Bryan Caplan  

Reflections on Rod Long's "Libertarian Three-Step Program"

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Philosopher Rod Long's gotten a lot of attention for his recent post on Bleeding Heart Libertarians, and it's easy to see why.  Rod leads with Wolf Blitzer's "gotcha" for Ron Paul:

Wolf Blitzer: You're a physician, Ron Paul, so you're a doctor. You know something about this subject. Let me ask you this hypothetical question.

A healthy 30-year-old young man has a good job, makes a good living, but decides: "You know what? I'm not going to spend $200 or $300 a month for health insurance because I'm healthy, I don't need it." But something terrible happens, all of a sudden he needs it. Who's going to pay if he goes into a coma, for example? Who pays for that?

Ron Paul has a three-part answer: (1) The young man should have been more responsible, and strangers shouldn't be forced to bail him out; (2) private charity will help; and (3) regulation makes health insurance needlessly expensive.  Rod argues that this is a philosophical and rhetorical mess:

This is the kind of question that libertarians usually give stupid answers to. Their first impulse is to stress that no one has the right to force other people to pay her medical bills - which is true enough, but a weird place to start. This answer in effect treats the free market as the present system minus welfare, and so takes for granted that the problem described is likely in a free market. It also casts the sick person as a threat to others' liberty rather than as a person who can be better helped by libertarian methods than by statist ones. If someone is looking to smear libertarians as people who want to let sick people die, this hands them the opportunity on a platter.

So what should libertarians say?  Rod's approach:

The right way to answer a question like Blitzer's is to proceed in precisely the opposite order. Start by asking what causes people like the hypothetical patient to be in the plight they're in. In other words, lead with stage three. Why didn't the patient buy insurance? Because the price was too high. Why is it so high? Talk about the specific ways in which corporatist policies drive up medical costs (and disempower the poor in other ways too).

Then, if you still have time, proceed to stage two. If someone doesn't have insurance and needs care, what's the most efficient way to get it to them? Talk about how charity and mutual aid are more efficient than government welfare, and how we therefore need to shift the venue of assistance from the latter to the former.

And then you can finish by pointing out that peaceful, voluntary solutions are not only pragmatically but morally superior to coercive ones.

Rod's advise is at once wise and dissatisfying.  If we can honestly say that laissez-faire will rapidly and decisively solve a problem, Rod's exactly correct.  Unfortunately, the real world is often a lot messier in two important ways:

1. Free markets do lead to higher economic growth, but this is a very gradual process.  

2. No matter how rich a society gets, irresponsible behavior will continue to have bad consequences.

Consider Blitzer's example.  I'm willing to believe that under laissez-faire, health insurance would cost half as much.  But if a healthy young man with a good job is unwilling to pay $200 or $300 for health insurance, he could easily continue to say no after free competition drives the price down to $100 or $150.  And then the question returns: What do "we as a society" do if the uninsured man goes into a coma? 

The libertarian can respond, "Voluntary charity will take care of him."  But ask yourself: How rich and generous will donors have to be before philanthropy can feed every hungry child on earth?  Until we get there, libertarians should just bite the bullet and say, "Healthy young men with a good jobs should do the responsible thing and buy health insurance - and it's perfectly reasonable not to bail them out if they don't."

Furthermore, there are many problems that laissez-faire won't much improve.  Take alcoholism.  Yea, you could claim that bad government policies drive people to drink.  But that's far from clear.  And don't liquor taxes make people drink less?  The hard fact is that free people make lots of bad choices.  Libertarians should accept this fact - not pretend that government policies are the "root cause" of bad choices.   

When you really think about it, Blitzer's "gotcha" for Ron Paul was actually a "softball."  Blitzer could have asked Paul about an unhealthy man.  Or a man without a job.  Or a child.  Or an orphan. 

