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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.
10.7.09
| From Minipundit
First of all, thanks to the Hastings Center for hosting this discussion, and for putting together such a thought-provoking set of essays. Connecting American Values with Health Reform brings up enough vital issues that I fear I will barely be able to scratch the surface in this space.
Let me start with Bruce Jennings’ fascinating opening essay on liberty. Given reform opponents’ frequent appeals to personal freedom both in specific cases–fears about government intrusion into end of life care, most notably–and in broader “the government is controlling your body” terms, establishing that health care reform is part and parcel of American ideals of freedom is absolutely essential, and so arguments like Jennings’ are absolutely critical to winning the debate.
That said, I fear Jennings is pursuing the wrong tack. I fear that buying into Isaiah Berlin’s famous distinction between positive and negative liberty is ultimately harmful both on this issue, and for advocates of progressive causes more generally. First off, the dichotomy is altogether too strict. As Cass Sunstein and Stephen Holmes argued in their The Cost of Rights, the negative rights we have are enabled by government protection, just as much as positive rights are. To pick the most obvious example, the negative right to property only exists in a world with police, firemen, and civil courts to protect that rights for individuals. Positive rights require more resources, perhaps, but this is a difference of degree, not of essence.
More to the point, a focus on positive liberty is essentially a focus on the least popular element of health reform, namely taxation. After all, the difference between positive and negative liberty in Berlin’s formulation is the necessity of tax dollars for the former, so defenses of positive liberty must necessarily be defenses of taxation. There is nothing wrong with this, of course; I have no problem with using tax dollars to reform the health care system, or indeed with raising taxes for that purpose if need be. However, in a nation with a long, distinguished history of tax revolts, this will be a difficult argument to win.
I would posit that a more productive conversation would focus on the gains health care reform would bring in terms of enabling greater freedom of action. A positive liberty conversation focuses on the costs health reform would exact due to financing issues, but a freedom of action conversation would focus on how American would have a greater ability to take risks, change jobs, and generally live freely without fear of medical bankruptcy or a similar calamity befalling them. The model here would be an exceptionally clever ad launched by Ron Wyden for his Wyden-Bennett health care bill. The ad emphasizes how health care reform would enable to change jobs without fear of losing their health care.
Of course, Wyden had a better bill to promote than the current watered-down legislation emanating from Max Baucus’ negotiations, but the principle is still one worth emphasizing. This approach recasts health care reform not as government intrusion in one’s health decisions, but as an end to insurance company and employer intrusion, and in doing so appeals to the traditional American ideal of self-reliance. That seems like a better debate to have than a head-on discussion of taxes, which is where a positive liberty debate would leave us.
value: Liberty
John Eley
11.20.09
I think that your reading of Jenning’s essay gives him entirely too much credit. You seem to suggest that his only error is his tendency to distinguish between negative and positive liberty. I would like to think that this is the case, but it is clear to me that Jennings wants to both eliminate negative liberty as a variable by which policy is judged and to replace it with a radically new concept of positive liberty. In the process he works against the mutually that you seem to favor.He does not use Berlin’s seminal work nearly so much as he abuses it. Let’s look more closely at what Jenning does and I think that you will see my point.
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”. This is clearly a very biased and unfair characterization of the motivation of a large number of us who treasure negative liberty because of the opportunities that it provides to develop and carry out our life plans, pace Rawls and ohthers.
Jennings contends that when negative liberty 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 essary 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, since he uses use a new redefined concept of positive liberty as the touchstone of an effort to redistribute resources in the name of health care reform, seeking greater equity. 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 dealt more directly with the primary value of equity and less with the instrumental value of positive liberty as he defines it.