Part 4: Health and Morality Politics

The series is not done yet! Today, I am writing about issues of American health and the ways in which they are bound up and influenced by morality politics.

There’s no point mincing words: American attitudes, by and large, are more conservative than those of citizens in other wealthy countries. We are more religious, we take religion more seriously, and part of that is assigning moral components to almost every public policy decision. When the question is raised of whether the government should be involved with a particular issue, critiques do not focus merely on whether a government response would be efficient or effective, but also whether it is even the morally right thing to do.

As someone who does not subscribe to any religious system, I don’t particularly care what is “moral.” I care what is ethical, in the sense that all human beings have rights which are entitled to be respected both by other individuals and governments. I also care about efficacy and efficiency when it comes to public policy. This is why, for instance, I have advocated just giving poor people money to alleviate poverty. Money can’t solve all problems, but it sure helps. Unfortunately, there is a moral quality attached to money in the minds of many Americans, and that’s where we run into trouble.

For the sake of argument, I will consider the moral objections described here as sincerely expressed by their sources, rather than cynical manipulation. In the world of politics, one can never be certain which is which, but I have to choose. So, I’ll assume people aren’t lying when they say they think, for instance, that Obamacare encourages laziness. I have, in the more distant past, tried to give such critiques a fair shake. There was a time when my political beliefs were what one might call “libertarian,” which necessitates a small, limited government and very little potential for moral hazards. The government can’t do much wrong when it’s as hands-off as possible, right?

Such beliefs tend to stem from a very narrow, ideologically rigid conception of both human rights and the role of government. It’s not inappropriate to demand respect for human rights, of course. But libertarian-minded individuals favor an incarnation of government that overwhelmingly preserves existing nongovernmental power structures and institutional biases. A libertarian government would be able to do little to combat systemic racism, for instance, since much of that is the result of aggregate human behaviors (that is, individual choices) rather than the enforcement of broad government policies.

Unsurprisingly, libertarians tend to vote for Republicans in the US because such views are more likely to be found in the right than the left. The Republican record on actually shrinking government budgets and curtailing government power remained poor until after the 2010 elections, in which more ideological Tea Party Republicans got a foothold in Congress and focused on fiscal conservatism.

The other half of the equation comes from Christian Americans–evangelicals in particular, though they aren’t the only religious community to be aligned with the right-wing. In addition to viewing government power as a potential vector for abuse of people who share their beliefs, there are a number of hot-button issues that have helped guard their loyalty to the Republican Party. I am speaking specifically of issues such as abortion and same-sex marriage, but there are a host of social issues alongside them where, again, moral concerns are held as more important than practical ones.

To my mind, these are two sides of the same coin. Ideological rigidity in the face of contrary evidence can only produce poor outcomes. I would not say that such tendencies are non-existing on the political left, but they quite clearly hold much less sway over both voters and public policy.

None of this would matter if it was purely hypothetical, if these were merely abstract issues discussed without actual repercussions. But these issues are real, and they hurt real people.

Take abortion. From a standpoint strictly of efficacy, the research is clear. Abortion rates are lowest where abortions are easiest to access. This sounds counter-intuitive until one considers the policy implications of an environment in which abortions are easy to obtain. Healthcare in general is also easier to obtain–including contraception. There are likely other public services available, as well. All of these factors make abortion less necessary. The Lancet study agrees:

The global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15–44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. The average annual percent change in the rate was nearly 2·4% between 1995 and 2003 and 0·3% between 2003 and 2008. Worldwide, 49% of abortions were unsafe in 2008, compared to 44% in 1995. About one in five pregnancies ended in abortion in 2008. The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05).

The substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals.

(Emphasis mine.)

In other words, if you want to reduce abortions, you don’t do it by restricting access. There will always be some level of demand for abortions due to a host of factors:

  1. Congenital defects and other pregnancy complications in which termination is either chosen or medically necessary.
  2. Changes in life circumstances that make birthing, raising, and supporting a child financially or otherwise untenable.
  3. Birth control failures that result in unplanned pregnancies.

