Abortion Raises Questions for Health Care Reform

Democratic gubernatorial candidate Creigh Deeds has spent the week tearing into opponent Bob McDonnell's record on abortion. Political kibbitzers have questioned the tactical wisdom of the attack. But Virginians should thank Deeds for reminding everybody there is still one health care decision Democrats want the government to stay out of.

The Democratic Party's approach to abortion is, generally speaking, libertarian. Pro-choicers -- and the party is officially pro-choice, even if some members might not be -- say the relevelant question is not whether abortion is good or bad, or whether the choice to abort is the right one or the wrong one in any particular circumstance. The relevant question asks who should make the choice. The answer, they say, is: the patient and her doctor. Or as Deeds put it the other day, "I believe it is up to a woman, her family, her doctor, and her spiritual adviser to make this decision. My opponent believes government should make this decision."

That stands in rather sharp tension with Democrats' communitarian approach to health care reform generally -- much of which involves directing individual choices to make things (ostensibly) better for society as a whole. As President Obama put it during a July press conference, Americans are "going to have to give up paying for things that don't make them healthier." He cited as an example duplicative tests: "That's raising your premiums. It's raising everybody's premiums . . . . We are also subsidizing some of that because there are tax breaks for health care. So, not only is it costing you money in terms of higher premiums, it's also costing you as a taxpayer."

Government, it follows, ought to take a firmer hand in eliminating duplicative tests. But if government should have a hand in that, then why shouldn't it have a hand in deciding how many abortions are performed? (Or vasectomies, fertility treatments, or other reproductive freedom procedures.) Advocates of health care reform don't say.

ONE CAN speculate about reasons easily enough: Abortion is a profoundly personal decision of great moral and psychological weight. A blood test for Vitamin D deficiency is not. Government should seek efficiencies in routine matters but not in matters of life and death.

Unfortunately, at least some of the president's allies and advisers have eroded that bright-line distinction, in large part because the real savings come from life-and-death matters, not routine tests. For example, Cornell law professor William Jacobson calls attention to a January paper by Obama health care adviser Ezekiel Emanuel, brother of White House chief of staff Rahm Emanuel and a medical ethicist at the National Institutes of Health.

In "Principles for Allocation of Scarce Medical Resources," Ezekiel Emanuel has advocated a "complete-life" decision matrix with "a priority curve on which individuals aged between roughly 15 and 40 years get the most chance, whereas the youngest and oldest people get chances that are attenuated." Older people merit fewer medical resources because they already have lived a full life, goes the theory. Adolescents deserve priority over infants because "adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments."

This sounds coldly utilitarian, but cold utilitarianism is what you get when you take a top-down, bird's-eye approach to medical care. Therein lies another great tension of health care reform: Most supporters do not want it because they are coldhearted utilitarians. They want it because they are warmhearted liberals who wish to ease suffering, particularly the suffering of the 47 million Americans who live in fear because they lack health insurance. The only way to do that, reformers believe, is to put the federal government in charge.

BUT ONCE YOU put the government in charge of deciding, say, that an 85-year-old woman should get only palliative care instead of aggressive treatment for breast cancer, it's hard to make a principled argument that the government should not also be able to decide to reduce the number of medically unnecessary abortions. Now, maybe after running the numbers the government might conclude there's no need to do so. No matter: At that point the final decision belongs to the government rather than "a woman, her family, her doctor, and her spiritual adviser."

Jonathan Haidt, an expert on moral psychology at the University of Virginia, has done some interesting work that helps explain how conservatives and liberals talk past one another. Liberals place a premium on reducing harm, for instance; conservatives highly value purity and sanctity. Perhaps it would lower the decibel level of the health care debate if liberals understood what conservatives are saying: The message isn't so much "death to the poor" as "keep your laws off my body."

My thoughts do not aim for your assent -- just place them alongside your own reflections for a while.

--Robert Nozick.

Contact A. Barton Hinkle at (804) 649-6627 or .