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Charges for public health ? professor Peter c. sMITH

Torture - a necessary evil ? JASPER LITTMANN

COMPASSIONATE RATIONALITY ILAF SCHEIKH ELARD

DESERT AND ARBITRARINESS dr morten e.j. nielsen

THE VALUE OF FREEDOM alexander j. malt

Editor Nicholas C.A. Jones

cHARGES FOR Public Health? Many people it is a matter of common humanity that the sick should not be charged for health care. Yet universal access to a comprehensive package of ‘free’ health care is quite a recent phenomenon, and must count as one of the quiet social triumphs achieved across Europe after the second world war. Compared to most countries, the UK places especially low reliance on user charges (about 10% of all health care expenditure), reflecting the founding principle of a NHS ‘free at the point of access’, and periodic attempts to introduce new user charges into the NHS have been fraught with difficulty. In particular, the imposition of prescription charges in 1951 led to the resignation of Aneurin Bevan, hastening the demise of the Atlee government.

Yet, although freedom from health care charges enjoys widespread popularity, its viability is coming under strain. First, there is a persistent concern that freedom from charges leads to ‘moral hazard’, in the form of excessive or unnecessary consumption of health care. This risk is exacerbated in many countries by the incentive for

doctors to encourage more utilization in order to increase their incomes. And second, as the scope and costs of health technologies increases, so questions are being asked about the sustainability of traditional public sources of finance. User charges can be used to address both concerns: by signalling preferred behaviour to patients, and by raising additional finance for the health system. There is in general a shortage of reliable evidence on the impact of user charges on the utilization of health care and the health of patients in developed countries. The major exception is the celebrated RAND experiment, under which over 2,000 US patients were randomly assigned to one of four charging regimes over an extended period in the 1970s. One group of patients enjoyed complete freedom from charges, while those at the other extreme were charged 95% of fees for virtually all care, up to a maximum annual ‘catastrophic’ liability of about $6,000 at current prices. Some results from the experiment are summarized in Table 1. They show consistent reductions in utilization across all types of health care as the charges became more severe. For example, physician consultations varied from 4.55 per annum amongst those incurring no charges, to 2.73 amongst those in the highest charging scheme, a reduction of 40%.

Table 1: Use and spending per person in the RAND health insurance experiment (Source: Newhouse, J. P. (2004), "Consumer-Directed Health Plans And The RAND Health Insurance Experiment", Health Affairs, 23(6), 107-113.)

However, with one major exception, evaluation of the experiment did not detect any material variations in health outcome associated with charging. Researchers have therefore concluded

Visit rates Admission rates Spending (2003$)

Coinsurance (percent) Number SE Number SE Amount SE

0 (free care) 4.55 0.17 0.128 0.0070 1,377 58

25 3.33 0.19 0.105 0.0070 1,116 51 50 3.03 0.22 0.092 0.0166 1,032 58 95 (high deductible) 2.73 0.18 0.099 0.0078 946 47

Contents

The Periodical of Politics, Economics and Philosophy November 2006 :: Volume 2 :: Issue 1 :: Autumn Term 2006

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that - for most of the population - charges succeeded in encouraging less profligate use of health care without serious health consequences. The one important exception was the finding that charging had a seriously adverse effect on those who were both poor and suffering from poor health. The RAND evaluation estimated that for this disadvantaged group there were a wide range of serious consequences, in spite of some cost subsidy for low-income families. For example, when charges were imposed, hypertension was less well controlled in this group, to the extent that the annual likelihood of death rose approximately 10 percent. Across Europe, in countries as diverse as Sweden, the Netherlands, Germany and France, there has nevertheless been a recent movement towards greater use of user charges in health care. In most cases these do not raise a significant volume of finance. Rather, their main purpose has been to encourage patients to use the health system to better purpose, by discouraging treatment when benefits are small and incentivizing efficient use of services when it is justified. Examples of objectives underlying these new charging schemes include:

