Posts Tagged ‘paternalism


Soda Welfare

A friend sent me this piece about New York City’s recent attempt to prevent food stamps from being used to buy sweetened drinks like soda on the idea that the public is simply financing health problems for the destitute. The article comes in response to a recent op-ed written by the health commissioners of both New York State and City respectively (see here for a considered economic analysis of fat tax type measures by Richard Posner).

What I find interesting about the policy to prevent food stamps from being used for sugary drinks is that it’s hard to see how the policy is either a) not justified or b) justified on grounds that would warrant its extension to more parts of the populace.

Consider the question of why NYC thinks this policy is worthwhile. Is it better for the actual people receiving food stamps and now use them to buy sugary drinks? Well, the people presumably take some pleasure in these drinks and are currently consume these drinks despite their deleterious affects on health. If we assume the poor are rational consumers, then we are effectively lower their overall welfare (according to a subjective view of welfare). But maybe the poor, like the rest of us, do not make decisions about our health rationally or perhaps we purchase with imperfect information about how damaging these drinks really are, in which case the justification for the policy is the health of the people buying these drinks. But if health is the goal of the policy, to be achieved by taxing a harmful activity, then taxes should be put in place so that the regular populace can also benefit from these measures (and be disincentivized to drink these harmful drinks). I hope the implication is not that only the poor are behaving irrationally with regard to sugar drink consumption.

Another point is that the government should not be spending money to help people continue to do something harmful, but this raises an interesting question of why we give people money at all. Do we give food stamps because we want poor people to have more PLEASUREFUL lives, because if that’s the reason, then we’re contradicting that goal by denying them the sweet release of a sugary soda (again, on the view that pleasure is determined by willingness to pay). Or do we give food stamps to poor people because we want them to live HEALTHIER lives, in which case the sugary drink restriction policy would be justified.

There is also a repeated mention of the money that obesity costs the public. Sugary drinks = obesity = various diseases like diabetes and heart disease = taxpayer dollars. Here too though, if tax dollars are lost to obesity, then we should be using a tax to recoup those lost dollars in ALL segments of society.

Anyway, I’m kind of vaguely dancing around the main question here, which is: why do we give poor people money so that they can eat and how does that goal interact with this soda policy? Are we trying to make the poor as well off as possible, or only ensure they have a certain minimum amount of welfare, or make sure that they can DO certain things, or make sure they are to a certain degree HEALTHY. All of these notions are separate.

These are tough questions, but my answer is this: I think we give money to the poor so that they can participate in society on equal footing with other people, and this means the money must go primarily not toward making poor happier (as if we could just buy a lot of cocaine for them, or some more sophisticated sedative) but toward making them be able to healthily participate in society (and not be obese and not sick), to be able to learn skills (education), impact our government (vote and have their voices heard).

Toward this goal, I think the policy of NYC is justified. The goal of the policy is to make public dollars maximally translate into able-bodied and capable citizens, and that’s why food stamps already don’t go to alcohol. The rest of public money should go to helping poor people purchase the things they need to be active members of society, so housing, healthcare, education, and food are obviously justified. Still, there will be some who are so ineffective at making use of these opportunities and so fall into miserable lives, and the government should not let these people languish in their suffering, but programs designed to address these people will not be based at ability to participate in society but in overall welfare or happiness.


a case that I think turns out to be easy

There is an issue in bioethics involving people like Jehovah’s Witnesses (JW), who refuse blood transfusions. According to believers, accepting blood into their body is the same as cannibalism and so will lead them to be damned. Naturally, they want to avoid that outcome and so will not consent to life saving infusions of blood. However, the JW does not go to hell merely be having foreign blood in his body. The issue is not purity but rather volition. If someone else forces the blood into his body, he won’t go to hell as long as he fought as strongly as possible. One can’t help the deeds of others.

The issue from bioethics is: should we treat Jehovah’s witnesses against their will or must we respect their refusals?

Often, the cases that are offered when considering forced treatment involve (1) mistaken beliefs or (2) unorthodox ends. For example, a patient might not believe that their condition is bad. Here’s a case, a woman is told that her gangrenous leg must be amputated in order for to live. She agrees that her goal is to live, but denies that the condition of leg will kill her. She insists that in the past, vaseline has cured her problems and so refuses to lose her leg (this is a real case); she will not consent. She has a false belief about the situation, viz. that death is imminent without an operation. Can we force such a person to undergo treatment?

