Who Decides Who Lives and Who Dies?

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Dan Callahan has written: "I doggedly believe we will one way or the other have to set limits on health care for the elderly, even if a specific age limit will not do…a good society ought to help young people become old people, but is under no obligation to help the old become indefinitely older."

When he says "we will" set limits, he means the collective "we." He means that the Medicare system will set limits. When he speaks of "society" helping young people but not old people, he means that Medicare will allocate money to young people but not old people.

Collectivist thinking about health care is not unusual today. After all, Medicare is a collectivist institution.

Collectivism, by common definition: "The principles or system of ownership and control of the means of production and distribution by the people collectively, usually under the supervision of a government." The "means of production" include all wealth. Wealth is anything that exchanges for a price.

The personal qualities of a person are sources of wealth. The personal qualities include a range of things like decisiveness, knowledge, skills, intellect, will, drive, know-how, emotions, attractiveness, leadership quality, decision-making ability, foresight, empathy, understanding, energy, drive, health, fortitude, stamina, plus moral and intellectual capacities. The personal qualities are used to provide labor and services that are bought and sold.

The vast majority of human wealth is through personal qualities. There is therefore no ownership and control of the means of production without controlling human beings. Collectivism to be collectivism has to be a system that includes control of the personal qualities of each person by all people collectively (which, in reality, means control by government officials and bureaucrats).

Collectivism is totalitarian, the latter meaning a system in which government exercises complete control over each person’s life or personal qualities. As Arthur M. Schlesinger, Jr. has written: "A totalitarian regime crushes all autonomous institutions in its drive to seize the human soul."

Seizure of the person is exactly what collectivism is about. It is about taking the property that each of us has in his person and life. This means we lose the power to make decisions over our own lives. In collectivism, the property in our lives and persons belongs to the collective. Through the centralization of health-care financing and rule-making, Medicare officials and bureaucrats decide who is going to live and who is going to die. Medicare is collectivist.

In Double Indemnity, Edward G. Robinson explains the predicament of Fred MacMurray and Barbara Stanwyck, who have committed a collective murder of Barbara’s husband. “They’ve committed a murder and it’s not like taking a trolley ride together where they can get off at different stops. They’re stuck with each other and they’ve got to ride all the way to the end of the line and it’s a one-way trip and the last stop is the cemetery.” They are bound together in a collective fate from which there is no escape short of the cemetery.

A person and his life either belong to him or they belong to others. Either we decide as persons how we live and die, or we give up those decision rights to the collective and faceless officials and bureaucrats of government. The trolley we are on is the latter, the totalitarian line. Some of us want to get off. We did not commit the murder. If the ones who want to ride that trolley will let us off, they can continue their ride. That is a peaceful solution. It will mean the end of the U.S. government as we know it. But there is no reason why several governments cannot operate on the territory now under the jurisdiction of the U.S.A.

But it is possible that the others won’t let us off, because they are collectivists and wish to control us. That sort of basic difference will not go away. It will lead to conflict.

The U.S. government, with the vague and diffuse blessing of majority America and the specific and narrow support of various health-care lobbies, committed a murder in 1965 when it instituted Medicare. On July 30, 1965, President Johnson signed the death warrant for markets in health care. On our behalf, the protestations of many of us notwithstanding, he placed us and our health-care system on a one-way trip to the cemetery. The murder was suicide by a slow-acting poison that is still spreading through the body politic and the associated economy.

The government already decides who lives and who dies via its large-scale intrusions into markets for health care. The connections to life and death are manifold, but they are beneath the surface of public recognition. They are felt, but they are largely unseen and unremarked. As the trolley approaches the cemetery, we get closer to that time when the government will decide ever more explicitly who lives and who dies.

The future in our government-dominated society is often visible in academia, because that is where the future is created and propagated by intellectual apologists for government. Academic intellectuals quite often act as if they are neutral scientists in search of truth when, in point of fact, they publish lengthy articles in which they accept and often support the premise of big government. Various governments support many intellectuals financially. This is a cozy, self-perpetuating, and thoroughly evil arrangement whereby the government gets to control the minds, if only partially but nonetheless effectively, of those who think they are getting educated. The government-academic nexus often ends up as a totalitarian mechanism.

