Guest Post by Daniel S. Goldberg
Several weeks ago, Representative Jason Chaffetz (R- Utah) found himself the target of some acid criticism in multiple news outlets for attempting to justify some of the provisions in the AHCA by stating that ‘people may have to choose between iPhones and health care.’
Predictably, a storm of controversy erupted. Opponents of Rep. Chaffetz’s perspective pointed out the basic functional significance of a smartphone for more marginalized groups, including taking the time to note how smartphones were important for disease management, family and community care, public health, etc. This matters a great deal because the vast majority of health care services (by volume) actually happens outside of inpatient settings, and frequently outside of clinical settings at all. There is little doubt that smartphone access is material to the informal caregiving that places such tremendous demands on the resources of caregivers and intimates. There is no reason why more disadvantaged groups would be excepted from this assessment.
But it was not the merits of the opposition that animated me. Rather, I was irritated by what I perceived as its technocratic nature. The intellectual framework driving Rep. Chaffetz’s statement was not one cast in the metals of 21st c. technology and smartphones. Rather, it seems obvious to me that Rep. Chaffetz was invoking an old tradition in the West, one saturated with important intellectual, political, social, and moral implications: the issue of dessert, especially as it relates to social welfare.
What do we owe each other? What do we owe those who have less than us? And if we choose, as a social order, to pay in to create some kind of welfare apparatus to support those who are less able to provide for themselves, how do we regulate that decision? Where are its limits?
These are grand, difficult questions, but my point is an utterly practical one, suggesting the significance of intellectual history for understanding contemporary social policy: ideas are social actors. That is, acting in concert with a variety of social and political forces, ideas can form the key impetus to all forms of social action. Ideas move people. They help animate organization, investment, and activity in all manner of social and political practices. This most certainly includes policymaking, as intellectual historiography on policy history makes abundantly clear.
So, what ideas help us understand Rep. Chaffetz’s statement about ‘difficult’ choices between iPhones and health care? The answer, of course, is Western and/or peculiarly American ideas about social welfare and its connections to concepts of desert. Via processes of public reason, societies may well come to some kind of collective agreement that some form of welfare apparatus is worth establishing. Yet, there is always an apparent need to establish eligibility for the benefits of the scheme. Who is to be granted access to the largesse of the welfare state? And in a world where humans are born to sin, there will inevitably be those ne’er do-wells who seek such access even if they do not deserve it according to social norms, legal strictures, or both.
This is the point, then: the effort to distinguish the deserving from the deserving poor is at least 400 years old in the West. It is literally core to the Elizabethan poor laws. But some of the important ideas I argue animate Rep. Chaffetz’s perspective may be quite a bit older: anxiety over feigned illness or “malingering” (a modern term) can be located in medieval sources. They appear again in early modern sources such as Paolo Zacchia’s intensely interesting Quaestionum (itself concerned with legal proceedings, where the 
adjudicative function – what is the truth of a person’s illness? – is of special relevance).
What do we owe each other? And how can we be sure the people we help via welfare structures truly merit the assistance we grant them?
We do ourselves no favors, in terms of understanding political discourse and the grit and grime of policymaking by thinking about Rep. Chaffetz’s statement solely in terms of the merits of a particular piece of technology (which I in no way deny!). Rather, as a powerful political figure at the center of a raging national contest over the appropriate nature of the U.S. welfare apparatus, Rep. Chaffetz’s statement is best understood as manifesting the intellectual frameworks noted above — the most important task, apparently, is to discern merit or desert. Those who make wise choices amidst their straitened circumstances are those to whom help will be given. Those who choose poorly — who select shiny new technologies — will bear the full social consequences of their own decision.
There is so much more that could be said here, from a historical perspective. Perhaps unsurprisingly, the moralist tradition of social welfare so palpable in current US discourse is also powerful in the UK (past and present). For example, most public health stakeholders in the US erroneously attribute the Sanitarian movements of the 19th c. (both US and Great Britain) to a quasi-revolutionary imperative — a desire to relieve the immiseration of the poor, to address the ails of rigid class structures and 19th c. dislocations that caused so much suffering and deprivation. In fact, as Christopher Hamlin has shown in his stunning text, the principal architect of British 19th c. public health reform, Edwin Chadwick, was motivated by a desire to maintain existing class hierarchy. A political conservative, Chadwick was concerned that the deprivation of the lower classes juxtaposed with the concentration of wealth among the affluent would lead to revolution (Chronology matters here: Chadwick was operating in the 1840s, when European revolutionary foment was reaching a fever pitch). Chadwick believed that a welfare apparatus should be designed intentionally to be just slightly less unpleasant than unemployment and abject poverty itself. He believed that alms houses should be so horrendous that no one would willingly seek them out or stay there unless they literally had no other choice. Moreover, for Chadwick, the unpleasant nature of the alms house would spur its users to seek out employment, thereby ensuring that welfare users were not content to rely on the largesse of the welfare state.
