post by Paul Kelleher
UPDATE: A mistaken citation has been corrected.
Despite having been ruled (mostly) constitutional by the Supreme Court, neither the Affordable Care nor the cause of universal insurance coverage in America is a sure thing. So much depends on the outcome of the November election, both at the national level and at the state level. And it's possible that many largely Republican states will drag their feet and find other ways to delay or derail implementation of the law.
Given how much supporters of the Affordable Care Act have poured into the fight to pass and implement it, it is completely reasonable that they would want to keep fighting, to see it through to the end. But other options are also available. After all, the world is a large place, and the suffering faced outside our borders is horrendous and of a scale few Americans can really imagine. Some ACA supporters will wonder, therefore, what obligations they have to poor foreigners, and whether those obligations are consistent with expending so much time and effort (and so much additional time and effort) bettering the lives of comparatively well-off Americans.
What we owe to foreigners depends of course on the reasons we have to turn our attention to them. It's possible that our duties to poor Americans are stronger than our duties to poor foreigners, but this should not be taken as a given. Political philosopher Charles Beitz breaks down the sorts of reasons we may have to turn our attention outside or borders:
The possibilities begin with two limiting cases. One is autarky; here, by hypothesis, there are no reasons other than those of beneficence in play. The other is benign interdependence, in which poor and non-poor societies cooperate as equals. The most important reasons in this case have to do with the fairness of individual transactions and of whatever cooperative practices and institutions there are. These polar cases are, however, unlikely. There are several intermediate and, on the whole, more likely possibilities which I hope can be suggested with descriptive labels: for example, harmful interaction, historical injustice, non-harmful exploitation, political dependence. Each pattern evokes a different kind of reason for action: for example, not to cause harm, to compensate for the results of harm done earlier, not to exploit one’s bargaining advantage, to respect the interest in collective self-determination. This does not exhaust the possibilities but it will illustrate the point. The relationships that characterize the various dyads of interacting poor and affluent societies are diverse, not only in the patterns of interaction they instantiate but also in the reasons why these patterns are morally salient. p. 171)
The duty "not to exploit one's bargaining advantage" is particularly salient in the context of Chief Justice Roberts's majority opinion in the ACA case. Roberts declared a provision in the ACA unconstitutional because, in his words, it put a "gun to the head" of states by forcing them to choose between expanding their Medicaid programs or losing all federal Medicaid assistance. While the Chief Justice was unwilling to “'fix the outermost line' where persuasion gives way to coercion," he nevertheless declared that "wherever that line may be, this statute is surely beyond it." Compare this to the way the United States has dealt in the past with reluctant trading partners over whom it wields significant bargaining power:
This trade and investment framework [negotiated in the Uruguay Round, and administered by the WTO] has been shaped by threats of exclusion or discrimination, through which major developed countries take advantage of the especially urgent need of developing countries for access to developed countries' markets. In the Uruguay Round negotiations, from 1981 to 1994, the United States frequently used threats of devastating trade discrimination---for example, U.S. Trade Representative Carla Hills' flamboyant warning that if others held out the U.S. would start "trade wars over all sorts of silly things," or Secretary of State James Baker's more measured but no less ominous intimation, "we hope that this follow-up liberalization will occur in the Uruguay Round. If not, we might be willing to explore a 'market liberalization club' approach, through minilateral arrangements or a series of bilateral agreements." The resulting regime has been sustained by similar bullying. For example, after a coalition of developing countries united in insistence on an end to rich-country farm subsidies in the Cancun WTO conference of 2003, Robert Zoellick, the U.S. Trade Representative (who was to become President of the World Bank four years later), noted that "the transformation of the WTO into a forum for the politics of protest ... dismayed" the United States, and announced an American commitment "in our hemisphere, and with sub-regions or individual countries ... to move towards free trade with can-do countries" excluding the "won't do" countries that had held out for an end to the subsidies. As intended, the threat led countries such as Costa Rica, highly dependent on access to U.S. markets and without good alternatives, to cave in and leave the [protesting] coalition. (Richard W. Miller, Globalizing Justice, p. 70)
Is this behavior by the U.S. morally wrong? It's certainly hard to say with a straight face that it amounts to persuasion rather than bullying and coercion. But in any case, exploitive bullying is just one reason Americans may have to feel morally bound to promote well-being abroad. All possible reasons should be given serious consideration in a full analysis of what we might owe others in the world.
If we do find that we have compelling reason to help others abroad, what is a conscientious American to do? After all, it is hard enough to get fellow Americans on board with helping other Americans. How in the world are we going to get them on board with helping others in the world? This is not a question that moral and political philosophy can answer on its own. Perhaps, when all the psychological facts are in, the best we can hope for is to make small improvements at home, since those are the only projects we can get Americans to embrace and/or abide. It is also possible that whatever we try to do, we will just make matters worse (as William Easterley has argued is the case with foreign aid.) Political philosopher Thomas Pogge has thought a lot about this question, and here are his tips for selecting morally worthy projects and reforms that are, in his words, "realistically feasible" while still being of benefit to poor folks abroad, to whom he believes we owe very strong duties (these are rough quotations, from about the 33min mark of this lecture):
1. These projects/reforms must benefit also at least some segment of the global elite (which includes normal Americans who are vastly better off than poor people abroad).
2. These projects/reforms must be scaleable, so that they can start small and then be expanded in light of what worked and what did not.
3. The projects should empower those whom we wish to protect, so that they can find their own voice and fend for their own intersts.
4. The projects should be the first steps in a path of reform that can ultimately reverse the relevant spiral of injustice and neglect.
I know it may sound silly to some, but in light of the recent weather across the US, I can't help but wonder whether the cause of greenhouse gas mitigation can become the sort of project that could satisfy Pogge's first condition. It is certainly an issue that has tremendous bearing on health worldwide, especially for the world's poorest countries who are most dependent on stable weather patterns and least prepared to adapt to new ones. It is also an issue that affects middle-income countries like China, as China's economic growth would not be what it is today if not for policies that are pretty bad for the environment. In short, climate change will affect everyone, and the world's worse off individuals have a serious interest in overall mitigation while retaining a serious interest in being able to do things that contribute to the problem.
Climate change is going to hit poor countries hard, and the negative impact on health worldwide will probably dwarf the positive impact that something like the ACA has in the US. As I have indicated, it is a very hard question whether (and to what extent) we are justified in continuing to spend so much time and effort on health care for Americans. (And---just so there is no confusion---by "a very hard question" I mean one that I do not have the answer to.) But despite appearances, tackling the problem of climate change may end up being exactly the world-enhancing project we can get Americans to sign onto---not necessarily today, of course, but perhaps soon. However, we may know whether it is only after some of us turn our attention away from health care for Americans and toward this other pressing issue. A fateful choice awaits.