Medicine & Politics
The congressional debate on Medicare led me to think about the nature of politics in the United States. On the surface, the issue has been health care, whose costs rise much faster than the general inflation rate, and for whom an increasing number of Americans are no longer protected with insurance. Let’s face it; all sides of the debate profess an interest in seeing to it that all citizens have the benefit of medical services at a reasonable cost both to the individuals and the nation as a whole. Further, I accept the sincerity of these claims. The other side (I know most of you lean toward liberal, so this means Conservative groups and institutions) tends to be demonized as heartless, malevolent and only interested in rewarding its supporters. I think this characterization is unfair. Someone can be wrong without being evil. Let us give them the benefit of the doubt; they really want to do what is best for the country. Then, what is wrong with it?
The (George W. Bush) Administration’s approach to solving the health crisis is to rely on competition—the market—both to find a way of extending service to everyone and to capping the excessive rise in costs. The first question to ask is whether competition will really have an effect on service and costs. A Jewish story tells of a man going to the top specialist in the city. The specialist gives the fellow his bill. The man chokes at the cost, and proceeds to bargain the doctor down to a figure only a fraction of the original bill. The exasperated doctor asks why the man came to him in the first place, knowing that he was going to be so expensive. The man replied: When it comes to my health, cost is no object!
The truth of the joke is that while markets are pretty effective at establishing value, good health tends to resist the setting of any price. Competition and health policy probably do not sufficiently mix.
The second question is why there is so much pressure to apply a market solution? I spent a few years in Canada where there is universal single-payer health insurance. International surveys have confirmed that Canadians are substantially healthier than Americans with a system that in aggregate is considerably less costly. Canadians, however, complain vociferously about their system. There are long waits for certain specialized services. Pressure is constantly exerted by different constituencies to allow individuals to pay more for faster care (they call it ‘jumping the queue’). When on a CBC interview program a few years ago, the Minister of Health was asked just what is wrong with a two-tier system, his answer was revealing. The Minister replied that if two tiers—extra pay for extra service—were introduced then people like the interviewer would tend to opt out of the basic system, and spend the money they could afford on what they wanted. The result would be that a very important constituency—those who are especially concerned about good quality health care—would no longer place pressure on the politicians and managers of the national system. The net result, he suggested would be poorer overall care and greater overall costs. (Something akin, I suppose, to the American experience.)
We see here, I think, a fundamental difference in approaches to political decision-making. The Canadian minister sees the public issue of health care as a constant and ongoing concern for the political system. The managers of health care, who are the elected members of the legislature, must continuously grapple with pressures placed on them by all constituencies, and make not-always-propitious decisions regarding changes in the system. In contrast, a strain of American thought seeks to move the issue out of the political arena, and rather into a more objective (read: impersonal) decision-making apparatus; hence, the faith expressed in the wonder-working powers of the market.
This fundamental distinction in attitudes toward decision-making is raised in an essay by Martin Buber, Plato and Isaiah (found in his collection of essays on the Bible, Moses). Buber compares Plato’s Republic to Isaiah’s call to prophecy. Plato felt that the well-ordered society was one run in accord with the transcendent ideals that reside in the real world of Ideas. A properly trained philosopher-king should be able to access that world and thus insure a good society. Later in his life, Plato had an opportunity to see his concept implemented when a student of his became the prince of Syracuse. In a brief while, the prince was assassinated, and the experiment came to naught.
Isaiah, on the other hand, also imbued with transcendent insight as a result of his prophetic vocation, is not called upon to take control of the kingdom. He is only expected to preach his divinely ordained truths before those in power. Moreover, from the start he is informed that his efforts will substantially fail!
Buber therefore compares two failed programs. Plato’s, however, leads not only to failure, but also to acute disappointment. The ideal is there. It can be known. (By the way, Aristotle, who opposes Plato’s metaphysical realm of Ideas, nonetheless, also poses that an ideal society can be achieved through prudence and observation. For him, politics is the achievement of the well-ordered polis.) Yet, efforts to establish it somehow tend to fall short. Isaiah represents not so much a system doomed to fail, but rather one whose expectations are well short of ideal. Human society will always be beset by imperfections, and God, the embodiment of perfection, will remain elusive, at least until the time of redemption. Thus, God tolerates, even over Samuel’s objections, the placing of a king over Israel. That king, as Deuteronomy makes clear, must nonetheless be constrained, so that even a relatively powerless prophet can censure his performance.
Jewish thought as reflected in Tanakh (Hebrew Scripture)—and one can make a case from the rabbinic literature as well—views politics as the everyday decision-making of communities and their leaders; inspired, yes, by God’s will, but ultimately left to their own imperfect devices. This is in opposition to the Greek notion of politics as the identification and implementation of ideals for the well-ordered society. The Jewish approach is messy and incremental. It evokes passions, arguments, recriminations, and is wearing on leaders and representatives. The Greek approach is therefore very attractive, even though it fails at least as often, with attendant accusations of betrayal, and occasional violence.
The late philosopher Walter Kaufmann coined the term ‘decidophobia,’ that referred to more than the reluctance to decide. The root of the term means “falling off,” as in a deciduous tree. Fearing to decide is fearing to risk falling over into one position or another. Choices, however, need to be made, so decidophobia is the effort at having someone—or something—else make the decision. One turns to the rules, the strong man, nature (human and physical) or God. Greek thought, and its manifestations in Christianity (particularly the Catholic Church’s natural theology) and most orthodoxies of every stripe, is decidophobic. I think one can see the decidophobia that runs through the most recent Medicare legislation, as with all efforts to reduce governmental deliberations in face of the mechanisms of the market.
Being a faithful Jew, if my analysis is correct, is permitting oneself to be consigned to the messy, mostly faulty and frustrating process of politics. It is also, I believe, the only way to move toward the society that God wishes for us.