Those Who Can’t
It is Sunday, and I have, on the CD player behind me, Vivaldi’s Four Seasons. This is not my usual thing on Sunday mornings, but today it kind of fits. Maybe that’s because we’re in our fourth day of storms, sort of storms, almost storms, it’ll be a storm in a minute, it’s a storm if there’s lightening even if there isn’t rain…
And that kind of thing.
In the meantime, however, I want to go back to the question of what we do about people who “can’t” help themselves, who can’t survive on their own or with their families.
And on one level, that question is very simple. For people who truly and unambiguously can’t–parapelegics, the mentally handicapped, people dying of debilitating catastrophic illnesses without family resources–we of course provide aid, both financial and (if necessary) professional.
Whether we do that through federal, state or local initiatives is a policy question, and unimportant for our purposes here.
The real question is: where on the continuum between “absolutely can’t” and “absolutely can” should we be providing “help.”
I put the “help” in square quotes for a reason.
If there is one thing I’m sure of in this, it is that help isn’t help if the person who gets it doesn’t want it.
For me, the fact that Ayn Rand may have been “better off” in some way for having been forced to pay into Social Security does not justify coercing her into doing it.
There may be other reasons for wanting Social Security–in fact, FDR’s reasons had nothing to do with seeing to retiree’s “own good,” they were based on the hope that such old age pensions would convince older workers to retire and open job places for younger ones–but it is never acceptible to me to pass a law coercing private behavior because they WOULD want it if they only had any sense.
One of the reasons why I oppose regulations issued by unelected bureaucracies that have the force of law is that they have, over the years, all too often had this character: we could never get this past an elected legislature, because the people don’t want it, so we’ll do it by regulation, because IT’S FOR YOUR OWN GOOD.
Here’s the thing: even if it is factually true that you will be in some sense “better off” for having been so coerced, you STILL suffer harm when you’re forced in this manner. You lose the very essence of your humanity, the right to make your own choices about your own life.
And if you are not allowed to make the “wrong” choice, then you’re not allowed to choose at all. You are not free unless you are free to make the wrong decision.
And take the consequences.
The courts have been maddeningly squiffy about this. When the coercion gets obvious and egregious enough, they tend to come down on it with both feet. That’s why we can’t get the mentally ill homeless off the streets and into mental institutions. Decades of allowing doctors and family members to lock up people they’d decided were “mentally ill”–including women who wanted a divorce–finally made the whole process of involuntary commitment look suspect. New rules were handed down. The housewives who didn’t want to be housewives were now safe. Some mentally ill people who really would be “better off” on a mental ward could no longer be coerced to go there if they didn’t want to.
Short of such egregious situations, however, the courts have tended to refuse to allow coercion “for your own good” if the “you” in that sentence is competent to make decisions.
Smoking is definitely bad for you, but the courts have stopped all efforts to outlaw it outright because, well, you’re all grown up, you get to go to hell in your own handbasket.
This restriction on the power of government, elected or otherwise, to make personal decisions for citizens is very important, because the foundational assumption of democracy is that adults are competent to make their own decisions not only about their own lives, but about the conduct of their government.
People who want to help always start by assuming that the people they want TO help will welcome their efforts. After all, being a drug addict or an alcoholic is a lousy way to live. And, hey–ergonomic chairs are better for you if you’re working on a computer. If you’re not using one–if you’re not using one, it must be because some evil, greedy employer is trying to save money at the expense of your health.
The problem comes when the people to be helped reject the help, and a lot of them do.
The quintessential case of this was, I think, the psychological services offered by both federal and state agencies in the aftermath of 9/11. Hundreds of mental health workers were hired, only to find themselves with virtually nothing to do. The vast majority of the first responders–police, fire departments, EMTS–wanted nothing to do with therapy, thank you very much.
The workers then started going door to door, knocking on apartments, offering their services–and, in the vast majority of cases, getting turned down.
And this is where the trouble starts. MMjust got angry at Mique’s contempt for the “helping” professions, but I get it–and one of the things I think those professions could use is some insight into why so many people respond that way.
Historically, the first response of the helping professions when their help has been refused is NOT to go “oh, hmm. Well, obviously, I’m not wanted here. He must have his reasons.”
