The Prisoners' Dilemma, Rawls' Theory of Justice and the Healthcare Debate
Napkin Presentation thanks to John-Folk Williams at Cross-Collaborate
Cheyney Ryan, a philosophy professor at the University of Oregon, contributed a short but extremely useful article to the must-have Negotiator's Fieldbook entitled Rawls on Negotiating Justice. John Rawls, Ryan explains, is the seminal philosopher of justice in the 20th century. "From the start," writes Ryan,
Rawls asked us to think of justice as a matter of agreement. He suggested that we think of the principles guiding a just society as the ones that individuals would agree to -- with the crucial proviso that they do not know where they themselves would end up in society, on the top or the bottom. They would thus act from behind a "veil of ignorance . . . Given this constraint, no individual could tailor the principles of justice to his or her special talents or circumstances, which is why Rawls called this approach "justice as fairness." Rawls suggested that the principles that would be agreed to would be ones that were deeply committed ot basic human rights and had a strong presumption in favor of economic equality. Inequalities would only be tolerated if they most greatly benefited the least well off.
According to Ryan, Rawls later concluded that the reciprocity inherent in bargained-for resolutions and a negotiated mutual advantage were insufficient to ensure justice. "The question to ask of principles of justice," Rawls asserted, was,
what were the most reasonable ones for people to agree to given the nature of our society and the nature of who we are? Justice, thus reconceived, lost the harsh individualism that Rawls' earlier theory seemed to possess. The stress on reasonableness meant that people taking others into account was an essential part of what justice was all about. His theory also moved away from his earlier hyper-abstraction, insofar as we talk of what is "reasonable" invariably refers not to some hypotheitcal persons with hypotheical aims but to real people -- in this case, us, here and now.
So this is what I'd like to ask my readers to do about the health care debate right after the jump.
It's a thought experiment. I don't want to urge you to think about it the way I do. I don't want you to think about it as a progressive, a liberal, a Republican, a Democrat or an Independent. I don't want you to think about it as an insurance executive or even as a taxpayer. I don't want you to think about the probable effect of the pending Bills on the economy (unless you're an economist with the credentials to do this). Here's what I want you to do and I want you to ask your friends and neighbors and congresspeople and senators and your insurance broker and chamber of commerce and PTA and Bar Associations to do:
Blind yourself to your socio-economic status, if only just temporarily. If it helps, think of someone who is as far distant from your own place in society as possible. If you are an insurance coverage attorney with a nice house in a good neighborhood with quality schools and a good health care plan, I want you to imagine yourself a pregnant teenager who has no father and whose mother works as a cashier at a local hardware store that cannot afford to purchase group health insurance. She is under-insured, having purchased the only plan she could afford. She was diagnosed with breast cancer just last week.
If you are unemployed and your COBRA benefits are running out, I want you to imagine yourself a United States Senator with responsibility for insuring that all Americans have access to quality health care while at the same time answering to the folks back home who are afraid the cost will show itself in increased taxes; the quality of care will plummet; and, the insurance industry will be hobbled, decreasing the benefit of private insurance plans to those who have them now.
Ready?
Now do what Rawls asks. Acting behind a veil of ignorance about your place in the social order, craft a principled means of providing Americans with healthcare (government-funded, privately offered or a combination of both) that is a fair and reasonable means for achieving the greatest good for the greatest number. If that seems daunting, shrink your world to the size of a tropical island like the ones the survivors of the TV series Lost live on. And if you've never seen Lost, just think of a society on an island cut off from communication with the rest of the world with about 100 people -- 50 in one "camp" and 50 in another -- with a single physician able to serve everyone's needs. Here are some season previews that will help you get the Lost idea.
Go! Please ask your friends to participate, leave your solutions in the comments box and tweet this!
The Prisoners' Dilemma piece of this before day's end.
Comments (13)
Read through and enter the discussion by using the form at the endTimothy R. Hughes - December 16, 2009 11:59 AM
The health care discussion makes my head hurt. I have read a lot about it, and it seems like there are so many issues, tangled together, that unraveling them is virtually impossible.
