Chapter 15 – The Critical Importance of Individual Autonomy

This is Chapter 15 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.

You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.

And here is the up-to-date archive for all the chapters that have been posted so far.
Update – September 1, 2012

Open Wide and Say Moo! is now revised and published!


You can find it on Kindle here.


Now available in the audiobook version!





Part III – What We Can Do About It


Chapter 15 – The Critical Importance of Individual Autonomy

As I write this, Chief Justice Roberts has just revealed his decision to stand with the Progressive wing of the Supreme Court, and declare Obamacare constitutional. Why he (supposedly a Conservative) has done so is a matter of widespread conjecture at the moment. I believe that Justice Roberts found a way (convoluted as it may be) to let the law stand precisely because this law represents a pivotal moment in American history, and he believes, therefore, that whether it goes forward or not ought to depend on the will of the people as expressed by their elected representatives, and should not rest on one swing voter on a 9-person panel. With a critical election only four months away, and with the bulk of Obamacare not yet implemented, Roberts (I maintain) manufactured a way to turn it back to the people. Let the people decide whether they want this law, and all it implies about the kind of country we will have. (If I am right, then Justice Roberts’ act essentially reflects a Conservative, non-Progressive reluctance to rely on expert panels for critically important decisions.)

The actual constitutional question turned on whether the federal government had the authority to invoke the “individual mandate” (i.e., the mandate under the law that all Americans must acquire an approved health insurance product by 2014, or pay a penalty). The Obama administration argued that the authority to do so is granted by the Commerce Clause. Opponents countered that the Commerce Clause cannot possibly give the government the power to force individuals to buy a specific product (or, more precisely, to enter into a specific contract) against their will, since, if the government had that power, it would necessarily also have the power to force individuals to do anything else the government wanted them to do.

The argument that the government ought to have such power goes to the very heart of Progressivism. In order for the Progressive Program to work, that is, in order to move toward a perfect society, individuals simply must behave according to the dictates of all those designated experts, who will determine what is best for society. Ideally, people will voluntarily follow such dictates because it’s the right thing to do. But for recalcitrants who do not agree to follow centralized directives voluntarily, there has to be a mechanism for forcing compliance. The Progressive Program will simply not work without being able to achieve universal cooperation.

So the question of the individual mandate goes to the fundamental problem of Progressivism.

It ought to be obvious to any objective observer that the US Constitution was designed specifically to deny the federal government any such authority over individuals. To have declared the individual mandate constitutional, to have granted that power to the federal government, would not merely have been a misapplication of the Commerce Clause. It would have turned the entire theory behind the Constitution on its head.

Justice Roberts managed to find a way to allow Obamacare to stand, while declaring that the individual mandate is not constitutional under the Commerce Clause. He did this by accepting the government’s argument (which had been offered only as a peripheral, back-up, secondary argument before the Court, and that nobody else had taken seriously) that the individual mandate is not actually a mandate, but a tax.

So Obamacare will stand, and in this way the Progressives have won a great victory – but it was by no means everything they were looking for. For Obamacare was allowed to stand in a way that did not finally gut the main idea behind the Constitution.

However, the Progressives are already busily working to rectify this shortcoming. No sooner was the ruling announced than the mainstream media began declaring, “Individual Mandate Found Constitutional.” And within minutes the President’s surrogates were dispatched to make the rounds on all the TV shows to celebrate the ruling – and at the same time to indignantly deny that the mandate is a tax, but is in fact a mandate as they asserted all along. In other words, the Progressive victors are doing everything they can to create the public perception that it was the individual mandate (and not some bogus tax) that was found to be permissible under the Constitution.

In a short time, likely few will remember that the individual mandate was actually called unconstitutional by the Court. The conventional wisdom will be that it is perfectly fine for the federal government to make mandates on individual behavior. So the next time the government decides to mandate that individuals must do this or that, it will not occur to very many people that a court challenge is in order. And the people to whom the notion does occur will be considered troublemakers, and will be dismissed out of hand (or worse).

That the Progressives are now loudly denying it’s a tax, and insisting that it’s a mandate after all, and that the mandate is in fact constitutional, is behavior that ought to further enlighten us as to the true nature of Progressivism. Specifically, true Progressivism is incompatible with the Constitution as it is written, and even with its underlying thesis. The individual autonomy that formed the basis for our constitutional government – the prerogative of individuals to act in their own best interests with an absolute minimum of interference – is fundamentally in opposition to Progressivism. And so the documents that establish the primacy of individual autonomy must be “reinterpreted.”

