Generative Anthropology Summer Conference 2011, May 19-21

Health Care

Health care, as we speak about it today, is a completely modern phenomenon. Hippocrates aside, if you go back maybe 150 years, doctors had no effect on their patients: your chances of recovery if you did see a doctor were identical to your chances if you didn’t. “Health care,” or the medical profession, emerges along with modern science and the application of the sciences to everyday life in the forms of hygiene and nutrition. And medicine has been a rich source of tropes for the framing of modern dilemmas, as recognized by the very widespread claim that, in our thinking about moral, political and ethical issues, “therapy,” and the associated categories of “healthy/sick,” “normal/pathological,” etc., has displaced notions of sin and guilt, good and evil.

It makes perfect sense, then, that progressive politics has always seen the incorporation of health care into the cradle to grave welfare system of the modern state as the jewel in the crown of the expert-centered organization of life central to such politics. The nationalization of health care makes state power potentially unlimited: not only directly medical issues, involving coverage, treatment, price of medical services, training of practitioners, research and innovation, etc., come directly within reach, but all questions indirectly bearing upon health do as well. And which questions don’t bear indirectly upon health? Whether it’s what parents tell their children about homosexuality, the hamburger you had for dinner, or the availability of birth control and, increasingly, social situations such as bullying, shyness, etc.—all affect health, all impose potential costs on the system, all sprout new forms of expertise and regulation. To use a medical metaphor, whether health care is centralized or decentralized is a life or death question for the free society.

The libertarian answer, to privatize medicine and insurance and render them sets of voluntary exchanges, is good as far as it goes. Libertarians rightly argue that what we call health insurance today is not really insurance in any meaningful sense—it is simply a way of pooling costs in government mandated ways, and in ways that makes the real costs of medical procedures inscrutable. Health insurance should be like car or home insurance: a premium in exchange for coverage for specified health care needs. But this analogy is limited—the sum total of bad things that can happen to your car or house is known in advance: if your house is worth 300,000$, then the insurance company knows that no catastrophe can exceed that. But there is no such ceiling when it comes to your body—if your insurance company agrees to cover “cancer treatments,” must that include a decade of increasingly expensive treatments with ever diminishing effect? Who decides? A court—according to what criteria? The doctor—which one? It seems that at some point, some irreconcilable disagreement between the parties is very likely, generating enormous resentment and terror as our media-saturated society is flooded with images of beloved parents and grandparents cut off from their treatments either by evil insurance companies or daughters and sons afraid of going broke. Politics is sure to channel such resentments, compromising the independence of independent arbiters of insurance contracts.

Such a system could only work if a significant majority of the members of society could openly accept the basic unfairness of life chances and death. We would have to be able to look on, with equanimity, as insurance companies withdraw support from dying patients, including those we love and ultimately ourselves; as grown children decide that funding their children’s education is more important than a few more years of life for their own parents, etc. And, of course, such equanimity would have to coincide with an acute awareness of the unprecedented character of all this, including the heart-wrenching possibility that a few more years might have lessened or even eliminated your particular dilemma. We don’t have to go back further than the lifetimes of many living today to recall when “health care” involved very few decisions, and certainly not the impossible ethical ones we are constantly confronted with today: you accepted your fate, you made people comfortable as they accepted the inevitable. Even as some reliable treatments became widespread and childhood mortality almost eliminated, aging, sickness and death still provided the proverbial contours of our existence—the problem is, they still do.

Here, it seems to me that the much maligned (especially by conservatives) “therapeutic culture” might come to our aid. Despite the vituperation and ridicule heaped upon the therapeutic, is there any reason to assume that the distinction between, say, “good” and “evil” is any more originary than that between “healthy” and “sick”? If we take the most basic distinction to be the one distinguishing sacred from profane, why is that distinction more adequately modeled on one binary rather than the other? They are just different ways of framing the more inclusive distinction between whole and rent—integrity vs. corruption, working vs. impaired, fixed vs. broken, etc., being other versions. To be healthy is to be whole, to retain one’s integrity, to be articulated, symmetrical—all are near synonyms for wholeness, which means to have a formal reality embodied in your physical one—just like the central object once we have all pointed to it and agreed to let it be.

