Ronald Dworkin: Heartless Libertarian?

Ronald Dworkin is probably the most prominent living liberal political philosopher in the United States. Unsurprisingly, he favors a national system of universal healthcare. But at a philosophical level, Dworkin also very clearly holds exactly the same position a lot of viewers seem to regard as not simply wrong, but self evidently monstrous when it was ascribed to Ron Paul (or at least Republicans in the audience) after the recent Tea Party debate. That is, Dworkin believes that if someone enjoys a fair share of social wealth and resources, and makes a free and informed choice about the level of health coverage and care they wish to purchase, then justice is satisfied when they receive the care they have chosen to pay for (either directly or by way of insurance). If it turns out that someone then needs care beyond what they chose to purchase under these conditions, it is not morally incumbent on society to provide that care. If you want to be melodramatic about it: Society (or at least the government) should “let him die.”

You don’t have to take my word for it, of course: Go read chapter 8 of Sovereign Virtue, Dworkin’s major work of political (as opposed to legal) philosophy. As he makes clear there, he believes government should provide some level of universal coverage under conditions where wealth and genetic luck are unjustly distributed, and the difficulty of becoming properly informed about the state of medical care and relevant statistics is so great. But he also reasonably rejects a general “rescue principle” for healthcare—the principle that society must never “let someone die” or go without care if there is money in the public coffers to intervene—as “useless,” “preposterous,” and one that “no sane society” would adopt. The correct standard for what kind of coverage a society should provide, he argues, is given by trying to figure out what kind of health insurance policy and coverage most members of a particular society would choose if they were well informed and had whatever fair share of social resources is specified by general principles of economic justice. (Those principles might specify that people just born with unlucky ailments are independently entitled to a larger share; Dworkin is mostly thinking here about people who begin life reasonably healthy and will require different levels and types of care over time owing to the vagaries of life.)

Most people, Dworkin acknowledges, would reasonably forgo coverage for many types of risks or treatments, preferring lower premiums and greater present consumption. He suggests, for instance, that most reasonable people under his idealized conditions would not find it worthwhile to purchase coverage that would support their indefinite sustenance in a persistent vegetative state, or heroic and expensive interventions likely to extend life by a few months in old age.

In a society where Dworkin’s background conditions are met:

[H]owever health care is distributed in that society is just for that society: justice would not require providing health care for anyone that he or his family had not purchased. These claims follow directly from an extremely appealing assumption: that a just distribution is one that well-informed people create for themselves by individual choices, provided that the economic system and the distribution of wealth in the community in which these choices are made are themselves just.

Now, again, Dworkin’s premise all along in this argument is precisely that our society does not meet his background conditions, requiring government to supply care as a kind of second best. In our far-from-ideal world, he writes, the government should simply “construct a mandatory coverage scheme on the basis of assumptions about what all but a small number of people could think appropriate, allowing those few who would be willing to spend more on special care to do so, if they can afford it, through supplemental insurance.” In Dworkin’s view, then, if someone needs medical care that the model informed consumer would not have chosen to cover under conditions of economic justice, that patient should get that treatment if and only if he has chosen to purchase supplemental insurance. If he has not chosen to purchase that coverage, there is no moral requirement for the public to provide it. Or again, if you still want to be melodramatic, society should “let him die.”

In a society that did satisfy Dworkin’s background ideal of economic justice—a society not perfectly egalitarian, but clearly far more so than our own—it follows from his argument that someone who made a free and informed choice to purchase less coverage than most also need not be provided by society with additional care. Our own society, of course, does not meet Dworkin’s background conditions. But Wolf Blitzer’s thought experiment at least arguably does satisfy them, if we take the liberty of reading his stipulation that the imagined patient “makes a good living” to imply that the person enjoys an economically just share of social resources, and has made the choice to forgo coverage after informed deliberation.

So under appropriate conditions—clearly not satisfied for very many poor Americans, but at least arguably satisfied within parameters of Blitzer’s hypothetical—the most prominent living liberal philosopher gives pretty much the same answer as Ron Paul: People should bear the consequences of their freely assumed risks, and “society”—or at least the government—should let them.

”But,” I hear the indignant cry, “Dworkin still advocates universal healthcare as a matter of public policy!” Well, yes. But you don’t pose stripped down, idealized, and unrealistic hypotheticals about single individuals to answer complicated public policy questions. You use them to get at very elementary moral principles. If the question is really about what kind of complex institutions should be established by statute in light of all we know about healthcare markets, reducing it to a single decision about how to respond to one imaginary person is obtuse. If the point is to reveal underlying principles, then those are valid or invalid independently of how they interact with other moral or political principles, or empirical considerations, to generate a real-world policy view.

Anyone who thinks Ron Paul’s answer to the hypothetical is appalling and outrageous, then, should direct some appalled outrage at Dworkin, because he gives exactly the same answer within its artificial, stipulated parameters. If Paul is a ghoul but Dworkin’s cool in virtue of their different policy positions outside the conditions of the hypothetical, then those who see Paul’s view as appalling should acknowledge that the reaction to the Blitzer thought experiment is an irrelevant red herring, and what matters is (say) Paul’s awful views on economic justice, where he pretty clearly does differ from Dworkin. Then at least everyone can work up a righteous lather about the correct issue.