Publisher: University of North Carolina Press
For an American living abroad during the late 1980s and the 1990s as I was, watching the American health care system disassemble was like watching a brand new Cadillac start to roll slowly, heavily down the mountain. First, a moment of horrified panic as you realize the car is rolling. Next, a bit of guilty pleasure: it is, after all, someone else’s Cadillac, and few delights compare to watching another person’s expensive, self-indulgent luxury item being smashed to pieces on the rocks. Finally, another reversal: the doomed realization that this heavy machine is not going to come to a stop before it does some damage to innocent people. It has acquired a momentum of its own, and all you can do is watch its slow descent, hoping that no one gets hurt.
Now that I am back in the United States, this metaphor seems terribly misguided. For one thing, it is not someone else’s car. For another, it is definitely not a Cadillac. It is a poor man’s vehicle; a beat-up Volkswagen, or maybe an aging city bus. The Cadillacs, meanwhile, have only gotten bigger and faster and more luxurious. As health care reform has failed, the poor have moved out of the public eye, the numbers of uninsured Americans have swelled, and corporate medicine has flourished in a way I had never imagined. When I moved back to the United States in 1997, I returned to a country where hospitals were trolling for patients with magazine ads and roadside billboards, family doctors were setting up practices in shopping malls, the American Medical Association was considering product endorsements, and managed care organizations were gobbling up everything in sight. US health care is now synonymous with big business, and it is a very profitable business indeed. These days it is possible, as Laurie Zoloth reminds us, for the chief executive officer of a managed care organization to complain that his annual remuneration of $8.8 million is too little, because he and others like him have, after all, “saved health care.”
Writing about the care of the poor can be a frustrating task. Readers on the political right simply ignore you, and those on the left usually agree with your conclusions before you have even started your argument, so that not only are you preaching to the converted, you may well be preaching them a sermon of such sophistication and intricacy that you risk putting them to sleep. The difficult task is to win over those readers whose minds are not already made up. It is a task suited only to the most talented of writers, and fortunately for those of us who sit with her on the left, Laurie Zoloth is as talented as they come. Health Care and the Ethics of Encountera prosaic title for a beautifully poetic bookis a project with the ambitious aim of developing an alternative vocabulary with which to discuss justice in US health care. It will surprise no one who is familiar with Zoloth’s work to hear that she succeeds brilliantly.
The problem facing Zoloth goes something like this. If a wealthy American is not prepared to make even the smallest sacrifice for the sake of another American who is sick, how do you change his or her mind? In fact, how do you change anyone’s mind if the moral deck is stacked against you from the startthat is, if the very vocabulary you are expected to use is all about personal liberty, self-fulfillment, and property rights? These are not mere words. They are values entrenched in the culture itself, values that Americans are brought up to believe in and which continue to move them deeply. Liberty and the pursuit of happiness, however, do not do much for the poor.
Zoloth does not simply try to show us what is deficient in the old vocabulary but goes on to point the way toward a new one. She develops her “ethics of encounter” through Jewish sources, the philosophy of Emmanuel Levinas, contemporary feminist thought, and, finally, a lovingly careful reading of the Book of Ruth. Politically, she finds hope in the kind of small-group encounters that characterized the emerging feminist movement in the late 1960s and 1970s and the community discussions that motivated the Oregon health care reform movement. As for current health care reform, Zoloth finds cause for optimism in many hospital ethics committees. A clinician herself, she never strays too far from clinical practice. Her guiding metaphor is the personal encounter with the poor and the dispossessed: the orphan, the widow, the stranger at the gate, the traveler on the road.
To call Laurie Zoloth a postmodern Jewish feminist philosopher, as I am tempted to do, would probably be to discourage, with a single stroke, large numbers of people who otherwise might have been tempted to read her book that is, everyone who sees feminism as something for women, Jewish theology as something for Jews, and postmodernism as something for academics with nothing better to do. But fear not, clinician readers. Zoloth has written a book that is clinically astute, politically relevant, and abundant in wisdom and grace.
-Reprinted from JAMA
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