Our Obamacare

In any case, what we are left with is Obamacare. And thanks to the Supreme Court we are going to have one final chance to decide, as a people, whether we want to keep it or not. The outcome of our decision is far from clear.

Obamacare offers the people several goodies, and from proponents it is only the goodies we hear about. Even Republicans become tongue-tied when somebody points out that if they succeed in repealing Obamacare, they will be repealing provisions such as allowing adult children to remain on their parent’s insurance for a very long time, guaranteeing that people with preexisting medical conditions can buy insurance, and forbidding insurance companies from cancelling policies when people get sick.

But what we get along with these well-publicized goodies, while seldom mentioned in any cogent way, is not pretty. We will get a centrally-controlled, top-down, expert-driven healthcare system. Important medical decisions will not be made on the ground, between the doctor and the patient, but rather will be made by distant expert panels under the precepts of herd medicine. The medical actions that are deemed best for the herd will be transmitted down to our physicians, who, acting as agents of the Central Authority instead of as our personal advocates, will let us know what our limited “options” are.

It is inevitable that eventually (if not immediately) the overwhelming fiscal catastrophe that healthcare costs threaten to bring down upon all of us will cause our Progressive leaders to mandate (now that such mandates are widely acknowledged to be legitimate) that we all must engage in sufficiently healthy lifestyles (since our gluttony, sloth, driving habits, hobbies, and other proclivities are creating an unfair strain on our precious healthcare system). People who allow themselves to become too fat or too old, or who injure too many joints because of carelessness or poor choice of pasttimes, or who (by virtue of the fact that they have developed preventable diseases such as cancer, heart attack or stroke) demonstrate that they have paid insufficient attention to proper preventive measures, will (at the very least) have a lesser priority when it comes to receiving healthcare services. Good citizens (the ones who behave themselves, and whose good behavior is manifested by good health) will be taught from an early age to disdain the likes of these lazy, careless, and intemperate individuals who become fat or sick, who care nothing for their fellow citizens, and whose selfish personal choices place those good citizens in unnecessary jeopardy.

Worst of all, full-blown Obamacare means the end of the Great American Experiment.

America is exceptional. But it is not exceptional because we are richer or economically superior to other lands, or that we have been particularly innovative or inventive, or that we have had the strongest military and have won most of our wars, or that we have habitually come to the rescue of Europe and other places threatened by totalitarianism, or that we have been a melting pot of multiple cultures, or that poor immigrants have been able to come here and work their way up to prosperity. America is exceptional because it is the only nation in the history of man that was not founded on the basis of geography, race, culture, language or religion. Rather, it was founded on an idea: the idea of the primacy of the individual, of individual autonomy – the idea that all people have a natural right to live their lives as they see fit, without unnecessary interference.

This idea first developed in Europe nearly 500 years ago, but had trouble taking root there, and really only flowered when Europeans first came to America and had the opportunity to put it to work in an isolated location, where rigid social structures were not already in place. The development of this idea culminated with America’s Declaration of Independence, in which our founders declared individual autonomy (life, liberty and the pursuit of happiness) to be an “inalienable” right granted by the Creator, and thus predating and taking precedence over any government created by mankind. And since that time the primacy of the individual in American culture has, more or less, remained our chief operating principle. Individual autonomy – or to put it in more familiar terms, individual freedom – is the foundational principle of our culture. This idea is what has made us great, and why America is exceptional. And until recent years it is an idea that the vast majority of Americans have agreed is worth fighting for.

Whether a nation and a culture founded on such an idea can persist is the Great American Experiment.

Under the Great American Experiment, the only legitimate duties of the government are to protect the citizenry from foreign aggressors, to grease the skids of a free economy, and to allow free Americans to strive as they will as long as they do not impinge on the rights of others. And in so doing, the government may utilize only its very few, explicitly enumerated powers. Otherwise, the government must stay out of our way.