Each of these may be addressed in a variety of ways, but none of them can be effectively reduced by simply cutting off access to abortions.

To continue with abortion for a bit longer, there is a highly-publicized racial gap in the utilization of abortion in the US. While the abortion rate for white people is at its lowest level since abortion was legalized, the rate for people of color is five times higher. This is a tremendous difference. Why does it exist?

Christine Dehlendorf, a professor of family and community medicine at the University of California, San Francisco (UCSF) who specializes in reproductive health research, said that the discrepancy is reflective of the broader inequities people of color face in every arena.

“There are a multitude of reasons, and we don’t fully understand what’s going on,” Dehlendorf said. “But ultimately I think it’s about structural determinants— economic reasons, issues related to racism, differences in opportunities, differences in social and historical context.”

She emphasized that money is often a decisive factor. The median wealth of white households is 18 times that of Hispanic households and 20 times that of black households, according to the Pew Research Center, but across the board, low-income women have a higher rate of unintended pregnancy and abortion regardless of race. They are less likely to have health insurance or consistent access to healthcare, and therefore birth control, according to a study by the Kaiser Family Foundation. The Guttmacher report credited the increase in popularity of contraceptive intrauterine devices (IUDs) with contributing to the decline of the abortion rate. IUDs are among the longest-lasting and most effective methods of birth control—but they’re also among the most expensive, and therefore not an option for many low-income women.

Once again, it comes down to money. This is the common theme in almost every social issue that is framed in moral terms. It is believed that more “moral” behavior will produce the right outcomes, when money is often the tool most likely to make a difference.

And that’s exactly what money is: a tool. We may have imbued it with a peculiar level of mystique–how it really works, most of us don’t even pretend to understand–and more damagingly, we have ascribed significant moral qualities to it. A dollar you earn is not just a means of purchasing the things you need and want, it’s a symbol, a trophy of your labors. To have it taken from you and handed to someone who didn’t earn it is considered morally repugnant. This is the conservative argument against social welfare policies in general: they are doubly criminal, in that they steal from the worthy and facilitate the moral degeneracy of the unworthy. The former have done no wrong and deserve no punishment; the latter are in desperate need of God, or at least a stronger moral fiber. Such views conveniently erase layers and layers of complexity, and ignore the sprawling, interlinked systems that produce such curious results as geography and parentage having tremendous influence over your economic mobility. It’s nice to think that we are all the results of our own choices–that our success or failure is caused and owned by no one but ourselves–but there are so many outside factors at work that one is about as likely to succeed through hard work as through pure luck.

It doesn’t mean that hard work is worthless, or that work in general shouldn’t be encouraged, but imbuing it and the proceeds from it with moral qualities stymies effective approaches to dealing with broader social issues, many of which affect health. As I have stressed in the course of this series, poverty damages your health. If it’s not because you live in a neighborhood where you are exposed to lead and other toxins, it’s because living so close to the edge of financial ruin for years or decades takes an enormous physical and mental toll. To take such circumstances and ascribe them simply to failings of personal character is not just insensitive, it’s empirically wrong.

I don’t expect that the people who would most benefit from absorbing this point will ever come across this piece, or engage with its message if they do. It frustrates me, because there is much suffering that could be alleviated if only we would prioritize attacking that over hand-wringing about how government services make people lazy (which they don’t).

If one is truly moral, and if one truly has principles, isn’t alleviating the suffering of the poor and vulnerable a good thing? Isn’t helping people a positive step? Isn’t making people healthier something we can all support? And if the government has the proper scale and wherewithal to do so effectively, then isn’t it the right institution to be charged with administering such help?

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James
James runs this blog and likes to write about society, culture, politics, science, technology, social justice, and pretty much anything else. Rumor has it people read his posts sometimes.

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Part 4: Health and Morality Politics

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