In my earliest days as a graduate student in political philosophy, my colleagues and I would spend endless hours debating the intricacies and nuances of the various philosophies we were studying, invariably culminating in that most subtle and sophisticated of all questions: “Who’s better—ancients or moderns?”
Now in this highly refined intellectual contest—conducted with all the finesse and grace of a Redskins-Giants game—the moderns initially fared poorly. After all, modernity seemed to be hopelessly self-contradictory and morally bankrupt, lurching from one understanding of human nature to another, each more distasteful than the last.
Opening with Hobbes’s unflattering view that human beings are little more than vicious brutes murderously obsessed with self-preservation, modernity soon reeled back in horror, seeking solace in Rousseau’s vision of man as a compassionate but effete and simpering sentimentalist. Then, perhaps light-headed after an ascent into the rarefied stratosphere of Kantian idealism, modernity skidded down the slippery slope of historicism, finally pitching face-first into the dark, desperate mire of contemporary nihilism.
In contrast to all this, it seemed to us, ancient political philosophy as formulated by Plato and Aristotle offered stability, comfort, and hope. It suggested that man possessed by nature the noble capacity for an ascent to certain high virtues or excellences. This ascent, in turn, pointed toward the existence of a serene realm of permanent, cosmic truths that not only provided moral bearings but promised respite from modernity’s frenetic, metaphysical to-and-fro, as well. Clearly, antiquity had modernity on the ropes.
Just as we began to plot ways to convert our own, hopelessly modern regime into the ancient polis, however, someone would pose this question: “But would you be willing to live without penicillin?” Suddenly, modernity rallied.
After all, in spite of its vacillating, contradictory, almost libelous treatment of human nature, modernity nonetheless had delivered on its central promise—to “relieve man’s estate.” In particular, the modern scientific enterprise had unlocked the mystery of disease, vanquished the hideous plagues and pestilences of old, and given us procedures and medications that even the most ardent admirer of ancient political philosophy would hesitate to do without. Since the only ancient pharmaceutical we were familiar with was hemlock, our yearning for a revival of antiquity quickly faded.
Recently, many years removed from these debates, I found myself in the very headquarters of the modern, disease-conquering scientific enterprise—otherwise known as the U.S. Department of Health and Human Services— pondering the profound difficulties that American health care faces today. Imagine my astonishment, then, when I found myself wondering whether it might not be necessary, after all, to have recourse to some ancient wisdom, to rescue us from a profoundly modern predicament.
Cost of Living
How can this be? Consider the problems our health care system faces today. For all its miracles, the modern medical enterprise has become staggeringly expensive, and it’s no longer apparent that we are healthier for it. We will spend some $750 billion on health care in 1991—fully 13 percent of our GNP. It’s estimated that we will spend $1.5 trillion annually for health care by the year 2000, consuming 21 percent of our GNP—by far the highest per capita spending on health care in the world.
For what we spend, most Americans have in fact enjoyed steady gains in longevity and health. Nonetheless, we rank only twenty-fourth among industrialized nations in infant mortality rates, and only twenty-second in life expectancy at birth. The health prospects of our poor and minority citizens lag considerably behind those of other Americans. Finally, over 31 million Americans have no health insurance to help them cover the spiraling costs of care.
Our predicament becomes clearer when we examine more closely the changing profile of the diseases afflicting us over this century. In the year 1900, acute infectious diseases were the leading causes of death, led by pneumonia and influenza. These, however, rapidly succumbed to prevention and cure by modern public health and medical technique—including the aforementioned penicillin and other antibiotics.
Today, the leading causes of mortality are chronic diseases, led by heart disease and cancer. We have not yet found cures for these, even after spending billions of dollars in biomedical research, nor are any cures in the immediate offing. What we have developed are highly sophisticated diagnostic tests and treatments for these diseases. These techniques represent the proud, cutting edge of modern scientific technology—but they are also extremely, indeed, exorbitantly, expensive.
Consider these facts, compiled by the Public Health Service:
• The leading cause of death today is heart disease, with coronary artery disease afflicting some 7 million Americans. Technology’s response is coronary bypass surgery, with 284,000 procedures performed annually—at an average cost per patient of $30,000.
• One million new cases of cancer—the second leading cause of death—are reported annually. Medical treatment for lung cancer costs about $29,000 per patient; for cervical cancer, $28,000.
