Barbara Weinstein, New York University, USA
Back during the Obama years, a prime accessory in the right-wing bag of tricks designed to sour public opinion on what would become the Affordable Care Act (ACA) was the idea of 'death panels'. Even though the final version of the ACA relied entirely on private health plans, the slightest hint of a role for the state in regulating costs and eligibility for procedures raised the alarm that finite resources would mean certain people might be ruled too old or too impaired to be worthy of expensive medical treatments, and would be 'terminated' by panels of experts.
Of course, right-wing anxiety about this should not be interpreted as an affirmation of an equal right to life-saving medical care. Most of the audience that was susceptible to the death panels meme readily endorsed the existing system in which differential access to market-based health care was (and is) determined by wealth, and correlated with race and gender. Apparently, in certain circumstances, life is a thing that money should be able to buy — the rich live, and the poor die. In the post-Reagan/Thatcher world, neoliberal reason deemed this unequal access inevitable, and therefore natural and even moral. As Maggie herself put it, 'There’s no such thing as society. There are individual men and women and there are families'. That someone of low income — which would include most black and brown people — be less able to take advantage of life-saving treatments was the way the world worked; indeed, the way the world had to work. The idea that collective welfare or social considerations, rather than household wealth or personal resources, should play even the slightest role in life or death medical decisions was for many US Americans reprehensible, even repugnant. True, the death panels meme did not stop the passage of the Affordable Care Act, but it probably contributed to stymying the effort to include a public option.
In the world that Reagan and Thatcher created, the 'beware of death panels' meme, analogous to the anti-abortion crusade, could lend a gloss of morality, of valuing individual life above all else, to a campaign against universal health coverage that might otherwise be dismissed as heartless and cruel. And by implication, it positioned people on the left, with worldviews rooted in a belief in a collectivity beyond the individual and his/her family, as more willing to sacrifice the very elderly or the very sick if 'society' required it. So was there any truth to this?
My personal test case of this proposition came when my mother was dying (or to be more precise, when I perceived her as dying). She was nearly 96 and for several years had been suffering from dementia, including severe short and long-term memory loss — she no longer could remember her brothers and sisters, with whom she had been very close, and couldn’t tell me apart from my sister. She could not go to the bathroom unassisted, and her diet consisted of substances similar to baby food. Then she started having a series of strokes that caused her to lose her swallowing reflex, meaning that she could only stay alive with the help of a feeding tube that had to be surgically inserted into her abdomen. To me, the left-wing daughter, it was clear that her time had come. Her quality of life was already severely limited, and when she was still lucid she had confided in me that she hoped that she would go to sleep one night and not wake up. It seemed inhumane to put her through the surgery necessary to insert the feeding tube, just to keep her alive a little longer. But to be honest, I also felt that there was something obscene about spending a large number of Medicare dollars to stretch out my mother’s time on earth, which clearly was bringing her little enjoyment and a great deal of suffering. In contrast, my sister, a right-wing Republican, argued for heroic measures to keep my mother alive, and even briefly insisted that we opt for the feeding tube. Her reasons for this were complex — my mother had been in a facility for the aged near my sister’s home, and my sister had spent far more time with her during this final stretch of her life than my brother or I had. So I would never say that her sentiments could be reduced to a matter of ideology. But I am quite sure that my sister never gave a thought to the resources being expended to extend my mother’s life, and she probably would have been extremely upset if I had mentioned that as a consideration. Knowing that, I restricted my arguments to our shared concerns about the pain and distress that would inevitably accompany the feeding tube insertion, and the likelihood that the strokes would continue. We ultimately decided to forgo heroic measures, though letting my mother die entailed a longer and more excruciating process that we had imagined.
I was reminded a few weeks ago of this agonising decision when reading an Op-Ed piece in the New York Times authored by an emergency room physician, Yoojin Na. As one might expect, the article was a rumination on matters of life and death in a typical New York City hospital in the age of the coronavirus pandemic. Entitled 'Doctors Can’t "Do Everything’ and ‘Save Everyone"', it opened with Dr Na yelling into a phone (the only way she could be heard through the surgical mask), trying to convince the granddaughter of a man in his 90s with advanced dementia and multiple other chronic conditions that there was no point in intubating him. She quotes herself as initiating the conversation by declaring 'We are in middle of a pandemic. The decision you make is not just about your family member'. Judging from that statement, Dr Na clearly found the granddaughter’s insistence that 'everything [be] done' unreasonable and even callous, given the bevy of healthcare workers and other resources that would be required to intubate her grandfather. But she likely understood that this was a losing argument and, similar to my conversation with my sister, switched to making the perfectly reasonable point that intubation would merely 'prolong his suffering'. Even under great duress, she wanted to avoid sounding like a member of the dreaded 'death panel'.