- moderating use of drugs - encouraging use of cheaper generic drugs - discouraging multiple consultations for a

single condition - encouraging the use of less costly or higher

quality ‘preferred’ providers - encouraging early discharge of patients

from hospital. Many other experiments in a similar vein could be envisaged, such as offering patients a rebate on charges for GP or outpatient visits if the first appointment is honoured (in order to discourage non-attendance), or offering exemption from charges if a patient complies with a course of treatment in its entirety. As well as these largely symbolic charges, some middle income countries such as Chile have introduced more substantive user charges. A particularly ambitious scheme of ‘diagnosis based reimbursement’ is being introduced in the Slovak republic. A national tariff for reimbursing health care providers is set for all interventions, according to diagnosis. Patients are then reimbursed for a proportion of the costs of treatment, depending on the diagnosis group. The proportion reimbursed depends on the estimated benefits and costs of treatment, and there is full reimbursement for 33% of diagnoses. This scheme is consistent with the prescriptions of the theory of ‘optimal’ commodity taxation developed by economists. However, as experience unfolds, it will be important to see

whether the approach is in practice sustainable, whether unintended behavioural responses on the part of doctors or patients emerge, and whether the lack of exemptions leads to especially adverse outcomes for poor and sick people. I believe that – if and when the wealthiest countries such as the UK find it impossible to fund all health care interventions out of the public purse – approaches such as this, implemented alongside a carefully crafted system of exemptions from charges for very poor citizens, offer the most efficient and fairest approach to making operational the consequent rationing decisions. This approach may at first glance appear unattractive compared to the stated principle of a comprehensive NHS, free at the point of access. Yet many commentators feel that it will be infeasible to adhere to that principle indefinitely, as the scope of health care increases inexorably and the limits to popular willingness to pay the necessary taxes are reached. If this is the case, economic principles offer policy makers a framework for making the hard choices that follow. It will take political courage to implement such explicit rationing, but the alternative may be steadily to degrade the scope and quality of the NHS by stealth, and reduce the widespread support for funding it through taxation. In conclusion, it is worth noting that many lower income countries do not offer patients the protection from charges enjoyed in high income countries. Indeed, worldwide over 50% of health care finance is in the form of out of pocket payments. High reliance on user charges is inescapable in low income countries in which a governmental or private insurance capacity is infeasible, and generally leads to very poor health system performance. One of the greatest challenges confronting mankind is to find better ways of financing and delivering health care in low income countries. Peter C. Smith is a Professor of Health Economics at the Centre for Health Economics at the University of York Torture- A necessary evil? When the war on terror was declared after 9/11 and the question of how nation states should face the threat of international terrorism arose, the debate about legislating torture experienced a renaissance. Just before 2001 hardly anyone would have thought that western democracies would

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seriously consider legalizing and utilizing torture as a means of protection against a terrorist threat. Yet suddenly it seemed that the allegedly desperate times called for desperate measures. The US-vice president Dick Cheney said in an Interview on Meet the press in 2001 that “now [after the attacks on the World Trade Center] the time has come to kind of use the darker channels” (New Yorker) in order to protect the country. What these darker channels look like has been displayed at prison camps such as Abu Ghraib and Guantanamo. Most of you will probably remember the picture of a blindfolded man, standing on a cardboard box, wires attached to his hands, experiencing first-hand how western democracies now protect themselves.

But it is not the aim of this article to list the failures of national security policy. The issue I would like to address here is the thesis that torture is not only a nasty side effect of going to war but a necessary investigative tool that needs to be legalized under certain conditions. This thesis stems from a highly respected professor of law at Harvard University, Alan Dershowitz, by no means a right-wing anti-democrat. Dershowitz and the “ticking bomb scenario” Generally the scenario used to justify torture goes something like this: A terrorist has been captured, investigators have found out that a bomb with a time fuse has been planted, and the involvement of the captured is obvious. The terrorist however refuses to name the location of the bomb, which when it detonates is likely to cause a high number of casualties. The question that arises from this scenario is now: “What actions may an investigator undertake in order to find the bomb?” Although highly speculative and theoretical, the “ticking bomb scenario” depicts a legal dilemma, a kind of judicial worst case scenario. This is because both advocates and opponents agree that in such a scenario torture would be utilized to find the bomb, irrespective of the legal status. According to Alan Dershowitz the argument for a legal framework in which torture is permitted can be summed up as follows: If a ticking bomb scenario makes the use of torture highly probable because investigators may feel morally obliged to do everything within their powers to save the life of potential victims and if even the opponents of torture acknowledge this fact, then the current legal ban on torture is dishonest. What makes it dishonest is the fact that the breach of law is anticipated. It is well