Finally, Chadwick, like most of his Sanitarian colleagues, was a hygienist, which in 19th c. Anglophone parlance, had a strong and intentional moral valence. (Check out the historiography on Florence Nightingale for some excellent discussion on this). Hygiene was a means of purification as well as a demonstration of virtue and right living. Hygiene, as historians of public health have shown repeatedly, was distinctly moral. This has profound implications for the judgments and moralism we see saturating public discourse over welfare policy in the US, because questions of desert are necessarily moral questions — ‘what do we owe each other’ is simply another way of framing the fundamental question of justice.
Once we understand these intellectual frameworks and the way they shape contemporary public reason as to welfare policy in the US, the broader impulse underlining Rep. Chaffetz’s comments is evident. And we can test the validity of the framework by seeing whether it helps explain other statements and perspectives swirling around contemporary US discourse on welfare policy, especially welfare policy targeted at the poor.
For example, there are proposals, some of which have made it into draft form as bills in the US Congress, to attach labor or labor-seeking requirements to Medicaid policy. Medicaid is an arm of the US welfare apparatus that most directly benefits poorer and more marginalized groups. Where a principal question that animates US welfare policy is one of desert, desire to work is a fundamental marker of virtue and merit. Chadwick would most certainly approve, as would architects of the Elizabethan poor laws. Note also that such requirements might well be experienced by many welfare users as degrading or demeaning, which also fits the Chadwickian aim — to make the receipt of alms so upsetting that only the truly immiserated would willingly seek it out, and would also attempt to cease such receipt just as soon as possible. This latter point connects to the oft-stated desire among policymakers in the US to “disincentivize” welfare usage in the US, to ensure that welfare users are “properly motivated” to seek work.
Or, consider the increasing efforts by states to subject welfare recipients to random drug-testing. Despite the uniform evidence that welfare recipients use drugs and alcohol at rates no greater, and often significantly lesser, than the non-welfare population, and despite consistent evidence that such drug-testing programs are incredibly cost-ineffective, efforts to institute such regimes are increasing. In the face of a mountain of evidence suggesting the waste and inefficacy of such programs, states are redoubling their efforts to implement them, and the federal government is only to eager to facilitate such implementation. How can this be explained outside of the power of ideas regarding desert — the need to distinguish the deserving from the undeserving poor? It cannot (although of course I do not claim the power of such ideas is the entire explanation – only that it is a necessary one).
The temptation to read political statements solely on their own terms is obvious. And of course, the merits of statements like Rep. Chaffetz’s are entirely meet for independent analysis. But if we disconnect statements made in the storm of public reason from the deeply-rooted intellectual frameworks that animate them, we impoverish our understanding of those political and social contests, and perhaps even our ability to influence them. In short, ideas are social actors.
“Daniel S. Goldberg is trained as an attorney, a bioethicist, and an intellectual historian. As to the latter, he is a 19th-early 20th c. Americanist, focusing primarily on the history of chronic pain and the history of medical imaging (especially the X-ray). His work on pain implicates multiple issues in disability, policy, and welfare.”
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Typo: “desert” (not ‘dessert’). I will have more to say about that (not the typo but the moralized notion used in political discourse) anon.
I think this piece would be improved if one expanded the intellectual framework to include a more prominent politician than an inconsequential Congressman from Utah than even the most rabid political junkie would find difficult to name. From the piece, it would be hard not to draw the conclusion that such backward thinking only emanates from the neanderthal wing of the Republican party. The belief you document is in fact bipartisan. Check out this video https://www.youtube.com/watch?v=ijQIJAK0NFA
This is not the only incidence of President Obama has used identical talking points as Republicans. Means testing is quite the fetish among partisans of both political parties. Look no further than the Democratic Presidential nominee’s take down of Bernie Sanders’ universal college plan by stating that the taxpayers shouldn’t have to pay for Donald Trump’s kids’ tuitions.
The belief concerning the “deserving” versus “undeserving” has even infiltrated the thinking of the historical profession. Five years ago when she was a graduate student, Professor Burnett wrote a piece entitled “Professing History.” To this day, this piece has irritated me. It wasn’t the content of the piece, but the comments. it wasn’t the structure or the inherent defects of the “job market” that was preventing young scholars from getting tenure track jobs, it was their inherent defects.
A wonderful post.