It is inherently true that the Great American Experiment – and thus our founding documents – are entirely incompatible with the perfect, expert-led society envisioned by Progressives. Progressives only rarely say this in public, since most Americans (including the vast majority of Americans who consider themselves to be Progressives) still value the American ideal. But every step of the way, the true Progressives have been working for over a century to undermine the fundamental tenets of our Constitution. They have no choice about this, as Progressivism is incompatible with the idea behind the Constitution.

Each time they act to undermine the Great American Experiment, of course, they do it for the benefit of the people. The doctrine of religious freedom can be wrecked, but only so that women can receive free contraceptives. Legal contracts can be abrogated, but only so that union auto workers can retain their benefits. Laws passed by the People’s House can be arbitrarily nullified by the chief executive, but only so that young people brought to America illegally through no fault of their own can be given amnesty. Laws can be applied to different groups of Americans in different ways, but only to achieve social justice. Individuals can be forced to enter contracts (heretofore voluntary agreements between co-equal parties) against their will, but only so that 25-year-olds can remain on their parent’s health insurance policies.

It is critical to understand that once the people ratify with their votes what the Supreme Court has done, and decide that Obamacare will stand, the game is about up. When we grant that the government has the authority to establish “healthcare” as a right, and thus has the authority to administer that right to all the people (i.e., to determine who gets what, when and how), then the government will also have the authority – indeed, the responsibility – to control all those choices we make that might affect our utilization of healthcare, which is to say, every choice we make. Obamacare, when fully developed, will cede to the Central Authority, at last, nearly complete control over almost every important aspect of our lives. Such control is the Holy Grail of true Progressives. And this is why controlling our healthcare system is the lynchpin of Progressivism.

Obamacare, along with the individual mandate that (de facto) enabled it, will herald the death throes of the Great American Experiment. We can have Obamacare, or we can have individual freedom. We cannot have both.

And so, for anyone who is not yet ready to declare the Great American Experiment to have failed, repealing Obamacare will be Job One. We have one last chance to do it.

Repealing Obamacare Will Not Be Enough

Repealing Obamacare will not be easy. Even if, through some monumental effort, Americans manage to elect a Republican President, a Republican House, and a Republican Senate, and even if all these Republicans are elected on the promise of repeal, repeal is anything but assured. To affect a total repeal, Americans will have to hold the elected Republicans’ feet to the fire, somehow forcing them to act with totally uncharacteristic resolve against the onslaught of scathing editorials, slanted news reports, threats by the insurance industry to renew their depredations upon the people, and multitudes of human interest stories appearing everywhere, depicting unfortunate souls who will “lose their healthcare” and die if the Republicans go ahead and do what they have been elected to do.

The worst part is that even if by some miracle we manage to repeal Obamacare in its entirety, as critical as the repeal may be to the Great American Experiment, it will itself not be sufficient to fix the problem. As I have attempted to show, well before anyone ever heard of Obamacare we were a long, long way down the road toward a Progressive healthcare system. Repealing Obamacare, if that’s all we do, will merely put us on a somewhat slower trajectory toward that end. That, after all, is what happened after Hillarycare was defeated in 1994.

After the demise of Hillarycare, our healthcare system became steadily and unrelentingly more Progressive, and indeed instituted many of the main ideas embodied in Hillarycare. Chief among these, the control exerted by the Central Authority over the behavior of physicians has grown continuously, to the point that, as early as 2002, the medical profession finally capitulated, and agreed to adopt a new set of medical ethics centered around “social justice.” No longer do their ethical standards pledge doctors to concentrate on the needs of their individual patients; the needs of the collective now carries at least equal weight. And so, when doctors find themselves coerced into pleasing the Central Authority instead of doing what’s right for their patient, at least they can console themselves with the knowledge that they are behaving “ethically.”

Also since the demise of Hillarycare, the prerogatives of the individual patient have steadily eroded. This is because Progressive healthcare system simply cannot tolerate autonomous, independent patients. There are, of course, the obvious limitations imposed by managed care plans regarding the doctors, drugs, procedures and hospitals that a person is allowed to access. These limitations at least have the virtue of being relatively transparent. But more sinister (and less well known) limitations on individuals have evolved in the intervening years, such as the Medicare patient’s inability to purchase healthcare services that are denied to them by Medicare, and the recent court ruling that Medicare patients must remain on Medicare whether they want to or not (unless they are willing to return all past, and forgo all future, Social Security payments). (See Chapter 7.) With virtually no discussion of the implications of doing so, the tenets of herd medicine are being employed to decide which treatments to offer or withhold from specific patients; that is, treatment decisions are being made based on group statistics, even when an individual’s own particular situation suggests that an exception ought to be made. For their doctor to attempt to individualize their care would be a grave violation of modern medical ethics, and would likely constitute healthcare fraud. (See Chapter 9.)