understood by all parties that torture would in all likelihood be utilized. But to keep up the appearance of a “clean” investigation it is criminalized even though it may already be incorporated in an investigative system. Dershowitz himself says that he is absolutely against the use of torture but, to end its existence in a legal twilight zone, he has suggested that torture be legalized in particular circumstances and only at the signature of a warrant, thereby making someone officially accountable for its use. Dershowitz does not try to morally justify the use of torture. While some utilitarians argue that an obligation to torture in a situation such as the “ticking bomb scenario” can be derived from the anticipated number of casualties that may make the use of torture morally imperative, Dershowitz acknowledges the fundamental human rights violation that torture inevitably entails. He shifts the focus of the debate from moral to practical considerations. Because it seems unlikely that law enforcement agencies or secret services would act within the boundaries of current law, should a “ticking bomb scenario” become reality, Dershowitz pleads for an extension of legal systems, to include clear rules on the limited use on non-lethal torture in the case of a ticking bomb. The case against At first glance, the Dershowitz argument seems to make sense. In the case of a ticking bomb with possibly a high number of casualties, who wouldn’t be tempted to trade in the human rights of one terrorist for the lives of all potencial victims? Also it seems reasonable to assume that investigators, when facing this choice, would neglect the rights of one to save the lives of many. But does the necessity of a torture warrant follow? I believe that Dershowitz’s argument can be attacked on three levels: First, it wants to derive very real consequences from a theoretical legal problem which is based on so many premises that it is unlikely ever to occur in this exact way. The abolition of human rights under certain conditions would be based on a scenario for which there exists no real example. Secondly, Dershowitz ignores the fact that a ban on torture and the strict adherence to a moral code that is based on human rights are one of the fundamental achievements of democracy. But human rights cannot be bent. You either respect them or you don’t and the case he makes for torture in special circumstances is a clear statement against the universal application of these rights. It seems paradoxical that a society should be

protected by abandoning the values which form its very foundation. Finally, it misses out on reality. Torture is not a potential phenomenon, only possible in a ticking bomb scenario; it is already happening – even in democratic countries that officially accept human rights. We don’t need a law for theoretical case studies, we need a mechanism which ensures that governments live up to the moral standards that they claim to stand for. Admittedly adhering to high moral standards when others do not is a decision that in its result may be trying. But as Aharon Barak, former president of the Israeli Supreme court pointed out, “Democracy sometimes has to fight with one hand tied to its back” in order to maintain a set of values different to that of terrorists. And it is this difference in moral standards that defines who we are and what we stand for. Democratic states cannot fight with the same weapons as their opponents because it is that particular difference in moral standards that sets us apart from them . This is what Michael Ignatieff meant when in an essay for Human Rights Watch, he said that we cannot use torture because of who we are. And here one should add the words of the German sociologist Jan-Philipp Reemtsma who wrote that “We are what we do – and what we promise never to do”. Steve Crashaw “Torture doesn’t work” http://hrw.org/english/docs/2006/04/27/global13281.htmAlan Dershowitz “Tortured Reasoning” http://www.alandershowitz.com/faqs/ouptorture.html Jasper Littmann is a second year PPE student at the University of York

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This term the Club of PEP held the first ever YorkWorks careers fair, which along with the perenially popular Finance Fair was both well attended and attracted a great deal of positive feedback from both employers and students. In addition the club held a Q&A session on internships, which was viewed as both interesting and productive by those who attended. In the spring term we have the phenomenal Club of PEP annual ball, and for those who could not wait until a group of PEPist’s will be travelling to the annual ball of the University of Lund in Sweden.

Compassionate rationality “If alms were only given out of pity, all the beggars would have starved to death.”

- Friedrich Nietzsche “O, I have suffered. With those that I saw suffer!”

