Responsibility: Shane and Joe

Man is condemned to be free; because once thrown into the world, he is responsible for everything he does.
—Jean-Paul Sartre

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

We in the United States are deeply committed to “responsibility” as a core American value.  Being responsible and taking responsibility are good. Being irresponsible is bad. But “responsibility” means very different things to different people. As a result, calling for “responsibility” in U.S. public discourse is like waving a red flag at a convention of bulls — it elicits passion, rancor, and disorderly conflict.

There’s no better place to go to understand the two main ways Americans take responsibility as a guiding value than the movies, especially westerns. Take the 1953 classic, Shane, in which lit­tle Joey Starrett is torn be­tween two icons of respon­sibility—his father, Joe, the homesteader, and Shane, the mysterious gunslinger cowboy. Joe and Shane em­body the two poles of re­sponsibility in U.S. moral discourse.

Joe exemplifies respon­sibility as social solidarity—building a caring community that takes responsibili­ty for the welfare of its members. Joe is committed to farm, family, and his nascent frontier town. For home­steaders like Joe, the emblem of responsibility is barn-raising, a ceremony in which the community joins to­gether to help individuals meet a basic need.

Shane exemplifies responsibility as individual action— making your own choices, doing what has to be done, and doing it on your own. For cowboys like Shane, the emblem of responsibility is the six-gun and the self-re­liance and strength that comes from skill at knowing when and how to use one.

These contrasting images of what responsibility means—communal barn-raising versus individualistic cowboy gunslinging—lie behind the current competing health care reform propos­als. They are also the source of some of the pas­sion, rancor, and disorder­ly conflict we have seen in our ineffectual previous ef­forts at health care reform.

Our love affair with the myth of the heroic cowboy enhances the attractiveness of market-based reform proposals. But in place of the cowboy, market proposals envision a heroically em­powered “consumer.” This swaggerer is armed with con­fidence, information, and choices when striding into the health care “marketplace” to make prudent “purchases” of high-quality, low-cost health care. The consumer enforces change via purchasing power and the invisible hand of the market, not a six-gun. Some of the intuitive emotion­al appeal of reform proposals that depend on competitive market forces comes from our cultur­al ego ideal of the self-reliant cowboy, who is always prepared to put “skin into the game” of life.

We can also discern the high value we place on heroic cowboys like Shane in the language of obituaries. The dead person is extolled for hav­ing “fought a brave battle” against an illness that ultimately prevailed. An old joke speaks to the worldview be­hind all our talk about fight: In India, death is a potential step away from reincarnation and toward Nirvana. In Europe, death is an existential tragedy we all must face. In the Unit­ed States, death is optional. When I was growing up, boys were taught that only sissies give up a fight. That macho approach to life may be well suited to trench warfare, but its use­fulness as a guide for health care re­form is limited.

Good Guys and Bad Guys

Proposals that emphasize universal coverage—like the single-payer plan—are enhanced by our beloved myth of social solidarity in an Edenic, barn-raising frontier. Building on the vision of a caring community that joins forces, the single-payer plan en­visions a society that pools its re­sources to minister to the health care needs of the individual. The energy for change comes from social cooper­ation—citizens contribute funds via their taxes to allow patients and clini­cians to collaborate on behalf of health.

Like westerns, health care reform proposals envision villains as well as good guys. In Shane, the bad guys are ranchers and their hired thugs. For market proposals, the bad guys are the demanding, entitled individu­als—free-riders who expect others to satisfy their expensive tastes in health care, but who are unwilling to take responsibility by putting any of their own financial skin into the game. For single-payer proposals, the bad guys are insurers who siphon money away from health care and into corporate profits and executive pay packages.

These are wildly oversimplified cartoon images of our major health care reform proposals. But values come from the gut, not the mind, and the gut is not a sophisticated thinker about the nuances of alterna­tive policy options. In addition to the logic and facts on which competing proposals are based—and the vested interests that support and oppose the different options—our visceral re­sponses to the values they embody are a significant part of what attaches us to the policies we favor and sets us against competing options.

In 1993, during the Clinton health care reform process—and forty years after Joey mournfully called “Shane! Come back!” at the end of the film—two new icons en­tered the U.S. health care reform dia-logue—Harry and Louise. In one ad­vertisement, Harry and Louise are sit­ting at their kitchen table. In the background an ominous voice says “the government may force us to pick from a few health care plans designed by government bureaucrats.” Harry and Louise agree—“Having choices we don’t like is no choice at all. They choose. We lose.” In another, Harry asks Louise about the insurance prac­tice of community rating. She replies disapprovingly, “Everyone pays the same rate, no matter their age, even if they smoke or whatever.” Their friend Pat reports that his health in­surance costs more than doubled with community rating—treating everyone the same was a disaster for his community. Harry is shocked— “Congress can do better than that!”

Harry and Louise put nails into the coffin of the Clinton health re­form proposal. Their power came from looking like ordinary Americans and drawing on core American val­ues. They invoked an intrusive nanny state that imposes limited choices on the population and takes away the opportunity to chart one’s indepen­dent path in life. The attack on com­munity rating raises the specter of people who refuse to take responsibil­ity for their own choices (“smoking or whatever”) or for the embarrassing fact that they’ve become old and cost­ly. Like Shane, Harry and Louise want individuals to be “free” to make their own choices and to take respon­sibility for any burdens their health care needs place on others.

Policy Implications

One reason the Massachusetts health care reform plan has at­tracted so much attention nationally is the way it addresses the deeply rooted American standoff between the proponents of individual respon­sibility (Shane) and societal responsi­bility (Joe Starrett). The architects of the Massachusetts plan like to point out that it requires everyone to take responsibility. Individuals are re­quired to purchase health insurance but are free to choose among a large number of private (“nongovern­ment”) plans. Employers are required to contribute. The state is required to pay for those too poor to buy their own insurance.

Nobody loves the Massachusetts plan—it is too awkward and complex to be lovable. Libertarians hate the individual mandate. Single-payer ad­vocates hate the failure to create a public plan that covers everyone. But it threads its way through the mine­field of competing values well enough to be acceptable to a substantial ma­jority and to evade the accusation of being “socialized medicine.” At this point, the opposition is too small and too divided to undermine public sup­port.

Much like the Massachusetts plan, the ostensibly oxymoronic political philosophy of “libertarian paternal­ism” (described recently by Richard Thaler and Cass Sunstein in their book Nudge) seeks to bridge the gap between those who make individual freedom the top value and those who put the social good into first place. Libertarian paternalists favor policies that engineer choice in ways that in­fluence people’s behavior without closing off their options. In health care, libertarian paternalists would support tobacco taxes (nudging me not to smoke but still giving me the choice) and tiered pharmacy benefits (letting me get the pricier, branded drug if I wish, but forcing me to pay more). In principle, a libertarian pa­ternalist could support the Massachu­setts mandate for individually pur­chased insurance because those who object to the mandate can pay the tax penalty alternative instead, and those who follow it can choose their insur­ance from a long list of options.

In his inauguration speech, Presi­dent Obama invoked responsibility as a major theme—“What is required of us now is a new era of responsibil­ity—a recognition, on the part of every American, that we have duties to ourselves, our nation and the world.” It sounds as if the president wants to side with both Shane and Joe Starrett. That’s a direction our forthcoming health care reform poli­cy debate should take.

Jim Sabin, MD, is a clinical professor of both ambulatory care/prevention and psychiatry at Harvard Medical School and director of the Harvard Pilgrim Health Care Ethics Program.