Our steady evolution toward a Progressive healthcare system has not depended in any way on Obamacare, and it will continue even if Obamacare is repealed. To our political leaders, to the doctors who care to rise to positions of leadership within medical organizations like the AMA, and to younger generations of physicians who have been trained from Day 1 that “stewardship of collective resources” is their primary function, the needs of the individual patient are relegated to a secondary concern, if it is a concern at all. And when collective concerns are primary, the notion that individual patients ought to have real autonomy (instead of “counseling” to help them understand that the options being presented to them are really very good options), simply does not register.

Repealing Obamacare, by itself, will not change any of this. Fundamentally Obamacare does not bring any new ideas to the table; it “merely” takes the things the Progressives have been slowly and relentlessly developing, and bundles them into one great package from which they can all be accomplished at once. Indeed the one great virtue of Obamacare is that it throws the goals of Progressive healthcare into stark relief – and makes the true aims of Progressives plain to anyone who cares to look.

Repealing Obamacare, therefore, will be critical to preserving the Great American Experiment. But it will not be sufficient.

Can American Healthcare Really Be Fixed?

The short answer is, yes. If the goal is to bring the healthcare system to a point of fiscal sanity, where it no longer promises to suck us into a fiscal black hole which will wreck our culture, there are actually several ways to accomplish this. I addressed this topic specifically in Chapter 4, where I pointed out that there are as many as four general approaches by which we can finally control healthcare costs.

Unfortunately, none of our political leaders (the ones who are proposing which of these methods we ought to use) have chosen to present the problem to us in the proper way. They act as if our healthcare itself is the chief consideration in deciding how to solve the problem, and they imply that the only thing we need to worry about is which proposed solution will offer us the best deal on healthcare.

This is not true. From the foregoing discussion, it ought to be clear by now that the chief consideration in deciding which kind of healthcare system we should choose is: What kind of country are we going to be? Are we going to continue with the Great American Experiment, and devise a healthcare system that is compatible with it? Or are we going to determine that the Great American Experiment is not worth preserving, and adopt Obamacare or some other Progressive plan?

The fundamental question in deciding how to fix our healthcare system, then, is whether we will choose a system that preserves and protects the primacy of the individual – or not. Whether implicitly or explicitly, we must answer this question before we can decide how to fix American healthcare.

We will settle this question once and for all, implicitly at least, if we allow Obamacare to stand. On the other hand, if we the people see to it that Obamacare is repealed, the question remains open (since a Progressive solution will still be possible, and perhaps even likely). So if Obamacare is repealed we will have a lot more work to do.

There are plenty of ways of devising a healthcare system that: a) preserves individual autonomy in making healthcare decisions; b) makes sure that everyone has access to at least basic and catastrophic healthcare services, and c) returns public spending on healthcare to fiscal sanity. All of these methods require individuals to make many of their own healthcare choices, and to pay at least a portion of the costs. (One way to tell you are dealing with a Progressive is to suggest such a solution, and watch for the look of utter horror on his/her face at the very idea of individuals being responsible for any of their own healthcare costs.)

The details of which variety of non-Progressive healthcare system would be the “best” is not something I am going to address in this book*. That, frankly, is of secondary concern. The first question – and the only question that really matters for our children and their children – is whether we are going to preserve the ideal of individual liberty in America, or not. Thanks to Obamacare the choice is stark, and it is upon us now.

* I described my proposal for such a system in detail in my earlier book, “Fixing American Healthcare.”

What Can We Do As Individuals?

It is not my intention here to urge readers to engage in whatever political action might be necessary to improve the chance that Obamacare is repealed. I am not a politically active person, and I have no expertise in this area. Furthermore, by the time this book is published the decision (on who will be elected in 2012, and whether the repeal of Obamacare will be successful) may already be taken.

