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A Tyranny of Health?

The dream of a society so perfect that no one will have to be good (as T.S. Eliot put it) is a beguiling one for intellectuals, perhaps because they think that they will be in charge of it, as a recent article in the Journal of the American Medical Association titled “The Moral Determinants of Health” well illustrates.

In this article, which has the merit of being clear and logical, no single instance of individual conduct is mentioned as being necessary for, or conducive, to health. In the healthy society envisaged by the author, who is a public health doctor in Massachusetts, no one will have to try to behave well—not drink or eat too much, refrain from smoking or taking drugs, not indulge in hazardous pastimes, take recommended but safe exercise and so forth—because everything will come as a matter of course to him. Living in a perfect society, he will behave perfectly. The author’s means of achieving these ends are entirely political, and wildly impractical examples of progressivism without practical wisdom—and as such, unremarkable.

More troublingly, in the author’s view, at least implicitly, health is the goal of goals to which all other considerations ought to be subordinate. It is perhaps natural for a doctor to think this, concerned as he is, day in, day out, with the health of others, but nevertheless this is a very reductive view of life.

It goes almost without saying that health is desirable; no one would actually prefer to be unhealthy than healthy, though a considerable number do prefer to claim to be unhealthy, or unhealthier than they are. But we should remember that a life is not well- or badly-lived according only to its length. Mozart died at thirty-six, but would anyone say that his life would have been better-lived had he survived to seventy-two but without having composed any of his music? People, moreover, sacrifice their lives for any number of reasons, from the noblest to the most ignoble. Would anyone say that Martin Luther King lived badly because he exposed himself to assassination, which a nice quiet life would not have done? As is known, assassination is bad for the health; we do not say, therefore, that people who tell the truth despite threats are bad because they betray the cause of health and thereby lower (albeit infinitesimally) life expectancy in their society.

Let us take the word determinant and examine the case of cigarette smoking. In Britain, as in America, there is a decline in life expectancy as one descends the socio-economic scale (though even the poorest have a life expectancy half as great as members of the British Royal Family in the middle of the 19th century). A very considerable proportion of the difference is accounted for by the prevalence of smoking, much higher in the lower classes than in the upper.

Why is this? It was not always so. However, when it was proved beyond reasonable doubt that smoking caused lung cancer, and then a variety of other serious diseases, the richer and better-educated portions of society abandoned smoking as a pleasure and a habit. The lower classes did so to a lesser extent (though still to some extent).

It is not that the lower classes do not know that smoking is bad for their health. In getting on for half a century, I have never met anyone of any class who did not know this. Many, however, say that they wish to take their chances; the pleasure or relief provided by smoking is such that they deem the risk worth it.

We cannot say that they are necessarily wrong, though it is not a choice we ourselves would make. I have indulged in many risky behaviours in my life, that nevertheless seemed to me worth the risk.

Now the author of “The Moral Determinants of Health,” who writes solely of poverty, inequality, racism, etc., would either have to take away the choice of people who choose to smoke, thus setting himself up as a dictator, or he would have to admit that there are individual determinants of health related to the choices people make. Correlation is not cause; the fact that more poor people smoke than rich is not the same as saying that poverty causes smoking. Men are not billiard balls whose direction is determined in a purely mechanistic way by the impact of a few physical forces.

…it is possible that a dictatorship of virtue would not be abhorrent to at least a large section of the population.

One does not have to go to the opposite extreme and claim that there are no social influences at all, and that men are total masters of their fate in all circumstances. Take the question of obesity: it is a sad fact that fat mothers have fat children because they overfeed them (quite apart from any genetic influence). Fat children are more likely to be fat adults: it is harder, though not impossible, for them to be otherwise. It is certainly not fair that fat children should have to struggle more than thin not to be fat in adulthood, but this again is not the same as saying that there is no moral dimension whatever to their individual body mass index, nor is it the same as saying that, if there is such a dimension, they should be denied all sympathy or assistance in trying to do something about their obesity. As Dr. Chasuble said to the morally exigent Miss Prism: “Charity, Miss Prism, charity, we are none of us perfect. I myself am peculiarly susceptible to draughts.”

The author of the article in JAMA is unaware that his opposition to mass incarceration actually undermines his argument, for it is a fact—a sad and horrible fact, but a fact nonetheless—that imprisonment decreases the death rate among prisoners compared with their peers outside. I worked it out that a prisoner is just over half as likely to die in prison in Britain as are his peers outside. If the avoidance of death were all-important, we should be imprisoning more, not fewer, young men. I presume that no one thinks this.

According to the figures provided by JAMA, over 100,000 people have read the article on-line. I would imagine, though I don’t know, that most of them are doctors. In the comments, there is not a single dissent from the premises of the article. Whether dissent would be censored, I do not know, but I very much doubt it.

