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The Connection is an open conversation, a group blog, and a nonpartisan effort to spark a rich discourse on fundamental values in health reform. Anyone can submit a post, and a selection of posts will appear here, on the Health Affairs blog, and in an upcoming volume.
9.28.09
| From The Center for Humans and Nature
Liberty without equality is a name of noble sound and squalid result.
—L.T. Hobhouse
This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.
America is the child of John Locke, the great philosopher of liberalism and natural rights. This commonplace observation holds a key to understanding the politics of health reform in the United States. The tradition of liberalism (in the philosophical sense of the term) is still the context of our political morality, our constitutional law, and much of our public policy. Liberty is the fundamental value of American politics; not the only one, to be sure, but the fundamental one nonetheless. Liberty has been central to the ethical justification for health reform in the past, and it will continue to be in the future.
As a fundamental value in American life, liberty has several interesting characteristics. It is talked about a lot; the word itself is often used, both in political and everyday speech, but even when the word is not spoken, the idea is there. Liberty is pretty much synonymous with freedom and, in bioethics jargon, with “autonomy.” Liberty often goes incognito, its resonance embedded in other values or ideas that on the surface seem to be about something else. For instance, liberty resides in terms like privacy, choice, property, civil rights, entrepreneurialism, markets, dignity, respect, individuality. Values so ubiquitousare often taken for granted and not sufficiently scrutinized. They therefore have great political power yet are vulnerable to cynical misuse and manipulation.
Liberty is no exception, and we need to think carefully and critically about its history, meaning, and political implications. Properly understood, liberty should be compatible with other ethical values that have often been pitted in conflict with it, such as equity. Such a conflict has been thought to arise, for example, when allowing all individuals the freedom to accumulate as much as they can undermines the capacity of the entire society to ensure that each individual receives a fair share. Why is this clash between appropriation and redistribution seen as a clash between liberty and equity? In order to set up this conflict in the first place, one must conceive of liberty as the unbridled expression of possessive individualism. But this is not the only or the most fruitful way to understand liberty. Herein lies my principal point: progress in establishing an ethical and political justification for health reform depends on reconciling liberty and equity, at least in the arena of health affairs. We must break out of the ideological grid that sets liberty and equity in opposition, indeed in a zero-sum relationship such that one of these values cancels out the other. The health reform conversation has to be reframed at the grass roots level so that a new way of seeing what liberty is and what it requires will grow out of that conversation. One tenet of this movement should be that equity in access to health care, reduction in group disparities in health status, and greater attention to the social determinants of the health of populations and individuals are all policy goals through which liberty will be enhanced, not diminished.
What Liberty Has Meant
The history and politics of health reform is an object lesson in this regard. In the past, appeals to the value of liberty have most often been made by opponents of governmental involvement and structural change. In the street language of American politics throughout the twentieth century, the main threat to liberty was “socialism” (a.k.a. big government), and the key plank of the indictment against health reform plans, from Woodrow Wilson through Bill Clinton, was the specter of “socialized medicine.” The main ally of liberty in the same period was free market competition. Health reformers struggled (mostly in vain, it must be said) against this interpretation of liberty. They countered with an appeal to the language of rights and to the countervailing value of equality. (Equality’s aliases are equity, fairness, social justice, solidarity.)
Stepping back, we can see that health reform has been caught in the same web of dichotomies and conflicting values that have ensnared every other facet of progressive and welfare state measures during the last century. Some of the worst snarls in this intricate web are: (1) individual responsibility and choice versus social assistance; (2) market initiative and competition versus governmental regulation and bureaucratic red tape; (3) efficiency versus entitlement; (4) autonomy (rugged individualism) versus elite paternalism (Big Brother, the nanny state, father knows best); and finally, at the personal, gut level, (5) fear of losing current benefits and quality services versus guilt based on a sense of justice and concern for those excluded from the current system, especially children and the “deserving” poor. I believe that we will never be able to resolve these dichotomies or untangle this web. Instead, what we need to do is to change the subject and reconceptualize the terms of these past dead-end debates.
