publicly-funded, single-payer insurance system, as advocated by PNHP (Physicians for a National Health Plan). Although a few readers wrote in support of my position, many (mostly anonymous) commentators were very critical. Nobody who wrote in really answered my question directly. I’d now like to address some of the criticisms of my piece, as well as to debunk some myths surrounding the history of the health care in this country. First, though, I need to sketch the general health care picture in the U.S. today.
Many commentators of all political stripes would agree that the U.S. health care system is in deep trouble. Despite our tremendous progress in medical research and technological innovation, our health care system is not “delivering” to those who need it most: the very poor and sick, whose friends, family, or community cannot or will not help them. Far from having “the best health care system in the world”—as some politicians have claimed—our system is failing in the most basic measures of medical care. This is not for lack of spending. As Victor Fuchs PhD, of Stanford University recently wrote in the New England Journal of Medicine (Dec. 2, 2010), the U.S. government “…currently spends more per capita for health care than eight European countries spend from all sources on health care. Though life expectancy is far from a perfect measure of the quality of care…life expectancy at birth in every one of these eight countries is higher than that in the U.S.” And, in a recent Commonwealth Fund-supported study comparing “preventable deaths” in 19 industrialized countries, researchers found that the United States placed last.
The huge amount of money spent on administrative costs in the U.S. –rather than on direct care—is a major factor in these disparities. At the same time, mental health care is badly under-funded, even allowing for the recent recession. More and more of the burden of caring for the destitute and homeless with mental illness is falling on our police force. As the New York Times recently reported (Dec. 5, 2010), “A lot of people view calling the police as the only way to get loved ones any kind of treatment…” with the result that “…many patients who need a doctor get a law officer instead.” People like Joe are barely able to scrape by in the best of times, with the aid of state and federally-funded programs like Medicaid. Abolishing such programs, as the Libertarian Party advocates, would likely be a death sentence for thousands of people like Joe.
But the prospect of such deaths does not seem to trouble some individuals who proclaim a “libertarian” ideology. One person who wrote to criticize my previous blog argued that “…Libertarianism accepts that life happens and some people will live less fulfilling lives and die early, but overall, everyone will live better…” Furthermore, this reader argued that the voluntary efforts of private groups and individuals have been far more reliable than government aid, pointing to the government’s response during Hurricane Katrina. This same reader also worried what would happen in a “liberal utopia” when “government support doesn’t materialize.” Let’s leave aside the question of how many more people would have died during Katrina, had the federal government not intervened, and consider this reader’s basic premise: it’s sad when some people die of starvation and neglect, but, hey—that’s life. It’s all in the service of the greater good. Presumably—and in an indirect response to my question—this reader believes that the federal and state government owes nothing to the destitute sick and hungry, even when their family and friends have deserted them. I was wrong, in my first article, to characterize such an attitude as one of “narcissism.” The correct term is “depraved indifference.” Now, I happen to believe that this particular reader, like most Americans, would “do the right thing” for someone like Joe. In general, I find that most people are better than some of their cockamamie theories. But the savage irony of libertarianism is that it pretends to honor the individual, while actually viewing any particular individual as a potential pawn—readily sacrificed in the name of the greater good. Libertarians are welcome to this predacious view of “governance”. I for one would not wish it on a pack of jackals.
As for that “liberal utopia”— “utopia” literally means, “no place”–it is striking that no place on earth has ever demonstrated that a purely libertarian form of governance can succeed, much less provide adequate health care for the destitute sick. I am not a political philosopher, but I consider caring for the destitute sick a profoundly conservative act. It conserves the most precious resource we have—our fellow citizens—and helps them return to health, work, and productivity. I am not talking about “charity” for someone like Joe—I am talking about food, shelter, and health care. I’m talking about a vocational rehabilitation program to help Joe get back into the work force.
Some self-described libertarians argue that a government that finances such services may eventually go bankrupt. I say that a government that shirks its obligations to the destitute poor is morally bankrupt and deserves no support from its citizens. When we pass by a river and see someone drowning, we take it upon ourselves to throw that person a life preserver. We do not protest, “But I might wrench my shoulder, if I have to do this three or four more times today!” Governments are not abstractions: they are collections of individuals. I do not want to hold government in the aggregate to a lower moral standard than the one I expect of individuals. The hypothetical fear of “bankruptcy” does not negate the government’s moral duty to protect the health and safety of its most vulnerable citizens.
