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Saint Martin of Tours and the new world of public policy.

I should start with a parable. In the Christian tradition, there is the story about Saint Martin of Tours, who in medieval times was riding his horse, alone and cold, through the deepening night toward the walled city which was his destination. Right outside the gate to the city, Saint Martin of Tours met a cold and starving beggar. In an act of charity that lives on in Christian tradition, Saint Martin of Tours divided his cloak in half and gave that with half of his dinner to the cold and starving beggar. It was clearly the ethical and moral course to take. It has served as an example of Christian charity for centuries.

Yet Brecht, in his play Mother Courage, raises the issue: what if, instead of one cold and starving beggar, there were 40-or, if you like, 100? What then is the duty of an ethical and moral person? It obviously does not make any sense to divide one's cloak into 40 or 100 painfully inadequate pieces. There is no reason to choose one among the many cold and starving beggars.

It is my passionate belief that this parable applies to the dilemma we are faced with in many areas of public policy. There is a new set of realities with which we are confronted, and public policy demands that we develop a new set of values and principles if we are to adequately confront these new realities. It will require us to rethink our liberal orthodoxies. John Lennon once said that "life is what happens to you when you are busy making other plans." So also in public policy. Politicians drive the ship of state by looking rearward and reacting to the world not so much as it is but as it was. A whole new world of public policy is being formed.

Take health care.

Marshall McLuhan once observed that "nothing fails like success." It is worth keeping in mind as we reform our health-care system. The more successful we are in treating acute disease, the more we must spend treating chronic disease. The faster we run, the further behind we fall.

Most of our "miracles" of medicine set us up for more expensive health care down the line. The life, time health-care costs of smokers is substantially under the lifetime health-care cost of nonsmokers. In any given year, we spend more on health care for smokers because it is a terribly health-impairing habit. Yet, from a systems standpoint, smokers die efficiently. Smokers generally die of their first or second disease while the rest of us are saved from four or five serious illnesses before we die a negotiated death in a hospital or nursing home. The same results follow many other of our "cures." Our medical miracles too often become our fiscal failures.

This does not mean that we should stop fighting cigarettes. I fought cigarettes every year I was in the political system. Cigarettes steal health and cause approximately 400,000 U.S. deaths a year. We need a smoke-free America because it will make us more healthy and productive--but it will not, in the long run, save us health-care costs. Those 400,000 people still die having consumed far more health care.

This public policy dilemma affects much of our health-care policy. Since we all must die of something, almost every "success" ends up costing us more health-care dollars and usually more Social Security dollars. Reform we must--but with open eyes.

The Population Reference Bureau published a study, Death and Taxes, which found that curing cancer and curing heart disease would increase federal spending. The bureau was not arguing that we shouldn't try, but it wanted us to do it with full realization of the consequences. It found that "the post-ponement of death increases federal costs, requiring more taxes." Like Faust, we were not fully aware of the tradeoffs. This is the wisdom of Dan Callahan, who states that "medicine should now restrain its ambitions at [the] frontier. It should give up its relentless drive to extend the life of the aged, turning its attention instead to the relief of the suffering and an improvement in their physical and mental quality of life."

Of course, we should continue to "cure" disease, but we cannot "cure" death. Chronic disease at the end of life is far more expensive than acute disease in mid-life. We need a deeper dialogue on how we set limits. We have invented more health care than we can afford to deliver to everyone. Unless we set some limits, we will bankrupt our children.

The Brave New World of Health Care

I believe that most thoughtful health-care providers now recognize that the genius of American medicine has invented more health care than we can afford to deliver to everyone. Like Saint Martin of Tours with 40 beggars, we have more need than resources. An aging society that is the world's largest debtor nation, and whose economic growth is only one-third of historic rates, needs to honestly deal with these issues. A society that is as inventive and creative as ours, yet has reduced means, kids itself when it avoids discussing rationing. This is a society that would benefit from an honest discussion of rationing.

The status quo in health care is unsustainable. France recently did a study asking how much it would cost to give all the health care that is "beneficial" to each citizen. The answer was five and a half times the French gross national product. The fatal flaw is in the yardstick. No modern society can afford to give all the health care that is "beneficial." Medical need is an infinitely expandable concept.

There is no end to the things that a creative and inventive society can do to aging bodies. It is a fiscal black hole into which we can pour all of our children's future. It does little justice to this great country to avoid these hard issues. The search for the health-care system that does not ration--like the search for the chocolate sundae diet--is not only futile but demeaning to a thoughtful people. The worst way to deal with a problem is to ignore it.

Just as the individual family must make choices within budgets, so must our national family on what we can afford and what we can't. There is no way we can keep up with health-care costs which are growing at two to two-and-a-half times the rate of inflation. Lamm's law of public policy states: anything that grows at two to two-and-a-half times the rate of inflation eventually destroys itself.

Geometric growth can never be sustained. Yes, we need more than increased efficiency and to end the waste, but this does not solve our problem. Rationing is the price we must pay for our creative success. It is the ugly child of the marriage of our creative and inventive society and our rather uniquely American desire (albeit an abstract desire) to have an egalitarian society which denies nothing to the poor that is available to the rich.

Yet it is more than recognizing reality. All nations ration--some by price, some by queuing, and some by setting priorities. I believe that a nation does not maximize its health until it starts to ask the hard question: how do you prioritize your money to buy the most health for the most people? Rationing is not something to apologize for; it should be promoted and advanced. You are not exploring the "opportunity costs" of limited dollars unless you admit that you cannot pay for everything. We need to ask ourselves: how do you maximize those dollars?