The most recent large-scale health reform effort in the United States, during President Clinton’s first term in the early 1990s, featured each of these snarls. No doubt there are many reasons why this plan was defeated in Congress, perhaps not the least of which was that big business ultimately decided that it could get a better deal to hold down health care costs from a private managed care approach than it could from Clinton’s combination of managed competition and a global health care budget. But at the level of public opinion, the debate tended to center more around individual liberty versus social equity. A mainstay of the attack on the Clinton plan—policy experts dismissed this as obvious nonsense, but it had a significant political effect—was the fear of losing personal liberty, and in particular, fear of losing the freedom to choose one’s own doctor and to control one’s own health care. The television advertising campaign against the Clinton plan, sponsored by a health insurance industry trade group and featuring the concerned middle-class couple Harry and Louise, focused on the loss of liberty and the erosion of quality that the plan would bring about. These professionally produced ads used the concept of liberty very artfully.
What is it about liberty that turns it into an arrow in the quiver of opponents of health reform? Is there a way to reframe it and to develop an alternative way of using it? Is there any reason to think that such a reformulation would have any traction in forthcoming political debate and the policy process? These will become increasingly important questions, I believe, in the round of health reform debate that is now beginning.
What Liberty Should Mean
The concept of liberty has two different facets, which are usually referred to as “negative liberty” and “positive liberty.” Negative liberty is about being free from obstacles or constraints: it is about having freedom of choice—even the freedom to make mistakes and poor choices. Having personal security and civil rights ensures negative liberty. Positive liberty is about being free to have options—being enabled or empowered to make choices or realize personal goals. Having the right to freedom of speech is a negative liberty; having access to an education that gives you something thoughtful to say is a positive liberty. Positive liberty is about having others do something for or with you that gives you the opportunity to change your life or achieve your goals. In a nutshell: negative liberty is about “don’t tread on me”; positive liberty is about “I need you to help me up.”
The libertarian interpretation of liberty and the privatized market model of health care err by focusing too exclusively on the negative side of liberty. Health care is inextricably bound up with the value of liberty, not simply because it prevents illness from limiting your life decisions, but also because it enables you to use your freedom more richly, to live your life in more meaningful and worthwhile ways. Health care is not simply about preserving you from the “outside” interference of others or of disease; it is also about obtaining the active assistance of others so as to enhance the types of activities you can pursue and the kinds of relationships you can have. Thus, health care is as much about positive liberty as it is about negative liberty. And what is true of health care is true as well of health itself, or of health status.
The positive, relational, and enabling side of liberty is what links it to equity. The zero-sum relationship between liberty and equity is an optical illusion that comes from an exclusive focus on negative liberty. Positive liberty is the concept that reminds us that the well-being of one individual is not a function of isolation but of context, community, and mutual interdependency. Equity is about mutual flourishing; negative liberty is about individual flourishing no matter what the condition of others; positive liberty is about the connection between individual flourishing and mutual flourishing. Positive liberty reminds us that no single individual, no matter how wealthy or powerful, can really be free except in a context of social justice and the common good.
Policy Implications
The health reform debate of the coming years will have a broader focus than past reform debates. It will not just be about acute-care health insurance reform and access to clinical, treatment-oriented medical services and technologies. Instead, it will take up the larger structural determinants of health and health promotion. The access to acute care and high technology clinical services is very important to particular individuals at particular times, but such access has been shown to have little effect on population health as a whole. And even at the individual level, the most important and challenging policy goal is access to health, not merely access to clinical medical care. Building a system that generates or promotes health requires that people have access to many specific and positive aspects of their natural and social environments. Achieving greater health for the whole population—a healthier nation—will require large-scale social reform and institutional transformation. These changes point in the direction of a more global kind of equity and social justice.
