November 13, 2007

Paternalistic Elitist Egalitarians vs Envious Non-Elitist Liberals

Support the hospitalLast week I blogged on CNE about the proposed law in Germany that would deny covering the cost for medical treatment for complications from beauty operation or piercing.

I'm of two minds about this. As a libertarian I think we should carry the costs of what we do. If people want to enhance themselves they should pay for that, and if things go wrong they should pay for that (or have insurance, where they will pay premiums).

That is fine in libertopia. But in Germany (and most other European countries) we have mandatory health insurance systems. This means not just healthcare altruism where we all pay for ensuring that everybody gets a chance of treatment, but also an incentive of worrying about the neighbour's health - if he is doing something to risk it, I'm going to have to pay a small part of the cost. Politicians and other authorities get a strong incentive to be paternalistic and keep people not just healthy but also from doing anything dangerous or unhealthy. As the healthcare costs grow to more and more of the GDP, expect not just smoking, alcohol and obesity to end up in the sights, but also generally risky behavior, exposing oneself to conditions that might cause dementia or expensive chronic disease and so on. Not to mention potentially risky medical enhancements.

Having to pay for a health insurance for everybody and then extra insurance (or direct costs) for oneself if one wants to enhance would make this more expensive than just paying directly for the enhancement and risk management. That is, it would become a more elitist thing. The German proposal might have as effect (if it passes) to make plastic surgery remain a status symbol signalling that one is significantly richer than most. And a similar treatment of enhancement may also help them remain expensive and inaccessible to the masses. Anti-enhancement thinkers would no doubt solve this by banning enhancement, but that only means that now only rich medical tourists or criminals are enhanced.

On the other hand, paying for all medical issues would cost the insurance system an arbitrary amount of money. It has to clearly state its limits. Michael Sandel claimed in a talk that health is a finite goal, once we are healthy nothing more needs to be done. This is clearly untrue, since there are always those that cannot be helped fully and will always benefit from ever more expensive treatments, and even when the basic problems are fixed we desire that extra little bit of health. Any medical insurance system must admit to its limitations and state them.

The problem is of course that few politicians want to be responsible for telling a suffering group that their ailment is not important enough to cover - even when that is rational.

As I see it the choice (or rather, a chance to interpolate) is between an egalitarian system that will promote elite advantage, or a system that accepts inequality but does not give the elite an advantage. The first system will try to expand its coverage for political reasons and become ever more expensive, making it paternalistic and willing to meddle in people's lives. People will be unhappy if their ailments are not in the cake and will try to expand their slice at somebody else's expense. The second one allows more freedom, but will leave many people unhappy because they still cannot afford what they want, and now they have nobody to blame.

Maybe that is the truly important thing to redistribute: blame. If blame is optimally redistributed we are all happy, right?

Posted by Anders3 at November 13, 2007 05:56 PM