254. "Who Should Pay for Care?" The (London) Sunday Times, (October 9, 1994), p. 3.7. Also published: "Een nieuw gevoel van verantwoordelijkheid" ODE, No. 3, (July/August 1995), pp. 31-34.
Consider the problem of the welfare state. It takes various forms in different countries, but at the end of the 20th century it poses some common problems throughout the world. Citizens, by and large, like the idea of a system to assist them if they fall on hard times. But, increasingly, governments everywhere are coming to the realisation that the public purse cannot afford to support welfare systems at current levels.
Until now there have been two responses to this. Those of a right-wing disposition say that welfare benefit in health, education and social security must be cut, with all public spending, because we can no longer afford it and because it induces a dependency culture and saps individual initiative. Those on the left say that if unemployment was reduced then the national exchequers would have the extra income, from the extra taxes, which would finance existing levels of expenditure. Neither of these approaches offers a sustainable solution.
Nobody is simply a helpless victim. So it is no good the left blaming The System for the fact that the poor are still with us along with all the other social ills. There are hard working, morally upright people in all socio-economic conditions. Hence, nobody should be exempt from contributing to their own betterment to the best of their ability. This means that some services now provided by the welfare state should and could be undertaken by people on their own.
At the same time, those on the right who see our social ills merely as signs of personal moral turpitude must face the fact that there are socio-economic conditions nobody can control which exact undue human costs.
An individual who loses a job due to technological change should not be forced to bear alone this "price of progress". Society must continue to share these burdens and some welfare state must exist to provide the mechanism to do that. Attempts to abolish the welfare state completely can never be justified.
As communitarians see it, a strong but scaled-back core of the welfare state therefore should be maintained. Other tasks, currently undertaken by the state, should be turned over to individuals, families, and communities.
The philosophical underpinning for this change requires the development of a new sense of both personal and mutual responsibility. But how do we work out which activities should be dealt with at which level of society?
By applying the principle of subsidiarity. This says that responsibility for any situation belongs first to those who are nearest to the problem. Only if a solution cannot be found by the individual does responsibility devolve to the family. Only if the family cannot cope should the local community become involved. Only if the problem is too big for it should the state become involved.
The first responsibility lies with the person at hand. Nobody is exempt. Take the most extreme of examples: suppose that as a result of a car accident a paraplegic is confined to a hospital bed; all he can do is operate a pencil-like stick with his mouth, with great effort, to turn the pages of a book. Should we assign to him a nurse's aide to help turn the pages? The communitarian view is that we should expect the confined person to do what he reasonably can, for reasons of both the dignity that comes with making a contribution to one's well-being and the accompanying reduction of burden on others.
The same holds for drug addicts, the poor, uneducated and handicapped nobody is exempt from making a contribution. In determining what these contributions should be, judgments must be made. This has not been the philosophy of recent times. In dealing with such groups social workers have tended to "validate" whatever lifestyle they encounter. They must stop doing this and return to their old role as agents of society, bringing core values to those otherwise out of reach. They ought to be "judgmental" and articulate advocates of healthy, responsible ways of living.
This has far-reaching consequences. We should hence lay a moral claim on one and all to give up smoking, cease abusing alcohol and drugs, and to engage only in safe sex. Levying small charges on those who do not respond to social messages is justified. In the United States some private health insurers charge $12.50 less a month for those who do not smoke, which of course is the same as imposing a $12.50 fine on smokers.
While in general, increases in user fees and co-insurance amount to regressive taxation, small charges on "sinful" behaviour are a proper and effective way of expressing the values of the society.
Significant improvements in lifestyle would save the society the money needed to cover rising health care costs.
The second line of responsibility lies with the family. The tendency of modern society has been to strip duties from the family and deposit them in state-run institutions. Children are placed in child care centres and the sick and elderly are put into nursing homes. This latter trend is only beginning in Britain but has progressed further in the United States.
This creeping institutionalisation of human relationships is a main source of rising welfare costs. At the same time the public's willingness to pay additional taxes to support further expansions of the welfare state has been exhausted. Combined, these produce a dangerous situation in which families become accustomed to not having to attend to their dependant and vulnerable loved ones and at the same time are unwilling or unable to finance a system to care for them through the public purse.
The solution lies in families re-assuming parts of those responsibilities, especially for infants and for those among the sick and elderly who can be maintained at home. Earlier discharge from hospitals following deliveries and most surgeries is a prime example.
The result has three benefits. It reduces public costs. It shores up the family. It gives the patients care which is, under most circumstances, more personalised and less subject to abuse than public service.
But to make this approach feasible, arrangements must be made to make it easier for families to discharge their duties, by broader introduction of flexi-time, shared jobs and technological arrangements that enable people to work from home.
Other ways to rely more on families might involve encouraging the development of parent co-operatives, in which fathers and mothers take turns attending to a group of their children or elderly relatives, either completely on their own or by supplementing the staff of state services.
New ways must be found to ensure that fathers who walk out on their children contribute to their upbringing.
The third line of responsibility lies within one's community. Neighourhoods can play a useful role in crime prevention, and provide auxiliary assistance to firefighters and emergency personnel. Friends can reduce the need for social work and some forms of mental health services. Civic associations can be a source of loans.
Such notions are not fanciful. Consider the example of Seattle. Some years ago its health authorities were alarmed by the discovery that those experiencing a heart attack had to be admitted to a hospital within four minutes to avoid irreversible brain damage, or worse. The cost of upgrading the city's ambulance service to cover this was prohibitive.
Instead 400,000 citizens, nearly half Seattle's population, were trained in first aid techniques to restart the heart; the result is that now a volunteer is likely to reach a victim within a minute anywhere, at any time, and at little public cost. The training helped make Seattle a city in which people are each other's saviours; people get to know one another socially in cardiac resuscitation refresher classes and are proud of their communitarian spirit.
Exactly which duties are left to the community and which are to be kept in the hands of the welfare state matters less than that there is a relatively clear understanding of who undertakes which mission.
The fourth level of responsibility lies with the society at large. Society has a responsibility to help those least able to help themselves, to share unexpected calamities, and to attend to the few services that the community agrees are best discharged via the state. There is no contradiction between demanding that everyone will do their share and realising that some still will need to be assisted after and as they discharge their duties.
The best way to determine who qualifies for state services is not through means testing (which stigmatises the recipients and in the long run undercuts public support for the programme), but by treating entitlements as taxable income. In this way all will continue to receive their child allowance, health benefits, and so on, but the more affluent the person the more will be returned to the public till through taxes.
Creating community service jobs for all those but the mothers of infants and the truly disabled workfare instead of welfare has much to recommend itself from the standpoints of morality, psychology, and the generation of shared goods.
Much of what has been outlined requires a new spirit. Whatever politicians might say, the true choice for the future is not between the welfare state and privatisation. We should recognise that in the past there were other structures in society which carried part of the social load on their own communities, families and individuals.
It is time to rediscover them and create a new welfare system in which all can honourably and reliably discharge their part.