It has been, rather, to assume that the person in question is “in denial” in some way, that he doesn’t know his own mind, that he can’t be taken seriously–he DOES need help, even if he thinks he doesn’t, and it’s in his own best interests if we force him to get it.
The courts, though, as I’ve said, have been wary of this kind of thing, and not only when it is being wielded against the choices of adults. Courts have affirmed the rights even of schoolchildren to refuse the “help” of “grief counselors” after school shootings and other tragedies.
Which is interesting in and of itself, because usually the best way to install a regulation of private life by government fiat is to declare that it is “for the children.” Children are, in most cases, considered to be by definition unable to know their own interests or make their own decisions.
But if you are a helping professional who wants to help people who do not want your help, your best bet is to find a way to redefine them as mentally incomptent to refuse.
And the best way to do this is to find a rationale that will allow you to declare more and more kinds of behavior as outside the willful control of human beings. Habits become “addictions.” Human temperamental variations outside a small proscribed area of “good function” become ‘disorders.”
A citizen has free will and can make up his own mind–and his mistakes are his own, and none of your business. A patient is sick, unable to make his own decisions, and in need of professional care and expert advice. It’s nice if he understands why all this treatment is good for him, but it isn’t surprising if he doesn’t. That’s part of his illness.
It’s that attitude, right there, that makes Mique angry and contemptuous of the helping professions, and that makes me want to insure that regulations with the force of law be required to pass AS laws in an elected legislature.
But I think I leave the rest of this until tomorrow, at the earliest. It is Sunday. I have tea.
But I do want to say one last thing–I think the people who evade attempts to help them quit their addictions “even though they want to quit”–don’t actually want to quit. I think they say what they know what they’re supposed to say. After all, in terms of what can happen to you if you continue using and admit that it’s your choice–like say, going to jail–being treated as a patient may be the lesser evil.
More tomorrow.
14 Responses to 'Those Who Can’t'
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Three cheers.
One variation on that last paragraph. For decades, I have been solemnly told that we “know” abused children grow up to be abusive adults. It may be true. But I have never seen real evidence offered. Not once.
The “proof” turns out to be that violent felons, once apprehended, customarily tell psychologists that they had terrible childhoods. What else are they supposed to say to the people influencing sentence length and parole? “I was raised right, but I’m a vicious sadistic person?”
When you think of it, this ought to be a pretty simple thing to verify. Go through the files on, say, 1,000 domestic abuse cases 20 or 30 years ago, then see whether the victims are more likely to show up in current records as perpetrators than their statistical counterparts. This is what computers and graduate students are for. It speaks volumes about psychology that I’ve never seen it done.
robert_piepenbrink
7 Aug 11 at 9:55 am
I don’t know if you ever read the book, GAMES PEOPLE PLAY. It’s an oldie but goodie, and includes such games as “Why Don’t You–Yes, But,” and “Now See What You Made Me Do.” One of the games described is “Rescue” (or some such name). The game has two participants, the rescuer and the rescuee. The rescuer puts in a lot of effort helping the rescuee, and then just when the rescuer thinks he has succeeded, the rescuee “falls off the wagon,” (or the equivalent for other situations) thereby showing that the rescuer has failed, i.e. has lost the game.
According to the book, the key to knowing if you are helping someone or if you are “rescuing” them is this: Is the person you are trying to help putting in at least 51% of the effort? If you find that you are putting in more than half the effort, then rather than helping the other person, you are playing the game of “rescue.”
This is why AA works and why most kinds of counseling programs don’t work.
This is also a good game to keep in mind when raising children. Children love to sucker you into playing the game of “rescue,” and it takes an alert parent to recognize each attempt.
Which doesn’t speak directly to what Jane is talking about here, namely the government’s (or society’s) right to force “help” on someone. I agree wholeheartedly with Jane that people have a right to autonomy, so long as they do not engage in criminal activities.
On the other hand, what about people who want autonomy (I want to smoke, or I want to ride a motorcycle without wearing a helmet, or I want to be an alcoholic, etc.), but who then want society to step in and provide them with free medical services when that same autonomy has resulted in their having gotten lung cancer or severe brain injury or a pickled liver–what then? Do we owe them both the freedom to choose and the right not to suffer the consequences of their choices?