The role of liberty will change in health reform debates when two things happen. First, we must see that health reform involves equitable access to the social preconditions of health, as well as to health care. Second, we must see that when anyone lacks such access, the liberty of all (not just of those who experience the inequity) is compromised. This, I believe, is where the health policy conversation is going in the years ahead, and as this shift occurs we will rethink the meaning and uses of the value of liberty in political argument. Liberty rethought can then be one of the touchstones for a democratic, grass roots movement for health reform that will demand health justice in a nation of free and equal persons.
Bruce Jennings, MA, is director of of the Center for Humans and Nature and a senior consultant at The Hastings Center. He teaches ethics at the Yale School of Public Health.
value: Liberty
coco
littleman
11.6.09
what is this ,it makes no sense at all
John Eley
11.20.09
In his essay on the value of liberty Bruce Jennings argues that assertions of negative liberty, frequently expressed as “don’t tread on me”, impose major obstacles against changes in the health care system that are needed in order to attain equity in health care necessary for social justice, or the common good. He argues that this form of liberty is used to justify “unbridled expression of possessive individualism”, the “freedom to “accumulate as much as a person can”, and/or “individual flourishing no matter what the condition of others”. He contends that when it is so conceived, the capacity of the entire society to ensure that each individual receives a fair share” is undermined and that a set of false dichotomies, such as individual responsibility and choice versus social assistance” and “autonomy (rugged individualism) versus elite paternalism are sustained.
It seems clear, to this reader at least that we are in the company of a one-sided argument which relies heavily biased interpretations of a concept of negative liberty which leads naturally to Jennings conclusion. In my reading of this essay Jennings has not given sufficient credence to Berlin’s characterizations of negative freedom which says nothing about the process of selfish accumulation of material goods. Fair use of Berlin’s concept, however, would not have allowed him to set up his straw man, which he could so easily destroy. At the very least he would have found it necessary to grapple with the central concern that governments that emphasize positive liberty and seek to empower persons by providing the resources essential for the exercise of certain rights can infringe on essential negative liberties, including those liberties that allow the development of wealth, without which non of the reallocation of wealth which Jennings seeks would be possible. Without freedom there is no motivation to create wealth and no assets to be more equitably allocation.
I believe that the major problem with this essay arise from the fact, at least as I interpret it, that the essay is not really about freedom or liberty at all. Liberty is so far from being the major focus of the essay that Jennings finds it necessary to offer a view of liberty that has little or no connection to dominant views about either positive or negative liberty. Jennings is concerned with equity, which is closely akin to equality, and he treats liberty as a concept which he can use in ways that he chooses for the sake of his more fundamental value.
As I read Jennings I encounter an idiosyncratic usage of the term positive liberty, which is embedded in his observation that “Positive liberty is about being free to have options—being enabled or empowered to make choices or realize personal goals….. having access to an education that gives you something thoughtful to say is a positive liberty. Positive liberty is about having others do something for or with you that gives you the opportunity to change your life or achieve your goals.” By this definition persons on welfare whose life opportunities are enhanced when they receive payments from others could be considered more free than those who do not receive such assistance. This is akin to the idea that the more dependent on another a person is, the freer that person becomes. I doubt very seriously that this is Jennings’ belief, and in this case the language may not speak for itself. It is likely that Jennings means that positive liberty as the capacity to make choices and act on them is sometimes dependent upon the possession of resources that one first acquires from others. I think that the difficulty arises in the use of the terms enabled and empowerd wich suggest that something is given to a person who lacked it previously. If one uses the terms able (or able to), rather than enabled, and capable of (rather than empowered) one gets a very different meaning out of the statement that freedom is about having options. Instead of having options by virtue of being “empowered or enabled” by others, freedom becomes that which is exercised when one is able to do something. This meaning is much closer to the concept of freedom as capability developed with great insight by A. Sen . This may not correspond to what Jennings has in mind, of course, since his objective is to use a new redefined concept of positive liberty as the touchstone of an effort to redistribute resources in the name of health care reform. Perhaps the real message is that Jennings is not really interested in the value of liberty but in the value of equity which he prefers to cast in a way that allows it to be interpreted as a value compatible with liberty. The argument would be a lot less strained if the essay dealth more directly with the primary value of equity and less with the instrumental value of liberty
Here I am trying to practice charity and economy in my treatment of Jennings’ argument since I would like to engage him in a meaningful discussion on the interplay between the concepts of negative and positive liberty in the deliberations on health care reform. I would like to narrow the range of dispute between him and myself so that we could increase the possibility of finding some common ground.