I happened to have raised the subject of assumptions surrounding ideologically-motivated normative conceptions of “desert” on the Right in the title of my post on Chaffetz’s remarks: “Meritocratic distributive justice rears its hideous head: the poor have only themselves to blame for their condition.” Here I agree with Rawls (at least the conclusion, although not necessarily the specific reasons whereby he reached it) that “the idea of desert in the strict sense, that is, the moral worth of a person’s character as a whole (and of a person’s several virtues) … as well as the moral worth of particular actions” “cannot be incorporated into a political conception of justice in view of the fact of reasonable pluralism.” Rawls goes on to distinguish this moral concept of desert from a conception of desert understood as “entitlement earned under fair conditions.”
I’d like to share some of material from Robert E. Goodin’s analytically and critically penetrating treatment of the notion of moral deserts as pivotal to the “New Right’s moralistic political economy” which, perhaps not surprisingly, is “a conjunction of dubious economics and even more dubious ethics.”* And I agree with Brian’s comment above that, at least since President Clinton, this is truly a bipartisan “problem:” “The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) is a United States federal law considered to be a major welfare reform. The bill was a cornerstone of the Republican Contract with America and was authored by Rep. E. Clay Shaw, Jr. (R-FL-22). President Bill Clinton signed PRWORA into law on August 22, 1996, fulfilling his 1992 campaign promise to ‘end welfare as we have come to know it.’”
As Goodin reminds us, this ideological discourse (which includes companion conceptions of self-reliance and freedom) was given a particularly strong defense in the nineteenth century (Daniel rightly notes its earlier origins) with the likes of Herbert Spencer, William Graham Sumner, and Thomas Malthus. Notions of moral desert “are predicated upon what people are or what they have done” and frequently assume that “market outcomes are at least prima facie deserved.” With regard to welfare state benefits, “characteristically, recipients will have done nothing (nothing meritorious anyway) to warrant payment of welfare benefits: they cannot be said to have done anything to ‘earn’ such assistance.” That may be obvious but irrelevant because the untenable attempt to discriminate between the “deserving” and “undeserving” poor relies instead on notions of blame that are derived from a prior causal account that views that latter as somehow responsible for their dire state of affairs, i.e., the conditions of poverty they are mired in.
Goodin explains how “people are said to ‘deserve’ things merely because that is what they would ordinarily or normally be expected to receive,” such positive desert claims being “parasitic upon some larger scheme, whether natural or social that gives rise to such expectations about what the ‘ordinary’ or ‘normal’ outcome would be:”
“ … [W]hen we talk about what people deserve we are merely talking about what they would receive (or would have received) absent the intervention of certain untoward (statistically unusual/morally improper) circumstances. The sharp moral edge of the notion of desert is on the negative side, challenging those illicit interventions which are undeserved and which preclude people from getting what, in the ordinary course of affairs, they would receive. The positive edge—what people would ordinarily receive—is morally very blunt indeed. There is a good reason for thinking that the former is negatively undeserved, but not for thinking the latter is positively deserved.” (Goodin proceeds to illustrate this with examples.)
The notion of positive deserts can be undermined by taking into account the often confusing or complex or “hidden” background conditions of life that are neither deserved nor undeserved. When people make causal attributions of blame or desert for the circumstances people find themselves in, they assume or imply that “the existing arrangements are themselves morally justifiable,” an eminently arguable assumption or presumption. Moreover, the reasons—moral and/or otherwise—we typically have “for setting up social institutions as we do … are not reasons of desert or merit. Indeed, to some extent what counts as merits or demerits may depend on the sort of institutions we set up.” To elaborate:
“There can be positive-desert claims arising _under_ a set of social rules; but not _to_ that set of social rules. Positive desert claims cannot provide the moral foundations for the rules themselves. Those must instead be derivative from some other moral values. So, too, consequently, must any positive-desert claims derivative from those rules themselves be ultimately derivative from other moral values unconnected with personal desert.”
Individualistic and moralized political economy rhetoric on the Right (old and new) often finds its speakers assuming that “you deserve whatever you get, in the absence of contraindications … [or untoward interventions’], just so long as there is something in your character or history that you deserve it fully.” But the causal accounts intrinsic to these presumptions are untenable because unrealistic if not plain wrong. Goodin shares an intriguing argument for social insurance schemes from Winston Churchill during his tenure as Home Secretary in 1911, one in which we see a rudimentary appreciation of the insuperable problems intrinsic to any attempt to invoke conceptions of responsibility, desert, and blame in such public policy debates:
‘The penalties of for misfortune are terrible today; they are wholly disproportionate, even when they are brought on by man’s own fault, either through the culpability of the individual or neglect of what is necessary to make him try or to make him take care. A man may have neglected to make provision for unemployment; he may have neglected to make provision for sickness’ he may be below the average standard as a workman; he may have contracted illness through his own folly or his own misconduct. No doubt he is a less good citizen for that reason than others who have taken more thought and trouble. But what relation is there between these weaknesses and occasions and the appalling catastrophes which occasionally follow in the wake of these failures? ….’
