Published November 2, 2017
Editor’s note: Pascal-Emmanuel Gobry, a conservative writer and a fellow at the Ethics and Public Policy Center, is writing a series of columns on uncomfortable truths about health care in America. Some will make conservatives more uncomfortable, others will make progressives more uncomfortable, but most should make everyone uncomfortable.
Politics is downstream from culture. This is a well-known dictum among conservatives, and it probably explains our long defeat. The 2010 book To Change the World, by the sociologist James Davison Hunter, clearly highlighted the fundamental mistake of the religious Right: It has ceded the culture to secular progressives, thinking that by sheer numbers, the “moral majority” would, in a democracy, protect America from its rotting influence. But culture’s endless celebration of expressive individualism turned the moral majority into a minority, even as the corruption that Christian politics are especially prone to turned the religious Right into “the people the religious right warned us about,” in conservative Evangelical leader Russell Moore’s memorable phrase.
What does this have to do with health care, you may ask? Well, if politics is downstream from culture, culture is downstream from metaphysics. Our health-care system is not driven by our choices in the sense that free-market economists would like. Instead, it is driven by our collective choices through political pressure on government programs and insurers.
And, put simply, one of the biggest drivers of those choices is the fact that Americans, as a whole, are simply too afraid to die.
About 1 percent of the U.S. population accounts for roughly 20 to 30 percent of health spending, and 5 percent for more than 50 percent, a finding that holds over time. These patients tend to be either newborns with catastrophic issues or the elderly. A 2004 study found that 10 percent of Medicare spending happens in the last trimester of life, and 30 percent in the last year of life. Since then, there has been a lot of gesticulation about doing less aggressive medicine in the last year of life, but “pull up the curtain on these statistics, and the drama that unfolds tells a very different story,” a 2013 summary by Kaiser Health News argued. “End-of-life care continues to be characterized by aggressive medical intervention and runaway costs.” And in the policy debates over health care, KHN noted, end-of-life care is the “third rail.”
And how else could it be? Of course, the Left believes that everyone is entitled to an essentially infinite quantity of care. Meanwhile, the Right, understandably, is afraid of anything that smacks of “death panels,” for libertarian reasons, or religious fears of euthanasia, or both.
But political coalitions are responsive to voters, so end-of-life health-care issues are only a signal of the underlying cultural problem. The limitless American pragmatism, with its faith in the possibility of technical solutions for every problem, is a powerful spur to heroic medicine when combined with fear of death.
And on that last point, one can’t ignore the obvious fact that Americans are much less religious than they used to be. America is not (yet) a nation of hypersecular Swedes or Richard Dawkins–style militant atheists; the vast majority of Americans profess some sort of belief in God, or an afterlife, or some spiritual reality. But at the same time, American religion has lost almost all its — for want of a better word — thickness. Whether in terms of adherence to a specific, rigorous creed, or in terms of religious practice or regular attendance of services, most Americans are much less religious than they used to be. And in such an environment, one might like to tell oneself bland spiritual platitudes, and one might like to tell pollsters that one likes to tell oneself such reassurances, but these spiritual platitudes are much less likely than a robust, thick religious belief to help someone face the impending prospect of his own death with equanimity.
Note that this point isn’t about Christianity specifically, or even any religion. Pre-Christian Pagan culture strongly emphasized the nobility and honor of facing death with courage, and this was only marginally connected to religious beliefs as such. Indeed, in the Stoics, it was linked to atheism, and we find it in almost every culture in one way or another. To say that this sort of discourse has pretty much vanished from American culture is an understatement. The big exception, of course, is the American military, but with a volunteer military in a society where trust in all other institutions has collapsed, the American veneration of the military is very much based on how different its values are from those of the society at large, which only reinforces the point.
When it’s time to go, it’s time to go. Dust must return to dust. If most Americans were less afraid of dying, we’d probably cut 10 or 20 percent from our total health-care bill, and bring Medicare spending much more under control.
Now try to convince a politician to say that in public.
— Pascal-Emmanuel Gobry is a fellow at the Ethics and Public Policy Center.