I have a friend who is an alcoholic. About thirty years ago he was arrested for driving while intoxicated. He chose not to quit drinking, but he also chose not to hurt other people with his drinking, which means he gave us his driver’s license, sold his car, and bought a bicycle. He lives ten miles outside a small town that has no public transportation, but for the last thirty years he has been riding his bicycle everywhere. Yes, friends sometimes give him rides, but he never asks for a ride unless he is ill.
Back to the subject of autonomy.
When my mother-in-law was at the end of her life, she had lost almost all her ability to taste food. As a consequence, about the only food that she still enjoyed eating was bacon. Unfortunately, her doctor decided that with her health problems, bacon was not good for her. So with my sister-in-law’s agreement, the nursing home was instructed not to allow her to have any bacon. My mother-in-law did not agree with this. She wanted her two slices of bacon at breakfast, and since the aides wouldn’t give her any, she began swiping the bacon off the plates of her neighbors, who were too senile to notice or protest. When this was discovered, the aides were instructed to move my mother-in-law to a different table and to keep an eye on her to make sure she didn’t figure out some other way to get bacon.
Two things to keep in mind here: My mother-in-law was not senile, and her health problems were so severe that everyone knew that she had less than a year to live. She understood what it meant when the doctor told her that bacon was bad for her health. Nevertheless, her repeated demands that she be allowed to make the decision about whether or not to eat bacon were overruled.
I found out about the bacon when we were at a family beach reunion. Everyone there was told by my sister-in-law, “Don’t give mama bacon. She’s not allowed to have bacon because it’s bad for her health.” My younger son, who was in med school at the time, tried to explain to her that one of the things he’d been taught in medical school was how important it is for every person to retain some degree of autonomy, and that for an elderly person food is frequently the last area where he or she has autonomy, but my sister-in-law was adamant–no bacon for “grandma.”
One afternoon, striking a blow for freedom, I volunteered to take my mother-in-law out, supposedly for a little window shopping, but as soon as we escaped from the food-nazi, we headed for a restaurant that served bacon. We had a wonderful time, talking and laughing and reminiscing about the good old days.
Unfortunately, neither my husband nor I lived close enough to be able to put a stop to the “no more bacon” edict imposed by the doctor and my sister-in-law. My mother-in-law died about three months later, still deprived of the only food she enjoyed eating, and all “for her own good.”
Whenever I think about my mother-in-law’s last days, I still get angry at the doctor and at my sister-in-law.
Charlou
7 Aug 11 at 11:45 am
For me, Charlou’s 6th paragraph is the significant point. I agree that free will is the essence of what makes us human and therefore we should all be allowed to exercise it. If I want to smoke or drink for example, both legal activities in our country, it’s a choice I should get to make. So, I have no problem with people who choose to smoke or drink.
Where I have the problem is with those same people expecting someone else to clean up their mess and not be accountable for the choices they make. If you smoke there is a very good chance that you will wind up with lung cancer or emphysema or any number of other nasty physical effects. So, given that this information is well documented and advertised and given that individuals still make the choice to put that in their mouths and strike a match, the rest of us shouldn’t be expected to pay the price for the medical care these people will eventually demand is theirs to receive.
Choose your path, and then be accountable for the consequences of your choices.
judy
7 Aug 11 at 2:40 pm
If you have a medical care system like Canada, in which we all pay into through our taxes and we all claim from according to our medical needs, everyone must be covered equally. I sincerely hope our politicians continue to remember this.
If, as prescribed above, we refused to pay for the medical care of those people who do things that are bad for their health, we would be using access to medical care to control or punish behaviour of which we disapprove. This is using superior power to try to control others in exactly the same way as trying to ‘rescue’ people whether they want to or not, with an added touch of vindictiveness. If you don’t stop smoking because I say it’s bad for you, you’re going to die a slower and more agonizing death than you would otherwise, and by doing that, you’ll save me money and provide a warning to other recalcitrant smokers.
Of course, if you have a medical system in which everyone pays their own way, you can get out of dying extra slowly and painfully if you have enough money.
People generally need to take responsibility for their own actions and they also need help when they’re down. What they don’t need is a medical system that denies them treatment in order to punish them even more than they’re being punished already with the fatal disease, early death and/or disability – and does so because they’ve transgressed by engaging in a vice that’s not only dangerous but temporarily unpopular.
Next thing to happen would be that I won’t get bacon because health care system that I’ve paid into all my working life won’t be provided because I’m fat.