Duke University began a journal in 1976 called Journal of Health Politics, Policy and Law. It is still published. The editor spoke of the major ultimate goal as "decent care for the suffering." He did not take to the pulpit to encourage us to help the suffering. He mentioned no religious figures. He did not delve into moral philosophy. He did not speak of how a free people alleviates its own suffering. He spoke instead of "health policy-making" as being the journal’s focal point, as befits its title.

I briefly mention the content of the first three articles in the first issue of this journal. The authors of these articles are, as we all are, on the trolley ride to that health-care cemetery, but they do not recognize the basic cause of that fact, which is Medicare. And so they recommend more government measures that actually speed up the trolley and make sure that everyone is aboard when it reaches its destination. Goodwill often combines with ignorance and bad philosophies to produce tragic results.

The first article in the first issue of the new journal was written by Theodore Cooper, Assistant Secretary of Health, U.S. Department of Health, Education, and Welfare. The title was "Federal Health Policy." The rhetoric of his opening lines is the rhetoric of today, some 33 years later. Obama could have spoken these words penned in 1976 by this government official:

"A host of problems today confronts the health care system. None is new but all are vastly larger and more pressing than ever before. There are problems having to do with the cost of health care, both the cost to individuals and the aggregate cost to society. There are problems concerning the quality of care, access to care, and the appropriateness of the manner and settings in which health care is dispensed…But the super-problem in health is cost. The intolerable escalation of cost throughout the system is pushing it toward significant change."

Connecting any of this to Medicare’s existence was beyond Cooper’s ken. From where he sat as a bureaucrat in government, Medicare was a given. To him, Medicare was there as an outcome of public policy. He thought that the legislation was an outcome of public demand. He mentioned the public’s expectations and the national expectation of health care. He noted that "people expect so much because of the inexorable movement toward the idea that personal health or medical care is a public responsibility. This is an ideological shift…"

The reality is that Medicare came into being as the result of decades of lobbying by various health care businesses and organizations, not as a result of public demand. Cooper’s reaction shows that bureaucrats who administer the program need not and may not understand the politics of Medicare’s beginnings or the economics of its replacement of markets in health care. What they see is a huge demand after the program is put in place, and they then rationalize that as a shift in ideology when it is really an expression of economics operating within the new political framework. And those who have that sort of belief, caused by witnessing the public demand under that program, do not realize that the demand exists just as powerfully in markets prior to government’s entry. They cannot recognize the government program as a source of problems that did not exist in unhampered markets, and they cannot recommend the termination of the government operation, which, by the way, employs them. Instead, to complete their rationalization, they seek to find fault with the markets and to fantasize that people in general wanted government health care.

Medicare, no matter how it came into being, is now operating as an independent cause of social change. It is now fueling the trolley’s movement. Because Medicare pools health care money, it creates a problem for government bureaucrats of deciding who will get that money. They then invoke arbitrary criteria. For example, seeing that elder care costs more money per person than middle-age care, they decide to allocate less to the elderly and more to the middle-aged. They then argue that this is fair and just. Seeing that procedure A is more expensive than procedure B, they control (lower) the price of procedure A, and this creates excess demand for procedure A. The number of rules, restrictions, and controls is endless. Medicine becomes a branch of politics.

The second article, again from 1976, reviewed national health insurance proposals. It said that the 1972 platforms of both parties spoke of comprehensive coverage. It said that the cost of a cradle-to-grave coverage was estimated as $285—$580 billion (in today’s dollars). We may note here that then, as now, government always under-estimates costs. The article spoke of a Massachusetts plan, just as several years ago Governor Romney of Massachusetts achieved a lot of publicity with his health insurance plan. Congress, we are told, was considering three proposals; and "The first is Senator Kennedy’s proposal…" That hasn’t changed either.

Health insurance covering all Americans is an aim of the current administration. It will probably be enacted in some form. They’ll probably dedicate it to Senator Kennedy. The trolley ride to the cemetery continues. The last stop is the death of markets in health care, replaced by a totalitarian system.

The third article, written by several members of the New York City Health and Hospitals Corporation, began by informing us that "Since 1965, the federal government has become the principal purchaser of health care services primarily through its financing of the Medicare and Medicaid programs." These health care professionals were on the receiving end of various laws passed by Congress in 1972 to deal with the problems of Medicare (cost increases, waste, deterioration of quality). But these laws created even more paperwork and cost! The authors called for quality care, while they bemoaned "the sheer quantity of paperwork that will force providers to hire additional staff," whose cost detracts from actually doctoring and nursing the ill. They complained about "the unbelievable crush of paperwork…" Then, not recognizing that Medicare and Medicaid were the source of the resulting problems of cost and excess demand or not willing to call for their termination, these authors called for changes in the control systems. This tinkering has now gone on for 43 years.

