Duty I
Michael A. Gillette, Ph.D.

As I sit down to write this article our government is presently shut down while the White House and the Congress wrangle over how to balance the federal budget. This shutdown is predicted to continue through the weekend, and I hope that by the time this newsletter is read the entire event will be only a distant memory. Still, in the midst of this situation, I can't help but think of the broader ethical and medical-ethical implications of the whole affair. My philosophical concern rests with fundamental questions: Even if we assume the most extreme version of libertarian philosophy (that government should be as unintrusive in the lives of citizens as possible), can we avoid a moral responsibility to provide governmental services to those in need? How far does this moral responsibility take us?

It seems clear that as a society we are committed to the idea that we care about what happens to the inhabitants of this country. While one party argues that government is fundamentally a necessary evil and that we will all benefit if we had as little of it as possible, others argue that we are dependent upon government for much of what we desire and that a large but lean government is desirable. I wonder now: where do the clients served by mental health and mental retardation facilities fit into the equation?

From an ethical perspective the entire problem would be solved if we decided that we just don't care about people who are unable to care for themselves. Or, more realistically, that caring is matter of personal choice. Individuals care and may spend their money as they wish in helping others, but it is no business of the government to require, through taxation, that everyone care.

If this is an acceptable political philosophy then we could slash budgets to all state run facilities without remorse. But I believe that people on both sides of the political fence do care about their fellow human beings and disagree only on how best to fulfill the function that our social arrangements are meant to satisfy. In fact, it seems that even if we grant the most libertarian of philosophical views, a caring government is still a moral imperative.

To begin the discussion from the libertarian view let me quickly review the position articulated in the early chapters of an important book by Robert Nozick entitled Anarchy State and Utopia. In that book Nozick attempts to determine what level of government is morally justifiable. He begins by imagining a situation in which no government exists at all, and asks what level of political organization it would be rational for any person to desire.

The first and most obvious reason that people would band together into a state of civil society is for protection. There is safety in numbers, and it is rational for individuals to create what Nozick calls "protective associations". These groups settle differences of opinion between group members and protect group members from attack by outsiders. It soon becomes clear, however, that multiple protective associations spring up, and that disputes between protective associations require rational solution. Either one association becomes dominant by means of superior strength, or all the associations voluntarily agree to create an umbrella association to solve disagreements. In either event, a single protective association comes into existence. This single power forms the rudiments of government. It provides an army, police force, judges and jailers. But that level of government, often referred to as a "night watchman state", is not sufficient.

Some of the strongest people will not agree to enter the protective association. They are willing to take their chances in the untamed state of nature. Do we have any ethical reason to force them into our state? The answer, according to Nozick, is yes. If our rules do not apply to the outsiders, then we will always fear their attack. After an unjust attack, our protective association will come to our aid and demand retribution for the wrong done, but that does not satisfy us. We want protection in advance, so we insist that the outsiders be stripped of their freedom to settle their own disputes according to their own ways of thinking. We require that if an outsider has a complaint against one of us, he must follow our laws and prove in our courts that his claim is valid. In effect, we force the outsiders to become insiders.

This forcible inclusion in society disadvantages the would-be outsiders. They have lost a fundamental freedom and are thus harmed. Since we have forced a harm on these people, it is up to us to compensate them. Since we have forced them to give up their ability to protect themselves by use of their own strength, we must provide protection for them. Even if they cannot afford to pay for protective services, since we have limited their ability to protect themselves, we must pay for their protection.

The point of this argument is that even if we begin with the most libertarian view, we cannot avoid recognizing that there are situations in which the rich must subsidize the poor. There are functions that only a government can provide, and for which we all must pay.

How does this relate to health care ethics? In facing an individual with mental retardation or mental illness one might argue from a libertarian perspective "I didn't make you ill. Your developmental disability is not my fault. Why should I have to pay for your care?" But the answer is clear. We have created a society in which an individual with developmental disabilities or mental illness cannot function effectively on his or her own. We could have made social living simpler or safer, but in order to maintain our standard of living we have made the social environment complex. Furthermore, we do not allow people who are disruptive to live among us. We place limitations on the freedom of such individuals for our own good, and now that we have caused a disadvantage, it is our responsibility to compensate for the harm caused.

The answer to my present query is that although we may not have caused the illness, we have turned the illness into a clear disadvantage. Since we have done that, we cannot avoid the responsibility to care. Some social programs cannot, ethically, be cut. Having made that point, I will leave the details to the politicians.