Cheryl
7 Aug 11 at 6:20 pm
Australia has a system where the government has a list of prescription drugs which is subsidizes. If a drug is on the list, then the most you pay is $29 no matter how expensive the drug. Every once in a while, the media comes up with a sob story about someone with a rare disease and an experimental drug whioch isn’t on the list and costs $15000 a dose.
I favor a system of basic care where the government pays for broken arms and tetanus vaccine but doesn’t pay for heart transplants. But judging from the fuss about experimental drugs, it is politically impossible to draw a line.
jd
7 Aug 11 at 8:03 pm
Actually, I’m not implying people should be punished But I am saying that people should be responsible for their choices. If I choose to smoke, why should you have to pay hundreds of thousands of dollars to care for me when I have knowingly, deliberately, chosen?
judy
7 Aug 11 at 8:25 pm
You know, two years ago I was bombarded with stories of the evil vicious insurance companies trying to prove that Joe was already sick with whatever when his current policy went into efect. I’m not altogether sure that sending the FBI around to prove that a cancer victim had been a smoker, and so reduce Medicare expenditures would be a vast improvement. Besides, you’ll die younger and save the next generation a fortune in Social Security costs.
Please note we don’t deprive anyone of unemployment benefits for choosing a major with poor prospects, or not studying hard in school.
I don’t see any way to have a free people, a nationally-funded health care system and penalties for unhealthy behavior all at once. Any two of the three, yes.
robert_piepenbrink
7 Aug 11 at 9:40 pm
“Choose your path, and then be accountable for the consequences of your choices.”
So, which scientific “expert” advice will we trust when we make these decisions to deny free or taxpayer subsidised medical attention whose lifestyles don’t conform with the current received wisdom? If the current debate on “climate change” teaches us anything, it should be that in this day and age scientific opinion is whatever “tune” the piper is paid to play.
As with everything to do with public policy where there is a range of views, the fashions in public opinion wax and wane, sometimes even reversing themselves in relatively short order.
The one certainty is that anyone with a serious barrow to push on any given issue will eventually appeal to scientific authority and ad hominem argument before eventually appealing to brute force to impose their druthers. The list is almost endless: “direct” smoking; passive smoking; “junk” food which was originally defined as candy, soft drinks, and so on, but which was quickly extended to include just about any “fast” food the do-gooders don’t like; alcohol; lack of exercise; obesity and on and on.
I’ll listen to arguments about denying essential health services to unrehabilited smokers, drinkers and obese people and other recalcitrants when those proposing such restrictions also agree to deny services to people who indulge in high-risk sports such as tennis, athletics, sky-diving, skiing, snow-boarding, mountain climbing, cycling, riding motorbikes with or without helmets, on or off road, and so on. Deny smokers their heart and lung surgery, and I’d deny obsessive compulsive joggers and other power exercisers their knee and hip replacements.
Mique
7 Aug 11 at 10:13 pm
Might I just add here, that I would also deny hearing aids, cochlear implants and the like to anyone who has ever voluntarily exposed themselves to loud noise such as that generated at rock concerts, in nightclubs, rave and other dance parties, listening to music at warp volumes on IPods and similar technology.
Oh, what self-indulgent pleasures in store for little old right-thinker me! What a shame I didn’t think to join this crusade 50 years ago. :-)
Mique
7 Aug 11 at 10:19 pm
I thought I knew what I was talking about when I posted a comment earlier today, but it appears that I hadn’t considered all the sides of the question.
Now that you all have shown me other sides of the question, I can only say that the problem does not allow for a solution–like trying to solve for the square root of -1.
I think somewhere along the line we have to say, WAIT A MINUTE! What we should (out of compassionate grounds) do or what is fair (we all engage in some activity or other that can lead to poor health in later years) to do is not the point.
The point is that if we raise taxes enough to provide everyone with everything they can’t afford — basic health care for everyone, for example — then the tax burden is so great that no one can provide food for their own family.
I’m not exaggerating here.
Okay, so we start making tough decisions: Transplants are out because they are too expensive. How about dialysis? Is that too expensive?
What do we do when the parents of a sick child beg for help even when there is only a one-in-ten chance the child can survive with the super expensive treatment? And the child, of course, if cute (and white, of course), and appealing, and the media pulls out all the stops (organ analogy, not harpsichord analogy).