• The third leading cause of death, stroke, claims 600,000 victims per year, with hemiplegia treatment and rehabilitation costing some $22,000 per patient.
• The fourth leading cause of death—injuries—send some 2.3 million individuals to the hospital each year, 177,000 with spinal cord injuries. Lifetime treatment and rehabilitation costs for quadriplegia run about $570,000; for severe head injury, $310,000.
• Treatment of AIDS, affecting some 1.5 million individuals, costs $75,000 over a lifetime.
• Liver transplants, a desperate resort against the effects of the alcohol abused by some 18.5 million Americans, cost $250,000 per patient.
• Treatment of babies born to mothers on drugs, of which there may be as many as 375,000 annually, costs an average of $63,000 per baby over five years—although we’ve all read the newspaper accounts of hospital bills in the hundreds of thousands for treatment of so-called “crack babies” in neonatal intensive care units.
It should also be noted that these chronic diseases afflict minority citizens at higher rates than other Americans, and that this disparity among segments of our heterogeneous national population accounts for much of our diminished overall standing in international measures of health.
The point of this depressing litany is that the triumph of modern scientific medicine—the producer of penicillin, and the finest flower of the modern enterprise—has nonetheless led us to rely upon very expensive technological approaches to the chronic diseases afflicting us. This reliance is rapidly driving us to bankruptcy, and no amount of tinkering with the mechanism of financing it—which is the essence of most proposed health care reforms today— will affect that larger process.
We seem, then, to be reaching the limits of modernity’s ability to address one of our most critical public problems. Indeed, the problem is itself the distinctive product of advanced modernity. For further “relief of man’s estate,” we will have to look elsewhere. But where?
Happily, there is another avenue to explore. While difficult and expensive to treat, so many of today’s chronic ailments are readily preventable—that is, their rates of occurrence are affected by so-called “risk factors” over which we as individuals exercise considerable control.
• For heart disease, major risk factors within our control include tobacco use, elevated serum cholesterol and blood pressure, obesity, diabetes, and a sedentary life.
• For cancer, modifiable risk factors include tobacco use, improper diet, alcohol intake, occupational and environmental exposures.
• Similarly, stroke is affected by high blood pressure, tobacco use, and cholesterol levels.
• Risk factors for injuries include safety belt nonuse, alcohol and other drug use, and occupational and household hazards. Injuries are among the imminently preventable consequences of intentional violence, which is the leading cause of death of those under age 44.
• Cirrhosis and a host of other physical, psychological, and sociological afflictions could be reduced by more moderate use of alcohol.
• Infant mortality, often cited as evidence of the mean-spiritedness of our health care system, in fact is affected more by maternal patterns of nutrition and use of tobacco, alcohol, and drugs than by government spending on infant health.
• Finally, the risk factors associated with AIDS include unprotected sex and alcohol and drug abuse, especially intravenous drug abuse.
Were we to attend seriously to these controllable risk factors, studies have shown that we could eliminate 45 percent of deaths from cardiovascular disease, 23 percent of deaths from cancer, and more than 50 percent of the disabling complications of diabetes. Indeed, control of fewer than ten risk factors could prevent between 40 and 70 percent of all premature deaths, a third of all cases of acute disability, and two-thirds of all cases of chronic disability. Put in perspective, a study by the National Cancer Institute estimates that fully 50 percent of the variation in a person’s health status is accounted for by behavior or lifestyle, while medical care received accounts for only 10 percent, heredity 20 percent, and environment 20 percent.
The realization that so much of the pain and cost of modern disease is preventable has led HHS Secretary Louis Sullivan to focus on the behavioral changes we Americans need to make in our own, personal lives, if we are truly to solve our health care problems. In virtually every speech, he calls upon Americans to end drug abuse; avoid the high risk behavior that spreads the AIDS virus; reduce consumption of alcohol; seek early prenatal care; improve eating habits; wear seat belts and take other necessary precautions; increase exercise; seek the necessary vaccinations and examinations; and, above all, stop smoking. This message is particularly important for minority audiences, Dr. Sullivan believes—since they suffer disproportionately from preventable chronic diseases, they will benefit disproportionately, as well, from measures that prevent them.