Another case. There may be situations where patients don’t doubt that they will die, but deny that a recommended treatment will be effective. This same woman might say “Ok, I know I will die without treatment, and I don’t want to die, but I don’t think cutting my leg off will help and I don’t want to lose my leg for nothing, so I refuse treatment.” Can the doctors go ahead anyway?

Finally, there are cases when people don’t have mistaken beliefs but have unorthodox ends. Take the suicidal man who wants to die. That is his goal. We may not like this goal, but what’s to say that it is a wrong goal to have? Another example is an anorexic whose goal is to be skinny. She (it could be a he, guys have eating disorders too) might even believe that this goal conflicts with her desire to live, but simply rate her goal to be skinny as more important. Is there a rationality to deciding the relative values of different goals? Is the goal of being skinny even rational at all?

A minority of people think that no one should ever be able to refuse treatment, but most think that at least some of these cases I listed above cause trouble, but what I want to note in this post is that the case of the Jehovah’s witness is actually easier than all of these hypotheticals. Let’s return to the JW (at least the paradigm JW): he doesn’t have any false beliefs. He knows he will die without a blood transfusion and believes that having one would save his life. He’s also not suicidal and wishes to live if possible. He just also believes that he must resist the blood transfusion with all his might as part of his moral code. Notice though that forcing a blood transfusion on him would not violate that moral commitment because the commitment only references his own state of mind and actions. He is not allowed to accept or condone blood transfusions, but again, as I mentioned above, if someone forces it on him, then his moral probity remains. His morality concerns his actions and not that of the doctors.

Here’s an analogous case. Pretend that I want to live, and need penicillin to do so. I believe that the latter is necessary for the former. However, I have a strange moral belief. I will only accept penicillin that is put into my body despite my best efforts at resistance; nothing else is legitimate. You’re my doctor. Do you force penicillin into me? Of course you do! In fact, I think you are required to. I have a moral belief that restricts what you can do to me in a very strange way, but it’s easily accommodated. Imagine someone who says that they want penicillin to live, but can only accept penicillin out of a red container. By god, you get a red container for the penicillin and then give it to the person. You can satisfy their ends by using means that are acceptable to them.

The reason the JW case appears to be tricky is that he restricts the acceptable means to helping him to treatments that violate his informed consent (he will only “accept” blood that is forced into him against his will). But we don’t have to be fooled into thinking that we violate his rights by treating him against his will because, quite simply, he wants to be treated against his will (though he can’t say that. To escape damnation, he would always have to say to the doctors that he does NOT want the transfusion. In fact, he would, knowing that doctors have to obtain informed consent, probably tell us all sorts of lies to get us to believe that he doesn’t want the transfusion, but we shouldn’t be taken in by this gambit). We have rules about informed consent because we believe encroaching on the lives of others is to be avoided as much as possible (we can put people in jail if they are harming others of course), but in this case, we are not encroaching, but rather respecting the moral code of the person by forcing him to undergo helpful treatment. Not giving him the blood transfusion causes him to die when he could have been saved without contravening his ends, his beliefs, or the restrictions he must place on treatment.

To put it another way, the JW believes that if new blood is put in his body, he will live, which he wants. The state of affairs known as foreign-blood-being-in-his-body is not only unobjectionable (remember tranfusions per se are not wrong, he just can’t accept any of them), but in fact desirable to him. He just has to try and prevent this state from ever being realized. Once the state obtains though, he has no problem. He doesn’t even have an objection to the doctor’s pinning him down and forcing him into the operation. Sure, he thinks such people are evil, but what’s his judgment to the doctors who don’t share his metaphysical commitments?