And who is going to make the tough decisions about what is covered and what is not?
On the other hand, how can we justify continuing with our present course, where some people are given transplants, yet there are still children in this country who don’t get the most basic health care?
And where are we going to get the doctors needed to provide health care for everyone?
We have, and have had for years, a shortage of doctors (caveat: In some parts of the country there is no shortage of the higher-priced specialists). My son went to medical school and is now an E.R. doctor. He was lucky. He had several friends in college who were also in pre-med, and who had all the qualifications needed to go through medical school and be good doctors. But they didn’t get in because there are not enough places in medical schools in this country.
The med school my son went to couldn’t simply accept a few additional students. The classrooms, the labs, the whole system — everything they used was set up for a certain number of students. The only thing they could have done would have been to duplicate everything — to build a second set of classrooms, a second set of labs, hire a second set of professors, etc.. Obviously they were not going to do this.
Wouldn’t it be a good idea to build more medical schools? We have plenty of law schools, which means an overabundance of lawyers. So why do we have high medical costs because of a shortage of doctors? Yes, it costs a lot more money to build a medical school than just about any other graduate school, but with the population increasing, can we really afford to keep the same number of doctors?
Good laws/regulations that somehow went astray department:
It used to be that sometimes an intern or a resident would work a 40-hour shift. I’m not talking about a 40-hour workweek, I’m talking about a 40-hour shift. My son actually worked one of those while he was a medical student, but fortunately he was just the student and not the person in charge. As an resident he regularly worked over 100 hours a week.
So finally, after years of ridiculously long shifts and inhuman work weeks for residents, the government passed a law (or a regulation) limiting the number of hours an intern or resident could work in one shift and in one week.
The rest of the story? They didn’t require the hospitals who had been employing those residents to hire anyone to work the “lost” hours. So what it means is that those hospitals are now understaffed to the point that more people are dying unnecessarily than when the residents were working overly long shifts. In other words, a tired resident is still better than no doctor at all.
So I repeat my questions:
1) How are we going to pay for health care? Or 2) How are we going to limit the health care to what we (that’s the collective ‘we’, not the individual ‘we’) can pay for? And since we can’t provide everything for everybody, (3) who is going to make the decisions about who gets what?
Charlou
7 Aug 11 at 10:33 pm
“So I repeat my questions:
1) How are we going to pay for health care? Or 2) How are we going to limit the health care to what we (that’s the collective ‘we’, not the individual ‘we’) can pay for? And since we can’t provide everything for everybody, (3) who is going to make the decisions about who gets what?”
Answer: Be afraid; be very afraid.
Mique
8 Aug 11 at 1:31 am
Oh, I’m afraid, Mique. I’ve been very, very afraid for many years now.
And the sad part is that even if we (the ‘we’ who post on Jane’s blog) could figure out among ourselves what needs to be done and how it needs to be done, and even if we could come up with a way to pay for it, we’d still have to get it past Congress. Yeah, right! As if that would be possible!
Speaking of closing military bases, which some of us were talking about somewhere back a week or two ago, I remember back when the cold war ended (or maybe it was right after the Vietnam War ended–the decades just keep rolling along, and sometimes I think I’m being run over by them), and it was decided that we didn’t need all our military bases in the U.S. So a commission was appointed (notice I’m using the passive voice because I don’t know who decided or who appointed–could have been Congress, could have been the Pentagon, could have been the President) to study which bases should be closed. The members of the commission did their job, and then gave their recommendations to Congress. The recommendations were based on the current and projected future needs of the U.S. military. The pentagon had input, although I think the commission was composed of civilians… or maybe civilians plus military.
Anyway Congress, in it’s inevitable way, totally ignored the commission’s report and kept the bases that were in the home districts of whichever Representatives had the most political clout in Congress, closing even some of the bases that were at the very top of the “absolutely must keep” list because their Representatives happened to have offended the Speaker of the House.
So while I am, despite the impression I apparently gave some of you in previous postings, actually in favor of increasing the defense portion of the national budget (while cutting out foofy stuff like the National Endowment for the Arts, and boondoggles like Homeland Security), I’m not sure I’m in favor of turning the matter of how the military budget is spent over to Congress.
