Monday, September 29, 2008

Health Care Conservationism

This past weekend, I attended The Land Institute's 30th Annual Prairie Festival, in Salina, Kansas. This annual happening of conservation-minded, liberally oriented scholars, activists, and supporters examines problems of modern agriculture and proposes sustainable, less destructive solutions to feeding the world's population. Founded in 1978 by Salina native and 1992 MacArthur "genius grant" Fellow, Wes Jackson, The Land Institute finds its roots, quite literally, in protecting the ecological stability of the Kansas prairie. This year's Festival featured marque speakers, Barbara Kingsolver and her husband, Steven Hopp, authors of the best-selling book, Animal, Vegetable, Miracle, about their family's experience with eating locally grown and produced food for one year. This is all well and good. I adore Kingsolver's books. I personally make a conscious effort to reduce my own carbon footprint by eating local, organic foods, recycling, bike commuting, drying clothes on the line, and the like. And this weekend, I received an total immersion introduction to the vocabulary and theory of conservationism.

Professionally, I write about health care financing and public health through the lens of law and economics. I challenge my students and readers to examine their discomfort with thinking of health care in market-based principles of supply and demand, Adam Smith's invisible hand, goods to the highest bidder, and moral hazard. Health care, I urge, is a scarce resource -- like soil, timber, fossil fuels, and water -- that must allocated among a population of people, whether on market-based or other principles of rationing. As I have recently written, health care, like any other public good, presents a potential tragedy of the commons as individual interests and usage threaten to deplete the common pool.

Many people, especially well-intentioned, liberally minded people like those in attendance this past weekend, tend to find application of economics to health care uncomfortable if not outrageous. Health care is a human right, an entitlement. It is scandalous, as a modern, industrialized society, the richest nation in the world, that we cannot provide health care for our entire population. The panacea, as Michael Moore so colorfully urged in his docu-tainment movie, Sicko, is government-sponsored or organized universal health care.

What stuck me, at the Prairie Festival, were speakers' embrace, in the context of conservationism, of language and ideas of the conservative health care reform agenda. One speaker talked of the importance of "individual responsibility," a fundamental tenet of Governor Romney's individual health insurance mandate and Senator McCain's market-based health care reform. Repeated references were made to Jevon's Pardox, which suggests that improving the efficiency with which a resource is produced or used has the tendency to increase, rather than decrease, its consumption. I struggled to find the paradox: Of course, efficiency results in lower cost to supply a good, and thereby lower price to sell the good, which causes demand for the good to increase; that's elementary supply and demand. Then it dawned on me that they weren't describing an economic paradox, but a conservation paradox.

One speaker went so far as to tout, mostly for purposes of illustration, the merits of World War II-era rationing, under which rich and poor alike received the same basic allotment of gasoline and food, with which to make do, or learn to do without. The lesson borrowed into the conservationism discussion seemed to be that we could, if we thought about it and tried a little harder, make do with less or without that we now consider essential.

I wondered, as I listened to the strong, earnest rhetoric, why efficiency, individual responsibility, and rationing connote noble, progressive ways of thinking about conserving natural resources, like land and water, but evoke dispassionate, hard-nosed conservative notions of reforming health care. Is there a way for the health care debate to recapture the language and literature of conservationism?


Blogger Patrick S. O'Donnell said...

Time constraints preclude me from addressing the conservation metaphor, but I would like to mention some literature germane to the question of personal responsibility and health care courtesy of Mike W. Martin (Philosophy, Chapman University). As Martin notes, the idea of responsibility for health "has a long lineage." He cites the following by way of illustration:

S.J. Reiser, "Responsibility for Personal Health: A Historical Perspective," Journal of Medicine and Philosophy, 10 (1985): 7-17;

Meredith Minkler, "Personal Responsibility for Health: Contexts and Controversies," in Daniel Callahan, ed., Promoting Healthy Behavior: How Much Freedom? Whose Responsibility? (Washington, DC: Georgetown University Press, 2002), pp. 1-22;

Daniel Callahan, "Freedom, Healthism, and Health Promotion: Finding the Right Balance," in the aforementioned volume, pp. 138-152; and

Daniel Callahan, False Hopes (New York: Simon and Schuster, 1998), pp. 173-207.

One should also read John P. Allegrante and Lawrence W. Green, "When Health Policy Becomes Victim Blaming," New England Journal of Medicine, 305 (1991): 1528-1529.

Finally, and most importantly, Martin himself discusses this issue in a remarkably erudite, imaginative and timely book, From Morality to Mental Health: Virtue and Vice in a Therapeutic Culture (New York: Oxford University Press, 2006). See, especially, Part II, "Responsibility for Health," chps. 4, 5, and 6. Martin clearly has no ideological axe to grind and he is adept at appreciating the strengths and limits of the notion of (moral) responsibility in the context of health care. The book is valuable for other reasons as well, but this will have to suffice for now.

10/10/2008 9:03 AM  

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