eugenics and health care

The unedited version of my essay, as commissioned by the Center for Public Justice...

Eugenics is the study of the hereditary improvement of the human race by controlled, selective breeding. The word derives from its Latin components—eu meaning well or good and genics meaning born or birth. In other words, eugenics seeks the products of “good birth” or being “well born”—“better” human beings or a “better” human race—through selective breeding.

From there, two categories emerge. “Positive eugenics” is the study of “good” outcomes achieved through breeding. “Negative eugenics” is the study of “bad” outcomes—when undesirable characteristics are lessened or eliminated through selective breeding. But beyond mere study, eugenics typically leads to a set of recommended practices.

Even though we are now repelled by explicitly eugenic sentiments, the eugenic reflex still lives. In its heyday, the embrace of eugenics was often connected to racism and concerns about poverty, those with mental handicaps, and immigration. Today, such sentiments are still occasionally expressed in politically-incorrect circles on the Right. But in polite company on the Left, it's still permitted if not desirable to talk about eugenics, given misplaced concerns about over-population and environmental issues.

From there, the prescriptions range from the personal (the desire to control one’s own life) to the corporate (the desire to use government policy to regulate the lives of others).

How does eugenics play out today? Let's start with abortion—from state policy in China to cultural pressures in India to personal preferences in the West when babies have less desirable characteristics. Beyond abortion, “medical eugenics”—in utero and in the test tube—are increasingly used to produce "designer" babies.

But the implications of a eugenics reflex are far wider—influencing a broad array of issues within sexual and reproductive ethics (e.g., birth control), ethics within scientific research (e.g., cloning and embryonic stem-cell research), and most broadly, in speaking to a "culture" of death or life (e.g., euthanasia).

This brings us to the current debate over health care reform.

I've written frequently on eugenics. (My essay on eugenics in American history—which ironically starts in my state of Indiana—is available at SchansBlog.com.) But it was not until recently that I was struck by the following combination. First, the health care reforms proposed by Democrats would result in more rationing of health care services. Second, especially when listening to some of those who would implement the additional rationing, it seems likely to be concentrated among the elderly, newborns, and those with "bad" lifestyle choices. Third, society in general—and the Left in particular—have a significant eugenics reflex.

Developing the first point, government proposals to increase health care coverage would almost certainly result in higher costs, more rationing, or both. (The unlikely exception: if the federal government can, somehow, provide an increase in efficiency.) At present, it looks like both costs and rationing would increase under the current Democratic proposals. Cost estimates range from $900 billion to $1.6 trillion. Meanwhile, President Obama pledges to decrease spending in Medicare, implying reduced services for the elderly. Beyond that, as the health care costs supported by taxpayers continue to increase, the subsequent budgetary pressures are likely to yield future cost-cutting measures and more rationing.

Developing the second point, consider Dr. Ezekiel Emanuel—the brother of Rahm Emanuel, the president’s chief of staff. Dr. Emanuel has already been appointed as a health-policy advisor at the Office of Management and Budget and is a member of the Federal Council on Comparative Effectiveness Research. He clearly will play a significant role guiding the White House's health initiative.

In January 2009, Dr. Emanuel had an article published in The Lancet—a prominent medical journal. In the article, he proposed rationing guidelines, including a relatively famous graph depicting an ideal “probability of receiving an intervention” at various ages. Babies, toddlers (up to age 4), and those over 60 years old would be least likely to receive an intervention—less than one-third as likely as those who are 20-30 years old.

Of course, we don’t know whether Dr. Emanuel’s preferences would become the drive behind bureaucratic fiat. In any case, increased rationing will result in more difficult choices. Under dramatically increased government involvement, this translates to politicians and bureaucrats making more and more decisions about the care that would be available to people.

Over the past two decades, more and more attention has been paid to lifestyle choices—whether stricter prohibition efforts in the War on Drugs, the increasing squeeze on tobacco use, or the increasingly louder drumbeat against obesity, fat intake and unhealthy diets. A natural application of this paternalistic mindset would result in greater rationing efforts upon those who make the “wrong” decisions about diet, smoking, and so on.

Less treatment for the obese and those who smoke will result in earlier deaths for them. Maybe that's one of the points. This certainly resembles a Darwinian emphasis on the survival of the fittest and healthiest. Meanwhile, those who are the least healthy and lowest on the utilitarian scale of usefulness will be culled from the population through natural selection.

I know this sounds harsh—and I don’t mean to imply that proponents of health care have connected these dots. But the results—intended or not—are likely to follow the path I have laid out here.

It’s also worth noting that the (free) market—if allowed to work—would achieve similar ends, even if by profoundly different means. The unhealthy would pay higher insurance premiums and be encouraged to change their lifestyles—or pay the proverbial piper.

Even so, the motives of the market-oriented are more about individual freedom and responsibility than having a set of elites who would ration care to those who "deserve" it.

What will we do with health care and health care reform?