Having said all of this in criticism I would like to see if there is an interpretation of Jennings’ essay that might stimulate a useful conversation I think that his essay provides some good raw material for one such as myself who believes firmly that the value of any contribution on a major value lies not in what it gives us but it want it opens up for discussion. In my experience the principles of charity and economy in discourse are very useful in any effort to begin and sustain a conversation even in the face of initial disagreement.
In order to practice charity toward Jennings’ argument I would transform him a charitable paraphrase of his statements about negative liberty that gives it what I would consider the best possible interpretation, at least from my pespective. . Viewed this way, Jennings’ argument would be that we need to recognize that some advocates of negative liberty sometimes use the concept to justify behaviors and attitudes that in fact encroach on the negative and positive liberty of others . When this happens we can easily misconstrue negative liberty as a concept always antithetical to the development of positive liberty in the society. We do not need to do so, however, as negative liberty is a concept with a long history and considerable value in a democratic polity. Nor do have to limit ourselves to negative liberty, since positive liberty is an equally legitimate concept.
This less provocative view of the use of negative liberty might open the way for a more extended discussion of the relationship between these two forms of liberty and the ways in which they are used. Jennings’ argument, as modified, could encourage advocates of the value of negative liberty to explore the dynamics between the protection of individuals from unreasonable external coercion (negative liberty) and the empowerment of individuals lacking the wherewithal to set their own personal goals and make individual choices (his view of positive liberty). This would cast the debate in very different light and allow participants to talk to each other across a much narrower divide than the one envisioned by Jennings.
This strikes me as considerably more democratic and effective than a deliberation conducted along the lines that Jennings proposes. He would in effect eliminate negative liberty as a legitimate value in public deliberation and replace it with his own idiosyncratic approach to positive liberty. He would do so in the expectation that a deliberation centered around his concept would somehow lead to greater equity in health care policies, practices and outcomes. At this point one wonders how denial of equity in deliberation, pace Habermas, which insists upon the right of all affected parties to offer norms for consideration by others, could lead to equity in health care, in the eyes of those whose core values are treated in this negative way. If a health care system excludes many individuals from participation because the rules work against them, as Jennings and others would argue, and is therefore inequitable, surely a process that precludes the active and equal consideration of core values held by some of the participants, is also inequitable. It would produce a form of social justice which denies justice to all those who feel excluded by fiat.
Is there a way of narrowing the differences that I have with Jennings over this matter? Again I think that there is one way: allowing a wide range of subjects into the deliberative process. In my reading, By insisting that liberty ought to mean positive liberty, Jennings comes very close to delegitimizing negative liberty as a value worth bringing to the table. In my view, this would be an unwarranted exclusion. I would simply add his approach to positive liberty to the list of approaches that are worthy of consideration, on the grounds that there are some persons who wish to have them examined, and then actively debate the subject. Under this approach Jennings would have to defend and explain his concepts of both negative and positive liberty and propose, rather than insist, that health reform involves equitable access to the social preconditions of health, as well as to health care itself and that its absence compromises the liberty of all. Others believing otherwise, who favor emphasizing negative liberty, would also have to make their claims, offer their reasons and respond to critical comments and difficult questions. It is hard to see how anything less would contribute to liberty and increase the chances of an equitable outcome, because it would allow for the full participation of free and equal persons. By contrast exclusionary policies, which would place discussions of value of negative liberty out of bounds, would promote neither freedom nor equality.