I wish Rod's Three-Step Program had credible solutions for all these cases.  But it doesn't.  Free markets quickly make life better in some ways, and gradually make life better in almost all ways.  But critics of libertarianism will never run out of empirically plausible "hard cases."  When faced with these hard cases, the best response we'll ever have is, "Charity can probably provide for the deserving poor.  Everyone else should live with the consequences of their actions - and stop blaming total strangers for failing to help them."

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COMMENTS (19 to date)
Duncan Earley writes:

It's an interesting question to think about the hardest example a libertarian could face. How about this....

In a small town a 3 year old child is daignosed with leukemia. The parents don't have health insurance. Even if most of the town donate a sizable amount of their income it wouldnt be enough to cover the treatment. There is one billionaire in town. He's just brought his third Ferrari. Do the towns folk have the right to vote to force the billionaire to sell the Ferrari and pay for the child's treatment?

Ari T writes:

I think these kind of problems are one of the hardest questions in libertarianism. Gun controls etc. seem completely trivial in regard to this.

I think the best idea is to gather empirical evidence from the real world to show libertarian beliefs live to the reality and not only in fantasies. Easily these kind of problems fall down to rhetoric.

I think Bryan Caplan is missing one important point here. Health insurance is not a redistribution framework. The moment we get the ability to forecast sickness 90% from genes etc. people who are 80% likely to face a health problem will have to pay 80% out of pocket, and that's how markets work. Provide the evidence that charity, family etc. will help them, or be ready to accept their deaths as a part of the ideal society. That may come to as a bit of nasty fact for some, but reality is not a rose garden.

I hope we would see prediction market so we would exactly see how good the free-market approach is, although Caplan's estimate of half as cheap medical care under free-market reforms sounds reasonable. In these kind of questions, overconfidence of whether its effectiveness of Obamacare or charity is not unforgivable.

Steve_0 writes:

Good response, but even BC here misses second order actions.

I believe in a libertarian world where people are likely to indeed continue to make stupid decisions, YET are held by reality and law to their own consequences, people will in fact begin to learn and make different choices. Everyone? Nope. At the margin? Yes. And no one can claim to know how large that margin is.

It is very easy, even for classical liberals to get sucked in to assuming how much of our current world we accept as a "given", and forget how this would change in a truly free regime.

andy writes:

The question can be slightly changed:
- suppose a man has a terminal illness and he knows that; suppose, the cure costs $1 million. Suppose, the man is given $1 million, so that he can cure himself. And let's suppose the man decides to spend the money in some other way.

Will you let him die?

Jack Davis writes:

"Yea, you could claim that bad government policies drive people to drink."

I'll try that on my next DUI, but I don't anticipate success:)

On a more serious note, I don't see how we can easily, if at all, distinguish who is the "deserving" poor from the "undeserving." Would there be some kind of board determining this? The cries of death panels aren't far away.

e.g. Someone who is unemployed for six months and is close to starving. He might be someone who is just unlucky in this economy; he might also just be lazy. There is no obvious way to determine whether he's deserving or undeserving. How about someone with a severe mental illness but who looks fine on the outside? Outsiders who see him not working will decide he's undeserving, but that may not be a fair evaluation.

Adam writes:

A libertarian surgeon saves the guy's life. They talk and become friends as the guy recuperates. The guy becomes a new man. He works out a payment plan with the hospital. He becomes a medical entrepreneur, a radical libertarian and gets elected President. His 3rd party takes both houses of Congress and all the state-houses. They amend the Constitution to eliminate the Post Office and Fed power to borrow and print money. The socialist hegemonic state falls apart, and the economy prospers, growing at 11% per year with no environmental effects. We all live happily ever after!

Randy writes:

If he's not in my family he's not my problem. There are many more people in this world who are not my problem than there are people who are my problem. The politicians want to convince you and me that the order should be inverted - that everyone is my problem except my family. They do this because there is power and money in it for them if they succeed. Call me heartless or antisocial if you will, but before you do, know that your opinions are not my problem either.