We pay way too much and do not get better results. It seems like basics of broadened basic coverage coupled with some level of tort protection to limit defensive medicine, better definition of best practices based on actual scientific results, and more realistic use of medicine for end of life is necessary to get the system back into balance.
Debra Healy - December 16, 2009 3:41 PM
Regarding "If you are unemployed and your COBRA benefits are running out..."
It is highly unlikely that if you are unemployed you can afford the exorbitant cost of COBRA coverage.
Furthermore, it is very likely that if you're "fortunate" enough to own a home and you're unemployed, the home is in foreclosure.
Okay - now imagine you're diagnosed with cancer.
Thanks.
Debra
Vickie Pynchon - December 16, 2009 6:09 PM
Thanks Tim and Debra for dropping by to discuss health care reform. Tim rightly notes that the devil is in the details as Debra reminds me that I haven't gone low enough on the socio-economic scale to represent the true extent of the dire circumstances in which so many Americans find themselves.
Because I'm no economist nor an expert on the health care industry, I'm going directly to desired outcomes from the point of view of a self-employed woman aged 58-60 whose husband has retired and who has moved into the Medicare system.
The self-employed 58-60 year old woman is now seeking health care insurance in the open market. She, like 99.9% of all 58-60 year old women, has one or more pre-existing conditions that would make an insurance carrier deny her coverage as things stand today.
I don't want to expend my last saved nickel on health care before being thrown into an underfunded public system as a powerless elderly citizen of a country to which I and my family has contributed so much. And I don't want to live a life of luxury while my fellow citizens suffer from hunger, homelessness and untreated disease.
Wherever I end up on the economic scale (and I have lived on every rung) I want affordable health care for myself and my family.
I don't really care HOW this is accomplished by the wizards in Washington, D.C. If they can't provide this benefit, they do not deserve to be in office and the bums will be thrown out by the people who pay their salaries and, by the by, for their excellent health care coverage.
Joe Markowitz - December 17, 2009 1:44 AM
I think the leap that people have to make in their imaginations is not so much between being rich or poor, or being employed or unemployed, as it is imagining yourself sick when you are healthy. Because once you try to imagine yourself with a serious, expensive illness, you would just want to make sure that you have coverage for almost all your medical bills, or access to quality charity or government-run hospitals. You would want those options almost regardless of how well off you might be. A catastrophic illness would be a huge financial hit on almost anyone who does not have insurance.
But assuming everyone would probably agree that they want all that even from behind their veils of ignorance as to their economic circumstances, I think people might still divide on this issue on ideological lines. If you are a believer in markets, then you would advocate individual health savings accounts, possibly with some kind of subsidy for the poor, or you might even advocate leaving insurance decisions up to the individual, again possibly with subsidies for the poor. If you lean toward more socialistic solutions, then you would tend to advocate something more like a Medicare for everyone type of solution. But most probably hardly anyone starting from scratch would advocate the employer-based system that we currently have. That was only a product of historical factors (a way to get around wage-price controls) and quirks of the tax code. It doesn't make much sense from an efficiency standpoint to have thousands of individual employers each trying to design their own health care system for each of their companies, along with three different socialized systems (Medicare, Medicaid, and the VA). The funny thing is that it is so entrenched that there is no politically feasible solution to the health care problem that contemplates getting rid of the Rube Goldberg contraption that currently supplies most of our health insurance.
Vickie - December 17, 2009 2:16 AM
It's the "possibly with subsidies for the poor" that's part of the problem for "believers in markets." Let's say I believe in markets - providing the greatest good for the greatest number ( recent market failures aside). So far the market hasn't provided affordable universal health care nor have I heard it suggested that saying "no" to health care reform will make such care available.
So, assume you're poor. And there are no subsidies for your care. Or you're middle class - you get sick & lose your job and you lose your house & no one will rent to you because you have a foreclosure on your credit report.
