Canadian Healthcare’s Moral Dilemma

By Gerrit Van Wyk.

Liberalism and capitalism are mutually exclusive.

Nigel Warburton wrote an interesting essay in Aeon, arguing that the liberal tradition at heart contains a contradiction. It seeks a society of equals in which everyone is entitled and empowered to make decisions about their own lives, and equally participate in governance of that society to protect their liberties, some personal and some political, but then runs into a problem.

Liberalism is often associated with capitalism, i.e., private ownership of the means of production. Liberalism argues for protecting rights and liberties, which means you can do what you want with what you own. Production requires cooperation, which means dividing labor and organizing economic production.

Industrialization makes profitable production expensive, which reduces the ownership pool, resulting in class stratification. Those with capital own the means of production, and wage workers are employed by the capital owners. Capital owners make investment decisions which both influences society and dictate the lives of workers.

That is the dilemma: liberalism defends the rights of capital owners to do so, but it comes at the expense of workers losing their rights, thereby destroying the principle of a society of equals sharing governance.

Rawls consequently pointed out that a hierarchical society with owner/capitalists above and workers below violates two core assumptions of liberalism: that of social equality, and of political liberty.

That Western societies in general and North American versions specifically is socially unequal is a fact. As Rawls pointed out, capital owners actively participate in society via their decisions, workers cannot, and therefore participate passively. Rawls’ worry, and what Bourdieu and others showed, is decision makers create a narrative of dominance and inferiority which becomes part of the social world and difficult to question. Nothing could be further removed from the liberal ideal than that.

Warburton writes many political scientists argue our democracies in practice are like oligarchies benefiting the rich, and ignoring the poor if their interests diverge. Hierarchies confer social power, which means politically you become irrelevant without capital. It means social and political inequality become two sides of the same coin, because social power also gives you political power and the ability to control legislation, conversation, and the strings of political and social patronage. Instead of politics ruling money, money rules and constrains politics under capitalism.

In fact, historically, capitalist societies never entertain the liberal option of policies protecting political freedom. Which means the free-market ideal is a principle that failed in practice. If markets were allowed to be truly free without the political interference of capitalism to rig the game, or, if from the beginning capitalist wings were clipped to create a more level playing field, we may not have been in this pickle today. Instead of becoming a just society, as liberalism proposes, we became an unjust one.

Liberalism is at heart cooperative, involving conversation, dialogue, and give and take, capitalism on the other hand is competitive and a zero-sum game; some win and others lose at the winners’ expensive. Rawls concludes; while capitalism rules, liberal politics will fail.

Capitalists argue there is no serious alternative to capitalism, given its ability to provide more people with more goods, communists that the only way to a just society is revolution and overthrowing capitalism. But As Orwell pointed out in Animal Farm, and communism proved without a shadow of doubt, all that does is create a new hierarchy of domination, restarting the same type of cycle. Rawls’ solution is vigorous moral critique, thereby trying to provide a moral compass as a counterweight to capitalism, which lacks both a moral and ethical one.

The basic problem with liberalism and all other isms, is they all rely on a foundational assumption our world works like a machine, which means we can theorize about it, plan for it, change it, control it, etc., from the outside in. If, on the other hand, you see it as the complex reality it is, that all flies out the window.

It means, as Rawls theorized, but for the wrong reasons, what we need is local cooperation based on the core liberal values of equality and liberty, where we act, observe, adjust, and learn together, not knowing with any degree of certainty what may happen next.

The liberalism debate and Rawls’ contribution is not a trivial matter for healthcare. Tommy Douglas contracted osteomyelitis, a serious bone infection, of his leg. As a child from a poor neighborhood, the standard of care was to have the leg amputated, but, as luck would have it, a surgeon working in the hospital for well-off people had an interest in the condition, which saved Douglas’ leg. When he became Prime Minister of Saskatchewan in Canada, he vowed no child would ever lose a leg again because the family could not pay for better care, which was the beginning of Canadian Medicare. We forget today that some liberal traditions are at the foundation of our healthcare system.

What drives the debate today is capitalism. Many want those with money to buy the healthcare means of production to turn a profit, arguing it leads to cost-saving, efficiency, and better productivity, for which there is not a shred of credible evidence. In fact, the most common reasons for bankruptcy in the US, the foremost proponent of capitalist healthcare, is medical bills. And the reason that happens is US-style healthcare is not a free market, it is a monopoly underwritten by US capitalist policies and politics.

Illness is not a product you pick up from a shelf, it is one that comes to you without asking or choice, often when you can least afford it, which puts you in a decidedly weak position when trying to negotiate with the healthcare system. A position capitalists exploit using a perverted notion of a free-market system to justify it.

I worked in US-style market-driven healthcare, and was happy when I left it. I don’t put myself in any ism or ist category, but find, as a physician, not being able to treat all patients equally, as per the liberal tradition, repugnant. And that should be the core of the discussion about the future of healthcare; how do we ensure no-one is left behind when illness strikes, rather than how can we save money, improve quality, make things more efficient, and so on. You either start from a foundation with a collective moral compass, or from a profit motive without one. In this, each of us have a choice to make and should seriously consider which side you are on, and what the ramifications are of that.