I think, then, that it is possible that a dictatorship of virtue would not be abhorrent to at least a large section of the population.

Reader Discussion

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on July 29, 2020 at 08:04:13 am

Ah, the "dictatorship of virtue!"

Now there's a topic worthy of a webinar by philosophical, historical, literary and political minds as diverse as Plato, Aristotle, Thucydides, Cicero, Seneca, Augustus Caesar, Marcus Aurelius, Thomas More, Montaigne, Shakespeare, Pascal; Voltaire, Diderot and Rousseau, Johnson and Boswell, Adam Smith, Edmond Burke, Gibbon, Danton and Robespierre, Napoleon, Jefferson, Hamilton, both Adams, Robert Owen, Macaulay, Carlyle, Marx, Orestes Brownson; Freud, his disciples and his revisionists; William Jennings Bryant, G.K. Chesterton, Woodrow Wilson, Lenin, Freud, his disciples and his revisionists; Stalin, Hitler, FDR, Mao, Orwell, Muggeridge, Reinhold Niebuhr, Arnold Toynbee, Will and Ariel Durant, von Hayek, Eric Hoffer, Ernest Becker, Billy Graham, Fidel Castro, Pope JP II, Ronald Reagan, Mikhail Gorbachev and Barack Obama.

And the focus of their webinar should be not on how to form a "dictatorship of virtue" or on what such a dictatorship should seek to accomplish or on how a dictatorship of virtue should be managed or on the political and moral consequences of a dictatorship of virtue or on the long, sordid and sad history of failed attempts at virtuous dictatorship, but rather their webinar's sole focus should be on WHY in every era of history some very few restless men have agitated to impose the physical pain and psychological torture of a virtuous society on the vast majority of quiet men.

To answer that inquiry is to know the raison d'etre of today's Revolutionary Democrat Party.

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paladin
on July 29, 2020 at 08:43:11 am

And I should have invited Russell Kirk and Aleksandr Solzhenitsyn.

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paladin
on July 29, 2020 at 09:23:45 am

An excellent treatment of the main flaw of radical idealism. See also the author’s amusing and penetrating Intelligent Man’s Guide to Medicine. Thank you Mr. Daniels for a lifetime of richly thought-provoking essays turned in an English I wish were common practice.

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Morgan Walsh
on July 29, 2020 at 10:31:27 am

I skimmed the article and the comments. The article is nothing more than a great example of American leftist propaganda. The story here is the fact that JAMA is being used in this case for the diffusion of partisan propaganda. Where are the comments from Dalrymple at the end of the article?

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Scott Amorian
on July 29, 2020 at 11:51:05 am

Critical race theory, climate change and the China Virus are the largest pseudo-intellectual facades since Lysenkoism to be used by partisan ideologues seeking to advance the cause of crypto-fascism. To that end, the sciences and the wannabe sciences (the soi-disant ''social sciences",) most especially environmental science, climate science, biology, neurology, preventative public health and curative medicine, psychology, sociology, epidemiology and computer modelling. And many of the journals which publish or promote their propaganda and most of what, nowadays, is called "journalism" have been as thoroughly politicized and deployed as weapons in the crypto-fascist revolution as were Walter Duranty's writings for the New York Times on Stalin, Soviet Russia and the Holodomor.

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paladin
on July 29, 2020 at 14:37:56 pm

The day that Challenger blew up, I told people that if NASA called me that afternoon to come down to be on a launch tomorrow, I wouldn't hesitate for a moment. Most people didn't seem to understand how I could say that. Seven people just died in view of the entire world. Yes, but it would still be the chance of a lifetime, one I would be more than willing to risk my life to be able to take. Health and safety are not always the most important things in life.

We have become a terribly risk averse society, yet even so, there are significant risks we take all the time but never think about because they're so much of the fabric of everyday life. Every time you pull out of your driveway. Evey time you jump in a pool. Every time you climb a ladder. Every time you enter a crowed elevator (and they will be crowded again some day). Everyone, consciously or not, evaluates the risks aginst their potential rewards (even if it's just cooling off on a hot day or running out for fast food because you don't feel like cooking) on their own personal risk scales.

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Diane Merriam
on July 29, 2020 at 15:39:32 pm

When all you have is a hammer, the whole world looks like a nail.