We can no longer merely express our compassion by saying "yes." In a world of limited resources, you cannot say "yes" unless you say "no." You cannot explore the best use of your resources, the so-called opportunity costs of each dollar, unless you have that dialogue. We must start a community dialogue about how we put our health-care dollars to the highest and best use. It is an inevitable dialogue, and we ought to make a virtue out of necessity.

Saint Martin of Tours and the Statue of Liberty

I feel we have a similar dilemma in regard to immigration policy in America. Our compassion to the world's economically dislocated should no longer be expressed by our immigration policy. We are told by reputable organizations that perhaps three-quarters of the world's 5.4 billion people live under conditions that are "not free" or "partially free." I just returned from a trip around the world visiting many countries whose per capita incomes are under $400 per year. In China, the official poverty level is $38 per year, and 50 million Chinese have incomes less than 10 cents a day. There is an incredible number of people who would like to come to the United States. Polls in Korea, in Mexico, and in many other places show an incredible desire to move to the United States. We are part of the geography of hope.

When you see a potential immigrant on television, our whole heritage says that we must make room for him or her; but I increasingly question whether we should or can. Of the 160 countries that belong to the United Nations, only three take any appreciable number of legal immigrants. The United States takes about one million a year, Canada takes about 150,000 per year, and Australia takes about 125,000. So, perhaps, 1.25 million people in a total pool of three billion people are lucky enough to come to one of the immigrant-receiving countries. Yet that pool increases by about 80 million people a year (90 percent of the 90 million people the global population increases by every year are born in less-developed countries).

The maximum amount of "good" that the immigrant-receiving countries can do to alleviate the pressures on those countries where people want to migrate is infinitesimally small--less than 0.05 percent.

The maximum amount of "good" that we can do from the standpoint of alleviating those pressures is ridiculously small. We may be able to save a few highly identified individuals that appear on the evening news, but, in terms of alleviating the pressures of world population, economic disruption, revolts, and revolutions, it is a small contribution. Most people will have to solve their problems within their country of origin. In an increasingly crowded world, we have to take great care not to engender unrealistic expectations. Most people, as John Tanton has said so well, "must bloom where they are planted." We cannot be the home of last resort for the world's dislocated or ambitious. Our immigration policy should be driven by what makes sense for America.

The Environment: Growth in a Finite World

There is increasing empirical evidence that the demands of human economic activity are placing unsustainable burdens on the ecosystem. They already exceed what the ecosystem can sustain. As one author said, "We have filled the ecological space available to us."

An important turning point in history has been reached, though we are only beginning to grasp the full implications. Like Saint Martin of Tours with 40 beggars, our compassion exceeds our practical response. We must soon recognize that a finite world requires stabilization of population and rethinking of consumption patterns.

We are rapidly adding pollutants to our earth's atmosphere faster than the natural processes can reabsorb them. The ozone layer is thinning; massive climate changes threaten to melt the polar icecaps, flooding vast coastal areas and turning presently fertile agricultural areas into desert. Soils are being depleted faster than nature can regenerate them, leaving at risk our exploding population. Fresh water has become a resource that nations fight over. Garbage is accumulating faster than we can find ways to dispose of it. Chemical and radioactive wastes are contaminating more and more of the earth's surface, rendering many areas unusable. Fossil fuels are being exhausted.

Can the earth support the projected population of 14 billion people? Can we possibly support that many people at any kind of decent standard of living? Were consumption per capita to continue at even 2 percent (only two-thirds the rate we have grown in the last 25 years), it would double in 35 years and quadruple in 70 years. If one multiplies the projected increase in consumption with the 2.6-fold increase in population, the globe would consume 20 times the physical resources we consume today. Of course, we can and will reduce the environmental damage and resource consumption of economic growth, but however successful we are, there will be huge increments of growth demand on our land, water, climate, and resources. Can the ecosystem possibly absorb the wastes which flow out of these numbers?

It is clear to many that we have to have a new perception of economic growth and progress. The implications of this are Copernican. If we are to survive them, there will have to be great changes in human thinking.

A few policymakers have acknowledged this new reality and its implications. As one author said, "Only a radical transformation of thought, policies, and institutions will allow us to avoid a social and ecological breakdown."

The question is: do we have our basic assumptions correct? "Human society has built its economic theory and institutions on the premise that the total demands that human economic activity places on the environment is inconsequential relative to the environment's regenerative capacity. In short, contemporary economic theory and policy assume an empty world "

We now face a new reality. With alarming data on global warming, ozone depletion, land degradation, shrinking biomass, and waning biodiversity, we must now consider the fact that human activity has grown to the point that it now either fills the available ecological space, or will within a few years.

Thus, "as we approach the new millennium, we increasingly recognize that we are fast approaching the carrying capacity for life on this planet. It requires us to rethink everything. Where once we thought in terms of expansion and growth, we now are recognizing limits and constraints. Where once we thought the planet endless, we now recognize it as fragile. A new set of values is emerging in the human spirit. We have come to understand the interrelatedness of life and the interrelatedness of budgets."

We are living in a hinge of history. The old world of ideas is dying and a new world is being born. It is a world of finitude. It is a world where we will not be able to give all the medical care we have invented to everybody, nor will we be able to take in every deserving immigrant. It is a world challenged by too many people and too much consumption. It is a world that must inevitably rethink what it means by compassion. Warm hearts must be balanced by hard thinking.
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Title Annotation:limited resources
Author:Lamm, Richard D.
Publication:The Humanist
Date:Sep 1, 1993
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