You will notice that we have now travelled very far, indeed, from the realm of scientific medicine. By raising the need for a heightened sense of personal responsibility for and tighter control over sexuality, drinking, drug-taking, exercise, eating, and a vast range of other human pleasures and activities, we seem to have wandered into territory traditionally governed by ethics or morals. Only in this realm can we search for some consistent, rational higher standard by which to regulate our behavior—some moral principle by which to govern more effectively our appetites and impulses. Such a discussion of right and wrong behavior, it seems, is essential if we are to escape the quandary into which modern science has led us.
Can modern morality help us with this discussion? Not likely. When we left modern morality, as you recall, it was lying face-first in the mire of nihilism. There it remains today. The moral teaching of modernity—at least as it’s practiced and preached by our nation’s cultural and intellectual elites—is that there is no principled way to distinguish right from wrong, or good from bad. Consequently, “anything goes.” From the ethical principle of the ’60s—”if it feels good, do it”—we have arrived at the ethical principle of the ’90s—”just do it”—as if even feeling good were too rigorous and judgmental a standard by which to govern our behavior.
Clearly, modernity’s moral posture has translated itself into our health behavior, with disastrous results. We act toward our own bodies and others as if anything does, indeed, go. We eat, drink, smoke, and engage in sex without fear of moral sanction (or hope of moral direction), all the while expecting our high-tech medical apparatus to shield us from the harshest consequences of our self-indulgent ways. To enjoy Wilt Chamberlain’s sexual excess, all that’s required is Magic Johnson’s “safe-sex” technology. Clearly, modern morality has done much to create the situation that modern science can no longer economically fix.
Conversely, it must be said that science itself helped bring about today’s ethical dilemma. The resolution of nature into infinite webs of cause and effect—which proved so useful to science— nonetheless proved fatal to morality, as it came to be applied to human behavior. Since human beings, too, are apparently caught up in the ebb and flow of aimless causality—since we are merely the passive playthings of sociological or psychological or economic circumstance—it is retrograde and unfair to propose that we be held responsible for our actions. The very suggestion that we be expected to govern ourselves according to notions of right and wrong is to “blame the victim.”
We have not always been so foolish or self-destructive in our thinking about the relationship of morality and physical health. Those benighted ancients—who might seem to have so little to say about our modern nightmare—understood full well that one’s moral posture had a critical bearing on one’s health. Indeed, much of Aristotle’s discussion of human virtue or excellence focuses on the search for the right or healthy ordering of bodily desires according to some higher, governing principle of ethical reasoning.
In particular, the individual displaying Aristotle’s virtue of temperance or moderation seeks the healthy mean in relation to the indulgence of pleasures like eating, drinking, and sex, as determined by ethical principle: “Such pleasures as conduce to health and fitness, the temperate man will try to obtain in a moderate and right degree . . . he only cares for them as right principle enjoins.” Only in an “irrational being is the appetite for pleasure . . . insatiable and undiscriminating.” For Aristotle and other ancients, only the truly virtuous individual—the individual displaying the human excellences, and possessed of what we once called good character—can also be the truly healthy individual.
The physician Leon Kass, in an insightful article entitled “The End of Medicine and the Pursuit of Health,” arrives at the same conclusion about the wisdom of the ancients. He commends to us Socrates’ conclusion in the Charmides that “health is at least in large part affected by or dependent upon virtue, that being well in body has much to do with living well, with good habits not only of body but of life.” As he notes, Socrates “knew what we are today altogether too willing to forget: that we are in an important way responsible for our state of health, and that gluttony, drunkenness, and sloth take some of their wages in illness.” According to Kass, we would do well to recover the ancient understanding that in the most decisive sense “our health is influenced by our temperament, our character, our habits, our whole way of life.”
The Virtues of Health
Our modern health care dilemma, then, seems to demand that we look beyond the borders of scientific medicine, indeed, beyond the borders of the modern scientific project altogether, to a way of thinking about health and morality that is best embodied in an earlier wisdom. If this seems hopelessly naïve or atavistic in this high-tech, morally skeptical age, consider the message that Secretary Sullivan—himself a physician—has been preaching to the American people from the very citadel of modern technological medicine.
