Socialized Healthcare, Coronavirus and the Ethic of Reciprocal Altruism

When my American husband became part of my British family it was necessary for him to be trained up on tea. He took to the subject matter well, and is careful to remind my mum whenever it is time to send more Marks & Spencer extra strong teabags stateside. What has struck him as noteworthy about our ritual of tea is the following pattern: Person A and Person B are sitting relaxing. Person A says to Person B, “Make us a cup of tea.” Person B says, “Ok” and gets up and does so. My husband noticed that Person B doesn’t seem to resent being tasked even though Person A is perfectly capable of making his own damn tea. The primary explanation for that, of course, is that the next day (or, indeed, the next hour) the same scenario could occur but with the roles of A and B reversed. There is reciprocity at play.

That explanation doesn’t suffice though, because it remains the case that A could make the tea when A wants tea, and B could make the tea when B wants tea, and the tea would be efficiently distributed where it is wanted. To have A serving B and B serving A seems to add an unnecessary layer of complication to the equation. Unless, that is, you pan out and see this tea ritual as part of a broader culture of cooperation across time. Which, it seems, you should. Through rituals of reciprocity, again and again and again we act out both serving and being served, to the point that it is second nature.

In fact, the phrase second nature fails to convey the depth at which reciprocity is engrained in us. Pan out even further to consider it across time, space and species and reciprocity isn’t some quaint cultural development, it’s a survival mechanism. Evolutionary biologists have a name for the kind of culture of cooperation that is exemplified by the tea ritual. It is reciprocal altruism. Reciprocal altruism occurs whenever a creature acts in an unselfish way to the benefit of another with no immediate expectation of their own benefit, and there are both ongoing opportunities for interchange and the capacity to detect when cheaters are trying to take advantage.

When you consider the naturally occurring stages of vulnerability in human life compounded by the slings and arrows of outrageous fortune, it’s obvious why reciprocal altruism is inculcated within the family unit. The performative dependence that is the tea ritual lays the foundation for the day on which A is actually dependent on B, or B on A. At the level of the family unit, interdependence scales. “Make us a cup of tea” becomes “be with me in my darkest hour.”

As well as scaling up within the family, reciprocal altruism can scale up beyond the family, as the circle of concern is widened. This is the foundation of Britain’s beloved National Health Service. It was founded in the wake of the Second World War which had fortified the sense of solidarity within the nation. Those who were willing to die for each other were, naturally, willing to mutually ensure each other’s access to healthcare. Over 70 years later, the National Health Service is still treasured by people across the political spectrum and, despite its perennial struggles, holds its own against privately funded systems around the world to the point that it has even been ranked number 1.

The degree to which the NHS is loved by the British population so long after its founding is perhaps explained by individuals’ ongoing experience of the ways in which it is both civilized and civilizing. Mosts Brits are born in the NHS, a great many die in the NHS, and an even greater number go there in their hour of need. The care and compassion they receive from the doctors, nurses and staff they encounter reinforces the idea that this is our NHS. In the NHS the ethic of “make us a cup of tea” has scaled to the level of “ensure I’m not filing for bankruptcy while dying of stage 4 cancer” and that is civilized indeed.

It’s not obvious, however, that it is particularly easy for reciprocal altruism to scale up from a small group to a very large group. Nassim Nicholas Taleb has made the point that he is a communist with his family and friends, a Democrat at the local level, a Republican at the state level and a libertarian at the federal level. The idea, implicit in Taleb’s position, is that as the circle of concern widens the degree of mutual responsibility decreases. This seems to have a lot of coherence to it and a certain structural soundness, yet the left, in recent times, has been coming at it from the opposite direction. There is suspicion of solidarity at the lower levels, particularly at the level of the nation state, yet great openness to community on very large scales. One of the many undercurrents of the Brexit debate was the idea that the grander the scale of a political community, the more moral or ethical it is and that, by implication, a penchant for the parochial is unenlightened or even downright unethical.

What doesn’t seem to have been articulated is how an ethic at the supranational level functions when group ethics at lower scales have been dismissed in favor of national nihilism and oikophobia. That looks to be structurally unsound. If the argument is that people should widen their circle of concern, what is at the center of that circle? It would seem that those advocating for increasing the range of reciprocal altruism would do well to identify the core levels upon which that increase is to operate. Those core levels are, by their very nature, neither inclusive nor diverse though, and perhaps that is why the left struggles with them in the current ideological paradigm.

I once had a conversation with a fellow Brit in America who felt it was important for Brits to bear witness to the NHS, promote it as a model for America and ensure it is not limited to citizens and those who have immigration status. I pointed out that the latter stipulation is not the NHS model, or at least not its founding ethic. Those receiving healthcare for the first time in Britain were not doing so on account of the magnanimity of feudal lords, they were doing so as equal citizens who had paid their dues in that relationship. This, from Andrew Marr’s A History of Modern Britain, indicates how that reciprocity was not just the founding ethic, but is the sustaining ethic.

There are many moving accounts of the queues of unwell, impoverished people surging forward for treatment in the early days of the NHS, arriving in hospitals and doctors’ waiting rooms for the first time not as beggars but as citizens with a sense of right. If there was one single domestic good that the British took from the sacrifices of the war, it was a health service free at the point of use. We have clung to it tenaciously ever since and no mainstream party has dared suggest taking it away.

To my point that the NHS model is one which functions in the context of a defined group with strong levels of reciprocity, my interlocutor replied that making it open to all was about showing solidarity. I’m not sure solidarity is the word he was looking for though— compassion, empathy or magnanimity would work better in the context. The concept of solidarity comes from Roman Law where an obligatio in solidum meant mutual responsibility for a debt, usually within a family or low level community. Our modern understanding of it has grown to imply mutual responsibility beyond the context of debt, but the core of the concept brings us right back to the core of the circle of concern and the high levels of reciprocity in play at that nexus.