Or you're rich & same as above. No family to take you in. The market is in the business of making profits. The government is in the business of providing essential public services. Hit me upside the head if I'm missing something. The market does not provide affordable health care for anyone who can't afford market prices & to suggest it do so is to raise the spectre of inept government regulation. I'm perplexed that we don't vote ourselves care when we're sick. Who do we believe we're benefitting?
Joe Markowitz - December 17, 2009 3:09 AM
Vickie take a look at David Goldhill's article in the September Atlantic - http://www.theatlantic.com/doc/200909/health-care
- which makes a pretty good case for a market-oriented solution. Personally, I would prefer a European or Canadian-type system, because those models have already shown they can get better results for less money than we spend. And there is really no good model out there for a market-type solution that works well for the greatest number of people. But my point is that people can sincerely disagree on this issue, and they would disagree on this ideological point even if they did not know in advance where they would fit in class-wise in society. In other words, I don't think a Rawls-type experiment necessarily tells us the right answer to this problem.
Vickie Pynchon - December 17, 2009 11:54 AM
Thanks for the article Joe. I've now read it. I'd already read the Gawande article he mentions about the historic anomaly that created employer-based health care insurance.
I take your point to be this: even if the law-makers (that's us, supposedly) make a class-blind decision to provide affordable health care to everyone, we will never be well-informed or smart enough to create the system we want.
Yet, I still don't think the problem is ideological.
I think the problem lies with whom I'm suggesting engage in the Rawls' thought experiment because they (us) are not the law makers. Even our elected representatives are not the real law makers for whom the thought experiment would be beneficial.
The real law makers are the corporate and organizational interests that have purchased Congress. Insurance, trial attorneys, the AMA, BigPharma, heck, any organization with the ability to raise enough money to get one of the "people's" representatives to create a "perverse incentive" to benefit the one over the many.
These law-makers (lobbyists) can't do the thought experiment because they don't THINK; they only act in favor of what they believe their members want them to do, which is to benefit their members' individual interests over the interests of all of the other inhabitants of the island.
That's why I'm suggesting that we do the thought experiment on a tropical island with a population of 100. I believe it's scalable.
There's one doctor, one herbal remedy inventor, one manufacturer of herbal remedies, five sick people; 10 fishers; 2 hunters; 20 gardeners; 15 fruit and nut gatherers; and, one individual who maintains the space for healing (the hospital). The remainder of the population doesn't "work" strictly, but provides other services - love and comfort and wisdom and spiritual succor. Even those people who are completely helpless (there's one infant on the island) contribute to the island's well-being because the baby gives everyone else purpose.
The only perverse incentives on the island are the incentives to: (1) impose our ideology, values, religion, etc. on everyone else - control what they do; and, (2) gather secret stores of food, water, clothing, herbs, and firearms (there are two guns on the island) - control our access to the island's resources.
The island's evil-doer (yes, there's one of those too) spends his time telling one member of the group that another member of the group is out to do him/her harm or is taking more than his/her share or cannot be trusted to provide herbal remedies in the event he/she gets sick one day. That evil-doer thereby amasses power and assets disproportionate to his contribution to the island's well-being because the now-frightened, untrusting island citizens mistakenly throw their lot in with the evil-doer as the lesser of two evils.
Where I want to start with Rawls (and the Prisoners' Dilemma when I've finally gotten around to writing that part) is here: the greater danger to the island's inhabitants is to allow themselves to believe they'll do better playing a zero-sum game than they will do cooperating in an effort to provide food, shelter, herbal remedies, clothing and fresh drinking water to everyone no matter what role they're playing on the island.
If we start there, is there any chance for us to have a better set of laws about the provision of health care or do we still tie ourselves up in ideological knots because we are not only "too big to fail" we are also "too big to succeed."