- Miranda in The Tempest, by William Shakespeare

Upon reading news of human suffering around the globe, most of us would feel compelled to help and to cry out like Shakespeare’s Miranda when she saw a ship wrecked, and all the crew drowned. Others, like Nietzsche disagree. On their view, compassion, as shared suffering, not only unnecessarily increases pain in the world, but also yields many other dire effects. They take the position of Robespierre, who famously uttered: “Pity is treason!” In this article I will outline the two different approaches to compassion and evaluate which is a better ground to help Africa to get out of poverty. I will conclude that both views, embracing and fully rejecting compassion are dangerous. There should be a middle ground, which includes enhancing imaginative creativity1, on the hand, and restricts compassionate blindness on the other. To start off with the positive interpretation of compassion, one notes that all major religions see compassion as a virtue. Pulling someone out of their misery is widely considered to be a good deed. In addition to this, through acting compassionately it is also possible to cast off your own distress at the sight of seeing someone else in agony. The distinguished writer Herman Hesse once noted: “You know quite well, deep within you, that there is only a single magic, a single power, a single salvation...and that is called loving. Well, then, love … suffering. Do not resist it, do not flee from it. It is your aversion that hurts, nothing else.“

PEPtalk

In opposition to this, there are those who are critical of compassion. The critical theorists, of whom Friedrich Nietzsche is their most famous advocate, argue that suffering with the unfortunates through compassionate emotions only increases the misery that already exists in the world. Nietzsche uses the German term “Mit-leid”

1 Frazer, M. The Compassion of Zarathustra: Nietzsche on Sympathy and Strength The Review of Politics, 68 (2006), pp. 49-78 <http://www.gov.harvard.edu/faculty/mfrazer/The%20Compassion%20of%20Zarathustra.pdf>

which, when translated into English, means “suffering-with”. Additionally compassion, since it resembles an emotion, is much like a dream. Being overwhelmed by one’s emotions, one disregards the reality when wanting to save the whole world. The day after, though, will be disastrous. Not only for the helpers, but even more for those who were thought to be helped. William Easterly, who wrote “The White Man's Burden: Why the West's Efforts to Aid the Rest Have Done So Much Ill and So Little Good” would agree. He says that compassion is not enough. “Donors must also be answerable to the people they claim to help.” If not “donors offer what they want to give, not what the poor can use, and they have little incentive to follow through on any charitable gesture they might make.”

Not only does this compassionate drive hurt the

inflicted by giving them inappropriate assistance, compassion is also an assault on the human dignity of the pitied. Those who help others are superior, and they assume that the objects of their assistance cannot handle the pain alone. The pitied are in need of a second “I”, for example, the development worker, who can assist them in handling their situation. It is helpful to look at the origin of the German word for compassion, i.e “Mitleid”. It shares the same root with “Beleidigung”, which means affront or invidiousness. Hence through compassionate actions, dignity and honour are desecrated and individual sovereignty violated.

The main question one has to ask is whether or not compassionate actions help the pitied or not. The critical interpreters have a dim outlook as they denounce actions that are motivated by compassion. Compassion is an emotion which is aroused at a special circumstance and focused on an individual case. Therefore, the assistance that comes out of compassion is restricted in its scope as it directs aid only to a particular case. Deciding to assist Africa in getting out of the poverty trap

will yield better and more sustainable results if the plan of action has a rational base.

Here one reaches the crux of the argument: the

danger of compassion occurs when one embraces it excessively so that one loses sight of reality. But, and more crucially, if one rejects compassion fiercely, then one has too narrow a view of what could be achieved. The West cannot lift Africa out of poverty by piecemeal means alone, both bold strokes and the more modest approach merit consideration. Here lies the danger of losing what Harvard Professor Michael Frazer terms “imaginative creativity”, i.e. envisioning possible, bold solutions to mankind’s grand problems.

