We are the state

Many moons ago, in the gap of time between when I graduated from medical school and when my residency began, I went on a medical mission trip to Central America.  Two of my best friends from school were also going, and though the trip was sponsored by a religious group with which I was not affiliated, I still felt like it would be worthwhile to go.  It was an illuminating trip for a variety of reasons, among them that it was my first time seeing what abject third-world poverty really looks like.

As I mentioned, the trip was religiously-sponsored.  What impact this sponsorship had on access to care became evident after we had set up our little clinic and started greeting patients.  Before they could get in to see the doctors and nurses, they had to sit through the sermon.  Following the sermon was an impassioned plea to accept the doctrines of the sponsoring religious group.  Only afterward did they get to come and see the medical personnel.

I found this arrangement deeply objectionable.  While it seems obvious to me that a religious group can deliver its charitable care however it sees fit, this struck me as the wrong way round.  You give people access to care because you believe doing so is in keeping with (in this case) Christ’s call to minister to the poor and the sick, not as a way of coercing a nominal religious conversion.  If they are moved by your charity to wonder why you would be inclined to do so and then stick around for the sermon, that is the arrangement that I would have strongly preferred.  But I wasn’t in charge, and so simply delivered what diagnoses and treatments I could and kept my mouth shut.

This experience sprung to mind when I read Jason’s post this morning about the relationship between entitlements and private charity:

Suppose I were a billionaire and I decided to spend my fortune supporting people who would otherwise have to rely on Medicare, Medicaid, or Social Security.

So I set up a trust fund for as many of them as I can afford to support in perpetuity. I tell them that they can draw on the fund for medical and basic living expenses, as long as they don’t become a drain on the U.S. government. No government checks for them.

My guess is that no one would applaud me. “Monstrous,” I can see the left-liberals saying. “You’re making them personally dependent on you, and that’s terribly undignified.”

Well, I can’t speak for left-liberals in general, but this particular liberal wouldn’t say that at all.  Let me explain.

What Jason calls “people who would otherwise have to rely on Medicare, Medicaid or Social Security,” I would describe as “people who would be rendered destitute by their medical and living expenses.”  Having worked in various medical settings with patients who fall into that category, I know that they have very real, pressing needs that, if unmet, leave them sicker, hungrier and less secure in their homes.  (In my corner of New England, it may also mean “freezing cold during the long winter.”)  I do not think it is monstrous to help them.  Quite the contrary.  I think it is commendable.

Now, we as a society can have several responses to their plight.  We can, as a whole, consign them to their fates, viewing that as the meet endpoint to whichever string of decisions led them to those straights in the first place.  We can view it as a morally corrupting influence to provide subsistence care for those who should be able to provide for themselves, and (as Jason writes) an assault on their dignity.  I do not take this view.  As I’ve already written, I know firsthand how the accidents of one’s birth can profoundly affect one’s chances of success in life, and I don’t really feel like I’m in a position to pronounce on the moral failures of people who were born into poverty.  Further, I live in a state that used to have several thriving industries that supported its numerous communities, and many of those industries have fled overseas.  It is hard for me to find a place to blame those who live in these now-blighted towns for the sudden and permanent loss of their livelihoods.

So that leaves this left-liberal with a desire to see the indigent given a certain baseline level of support to meet their needs for food, shelter and medical care.  If there are sufficient numbers of similarly-minded people out there, it follows that we as a society must then decide on a solution.

One possible solution is to exhort the affluent and generous to establish charities to meet these needs.  And I think it is wonderful when they do.  But relying on private charity alone to meet the needs of our country’s poor does not strike me as the final answer.  Putting the needy at the mercy of the wealthy’s largesse subjects them to the whims of their benefactors, and makes them reliant on the ongoing good will and good fortune of those doing the giving.  Should either of these factors change, the help for the needy evaporates.

What other entity exists as the agent of our societal wish to help the neediest among us than “the state”?  What is the state except the civic manifestation of our collective will?  The only other large-scale charities I can think of have religious sponsorship, and while I would have to be a fool to deny that religious charities do wonderful work, can anyone deny that they sometimes have ends other than simply the welfare of the poor?  Is it not an assault on their dignity to make them endure efforts to convert them in order for them to receive assistance?

I read Jason’s post and I see “the state” as something “other.”  Again, it is probably my left-liberalishness talking here, but that is not how I understand it.  I understand it to be an emanation of “us.”  It is not something separate from society, but  within it.  Ideally, in a democratic society it is responsive to the collective will of the people and does their bidding efficiently.  That it falls far short of this ideal should be apparent to anyone with anything better than a second-grader’s knowledge of the world.  But what alternative exists?

Having Medicare, Medicaid and Social Security provided by the state does not “ennoble” the care these services provide.  They are simply our best answer to the persistent reality that there will always be people who need help, and we feel it is in their best interests and ours to see that they get it.  These programs were created to keep the elderly and the poor healthier and somewhat less desperate.  Private charity lacks the stability and religious charity lacks the disinterest in other ends which should be hallmarks of our best solution as a compassionate society.  If the state does not act on our behalf to render these services, then who or what can we rely on to do so in its stead?

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. In a fit of optimism that doing so will yield more comments, I have decided to post this over at the main page. Please direct any comments there.

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