The therapeutic culture, by way of its victimary turn, has also created our ability to, it seems, confer healthiness upon ourselves and each other. Perhaps the one product of the victimary culture that deserves to survive is our sensitivity the ways we describe “disabilities” (I, like I suspect most of us, cringe upon hearing—or remembering hearing, since you never do anymore—an older one, the unmarked term of my parents’ generation—like “crippled,” much less the brutal terms for mental disability: moron, idiot, even “retarded,” the more humane replacement for the preceding, and which is currently the object of a vigorous campaign across college campuses to proscribe “the ‘R’ word”). It is really marvelous to see what people confined to wheelchairs (and the blind and deaf) are often able to do now, and our Gnostic, often cloying insistence that they can do it has certainly supplemented the prodigious technological innovations we must credit. We have also seen the emergence of an entire culture concerned with ways of coming to terms with disease, decline and death and the ability to turn, once all resources have been exhausted, from attributing responsibility to others (the doctor, the insurance company, the hospital, the state…) to simply seeing to the integrity and dignity of the patient and her loved ones. There is, we might say, a “healthy” way to finally let go.

The individualization of the sickening, recovering and dying processes thus introduced will not only guarantee our constant chafing at the restrictions and cookie-cutter categories of homogenized health care systems but further facilitate another process which I believe is inevitable, indeed, already well underway: the pluralization of therapies. Why shouldn’t the government or insurance company pay for, say, Native American cures? Because they haven’t been scientifically verified? You would have to have a very naïve faith in public confidence in the modern cult of professionalism and expertise to imagine that answer will hold the fort for long. There will be more and more things government and insurance companies will have to and can’t pay for—but, at least, it’s possible to imagine the emergence of insurance companies which cater to the eccentric and desperate. So, as government presence recedes, health care decisions will devolve to the individual, producing more flexible norms of expertise. Does someone really need 6 years of medical school, 10 years of internship and residency, to help me with my aching back or cough? I doubt it and, more importantly, more and more people will come to doubt it, especially when they are the ones weighing costs. In the end it will be obvious that our health care needs are better met in this more differentiated manner, and on the open market, with practitioners, inventers of medical technologies and promoters of new methods engaged in competition with a close eye on the actual costs of skills and procedures.

At the same time, such a process will generate, in the short term and perhaps longer, inequalities and mistakes that will seem monstrous to many. There will be plenty of cases of people purporting to fix backs breaking them, of con men hawking fake treatments without fear of the regulator or licensing board, of new, prohibitively expensive treatments conspicuously available for a while (a long enough while to count the dead resulting from “health apartheid”) to only the very wealthy. And the question for us, as a civilization, will be: can we abide that? Health problems, today, have come to be experienced less as “acts of God” or the inevitable workings of Nature than as a kind of violence, uniquely, unpredictably and terrifyingly directed at individuals, violence to which we are all ultimately equally vulnerable—violence from private and public greed and callousness (insurance companies, doctors driving Mercedes, companies pumping carcinogens into the environment, pencil-pushing bureaucrats putting rules over compassion, etc.). The demand for universal health care, or at least coverage, taps into a kind of originary terror. We would have to be able, to make ourselves whole, to suspend that attribution of violence, and learn to use our greater powers of physical healing as metaphors to enable healing of a more transcendent kind.

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6 comments to Health Care

  • Q

    Your idea that our “therapeutic culture” could actually promote individual responsibility for health decisions, acceptance of our mortal and human limitations, is hopeful in the best sense, but I think you have to recognize that it’s criticized correctly for doing the precise opposite. The problem is to get people to take responsibility for personal decisions that affect their health, and the best way to do this seems to be economically. Our current system encourages people to see every problem (e.g. alcoholism, sex/gender identity unease, etc.) as a “sickness” for which they are not responsible and demand a “cure” or costly accommodation. Would not originary anthropology teach us that our tendency to sacralize health care issues (more specifically, apparent “inequities” in life outcomes) is a problem (as I think you acknowledge)? That it needs to be addressed in more rational terms? I do like the idea of using the sacrality of the body/self (if I understand you correctly) as a way of conceptualizing the process of living, accepting our human limitations and mortality, but I just see how it’s currently misused.

    On a technical issue, I’m interested in Gnosticism, and I wonder why you characterize as Gnostic our insistence that the “challenged” can and should do everything that others can? I’m guessing that this is the tendency to see “knowledge” (specifically technology) as the answer to every problem, and that progress should be unlimited. But I wonder if technology is really a side issue here. True, prosthetic limbs and various accomodations help the disabled to function more effectively; but this also involves attitude perhaps more importantly. A deaf and blind person who decides to take up rock climbing or even skiing doesn’t depend so much on technical advancements as historical changes in attitudes going back to Helen Keller among others. Is Helen Keller’s optimism about the potential of the deaf/blind usefully characterized as “gnostic”?