Another critic of my first essay asked plaintively that we remember America during its “first 150 years” of existence. “Remember that America?” he wrote. “The land of the free? The land of opportunity? You ask for evidence that families, friends, churches, communities, and charity organizations would be enough to support the needs of society, discounting the fact that we successfully existed on such a system for the majority of our nation’s existence.”
Ah, yes—I do remember. I saw that America portrayed on an old TV show called “The Waltons”, in which a tough, decent family used to take in needy strangers during the worst years of the Great Depression. Perhaps the commentator I’m quoting would act in the same, decent manner. But there is little in the history of American health care that accords with that Hollywood script. (By the way, as regards “the land of the free” and “the land of opportunity”: did the writer forget that until 1865, 4 million black Americans were in chains? And that women did not get the vote until 1920?).
For most of the 18th century, prior to the rise of “poor houses” in this country, many paupers who could not secure family or community support were auctioned off like cattle. They were actually sold to the lowest bidder–the person who would agree to provide room and board for the lowest price—and effectively became indentured servants (see http://www.poorhousestory.com).
Prior to the Social Security Act of 1935, and for much of the 18th and 19th centuries,
“…most poverty relief was provided in the almshouses and poorhouses. Relief was made as unpleasant as possible in order to “discourage” dependency. Those receiving relief could lose their personal property, the right to vote, the right to move, and in some cases were required to wear a large “P” on their clothing to announce their status.” [http://www.ssa.gov/history/briefhistory3.html].
As for the destitute sick who lacked families to care for them, for much of the 19th century, they were dependent largely on “charity hospitals”, supported by generous donors, in which doctors provided care free of charge. This might seem to support the claim that we “successfully existed” with a charity-based system of health care. Unfortunately, charity hospitals were subject to the whims and means of their donors. For example, the Boston Lying-in Hospital (later, Brigham and Women’s Hospital) provided free care for indigent women, but had to close in 1856 because it could not meet expenses. It was not able to re-open until 1873. In our own time, similar financial problems forced closure of New Orleans’ famed “Charity Hospital” after Hurricane Katrina—an institution that cared for tens of thousands of the uninsured sick. In such circumstances, do we really want to say that the state and federal government have no obligations whatsoever, and no right to raise any revenues in behalf of the destitute sick?
As a nation, we can and must do better. There are feasible economic plans, described on PNHP website, that will allow us to provide basic health care to all Americans, without breaking the bank. “Joe” is not a lazy, ne’er-do-well, nor are the thousands like him in this country. Joe is your neighbor, your friend, or your cousin. More important: Joe is your brother.
References and readings
Victor R. Fuchs: Government payment for health care—causes and consequences. New England Journal of Medicine, Dec. 2, 2010.
Ellen Nolte, Ph.D, C. Martin McKee, M.D “Measuring the Health of Nations: Updating an Earlier Analysis” (Health Affairs, Jan./Feb. 2008),.e
Katie Zezima: State cuts put officers on front lines of mental care. New York Times, Dec. 5, 2010.
Boston Lying-in Hospital. Records, 1855–1983. Francis A. Countway Library of Medicine. Accessed at: http://oasis.lib.harvard.edu/oasis/deliver/~med00056
Pies R: Health Care is a Human Rights Issue. Psychiatric Times. Nov. 15, 2010. Accessible at: http://www.pnhp.org/news/2010/november/health-care-is-a-human-rights-issue
Single-Payer FAQ: Physicians for a National Health Program. Accessed at: http://www.pnhp.org/facts/single-payer-faq#costs_down
Libertarian Party Platform, 2010. Accessed at: http://www.lp.org/platform
Ronald Pies, MD, is Professor of Psychiatry and Lecturer on Bioethics at SUNY Upstate Medical University; and Clinical Professor of Psychiatry at Tufts University School of Medicine. He is the author of several books on comparative religious ethics, including Becoming a Mensch (Hamilton Books). Dr. Pies reports no financial arrangements or professional affiliations with any political party.