To be fair to my interlocutor, the argument he was making has a lot of traction within the UK. Just as is the case in the US, emergency medical treatment in the UK is open to all regardless of immigration status or ability to pay. Ongoing care, however, is, in theory, limited to a defined group, essentially citizens and those with some kind of long term immigration status—not overseas visitors. Despite that position being entirely consistent with the founding ethic of solidarity and reciprocity at the national level, it is actually very controversial in the NHS, particularly amongst medical staff.

For medical staff, the taxpayer funded nature of the NHS is such that the connection between the services they provide and the bill for providing those services has been almost entirely severed. The funding generally happens so far behind the scenes that when the government does seek to bring the question of cost directly into the arena of the hospital, medical staff balk at it as being anathema to their profession.  Dr John Chisholm, chair of the ethics committee of the British Medical Association, has explained this position: “The role of doctors — and all of their healthcare colleagues — must be to treat and care for patients, not to act as border guards, policing patients’ access to and payment for treatment.”

In America, doctors are far more acculturated to the idea that there is a necessary connection between the existence of medical services and the funding of medical services. Patients too are acutely aware of it—you don’t get very far through the door of a US hospital before encountering someone whose job it is to determine how your treatment is going to be paid for.

The sentiment that the NHS should provide care to all regardless of whether they fall into a category intended to approximate those who have paid in to the system is nevertheless a noble one and consistent with medicine as a vocation rather than a job. It represents an ethic of the Good Samaritan, which, like the ethic of reciprocal altruism, is deeply civilized and not something to be scorned. However, unlike reciprocal altruism, it doesn’t contain within it the kernel of a funding structure.

The Good Samaritan in the Bible helped one person. He probably would have gladly helped two people that day. He might even have managed to assist 20. Had there been 200 people needing his help, he would have struggled to be true to his own ethic. The point isn’t that we should refuse to play the role of Good Samaritan, it is that the ethic of the Good Samaritan cannot, alone, provide the foundation for a large scale, sustainable healthcare system. It fails for the reason that the related argument—that access to healthcare is a human right—fails. MRI machines and doctors’ salaries do not come down like manna from heaven. Their availability is contingent on the legal, political and economic framework in which they are made manifest. Appealing to metaphysics or piety does not change that fact, it just bats the conundrum off for someone else to have to deal with.

The NHS can certainly function with the ethic of reciprocal altruism as its base layer and the ethic of the Good Samaritan grafted onto it. The discussion should be an honest one, though, not one that is couched, as it so often is, in terms of an evil, horrible government expecting people to pay for healthcare.

Aside from the ethic of reciprocal altruism and the ethic of the Good Samaritan, there is another ethic for Americans to consider when looking at the NHS model. That ethic is the willingness of the individual to see their healthcare in the context of the healthcare available to the collective. This phenomenon is reflected in the fact that wards rather than private rooms are the norm in the NHS. It is also exemplified by an unsightly, but benign, subcutaneous horn which was growing out of my father’s forehead. He went to his family practice doctor who said he would cut it off himself, but that he would wait until there were about a dozen patients all needing that procedure and would then block out a morning to get it done.

Now, I’m not sure what the collective noun for subcutaneous horns is, but I suspect many Americans would be horrified at the idea of having to wait around for them to collect. For my dad, born in 1938 and growing up amidst the privations of the war and its aftermath, the collective, and healthcare as a function of the collective, are second nature. Americans, however, in their interactions with healthcare providers, are more likely to conceive of themselves as customers rather than citizens, and to regard their needs as being unrelated to the needs of the next patient in line. That attitude is on display when political debates about socialized healthcare promptly result in wailing about rationing and death panels. (As if the current system itself weren’t one particular manifestation of rationing and death panels.)

When it comes to subcutaneous horns, the really consequential distinction is not between having them removed one at a time or in batches of twelve, it is between having access to the care necessary to remove them and not having that access. A gallery of google images of people who haven’t been able to have theirs removed is like a parade from a Victorian circus. As benign as the condition might be, it is no doubt completely debilitating for a person who has no access to medical care. A civilized society is one in which subcutaneous horns are removed. Just as Oliver Wendell Holmes Jr. claimed to like paying his taxes because that is how one buys civilization, Americans might learn to like collectivizing their subcutaneous horns, because that is how one pays for a healthcare system that is free at the point of need.

If subcutaneous horns are not prevalent or severe enough to focus the mind on healthcare being a function of the collective, perhaps coronavirus will be. A recent Twitter thread by Dr Daniele Macchini, an ICU physician in Bergamo, Italy, relayed what life is like in the hospitals there: “And there are no more surgeons, urologists, orthopedists, we are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us. Every ventilator becomes like gold.”

When hypotheticals about who should get a ventilator when there aren’t enough to go around are no longer hypothetical, the inherently philosophical nature of the healthcare debate becomes tragically inescapable. It becomes clear that being a doctor or a nurse is, indeed, more than a paid job. It becomes clear that not only access to healthcare but health itself is a function of the collective. It becomes clear that viruses and exponential math don’t care about borders or healthcare capacity or a nation’s exceptionalism. It becomes clear that the very bottom line is that we are, indeed, in this together.

If coronavirus does end up shifting the healthcare debate in America in a more philosophical direction, the primary question at stake will no longer be that of funding. For as important as that question is, there is a more important one, a foundational question which is a priori to the issue of costs and which should be addressed by both those proposing socialized healthcare and those arguing against it. That question is: What are the ethics upon which your proposed system will rest?