    If I’m not mistaken, it’s Voegelin who has influentially characterized the modern world as gnostic, as trying to realize the kingdom of heaven on earth, relying on knowledge as deployed by elite experts. His characterization of the modern world is insightful in many ways; but calling it gnostic seems rather unfortunate to me. I see gnosticism as concerned with a cosmic battle between good and evil, the appropriation of power through magic, and the absence of any monotheistic, beneficent providence. Is technology really a modern form of magic? I’m not sure about that. Technology at least works. As I recall, Blumenberg makes an argument not too dissimilar to Voegelin; that gnosticism effectively means the absence of any omnipotent providence, so that moderns are driven to “self-assertion.” But I think Blumenberg sees gnosticism as more of a transitional stage rather than as characterizing the end result, except in the atheism implicit to both. Blumenberg argues against the “secularization theory” of modernity (i.e., modernity is simply Christianity without the sacred), and Voegelin seems to advocating a version of it: that a heretical form of christianity underlies modernity.

  • adam

    I’ll begin by conceding the point about “Gnosticism,” a term which I am at times a little lazy about using–here, I was actually using it to qualify a compliment: the belief in the capacities of of the disabled is, of course, increasingly justified–the need for the qualification is in the occasional insistence that even the term “disabled” be denounced. In truth, though, the notion of speaking of the “differently abled” doesn’t seem to have picked up much steam, so I don’t feel much need to argue the point. I do see modernity as Christianity applied beyond the strictly liturgical sphere, but with a strongly heretical tendency. Not exclusively heretical, but the anti-Christian element in modernity is highly polemical, using Christianity’s own principles to attack its established forms. Instead of good vs. evil, if we think about modernity as positing a before and after with a radical break between the two (benighted vs. enlightened, oppression vs, freedom, dependency vs. autonomy, etc.), I think that heretical tendency comes out.

    So, I don’t see modernity in terms of a “rational” vs. “sacred” distinction. I’ve never understood how we can speak about meaning outside of the sacred. We can sacralize rationality in certain circumstances (and in terms of certain understandings of rationality) and we can and, I believe, have, sacralize the human individual who cannot be coerced into any belief or action. We are free and therefore must persuade each other if we seek exchange or cooperation, but there is no obligation to do so in accord with any version of “rationality.” I don’t assume that a therapeutic culture must be linked to an entitlement culture–at any rate, this post is an attempt to think through some of the implications of their de-linking. The “therapeutic” provides us with a vocabulary: we can speak of a “sick” culture, of social “pathologies,” of relationships and personal wounds that need to be “healed.” This vocabulary might in part supplant, in part supplement, and in part continue, some of the more traditional vocabularies, organized around terms like “sin,” “guilt,” “virtue,” and so on. I’m exploring the possibility that it might do in ways that support the privatizations we need, economically speaking–especially in health care. As I suggest here, one important element of the therapeutic is the refusal to accept “offical” and “establishment” cures, and an insistence on one’s right to seek out unlicensed cures and treatments. In the end, it will be impossible to ask others to pay for it.

    At rate, I don’t see any reason why thinking in terms of “health,” “treatment,” “recovery,” etc., is necessarily any more or less rational than speaking in terms of “good and evil,” “guilt,” or even “rational vs. irrational.”

  • Q

    Thanks for your thoughtful reply. Your thoughts on modernity are helpful for me. I’m a little puzzled that you reject the sacred vs. rational distinction, at least in terms of modernity. The sacred is generally the label we give to something that’s not open to negotiation, rational or otherwise. If something can be explained in rational terms, then we don’t need the vocabulary of the sacred, except for historical description. On the originary scene, meaning is certainly sacred, but doesn’t that terminology reflect the participants’ lack of anthropological understanding? GA makes no appeal to the sacred qua supernatural to explain meaning, since meaning can be explained more economically in terms of ethical functionality. I agree we have to maintain a minimal sacrality, the sacrality of the self, the individual; we need that minimal level to protect us from quasi-rational movements, like Nazism, to purge the “degenerate,” “sick” members of society (a good example of how the language of health and sickness can lend themselves to irrational fears and behaviors). But in our society, the value of the individual is hardly something that we need to defend. Health care policy always involves cost-benefit decisions which, as you point out, might seem scandalous to our victimary sensitivities; they can only be defended on rational terms, as I see it.

    I would have to agree that sin and guilt are not necessarily more rational terms than health and sickness (in fact, just the opposite). They do have the advantage, however, of designating responsibility. Sin and guilt don’t have any currency in public discourse anymore, so that’s not an issue. Those designations only come up in more or less private religious discourse. I can see your point that “health and sickness” don’t have to be tied to an entitlement culture, and they are not always antithetical to personal responsibility. But they do lend themselves to that culture; grammatically, we tend to use the passive voice with sickness, something we “suffer.”