Dr. Sullivan maintains that much of the pain and suffering with which he must deal as HHS Secretary—not only the physical afflictions, but the social afflictions as well: drug and alcohol addiction, escalating child abuse and neglect, criminal violence, homicide and suicide, children born to unwed teen mothers—represent the “toll of our ethical dilemma, the tragic price of our cultural indifference.” They bespeak moral collapse and an insufficiency of character, reflecting our inability—or rather, our studied and sophisticated unwillingness—to assume responsibility for our own lives and behavior.
In response, Dr. Sullivan calls for what he describes as “a renewed sense of personal responsibility on the part of every American citizen—a new ‘culture of character.’ ” By stressing “character,” Dr. Sullivan intends to encourage what he describes as “the personal values and qualities encompassed by that sturdy, time-honored word— values like self-discipline, integrity, taking responsibility for one’s acts, respect for others, perseverance, moderation, and a commitment to serve others and the broader community.”
In such language—which must, to our elites, sound quaintly archaic or dangerously reactionary—Dr. Sullivan evidences an older understanding of the vital interconnection between moral discipline and physical well-being, pointing us back toward the view that virtue or character is crucial for good health. We simply cannot hope to solve the problems of today’s health care system, he argues, until we grasp this larger point, and begin to alter dramatically the way we order our own lives and our behavior toward others.
Not surprisingly, Dr. Sullivan’s appeal for more responsible behavior—delivered frequently to audiences of those minorities suffering disproportionately from self-inflicted morbidity—has been assailed as “blaming the victim.” To be sure, virtually any appeal to personal responsibility is, in the modern moral dispensation, to blame the victim, but to try to elicit responsible behavior from the “victims” of poverty and discrimination seems doubly unfair.
Dr. Sullivan has been mercifully uncowed by this ritualistic denunciation from the intellectual elite. He carefully notes that his call for more responsible behavior is by no means directed exclusively to minorities, but applies with equal force to all members of a society who have come to rely on technological solutions to moral problems. (His former Deputy Secretary, Constance Horner, goes even further, noting that less healthy poor and minority citizens are simply paying the steepest price for a moral code propagated throughout society by the nation’s elites.)
More important, Dr. Sullivan insists, it is “patronizing and insulting” to suggest that minorities “cannot improve their lives by drawing on their own strong traditional values and institutions.” He frequently notes his own debt to a strand of the black intellectual tradition—running through Frederick Douglass, Booker T. Washington, W.E.B. DuBois, and Martin Luther King, Jr.—that emphasized the attainment of good character as the surest route to sound, healthy lives for black Americans. Conversely, to maintain that minorities (or, for that matter, any of us) are merely hapless victims of circumstance who can only wait patiently for government rescue is, in Sullivan’s words, “to counsel resignation, defeat, pessimism, and despair.”
Even if character is vital for health, however, is it not naïve to expect our culture to nurture it? After all, the commanding heights of our culture are occupied by elites who are at best skeptical—and more likely contemptuous—of the very notion of good or decent character. And we know from the ancients that virtue in the highest sense demands nothing less than unanimous and strenuous support from every economic, political and cultural facet of the city—i.e., it calls for the polis.
Dr. Sullivan appreciates the larger difficulties involved. Indeed, he has taken on Hollywood and Madison Avenue about their complicity in the nation’s moral collapse and has roundly condemned their encouragement of irresponsible behavior like excessive drinking and smoking.
At the same time, though, Dr. Sullivan recognizes that at the grassroots level throughout America there are still local, community-based institutions that have successfully resisted the corrosive moral teachings of Hollywood and Madison Avenue. These include especially close, extended families; spiritually rigorous churches; strong neighborhoods; disciplined schools; service-oriented voluntary associations; and similar such community groups. Within these small, intense, tightly-knit groups, the teaching of morality and the shaping of character continue. When Dr. Sullivan raises the issue of culture, he aims, in his words, “to remind Americans that we can best cultivate character in our citizens by reinvigorating and shoring up such institutions, that teach and nurture values and principles of healthy behavior.”
Indeed, the Department has found that its most successful programs to promote healthy and life-sustaining behavior invariably are based in, or at least cooperate closely with, vibrant local neighborhood groups or associations. This holds true whether the purpose is to provide child development services to a preschooler, prevent disease and promote health, combat chemical abuse and addiction, reduce smoking, halt the spread of AIDS, fight child abuse and neglect, reduce youth homicide and violence, or lower the infant mortality rate.