One might imagine what Dr. Berwick's article had been titled had he chosen another profession. If he had been a bus driver, we might expect, in the appropriate trade journal, a piece titled "The Moral Determinants of Keeping on Schedule." If he were a landscaper, "The Moral Determinants of a Great-looking Lawn," if an auto mechanic "the Moral Determinants of Long Engine Life," etc. In every such case the necessary interventions will be the same. The policy prescriptions contained in the penultimate paragraph of Dr. Berwick's article ("speak out," "work with community organizations," "Lobby harder for universal health insurance coverage," etc.) apply as easily to florists as to brain surgeons. Dr. Berwick's article is an ideological polemic poorly disguised as medical literature. Contrary to Dr. Dalrymple's attempt to sound even-handed, the article is neither clear nor logical. It is written in a gullible style (note the way the term "despair" is uncritically used, and how "homelessness" is claimed to be "a completely addressable" issue) to appeal to a gullible audience.

That Dr. Berwick is a progressive ideologue is not surprising. It is also not surprising that this limits his influence and makes his arguments almost universally unpersuasive, except to those with the same ideological bent and same disregard of real-world consequences. The "Moral Determinants of Health" cannot be reasonably considered without attention paid to the much more historically relevant "Ideological Determinants of Human Misery."

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z9z99
on July 29, 2020 at 16:08:51 pm

It's a far, far greater risk to wear a Trump MAGA hat in Portland, Seattle, San Francisco, Minneapolis, St. Louis, Chicago, NYC, D.C., et cetera, et cetera, or on any university campus, or in any Starbucks than it is to become an astronaut, drive a car, jump in a pool, climb a ladder, get on a crowded elevator in flu season, fly commercial in Russia or single-engine in Zimbabwe, sky-dive, swim with gators in a Florida short river, ride the surf in shark waters and riot without your China Virus mask and your umbrella.

As we know and as Nick Sandmann would attest and as Bernell Trammell would say were he still among us, showing support for Donald Trump can incite journalists to defamation, white women to racist slurs, lawyers to fire bombing; Blacks to rioting, arson, looting and destruction; Democrat Members of Congress to frothing displays of public indecency and shamelessness, and ordinary Democrats to bloody assault and even murder.

But the risk of publicly showing one's support for Trump pales in comparison to the risk of being a police officer in any Blue City or Blue State or the risk of attempting in any Blue City or Blue State to use your Second Amendment right in order to protect the safety of your family and your constitutional right to life, liberty and property.

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paladin
on July 29, 2020 at 16:25:08 pm

If memory serves, this is not the first time Berwick, an Administrator of the Centers for Medicare and Medicaid Services (CMS) during the Obama administration, has advocated for a medicalised totalitarianism, replacing those icky proles with earnest people in clean white coats.

It is likely that a 'dictatorship of virtue' would be abhorrent to a large section of the population; to those who would expect to be in command not so much.

That physicians are increasingly reduced to the role of functionaries under the direction of government and/or insurance companies may well contribute to the desire to assume control.

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aelfheld
on July 29, 2020 at 19:15:55 pm

Healthcare is a human right so why do so many who claim that Healthcare is a human right deny that there have been many successful treatments resulting in full recovery when various Doctors have treated patients with Covid 19.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232869/

Wouldn’t you want to know what has proven to be successful if one of your beloved becomes sick with Covid 19?

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Nancy
on July 30, 2020 at 10:59:37 am

A right imposes no obligation beyond forebearance on others.

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aelfheld
on July 29, 2020 at 20:58:51 pm

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232869/
H/T Ann Barnhardt

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Nancy
on July 30, 2020 at 09:02:00 am

Nancy, thank you for the cite. The HCQ+zinc protocol is being widely used and overwhelming study data will be published. Will the official response be, ‘We had to lie so that the poor in Turkey, Brazil, India might be saved” ? If so the justification would be lauded.

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Morgan Walsh
on July 30, 2020 at 09:18:39 am

In a radio address on March 26, 1953 Jonas Salk announced his discovery of a polio vaccine. Had a Republican Donald Trump introduced Dr. Salk on that radio broadcast and were Democrat politics and major media then the morally-deranged, sociopathic entities they are today, the world would still be struggling to stamp out polio.

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paladin
on July 30, 2020 at 16:08:39 pm

I found it interesting that the "lower classes", those in lower socio-economic groups, smoke more these days, certainly in England and Wales, than their richer counterparts. One plausible explanation may be that they discount future benefits more sharply than those that are better off. If the poor grow up to believe that the future is stacked against them, they might behave in a manner that values immediate gratification over postponed gratification in anticipation of a brighter future. Higher discount rate of future benefits for this group is observed in, for example, educational choice. What is puzzling is that the middle aged middle (American: upper middle) classes in England and Wales are drinking far more wine than it is good for them. I have seen predictions of alarming rates of cancer in the next couple of decades for this prosperous group of people.

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Curious
on July 31, 2020 at 10:06:09 am

",,,iddle aged middle (American: upper middle) classes in England and Wales are drinking far more wine than it is good for them"

Well, Thank You for that, KAREN!!!!!

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Guttenburgs Press and Brewery

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