What the pandemic has made manifest is that triage or medical care rationing is inevitable during a severe health crisis. Running risks and using up scarce resources when someone’s prognosis is extremely bleak simply does not make sense, and may even be impossible under these kinds of conditions. And Dr Na, it is worth noting, made the same argument against intubation for a patient who was lucid and had been otherwise healthy, and who she found absolutely charming — but nonetheless felt was very unlikely to survive and would only experience greater suffering. There were no 'death panels' involved, just overworked doctors and nurses in overtaxed facilities. Yes, Maggie, there is such a thing as society, and under certain circumstances, life and death decisions are likely to be socialised. Structural factors continue to incline the grim reaper toward the poorer and the darker, but in a period of pandemic, even the rich and famous may be denied 'heroic measures' and waste away alone in a makeshift ICU.
Yet it is precisely the exceptional character of this moment, and the brief interval of healthcare rationing it has spawned, that vividly illustrate the utter absurdity of the death panel meme — and it has done so in two different ways. One is to demonstrate that it is only under the most peculiar and horrendous circumstances that 'experts' intervene in individual and familial decisions about life and death. (This is not to deny that medical personnel may be more attentive and sensitive to some patients than others, but that was certainly not the kind of 'rationing' that was the target of the 'death panels' propaganda.) And one can surmise from Dr Na’s Op-Ed piece that even amidst the avalanche of ailing New Yorkers, she did all she could to adhere to the wishes of the patients and their families, or at least to consult them. At one hospital in New York City, medical personnel began to worry that the sheer number of cases would cause them to stop thinking of their patients as individuals. So staff members designed and displayed posters by the patients’ beds to remind themselves that each one was a person with her/his own particular qualities and experiences. The Greek father of one of my colleagues had a sign posted by his bed that reminded his caregivers that Dionysius was a devoted father and grandfather, had a fondness for martinis and was a life-long Marxist.
One might assume that social distancing would be the icing on the cake for Thatcher’s 'no society' claim, but the effect seems to be, for most people, just the opposite — it has provoked an awareness of the response to COVID-19 as a social undertaking, and a craving for more social interaction — and this has occurred without the erasure of our individuality. When a MAGA-hatted protester in Colorado waves a sign demanding liberty and his 'right to work', it hardly takes a familiarity with political theory to see the flaw in his reasoning. He is demanding his right as an individual to work, but his identity as a worker has no meaning whatsoever in isolation from other workers.
Voices on the right calling for rapid re-openings have rested their demands on the rights of the individual and continued to deny that 'society' exists in any meaningful sense, but they have gone all-in on the 'economy'. For right-wingers everywhere in the aftermath of the neoliberal turn, 'society' is an unnatural/ideological construct that vainly requires individuals to subordinate some of their resources and desires to the greater good, and the 'shelter in place' orders could be seen as an extreme version of this subordination. In contrast, the 'economy' is regarded as natural, normal and operating according to laws and logic beyond the reach of ideology — at least when normalcy reigns. From this perspective, the various lockdowns and quarantines represent not just an interruption of everyday routines, but a challenge to the very normality of economic life.
The terror this unprecedented situation has triggered among right-wingers can be gauged by the measures they have proposed to address it. The willingness of right-wing politicians and their acolytes to openly call for the sacrifice of lives — tens of thousands, maybe hundreds of thousands of additional deaths — to revive the economy has been truly astonishing even for those of us with no illusions about conservative morality. Few have been as flagrant as the lieutenant-governor of Texas, Dan Patrick, who announced that he would gladly give his own life to COVID-19 to ensure a prosperous future for his grandchildren, and then suggested that all right-thinking, responsible individuals would be willing to do the same for their progeny. But even if less bluntly, many other pronouncements from the right have involved a similar calculus. Suddenly thousands of extra (mostly elderly) corpses seem a small price to pay for a return to what a portion of the population prior to the pandemic experienced as prosperity. A Republican senator, Pat Toomey, made the argument for re-opening his state as soon as possible by noting that a full half of the deaths in Pennsylvania were among nursing-home residents. He registered this fact in a television interview with a distinct air of disgust, as if the virus had spontaneously generated in the nursing homes among the disposable aged and decrepit (and their largely brown and black caregivers), who belonged to an entirely separate epidemiological universe, and therefore were of no concern to him. And lest this 'Economy of Death' theme seem like a peculiarly US American fixation, the extreme right in Brazil has taken up this rhetoric with gusto as Bolsonaro insists that real men don’t get COVID-19, and echoes the Trumpers’ claims that his enemies are taking advantage of the virus to ruin the economy and undermine his popularity. He has mirrored Trump in other matters as well, making endorsement of hydroxychloroquine — a drug shown to have no beneficial impact on patients with COVID-19 but at least one deadly side effect — a litmus test for those who aspire to serving as Brazil’s Minister of Health.