A final way to think about the case is this: imagine you come across someone unconscious. As far as you know, they don’t oppose blood transfusions and they aren’t suicidal etc. etc. Still, you can’t get consent from the person because they are unconscious. The natural reaction to the case is that you give them blood so they live, because based on what you know about the person and their interests, they would want to live. The JW case is no different. Pretend you find an unconscious JW witness. You know they want to live, and that they believe a blood transfusion will save them. You also know such a person vigorously resists transfusions and is required by their belief system to resist to the utmost. You say to the unconscious JW “I’m going to transfuse you, but against your will.” When the JW wakes up, what can they complain about? They will now live. Sure they have foreign blood in them, but it was forced on them, and so they are not damned. They are both alive and not-damned and not compromised in their belief system.


rational drug users

I recently read a nice paper, in which the authors make the point that if drugs are legalized, they might be made legal in a strategic way to help reluctant addicts to escape from compulsion while allowing more considerate drug users to still get high.

Their suggestion is that drugs should be legalized but unable to be purchased immediately. The idea is that the rational and in control drug user will plan ahead and so never penalized by this rule. The addict however, who bounces from craving to craving, would be protected by the fact that he could never satisfy a sudden craving. The authors put the point this way,

Another situation with similar characteristics is drug use. Scholars
recognize that “craving is a motivational state . . . equated with the subjective
desire for the effects of a drug.”123 Craving, like depression, not
only motivates certain behaviors, but it crowds out virtually all considerations
other than, in this case, drug taking. In a neurological study
of addiction, Frawley refers to a “process of . . . increasing the behavior
that facilitates drug or alcohol use and eliminating behavior that
interferes with or does not lead to drug or alcohol use. This leads to a
kind of ‘tunnel vision’ on the part of the addict.”124 This effect is most
dramatically evident in the behavior of cocaine addicts, who report
that “virtually all thoughts are focused on cocaine during binges;
nourishment, sleep, money, loved ones, responsibility, and survival
lose all significance.”125

An interesting feature of craving is that it drastically affects people’s
decisions about present actions, but has comparatively little effect
on decisions involving only future outcomes. Thus, an addict
might be willing to pay a tremendous amount to obtain a drug immediately,
but would not agree to pay such a large amount for the drug
in the future.126 This suggests a policy lever less drastic than banning
drugs and more asymmetrically paternalistic: dispense drugs legally
with a mandatory waiting period (much as a pharmacy takes time to
fill a prescription).127 This kind of forced waiting provides a way to
protect the future self from the craving current self. Since perfectly
rational users will plan ahead, the forced delay imposes little cost and
it may benefit drug users who are able to make comparatively rational
decisions for the future.

I’m not sure what I think about this point, but I guess the general idea is that the addict wouldn’t buy drugs in the middle of a craving because it would do nothing to end the craving. He would then face his purchase decision under more rational lights later after the craving has passed.



alienation and markets

Some — those who I will call extreme antipaternalists — claim that anything is alienable. I can give away my organs, or I can have sex with someone for money. Others carve out a distinction within alienation: the difference between a gift and a sale, or, in technical terms, the difference between market alienation and alienation period. To me, it seems that alienability implies market alienability but not vice versa. If I can give something away then I can give it away for something in return. If I can sell something however, that does not necessarily mean I can give it away (thought I can’t think of a good example off the top of my head of when the sale of something seems allowed but not the gifting of it). In any case, the antipaternalist claims that a possessor of something can choose what to do with that thing, including giving it a new possessor.

A more moderate position is that some things are alienable, and some things are INalienable. The prime examples are listed in our constitution. We have inalienable rights to life, liberty, and the pursuit of happiness. Here though, inalienable might mean, not that we can’t give them away, but that no one can take them away. However, I think this is a misreading. One might choose not to exercise one’s freedom, but one could not give away one’s right to liberty: that would just be slavery. Plausibly, one could not give away the right to pursue happiness, and this would be so even if I contracted with you to give you money in exchange for your abdication of your right to pursue future happiness. Certain things are inalienable because they are preconditions for a meaningful human life or a component of our ethical development. Such cannot be traded.

However, can this moderate position be stretched into a rationale for outlawing prostitution and organ sale. I’m not sure. Neither of these things are like the right to life or liberty. I can choose not to exercise my liberty even if I have the right to pursue it. The exercise of the right is discretionary. Prostitution and organ sale also seem to be a discretionary alienation of something, not the alienation of a right. The prostitute retains all rights and the same is true of the organ donor. This argument from alienation could be pressed further, but more would need to be said for the non-alienation argument against these two activities.