Even if its object is not explicitly to promote health, a strong, morally rich community life tends to reduce self-destructive behavior and produce healthier individuals. After a survey of numerous medical studies of this link, David B. Larson et al. concluded that “healthy, caring, committed relationships with family or friends are health producing in the individual,” and that even “religious commitment as measured by religious attendance or participation appears to promote both physical or mental health.”
The link between connectedness to community and health is illustrated by the dramatic difference in health status between the neighboring states of Utah and Nevada. Utah’s high ranking in health is directly related to its strong Mormon families and communities, while Nevada’s poor showing is linked to its rather secular and anomic lifestyle. Small, tightly-knit, morally and spiritually rigorous communities simply seem to be the best inculcators of ethical, life-sustaining behavior—the best nurseries of health as well as character.
It is no accident, of course, that we should find the echoes of ancient character in such small, intense communities, for those communities are themselves the faint echoes of the small, intense, ancient polis. Both reflect the truth that moral education proceeds most successfully where there is a dense network of mutually-reinforcing sources of instruction and support—where there are vigilant, on-the-spot authorities carrying weight with the citizens, who dispense and socially reinforce strong ethical messages.
To be sure, today’s community, no matter how tightly-knit, is but a muted echo of the polls. To the ancients, our neighborhoods and communities would appear woefully insufficient for inculcating moral virtue in its most exalted sense (like the village in Aristotle’s Politics, whose inadequacies merely pointed toward the need for the full-blown polls).
On the other hand, those concerned today about encouraging healthier behavior are not seeking to inculcate moral virtue in its most exalted, ancient sense. The virtue aimed at is itself but a faint echo of ancient virtue and consists largely of the temperance or moderation that, for Aristotle, merely prepared the way for the higher virtues at which he aimed.
Back to the Future
None of this, of course, is to suggest that we should turn our backs on modern scientific medicine in order to pursue a return to antiquity—that we should prefer the society that gave us hemlock to the one that gave us penicillin. Nor, on the other hand, is this to suggest that we’ve even begun to discuss all the moral problems created by modern scientific medicine—for indeed, the society that gave us penicillin has also produced, for some, the kind of twilight existence that gave us the Hemlock Society.
I would suggest, however, that if we are truly to come to grips with today’s health care dilemmas, we must rethink our approach to health care in the most thorough-going fashion. This means moving beyond today’s debates about mere mechanisms of finance. A shift to national health insurance, for instance, is simply tinkering at the edges, insofar as it proposes to finance, through new and oppressive taxation, the very same exorbitantly expensive, high-tech approach to health care that is rapidly bankrupting the present system.
Indeed, inasmuch as it would alienate citizens even further from a sense of personal responsibility for their own health by having the “government take care of it,” this move would be disastrous. We would be reinforced in our tendency to look after our own bodies with all the care and vigilance shown by collectivized farmers for their crops and tractors.
It would be wiser to find mechanisms of finance that reinforce, rather than undercut, the message of personal responsibility. In the short run, this might mean more favorable insurance rates for individuals with healthier behavior, wider use of health maintenance organizations, and steps to reduce the insulation from the consequences of irresponsible health behavior currently provided by third-party payments, first-dollar insurance coverage, and other features of our system.
In the long run, some variation of the Heritage Foundation’s proposal holds promise. That plan—making the citizen, rather than the employer, the purchaser of insurance—would make the individual more immediately aware of the high cost of irresponsible personal behavior. Furthermore, because the workplace would no longer constitute the insurance pool, various community associations might be encouraged to become the agents of insurance. By assuming so important an economic function (or “reassuming,” since associations thrived among early immigrants precisely because they provided burial and other forms of insurance), those associations would be reinforced and revivified. Thus social structures already effective at fostering healthy behavior would be given an even more compelling reason (i.e., an immediate economic stake) for doing so.
At any rate, the changes required by our current health care dilemma demand that we look deeply within ourselves, to our very conception of health and its relationship to human behavior. Emphasis on health promotion—often dismissed as a disingenuous excuse for government inaction, as “voodoo health care,” so to speak—in fact stimulates that deeper examination, if handled thoughtfully. That is because it leads us to reconsider an earlier understanding of the relation between moral and physical well-being—to recapture an older wisdom about culture and its role in producing sound, life-sustaining character; in short, to reopen the most profound and enduring questions of political philosophy.