RickC writes:

Jack Davis,

Once the decision making process is removed from the local, as we have now, there is no way to distinguish between who is "deserving" and who is "undeserving". That's the difference between charity and government largesse and one (I think) of the biggest reasons progressives have tried to eliminate the notion of "undeserving".

It's just anecdotal, but in the town/neighborhood where I grew up everyone knew who the "undeserving" were and who actually needed help and they directed their money and aid accordingly. No one ever seemed to starve of suffer needlessly. Even the lazy and shiftless would get help, but the help came with the expectation of reciprocity, ie. they had to earn it. I would expect to see the same for any town or neighborhood across the country. Maybe I'm wrong.

I just don't see how at the national, or even at the state level, we could stop the free riding and fraud inherent in government run programs for the poor. Also, since their jobs require the existence of poor people, why would any government run program want to see a decrease in the number of people defined as poor?

Sonic Charmer writes:

Mention of the man's family seems to be missing here. Surely the hypothetical man would have people actually close to him who have an interest in him not dying. One would assume they would step up. (If not, why not?)

Putting the onus on "we as a society" takes that responsibility away from his family. Why should it?

Seth writes:

It seems recently that a woman made the news for holding yard sales to raise money for medical treatments, and was shut down by local authorities because she was breaking ordinances.

I found it strange that there wasn't the typical "what should 'we' do" about this real life situation.

It should be easier to do that with fictional, 1-dimensional characters like Blitzer presents. Add additional info (like she was 'selling stuff to help her self') and people seem to care less.

What happens if we add additional info to Blitzer's character? We come to find out he was living well above his means driving a $50k car, had a nice downtown condo and frequently had bottle service at a posh downtown club.

Add this and I suspect more people would say that he should first sell his car and condo before 'we' help.

What if we found out that he led a modest life in most respects, but just had a couple smaller splurges like $200/month smartphone and a $200/month personal trainer?

I think more people start to ask, why couldn't he get a $40/month cell phone, a basic gym membership and health insurance? And they start to feel a lot less sorry for him and ask, where's his family?

Rod points out that Paul's answer assumes the free market.

Similarly, with the 1-dimensional 'he didn't buy insurance and got sick' characters, we tend to assume 'deserving poor' status, even though we do say he made bad choices. Start identifying exactly what those bad choices are exactly and, I think, sympathy levels go down.

Another assumption implied in Blitzer's character is a world with only two entities -- individuals and the state. So we think either he goes broke or the state pays.

We forget about family, friends, churches, medical care charities and countless other organizations, etc.

Tom West writes:

It really should be pointed out that under a system where healthcare is provided by the state, we *do* decide to let people die that we could very likely have saved simply because the cost is too high. Every system by definition does, as we don't spend trillions to save every life.

I support single-payer healthcare (I'm Canadian), but I don't need magical thinking that pretends that we don't face the same problem at a different level.

It's all about trade-offs, and every position has them. Unless Wolf's questions specifically addressed the costs of each of the participants position, I'd consider it unfair. (If he did, it's still difficult politics because people are used to paying the current price, and have a hard time accepting a new price, but at least it's fair).

Frank writes:

So what is Caplan's idea? He is correct that there is no panacea answer for this question but the same question applies to the corporatist healthcare we have now and the same question applies to a universal/single-payer system. What system is Caplan saying has an answer to this question (he didn't mention it in this post)?

Without the state, society would have an extra trillion a year that is currently spent on US empire (wars, bases overseas, DHS, etc.).

Google "The Healthcare Crisis: A Crisis of Artificial Scarcity" and "How Government Solved the Health Care Crisis" for a start.