Pete Salsich - December 17, 2009 2:04 PM
Great discussion of a complex and difficult issue. I look at it like this -- 21st Century America believes it is a capitalist, market-driven society, but it has latent socialist tendencies (which are not necessarily bad things). There are certain services--such as health care--that we as a society have come to believe should be available to all. The only disagreement is over how to provide (and pay for) them. I suspect that if you asked the vast majority of Americans whether they thought all people should have access to at least a basic level of competent health care--just that question, not how to pay for it--they would say yes. Your thought experiment of placing oneself in a different socio-economic situation demonstrates this well. But if we agree on this foundational proposition, a pure market-based system cannot be the answer.
The problem with a pure market-based system is that, by definition, it is not going to provide for everyone because that is not its purpose. Markets exist to acquire and distribute limited resources as a function of supply and demand, which will almost always drive prices up (and out of the reach of large sections of society). The goal of a market participant is to maximize its profit--if that can better be achieved by providing more limited services at higher prices, that's what the market will do. It's not personal, and it's not wrong (leaving aside actual wrongdoing and market manipulation). It's just what a market does. The health insurance industry as it is currently constructed is a perfect example of this.
I'm not sure I want a system that completely eliminates market participation--competition is important and health care professionals should be able to make a profit. But to suggest that we can meet our society's health care goals by simply leaving it to the market is to ignore the core nature of the market itself.
Debra - December 17, 2009 3:05 PM
Wonderful discussion. Thank you.
Of course,regarding the socio-economic scale, if you go far enough down the scale, things can kinda work out.
So, my closest friend should feel very fortunate: out of work for months and living far below the poverty level...but, she is now eligible for health care coverage through the State of Oregon.
Acknowledging how absolutely naive this sounds, I find it rather disturbing that the whole health care debate is centered on market profitably. Our society's way of attempting to "intellectualize" uncomfortable value differences?
Joe Markowitz - December 17, 2009 4:14 PM
I'm not exactly saying that we can never be well-informed enough to design the system that we want. What I'm trying to say is that even if we were as well-informed as possible and we had no idea what our position in society would be, we would still have some different ideas about what utopia would look like. Some people would come up with a communistic type of utopia, but others would believe that even if they were the poorest, sickest person on the island, they would still rather live in a society that allocates goods and services on a more competitive basis. Because that is more efficient in their view. Because that provides the greatest incentives for everyone to be as productive as they can, etc. The reason the health care debate is so difficult is not just that Congress has been corrupted by big pharma and big insurance companies (which it has been of course), but also that there is a genuine ideological issue at stake here. And a lot of people are not going to change their ideological views no matter how many studies you show them that Canada's socialistic health care system (for example) produces better outcomes for more people and for less money than our system. They still will think they can design a better system that is more in line with capitalistic values.
Vickie - December 19, 2009 12:55 PM
Joe,
I get your point and I think we're both trying to apply logic and reason to a debate that detached itself from the island of rational thought long ago and has been floating free in an ocean of disinformation ever since. My personal measure for this is my 85-year old mother who is one of the more loving and generous people on the planet. She opposes all public health care as "socialistic" while at the same time opposing any changes to her own (socialistic) medicare benefits. As a "teabagger" was quoted in one of the top 10 quotes of the year: "keep your government hands off my medicare."
As one solution, I'll propose Robin Williams' suggestion that our representatives in Washington D.C. act like NASCAR drivers and wear the badges of their sponsors on their suits. (someone more creative than I should photoshop Congress in this manner).
Happy holidays!
Vickie
Joe Markowitz - December 19, 2009 6:39 PM
Congress is corrupt. The health care debate is irrational. There are a lot of lies and misinformation being spread around. But you know what? Despite all of that depressing news, if Congress passes a health care reform bill, flawed as it is, we will have enshrined into law for the first time in American history the principle that every single American is entitled to affordable health insurance as a matter of right. Once that principle is established, we just have to keep working to make the system more efficient and fair. That is my hopeful message for the holidays.
Vickie Pynchon - December 20, 2009 12:19 PM
I will co-sign that hopeful message for the holidays!