  • adam

    I think you answer your own question about the relation between the sacred and the rational: we can’t have “ethical functionality” without the minimal sacrality of the individual; and if the individual is sacred, then our reasoning is locked into the terms established by that sacrality. We could, I suppose, have a discussion amongst several people regarding the pros and cons of killing and eating one of the participants in the discussion which might be perfectly rational in terms of its adherence to notions of causality, logicality, etc. And, yet, we would all immeditately recognize such a discussion as a perversion or parody of reason, because we reject its starting point–that another person can be subject to such calculations. There’s nothing irrational in the rejection of such a starting point–we could explain very well why we can’t talk about people in such ways, but such an explanation would bring us back to other, perfectly rational, discussions about the sacred.

    I should also say that I’m not nearly as confident as you are of the sturdiness of the sacralization of the individual in today’s world. There’s a very big difference between allowing social differentiation (and inequality) to play itself out in health care outcomes and appointing people to allocate life saving or denying health care on the basis of bureaucratic criteria. Paradoxically, the former approach would be the one that genuinely sacralizes the individual (because it allows everyone to match their resources to their needs as best they can, and to solicit help from others who donate voluntarily), and the more difficult approach–the one that would confront far stronger political headwinds. I’m not at all sure that the sacrality of the individual is deeply enough embedded for us to go in that direction.

    I don’t deny that discourses of “health” can be dangerous–I’m just exploring various directions one might go with it, especially if it gets imposed upon us whether we like it or not. To follow up on your question here, the way we could designate responsibility in terms of “health/sickness” would be by treating “health” as a source of metaphors for discussing social relations. Of course, this is what the totalitarians did (the Jews as a “virus,” etc.) but I don’t think we need to let the argument “ad Hitlerum” frighten us so much anymore. I don’t think there is anything inherently totalitarian about speaking of a “healthy” or “sick” social order, or in talking about beliefs or practices that “infect” institutions, with the corresponding use of terms like “inoculate” or “heal” to speak of protecting and restoring those institutions. If you could ask someone whether their proposal for social change or even their own individual choices will infect a weakened system or inoculate it against infection, we could then speak about responsibility. And the descriptive power of the vocabulary would have to be judged on its own terms.

  • Q

    In regard to rationalization. First of all, value and sacrality are not exactly the same. We can admit the value of every human being without calling in the sacred. Calling the individual “sacred,” as I did, is really just a way of indicating that his or her value is not open to negotiation. Asserting the incontrovertible value of the individual need not involve any appeal to God, the supernatural, or a metaphysical order. And in a public policy debate, it’s probably not helpful to appeal to the sacred as such.

    In political practice, the value of an individual is always relative. We admit that a certain number of individuals killed each year as the price allowing car traffic; not to mention war and other examples. Some Girardians have focused on such social calculations to argue that our social order is reprehensibly “sacrificial.” But the point is protect rights, not eliminate suffering or inequality. “Rights” articulate a minimal valuation of the individual. Each individual cannot be given “infinite value” (as a philosophy professor once put it) because values inevitably conflict; what’s “valuable” for me (having the best available health care for example), might be costly for you, such that you can’t afford the best available health care.

    Second, GA, as I understand it, provides a hypothetical narrative of how the individual becomes “sacred.” The sacrality of the individual is not a given, not universal, not atemporal, but a contingent event of history. Humans exist, but they don’t have to exist, and before our origin, humans didn’t exist. Insofar as we motivate the individual’s sacrality through a narrative hypothesis, we can say that the sacrality or rather value of the individual is rationalized. In general, if one gives reasons (without appealing to God or the equivalent) why one regards the individual as sacred or valuable, then we’ve rationalized individual value/sacrality. To that extent, GA has better rationalized the value of the individual better than any other thought-system of which I’m aware. Human rights advocates simply assert a priori that rights are universal. GA tells us why. That’s a great advance to my mind.

  • adam

    I think that “value,” by definition, is always open for negotiation, and so non-negotiable value is a contradiction in terms. And I don’t think we need to “appeal” to anything beyond the individual in order to sacralize it–the sacred is what you appeal to, and the individual is what we appeal to.

    I think the problem is resolved if what we consider sacred in the individual is not his/her life and well being, but his/her freedom. Any individual always transcends whatever “value” we could place on him or her, any knowledge we could have, anything we could predict they might do, etc. And so we don’t impose our sense of possibilities on any individual. That doesn’t mean we track them every day of their life to make sure nothing bad happens to them; quite to the contrary.

    I don’t think I disagree with you about the historical nature and intelligibility of the sacrality of the individual, and of all sacrality. Insofar as we do our rationalizing within language, though, we are presupposing the minimal sacrality constitutive of language–giving reasons is a gesture towards the other which constitutes the joint attention intrinsic to all understanding, and it is a gesture which makes sense, as the reasons we give only make sense, within particular traditions and disciplinary spaces, themselves founded upon some form of joint attention. GA illuminates this circularity but doesn’t get out of it–maybe part of the accomplishment of GA is that we can stop trying to get out of it.

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