Rather, I am going to assume that either Obamacare will not be repealed (I estimate the probability of repeal as 40-60), or that if it is repealed, the Republicans will have been so badly damaged by the process that they will accede to the sort of gradual Progressive “reforms” that we saw after Hillarycare failed (a probability which I place, sadly, at 80-20).

In either case, we will be entering a period in which the prerogatives of individual Americans to purchase the healthcare they want with their own money will be under heavy assault. Progressives can do nothing else.

I understand how inflammatory this statement is. Further, I understand that the large majority of Americans who consider themselves to have Progressive leanings will have no such behavior in mind, and will be extremely indignant that they are being accused of wanting to do such a thing. (The large majority of American Progressives are mainly interested in doing good; of seeing to it that the disadvantaged are not left to be trampled in the mud; of assuring that a modicum of equity and fairness exists in our culture, and really have no interest in stifling individual autonomy, or undermining our Constitution – except to the extent necessary to achieve these good things.)

The real implications of the Progressive Program are very seldom described in detail by Progressive leaders, even to their Progressive followers. They discuss their plans only by describing the near term benefits their efforts will produce (such as providing insurance for the ininsured), benefits which only the heartless can possibly dismiss. (Which immediately brands those of us who oppose their efforts as heartless.) But at its center, the Progressive Program utterly requires that individuals subsume their own “petty” and “selfish” interests for the good of the whole.

And when it comes to healthcare, this means that you will get the healthcare which the experts determine you should have, and no more. For the well-off (or the knowledgable) to purchase “extra” healthcare outside of the system would not only be horribly unfair, it would also call into question the wisdom of the decisions being made by the experts. It would undermine the whole Program, and so it will need to be stopped. It will need to be stopped only for the best of reasons – for fairness and equity – but it must be stopped.

The right to use your own resources to protect your own well-being, of course, is essential and fundamental to the American idea. Once the Progressives successfully establish the principle that, in the name of universal fairness, you may not do so, the whole concept of individual freedom evaporates, and with it, the Great American Experiment.

And so, here is the key to the whole mess: A truly Progressive healthcare system cannot exist without completely stifling the foundational American idea of individual autonomy. Conversely, the American idea of individual autonomy cannot persist without making a truly Progressive healthcare system impossible.

What this means is that, in order to prevent the worst of the damage which Obamacare – or any Progressive healthcare system – promises to inflict upon the American idea, and in order to force our leaders to come up with a healthcare system that is compatible with the Great American Experiment, a critical mass of individual Americans will have to stick to their guns, and do whatever it takes to exercise their inherent right to self-preservation. That is, they will have to act as autonomous individuals in the face of Progressivism. They will have to persist in this effort despite coercion, name-calling, demonization, and threats, and as they do so they will have to assert, loudly and often, that they are merely exercising a natural right granted to them by the Creator, a right which no human agency has the authority to take away.

If enough of us do this – whether our relationship to the healthcare system is as a doctor, a patient, or an entrepreneur – we will blaze a trail through the Progressive morass which others can follow. It will be slow going at first. Surveys looking at almost any healthcare system or any health insurance product traditionally show that something like 80% of participants are at least satisfied with what they have. This is because, at any given time, only 20% or so of patients (or citizens or subscribers) have had recent, personal encounters with the healthcare system. And people who have not had personal encounters within recent memory tend to believe all the hype about how wonderful everything is, especially since to believe otherwise would just create unactionable anxiety.

So those of us who refuse to accept what the Central Authority is handing out will not have all that much public sympathy, initially. But as time goes by and more and more people are exposed to the limitations inherent to, and the “misrepresentations” perpetrated by, any Progressive healthcare system, more and more people will be looking for alternatives, for some way to save themselves and their loved ones. And they will begin following the pathways cleared by the pioneers.

Once those pathways become highways, our Progressive healthcare system will no longer be feasible – because individual autonomy cannot persist without rendering a truly Progressive healthcare system impossible. Insisting on our own individual prerogatives is the key, and it is the key no matter what the Progressives do or don’t do; no matter what the Republicans do or don’t do. And eventually, we might finally be in a position to establish a healthcare system that solves our fiscal crisis, while still remaining compatible with the Great American Experiment.

The critical thing will be for us to invent ways to advance our own individual medical interests within the healthcare system (or outside of it), despite the best efforts of Progressives to stop us from doing so.