In light of the above, one should strike a

balance between rejecting compassion and being overwhelmed by it. Only when one uses one’s heart and mind in a balanced manner, will the problems of today’s world be solved more successfully. Ilaf Scheikh Elard is a first year PPE student at the University of York Desert and Arbitrariness- Moral, not metaphysical Probably the most influential and strong intuition buttressing the egalitarian position was famously put forward by Rawls in A Theory of Justice: Once we decide to look for a conception of justice that nullifies the accidents of natural endowment and the contingencies of social circumstance as counters in quest for political and economic advantage, we are led [to the principles of A Theory of Justice.] They express the result of leaving aside those aspects of the social world that seem arbitrary from a moral point of view. (TJ, p. 15, italics added.) Which is often read in conjunction with the following famous passage (and rightly so): It seems to be one of the fixed points of our considered judgments that no one deserves his place in the distribution of native endowments, any more than one deserves one’s initial starting place in society. The assertion that a man deserves the superior character that enables him to make the effort to cultivate his abilities is equally problematic; for his character depends in large part upon fortunate family and social circumstances for which he claim no credit. (TJ, p.104) This expresses – in the familiar, slightly roundabout Rawlsian way – a formidable intuition: Our (distributional) fate should not be determined by factors outside our control, by whatever is arbitrary. Our starting “package” in life – i.e., our genes, our talents, our social, familial, and educational

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circumstances etc., are, largely if not wholly arbitrary. Hence, they ought not to decide our distributional fate, no matter if we are lucky or unlucky in the initial distribution. Let’s call this the argument from arbitrariness. The argument is probably best known in discussions about desert. Here, the argument takes the following form:

X Deserves Y in virtue of Z only if X deserves Z

So, Abe (X) only deserves his high wage (Y), based on his superior education (Z) if he deserves (Z). But clearly, it is, at least in most conceivable conditions, a matter of arbitrary circumstances whether Abe ends up with a good education etc. Hence, the argument from arbitrariness undermines all desert-bases, and leaves the road open for massive redistribution in order to alleviate or eradicate the consequences of the evidently unequal distribution of assets, talents, circumstances. Arbitrariness undermines moral claims. But hang on there! If the point is that arbitrariness undermines moral claims, how can we make any moral claim? Including the redistributive claims of the kind typically made by egalitarians. After all, it is entirely contingent that I end up in a particular society with a specific gross national product and distributional set up, giving me a right to a certain level of resources. In fact, it is entirely arbitrary that I end up as a person; that these atoms etc. are configured as something that can claim moral status. Seen in a certain light, is it not the case that everything in the universe, could be entirely different, and is therefore arbitrary? What we need, then, is a bloody good explanation as to why some kinds of arbitrariness (the ones relevant for desert etc.) are “bad” in the sense that they undermine moral claims, while others are “good” or neutral vis-à-vis moral claims. In the proverbial nutshell, the argument from arbitrariness seems to be either much too strong (insofar as it renders any moral claim illegitimate) or, in the absence of a solid justification of the distinction between bad and good arbitrariness, inconclusive (if everything is arbitrary, why concern ourselves with only a part of it, or at all?) It seems to me that egalitarians (of the relevant kind) are facing a cross-road. Either they must downplay or completely abandon their reliance on arbitrariness in arguments for equality. Or, they

must come up with a solid explanation of why some varieties of arbitrariness are “bad” and undermine moral claims, whereas others are either “good” or irrelevant for moral claims. Regarding the second alternative, my intuition is that any such attempt will be undermined by the very fact that it is arbitrary that I am a person, that I live in a distributional set-up of this or that kind etc. Hence, when explaining “bad” vs “good” arbitrariness, the argument must, tacitly or otherwise, appeal to moral intuitions of fairness or goodness or whatever, that in their turn have very little to do with arbitrariness. Hence, trying to go down the second road will boomerang you on to the first: making a moral argument that does not rely on arbitrariness. Where does this leave egalitarianism? Actually, not in a very bad shape. It seems obvious that our egalitarian leanings are not completely dependent on the intuition about arbitrariness. First of all, if arbitrariness reigns supreme, we can comfortably ignore it! And face up to the question, are vast inequalities in resources, capabilities and welfare morally justified regardless of their arbitrariness? Is it fair or good that some have in excess, while others have nothing? Second, liberating egalitarianism from the grip of the argument from arbitrariness will, give a wider scope for other considerations, prominent among those considerations of desert. Such a pluralistic account of social justice seems closer to at least my moral intuitions, and, I might add, to the man on the Clapham Omnibus – which cannot always be a bad thing. Dr Morten E.J Nielsen is a Post Doctoral Fellow at Roskilde University, Denmark

The value of freedom Existentialism is one of the most famous and influential of philosophies. The phrase, ‘Man is condemned to be free.’ has resonated throughout the world, invigorating some and mortifying others. This catchphrase was coined by Sartre and is probably the most sacred of existentialist tenets. The belief expressed here is that of absolute freedom, inherited from Søren Kierkegaard, that not only is man free to choose what to do but also what to value and believe.

