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  • BIOETHICS FORUM ESSAY

With Liberty and Justice for All

Numerology might provide as much information as the ongoing economic analysis about the nuts and bolts—and costs and coverage—of the presidential candidates’ health plans. Depending on which economist you trust, according to a recent New York Times article, McCain’s health care reform plan is going to cover 27.5 million of the uninsured (McCain consultants)—or increase the number of uninsured by 5 million after five years (Obama consultants). Obama’s plan is going to cost taxpayers either $1.17 trillion over 10 years (Lewin Group), $1.6 trillion (Tax Policy Center)—or $6 trillion (McCain consultants).

Having spent a good amount of time trying to decipher the plans and reconcile the wildly different accounting, it was a relief to have Princeton economist Uwe Reinhardt explain in theTimes article that “economics as practiced in the political arena is often ‘just ideology marketed in the guise of science.’”  Whew! Health care reform, a core bioethics issue, should be wrapped in the mantle of values (which, after all, are what’s behind the different ideologies). To really move the debate forward, these values need to be made explicit, and not obscured by fuzzy math. Currently, the candidates jump from the symptoms (just about everyone agrees that the system is broken) to the treatments (minutiae-laden economic plans). They’re ignoring a crucial step: the diagnosis. The reason we’re not making headway on reform is that we haven’t framed the debate around the values we want our health care system to reflect. Arriving at the right remedy requires looking through that values lens.

Major social change in this country has always been framed by values, not a data dump. Think FDR’s “Four Freedoms”, Dr. Martin Luther King, Jr.’s “I Have a Dream,” and JFK’s inaugural address. As linguist George Lakoff writes in his book Don’t Think of an Elephant: Know your Values and Frame the Debate: “Frames are mental structures that shape the way we see the world…In politics our frames shape our social policies and the institutions we form to carry out  policies. To change our frames is to change all of this. Reframing is social change.”

Whack through the number weeds of the current proposals by McCain and Obama and you’ll unearth two bedrock American values: liberty and justice. Although we say “with liberty and justice for all” in one breath in the Pledge of Allegiance, these two values are in conflict, and not easily resolved. As Isaiah Berlin noted, “What is clear is that values clash…Both liberty and equality are among the primary goals pursued by human beings through many centuries. But total liberty for the wolves is death to the lambs. Equality may demand the restraint of the liberty of those who wish to dominate; liberty may have to be curtailed in order to make room for social welfare.” This tension needs to be recognized and addressed if the health reform debate is going to move forward.

Where do the candidates stand, then? Here’s what Obama says: “My health care plan has three central tenets. First, all Americans should have access to the benefit of modern medicine. Once and for all, we must ensure that this great country lives up to its ideas and ensures all Americans access to high-quality, affordable health care. …” Ensures all Americans access. That’s the aim of his plan, and it’s a justice claim, even though it includes traditional liberty-focused schemes that use the market in an effort to make coverage more affordable (for him, a nod to liberty and a secondary aim).

As for McCain, he says, “The road to reform does not lead through Washington and a hugely expensive, bureaucratic, government-controlled system….I believe we can do this in a simple but powerful way: restoring doctors and patients to the center of health care decisions….An essential benefit of [my] reform is that it will help to change the whole dynamic of the current health care system by putting individuals and families back in charge…” Putting individuals and families back in charge? That’s liberty straight out of Mill, who wrote in On Liberty: “Each is the proper guardian of his own health, whether bodily, or mental or spiritual.” McCain’s aim is to empower individuals to use the private sector without screens such as employer coverage, which he believes will lower costs and boost access (for him, a nod to justice and a secondary aim).

To understand what they’re buying into, Americans need to focus on these values. Dr. David Blumenthal, director of the Institute for Health Policy at Massachusetts General Hospital/Partners Healthcare System, recently wrote in the New England Journal of Medicine, “The most important questions raised by the health care proposals of the presidential candidates concern their values and judgment. The specifics of candidates’ proposals matter. But more important is what health plans communicate about a prospective president’s fundamental beliefs and character.” The specifics of each plan may be muddled and confusing, but the value differences are obvious. When it comes to health care, a vote for Obama is a vote for justice while a vote for McCain is a vote for liberty. The wolves and lambs have lined up, and voters have a clear choice.

Mary Crowley is the Director of Public Affairs and Communications at The Hastings Center.

Published on: October 24, 2008
Published in: Health Care Reform & Policy

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