GregS writes:

My response to Blitzer's hypothetical was different.
For one, there is nothing special about one million dollars. What if it cost 10 million, or a billion dollars? Does society have a responsibility to step in and help him then? I think every sane person has a cut-off point where they would say "no;" no one would spend all the world's wealth to save a single dying man.
For another thing, there is no such thing as a treatment that cures a terminal disease 100% of the time. The hypothetical was posed: we help him and he lives, we don't and he dies. In reality, the treatment would have some chance of succeeding and some chance of failing. A better hypothetical would give a price of treatment and the odds that he will recover. If the chance of recovery drops to, say, 50%, a lot of people will start to say, "No, we shouldn't help him." Some people think there is a moral principle causing people to give different answers to this question. I don't think there is one. Give a low enough chance of recovery or a high enough cost, almost everyone will say we shouldn't help the young man.

I asked my wife, who is a physician, if there were any ailment that approximates the young man's condition in the hypothetical; apparently some forms of leukemia are (1) extremely treatable and (2) extremely expensive to treat. I'm actually curious if anyone can quantify this for me: how often is something both extremely treatable (95% chance or better to cure, almost certainly fatal without treatment) and extremely expensive? How likely is the condition of the young man in the hypothetical?

david nh writes:

To add to what Tom West has said, in Canada, it's not just that we "let people die" because it's considered too costly for the socialized system or the treatment is on the "unapproved" list, it's that, in some cases, we prevent them from saving themselves and their loved ones by using their own resources.

It's one thing to say "we won't do it for you because we don't want to subsidize it or provide it for free (even though we've taken huge amounts in tax from you and your family for years to fund all sorts of things for others)" but something else entirely to say as well: "plus, in order that others don't become envious, we won't permit you to save yourself". This is beyond evil.

The problem with the style of argument Rod Long suggests is that it evades the fundamental question - that of ethics - and forces one to say "well gee it probably won't happen". It's odd that he finds that persuasive.

frankcross writes:

Ron Paul got it right. I realize the criticism is about spin, but libertarianism prevails by people believing in its truth, not spin. Charity is a massive copout and a lie. And the "deserving poor" is no better. There is no reason to think that charity will extend particularly to the deserving poor or fill the needs of the deserving poor, not to mention the fact that "deserving" undermines the libertarian message of personal responsibility. If they choose not to get health insurance, how are they deserving of charity.

Costard writes:

David nh and steve_o got it right.

Doctors in this country work long hours. It is not at all clear to me that they would perform more surgeries or save more lives, simply because more people demand their services.

Whereas one can look at government policies that restrict the number of doctors and encumber their performance, and say with reasonable certainty that less surgeries are performed and more lives lost.

Is the argument over healthcare really about saving more lives? Or is it about which lives get saved?

Tom West writes:

"plus, in order that others don't become envious, we won't permit you to save yourself". This is beyond evil.

At the risk of sidetracking this topic, I have to disagree as to the motive of not allowing a second tier.

It is one of the costs of having the healthcare system that Canada has, as it is not separable. If we had a nationally available second tier, the common (and I believe correct) wisdom is that the system as it now stands (and generally popular) would not survive due to doctors opting out, less support from the better off, etc.

As for beyond evil, again, I disagree. There are plenty of things that we as a Canadian society choose to prohibit that would make the individual better off, but we feel would make us as a whole worse off. Gun control anyone?

MBH writes:

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Jerome Bigge writes:

Prescription laws are a part of the problem. Minus prescription laws computer software would allow people to prescribe for themselves. Such "diagnosis software" actually exists, but is of little value to the public because you still need a doctor's prescription to obtain medicine. Without prescription laws most people would be able to take care of many medical problems themselves. Additionally, replacing government licensing with private agency certification means that people with less knowledge than the Ph.D level of an MD would still be able to use their knowledge to help the public at much lower cost than what people today have to pay for an office visit to a doctor. Additionally there would be no laws restricting the importation of medicine for one's personal use. Also there would be various levels of medical institutions with various cost levels for those who needed additional care.

All of this is why Libertarianism is a solution to the problem. Costs would be far less, and the majority of people would be spending far less than they do today for health care. I have calculated in my own case that the cost reduction would amount to close to 2/3 rds "less" than what I'm paying now. So don't be afraid to point out to the statists that there is a "Libertarian solution" and that our "solution" would cost far less!

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