These wild rhetorical swings — life is sacred, life is disposable — have to be viewed, in the first instance, as rankly opportunistic. But even the scoundrels who occupy the highest political office in the US and Brazil, or the slightly more reflective people in their inner circles, may occasionally give some thought to the possible contradictions in their pronouncements. One tactic is simply to play down the severity of the pandemic, again stressing how it mainly strikes the old and already infirm. As for the disproportionate impact that it has on low-income people, especially communities of colour who tend to be concentrated in cities, work in essential occupations and present more underlying conditions, this is a repercussion that can be dismissed out of hand, or even judged to be further evidence of the urban malaise. Indeed, for many on the far right, the high death rate in places like New York, Chicago, Detroit and Baltimore could probably be counted as a 'bonus feature' of the pandemic, though expressing such a sentiment requires an especially high-pitched dogwhistle, even in right-wing circles. Trump, however, did mention in one of his increasingly unhinged daily briefings that 'the numbers' [of deaths] for the US would look a lot better if you just subtracted New York City (Never mind that he himself grew up in Queens, which for a while was the hottest COVID-19 hotspot on the planet).
Ultimately, I would argue that these 'swings' are more apparent than real. Whether we’re talking 'death panels' or 'let’s sacrifice the elderly for the economy', both positions imply a fetishisation of the market and the extreme individuation of the citizenry. In effect, neoliberal reason not only unlinks society from economy and subordinates the former to the latter, but over time it seeks to obliterate the very idea of society and social welfare, and perfects ways of insulating the economy from social demands, whether by crushing unions, lowering taxes, neutering environmental regulations or rhetorically associating social welfare with the grievances of 'less deserving' ethno-racial groups. What far-right politicians offer in exchange is 'job creation' — the promise that capitalism unhindered will generate a nearly infinite stream of jobs that may not pay particularly well or include many benefits, but would be preferable to the humiliations of unemployment and going on the dole. This was the 'deal' that Trump offered white working-class voters in the rust-belt states, and the one he was counting on to ensure his re-election this coming November.
But this is the deal that has been totally upended by the pandemic. All of a sudden, a public health emergency has produced the highest unemployment rates since the Great Depression, and the government is handing out relief checks like they were supermarket coupons. A societal issue has not only proved impossible to dismiss, it has practically paralysed the economy. In the short-run, what this means to Trump and his minions is that his chances of getting re-elected this November are much reduced. But in the long-run, I would argue that the principal concern for those on the right is the way in which the global pandemic has revealed that there not only is a society, but that, under certain circumstances, it is the economic that will be subordinated to the social, not the other way around, even in nations where 'social democracy' is reviled by those in power. The stubborn insubordination of the social is on stunning display in the most unexpected of locations. Sweden, of all places, decided to eschew mandatory social distancing and keep schools and most commerce wide open. The result of this experiment is a rate of death per million in the population that is approximately four times that of Denmark, nine times that of Norway, and eight times that of nearby Finland. And most notably, Sweden is among the European economies expected to be affected most negatively by the pandemic.
I certainly do not mean to argue that COVID-19 has brought capitalism to its knees. Apparently, the wealthiest US Americans have become even wealthier over the last few months, and the immediate impact of the pandemic will be to widen inequalities, on both a domestic and international scale. Even less do I mean to argue that we don’t need a vigorous economy. But I do mean to argue that right-wing hymns to job creation will ring increasingly hollow; people will be desperate for employment, to be sure, but they will also be amply aware, in the global north as well as the global south, of how vulnerable even the most robust economy can be, how absurd it is to treat healthcare as something to be mediated by an easily disarticulated market, and how unprepared the so-called private sector is to address existential threats to human existence, especially as we face the probable devastations of climate change. Thinking locally, when the project of 'Medicare for All' finally comes before the US Congress and the public, I would strongly advise the Republican Party to forgo the 'death panels' critique — we all know now that right-wing politicians everywhere are willing to throw grandma and grandpa under the bus for the sake of the economy.
Barbara Weinstein is Silver Professor of History at New York University.