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Both Kierkegaard and Sartre screamed at people through their philosophy to accept responsibility for their entire lives – apathy is no excuse. Sartre sought to show through his plays that lack of resistance against the Nazi regime was tantamount to accepting it; Kierkegaard impressed upon Christians that simply turning up to church, singing the hymns, saying the prayers and then going for tea with the vicar was a pretty lame attempt at Christianity. Christians ought to fear God, not believe simply as a supernatural insurance policy. A modern existentialist would scorn those today who oppose the war in Iraq from the safety of organised protest marches and the local pub, yet still deny any responsibility for the event itself. To not try to stop the war in Iraq says something about the values of the apathetic person – they value peace, but not enough to bother doing something about it. Freedom is sacrosanct as it places the weight of the entire world upon man’s shoulders, and brings to the forefront of every ethical issue the importance of man’s capacity for action.

This colossal, overbearing freedom is taken by Existentialists to be man’s true essence. To deny it is not only cowardice, it is to try and reduce oneself. By denying this freedom you fall from a thing whose essence is Freedom, to for example a table, an object determined wholly in virtue of the fact that it is a table. It is to reduce human dignity. The cowardice that is present in denying responsibility is labelled by Sartre as ‘Bad Faith’. Conversely, living in recognition of man’s freedom, man’s power to act, is branded ‘authenticity’. It has often been wondered whether, the claims and beliefs of Existentialism are at all valuable. Many accuse it of being the most depressing of philosophies, particularly since the use of concepts such as ‘death’, ‘abandonment’, ‘absurdity’ and ‘anguish’ are commonplace amongst Existentialist philosophers. Some have commented that “when all the actualites have gone, it is a lot of noise about not very much!” Such attitudes tend to dismiss the philosophical tradition as an outdated manifestation

of the mood during the aftermath of the Second World War. I wish to argue here that the core belief of radical freedom described above is indeed valuable in the context of the modern world. Indeed, I feel it is a far nobler person to whom ‘I can’t’ is nonsensical. The main reason for this is that radical freedom carries with it profound responsibility; the world is more the image of man than man is of it. An individual willing to bear the weight of the entire world upon their shoulders, and not offload the blame, or part of, to other people is a exemplary person indeed. It seems in the modern world this responsibility is constantly evaded. At the most minor level this comes in the form of everything pathetic in modern culture. By this I am referring to ‘compensation culture’, ‘armchair activism’ and the rest of it; covering anyone who is intent that others are to blame for absolutely every shortcoming in the world, and thus are intent on muttering about the failures of others. I will not dwell on such people, because to do so is utterly unconstructive. There is a more important sphere in which Existentialist concepts are literally life-enhancing. The denial of responsibility known as Bad Faith is absent in people with regards to choosing the courses of their own life. I know many who say “I would love to do x, but I don’t have the time”, or alternatively “I have a lot of things to think about at the moment – maybe next year.” This manifestation of Bad Faith is most serious because you only live once. “I could have done x, if only (blah, blah, blah…)” is a nonsensical excuse, Sartre point out “Why should we attribute to Racine the capacity to write yet another tragedy when that is precisely what he did not write?” Does anyone wish to lie on their deathbed with regret on their mind? A life regretted is a life wasted. It is for this reason that I ascribe to Existential freedom a supreme importance in life. If we are only to live once then in order that life not be wasted it is necessary to seize the day and act on every opportunity. 1 Pierre Boulez, quoted from David Cooper’s Existentialism: A Reconstruction, pp. 194 [2004, Blackwell] Alexander J. Malt studies PPE at the University of Durham

If you are interested in writing for the next issue or would like to comment on the articles please write to ncaj500@york.ac.uk

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