Health Care and Our Limited Moral Intuitions

Ezra Klein wants to know “what happened to the the moral case for health-care reform?”

This year, however, it’s not just been the opponents of the policy who have relied on the “mellifluous language of the standard economic theory of markets.” It’s been the advocates of reform. Ask yourself what the administration’s one-line goal is on health-care reform. Is it “equal treatment for everybody?” Is it “if every American is guaranteed a lawyer, why not a doctor?” Is it even “guaranteed health care for everyone?”

No. It’s “bend the curve.” And the problem with “bending the curve” is that it’s a broadly testable proposition. This is, in part, why the Congressional Budget Office’s skeptical assessments pose such a threat to health-care reform. If the White House’s primary objective was health care for every American, or guaranteed care that you could keep even if you lost your job, or choice of insurance plans for every American, you could spend a bit more on health care and say you were achieving your goal. But if you say that the point of health-care reform is to save money, and then the outfit charged with estimating such things says it won’t, that strikes at the heart of the project.

There are basically two points operating together here.  The first, which Ezra draws out, is about confused messaging.  The center of the venn diagram of the bills floating around Congress is legislation that does a pretty good job of offering coverage to everyone and a mediocre job at controlling costs.  Yet, Ezra points out, the messaging out of the White House is all about “bending the curve” and cutting our long-term spending.  I think this is basically true, but it also ignores the perhaps more interesting question: why does the moral case for health care disappear so easily?

Perhaps things would be different if the administration were making its case to the broader public in the language of moral imperatives.  (And, for the record, I do believe it should be the moral imperative of a modern society to ensure health care for all citizens).  But why do congressmen and commentators so quickly dismiss the reality of increased coverage as they haggle over the numbers?  The Blue Dogs are barking rather loudly about cost–particularly with regard to subsidies–but when you follow these complaints to their logical conclusion, they’re arguing that fewer people should have access to health care (or, depending on how the math words, that certain people should have access to less health care).

Imagine that one night a stranger, bloodied from a car accident, knocked on one of these congressman’s door and asked for help.  Were the congressman to refuse and leave the stranger to die on his stoop–or even just to suffer all night until a good Samaritan  passed by–he would be met with universal opprobrium.  Such a decision would be a noxious affront to our moral sensibilities.  And yet, when congressmen take action that, however indirectly, leads to similarly adverse health outcomes for real people, they are praised by institutions of Washington commentary for their centrism and fiscal prudence.

To understand why this happens, it’s worthwhile to consider the (oft-discussed on this blog) work of Joshua Greene in the field of moral psychology.  I won’t spend too much time rehashing the details–for the uninitiated, see my earlier posts or Professor Greene’s website–but the basics are that our moral intuitions often cut in very different ways about situations that have similar consequences but different mechanisms.  Actions that involve close, personal interaction arouse–pushing someone off a footbridge into the path of an oncoming trolley or failing to help the man on our stoop–arouse our moral emotions and move us to express harsh condemnation.  Actions taken at a distance, however, are viewed more calculatingly, which often leads us to a different judgment.

When I worked in Professor Greene’s lab, we used to joke that some of the more complicated scenarios we employed to probe the moral sense seemed almost absurdly complex.  In one example, the protagonist pulls a switch that drops a workman through a trapdoor onto the path of an oncoming trolley, causing a collision that sounds an alarm and stops a separate trolley that would otherwise mow down five other workmen.  Compare that to the almost insane-looking chart of our current health care apparatus (chart thanks to the indispensable Jon Cohn).

The effect of those dense coils of arrows is to wring all of the moral responsibility from the system.  Although it’s true that the decisions of individual congressmen will lead to very real differences in the health outcomes of actual people, the path those decisions must take is far too convoluted for that fact to impress upon the emotional brain.  I’ve also theorized–but haven’t yet been able to test–that just using the language of costs and benefits shifts the brain into a mode that blunts the influence of moral intuition.  We certainly can put moral concerns up against fiscal ones, but I suspect that even if the White House had tried this it would have had limited effect.  Eye-deep in congressional procedure, it’s almost impossible to think in intuitively moral terms.

That said, the key word is “almost.”  There’s still a sound argument that it’s our absolute imperative to provide health care for all Americans.  Morality is on our side.  But it is not obviously so.  My recommendation for the August recess is to try to make a case for reform so that the public, as much as is possible, understands the moral consequences of the legislative process.