To summarize the lesson to this point:
“To say that P clearly deserves q, even if we are using the notion of positive desert in a truly moralized sense (as my previous arguments suggest is rarely justified), does not necessarily entail that P ought on balance morally to receive q. One reason may be that desert is only one consideration among many others carrying at least as much of a moral charge, and in any particular case those other considerations might outweigh claims of desert. [Consider, for example, the drunk driver injured in an accident: do we simply ignore the pain and suffering he is experiencing as a result of an event properly attributed to his excessive drinking? No: why not?] Another more interesting reason—which is particularly applicable to the welfare state … is that in certain sorts of circumstances questions of personal deserts are simply out of place.”
So, for instance, consider the myriad cases in which _needs_ should and do trump deserts such that even “the reckless and the feckless” cannot be said to “deserve” bad outcomes in any moral sense (some have good luck, others bad luck, regardless of their behavior). Goodin further illustrates this proposition in the case of the “’no-fault’ impulse in accident law,” wherein considerations of deserts (fault, blame, credit…) are “put into abeyance:” In this and similar situations, “At least one of the reasons we want to resist the suggestion that liability ought to be proportional to fault is that there is just too much fault on the part of too many agents for us to make any nonarbitrary allocations of fault, liability, or blame.”
The role of “background conditions” is among the reasons we have for circumscribing notions of personal fault (and perhaps reluctantly even then) to that comparatively small set of cases “where there is a small set of actors making discrete (separate or easily separable) and readily identifiable cause contributions to the outcome.”
To conclude my summary account of Goodin’s treatment of desert: “There are very few things, indeed, which people can, therefore, be said unequivocally to deserve or not deserve. ‘Nothing,’ says Tocqueville, ‘is so difficult to distinguish as the nuances which separate unmerited misfortune from an adversity produced by vice. How many miseries are simultaneously the result of both of these causes!’”
And I’ll conclude this rather long comment with material from my own post, which, in addition to broaching the question of “desert” (inextricably bound up with the ‘poverty is a choice’ claim), raised the topic of “relative deprivation” (as distinct from the concept of ‘absolute poverty’)—a concept Chaffetz appears either to not know or sufficiently appreciate—here introduced by Amartya Sen. “Relative deprivation” is another concept important to debates about the welfare state in general, and health justice and health care in particular, this time by way of its relevance to any direct or supplemental justification or warrant provided the former:
“As Adam Smith noted, the social capabilities may depend on a person’s relative income vis-à-vis those of others with whom he or she interacts. A person’s ability to be clothed appropriately (or to have other items of consumption good that have some visibility or social use), given the standards of the society in which he or she lives, may be crucial for the capability to mix with others in that society. This relates directly to relative income vis-à-vis the general level of prosperity in that community. A relative deprivation in terms of income can, thus, lead to absolute deprivation in terms of capabilities, and in this sense, the problems of poverty and inequality are closely interlinked. For example, being relatively poor in a rich country can be a great capability handicap, even when one’s absolute income is high by world standards. In a generally opulent country [like the U.S.], more income is needed to buy enough commodities to achieve the same social functioning. This foundational idea relates to a number of contemporary concerns, for example, ‘social exclusion.’”
As Sen goes on to note, with significance for our instant case, and building again on Smith’s insight, “the phenomenon of poverty in rich countries can be better understood through the perspective of relative deprivation.” So, for example [Smith cites the European day-laborer’s need, lest he feel ashamed, to wear a linen shirt while in public space, much like leather shoes had become a ‘necessary of life in England,’ for the ‘poorest creditable person of either sex would be ashamed to appear in public without them.’], in our time and place,
“a person in New York may well suffer from poverty despite having a level of income that would make him immune from poverty in Bangladesh or Ethiopia. This is not only because the capabilities that are taken to be minimally basic tend to change as a country becomes richer, but also because even for the same level of capability, the needed minimal income may itself rise, along with others in the community. For example, in order to take part in the life of the community, or for children to be able to communicate with others in the same school, the bundle of commodities needed may include a telephone [or cellphone!], a television, a car, and so on, in New York, in a way that would not apply in Addis Ababa or in Dhaka… [although we might imagine ‘relative deprivation’ could play a role within these cities as well].” — Amartya Sen, “Conceptualizing and Measuring Poverty,” in David B. Grusky and Ravi Kanbur, eds., Poverty and Inequality (Stanford University Press, 2006): 30-46.
* Please see Goodin’s book, Reasons for Welfare: The Political Theory of the Welfare State (Princeton University Press, 1988): 278-305.