Lest any of you misunderstand me, I’ll spell it out to you:
I believe the U.S. Congress is bloated in terms of staff and office space and salary and pensions and health benefits and junkets and a lot of other freebies, and yet despite all the public money they spend on themselves and the contributions to their own reelection campaigns that they spend, they appear to be either totally incompetent or corrupt or venal or all of the above.
If they have done anything right in the last thirty or forty years, it wasn’t very much and it was probably by accident. Personally, I cannot see any difference between the Democrats in Congress and the Republicans in Congress. And whatever the people who drafted the Constitution intended, what we have now is definitely NOT representational government, because our Representatives no longer pay any attention to what the people in their home districts want. (Warning: When you hear a Congressman say the phrase, “I know that The American People want…” then you should watch out, because he or she is either lying to you or is about to try to con you about something.)
I’ll accept that there are probably 5% of all Congressmen who are being maligned by my statements above, but I would be really surprised if the percentage went much higher than that.
So we should keep this in mind when we debate as to what the Federal government should or should not provide in the way of services for its citizens:
Whatever authority we give to Congress, they are going to use it to screw everything up something fierce. And if we don’t give them the authority to do something, they are probably going to take that authority unto themselves anyway, just to increase their power base.
Maybe ‘ranting’ is not the proper word. Maybe ‘foaming at the mouth’ would be more accurate…
Charlou
8 Aug 11 at 2:43 am
Can’t afford basic medical care for everyone? Not even when you eliminate the incredible layers of bureaucracy required when you have multiple insurers involved? For all the moaning we do here in Canada, we’ve mostly managed. It varies a bit by province, but basically you don’t get ‘optional’ stuff at all unless you pay for it – that covers just about all cosmetic procedures except those to repair accident or medical treatment damage, for example. Drugs are often only paid for if you are actually in hospital (some exceptions in some provinces with various levels of subsidy for the poor and elderly). Experimental procedures normally aren’t covered unless you’re part of a research project, and unproven procedures (not counting ones that have been in use so long everyone assumes that they work) don’t get covered at all unless the government is heavily lobbied by family and patients (which is only appropriate; people are supposed to be able to influence their government, which can then agree or not to the request). What’s left mostly seems to get paid for and obtained in a fairly timely manner for all the stuff in the media about waitlists and shortages – I know someone who’s been on a waitlist for going on a year for a fairly minor procedure. She’s turned down at least one ‘inconvenient’ appointment. That I know of.
Med school places here are regulated, and, as in the US, it’s a extremely expensive program to run and requires a lot more than simply opening up another classroom to increase the number of graduates by a large number. But it can be done. A few years ago even the Powers That Be finally admitted that they got their demographics a bit wrong some years back, and that they needed to arrange for more med school places, especially for potential GPs. Existing medical schools have been negotiating about just how many extra students they can squeeze in without having to build lots of new anatomy labs and having the budding doctors get too little practice because they are sharing too few patients. There’s a new medical school in Northern Ontario – they’ve already had one or two graduating classes. There’s plans for a one in New Brunswick (which might worsen the access to patients, actually, since both the one in Newfoundland and the one in Nova Scotia have been sending medical students there to get some hands-on experience).
So it is possible to change the medical training system in Canada. It isn’t easy or fast, it’s something like turning an ocean liner. it can’t be done on a dime. And it might have been better if they hadn’t thought, all those years ago, that they (in Canada, don’t know about the US) needed to graduate slightly fewer doctors. I suppose nothing’s perfect.
Cheryl
8 Aug 11 at 6:05 am
Oh, and the overwork thing? That’s taken quite seriously, especially by the residents’ unions, to the point at which in some specialties people are wondering whether their programs should be lengthened in order to give the residents enough time to practice, given that they’re now going home to sleep after the morning hand-over when they’ve been up all night. It’s a really drastic change in hospital culture, and although there are probably some holdouts, they aren’t that common. There’s also the point that women, who are now well over half the medical student population locally, are less likely than the males of a generation ago to work all hours – and they often take maternity leave, during their training or shortly afterwards. So more doctors are needed to allow for that.
Nevertheless, the health care authorities don’t seem to be able to use this as an excuse for under-staffing. They’d probably lose their accreditation if they tried. It’s their responsibility to see that their facilities are properly staffed.
Cheryl
8 Aug 11 at 6:12 am