Dan Callahan’s book on setting health care limits came out in 1987. The topic of rationing health care and the duty to die emerged in academia. One could find ancient writers who believed that the elderly should die, perhaps with society pushing them to die, so that resources would be made available for the young. The modern resurgence of interest in this topic was due to the government’s presence and prominence in medical care. Since the government controls the resources going to medical care, it has to say where they go and who gets them. As long as the government controls health care, it has to say who lives and who dies. The academics get into the act by advising government whom to kill, how to kill them, who should get the supposedly-released resources, who should get a CT-scan and who should not, and so on. Academics think, and they think about every aspect of the issue except one, which is getting the government out of health-care markets. The academics accept collectivism. It is their bread and butter. It is their mother’s milk. They analyze health care in the name of efficiency and occasionally in the name of justice. We are supposed to repose and take our guidance on these matters from the priests known as professors (not from the renegades of that class).

Adam Smith begins his inquiry into the wealth of nations by mentioning: "Such [savage] nations, however, are so miserably poor, that from mere want, they are frequently reduced, or, at least, think themselves reduced, to the necessity sometimes of directly destroying, and sometimes of abandoning their infants, their old people, and those afflicted with lingering diseases, to perish with hunger, or to be devoured by wild beasts."

Is America now in the class of savage nations that is so miserably poor that we are given to intellectual pondering about the destruction of old people? Do such investigations, ideas, and deeds naturally accompany the killing of infants? Do they naturally accompany socially-approved abortion? They do. These are all birds of a feather.

America’s turn to savagery does not originate in America’s being poor. Americans were poorer centuries ago without discussing the killing of old people and babies. Taking care of elderly persons has always been costly. Medicare brings out into the open the fact of resource limitations that always beset mankind. It exacerbates the rationing problem by centralizing all resources and decision-making. But, as we have seen, Medicare itself reflects the same factors that imply savagery, by which I mean brutal, merciless, and vicious.

Savagery is associated with a cluster of other ideas and beliefs that have a grip on American thought. They include collectivism, which is against a person having property in his own mind, body, and life; that is, having control over his own mind, body, and life. For once one owns and controls others, even via a collective sense of ownership, the sense of restraint that governs behavior when each of us has property in ourselves disappears. We are free to act as we will, and that allows a broader scope for our more evil and selfish impulses. Another of these ideas is collective utilitarianism, which is an attempt to tote up the costs and benefits of policies to broad collectives. Once we abandon the idea that each of us is a person who makes decisions for himself over his life, and replace that with the idea that a person’s essence arises by virtue of belonging to some collective group, and the idea that everyone within a group is the same, the way is open to mistreating vast numbers of persons by labeling them and treating them all in government-specified ways.

The Holy Bible expounds a social philosophy that is entirely at odds with the collectivization of medical care. There is no room for discussions of euthanasia and age-based rationing in such commandments as "Thou shalt not kill," and "Honour thy father and mother." There are no tradeoffs of young for old in "Thou shalt rise up before the hoary head, and honour the face of the old man, and fear thy God: I am the LORD." Can anyone doubt the meaning of "Hearken unto thy father that begat thee, and despise not thy mother when she is old"?

Professor Margaret P. Battin wrote an article in 1987 titled "Age Rationing and the Just Distribution of Health Care: Is There a Duty to Die?" After 24 pages of intense mental gymnastics that attempted to figure out what people would think about old-age medical care if they were placed in a Rawlsian veil of ignorance, she decided that thou shalt kill if there is a substantial scarcity of resources. (Who will decide that little matter?) She decided that one need not hearken to thy father after all and one might despise thy mother’s life as long as the resources released from this will be indeed transferred to the young. She also spoke up for talking older people into agreeing to end their lives. Her language was not as blunt as mine. A sample: "Nevertheless, whether death in old age is feared or welcomed is very much a product of social beliefs and expectations, and these not only undergo spontaneous transformations but can be quite readily altered and engineered."

As more and more retirees go on Medicare and the costs rapidly escalate, the government shall more and more explicitly be making life and death decisions. What we think is civilization in this regard is actually savagery.

Michael S. Rozeff [send him mail] is a retired Professor of Finance living in East Amherst, New York.

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