"Shared Risk, Shared Responsibility and the 'Just World'" by Jean Sullivan

This article is more than 12 years old.

Social science experiments show that we humans, absent conscious contemplation, gravitate toward a reflexive belief that the world is just. Psychologists call it the “Just World” hypothesis, or theory, and have demonstrated its pervasive influence. The “just world” theory attempts to explain this powerful human bias and its connection to the moral judgments we make in response to another’s misfortune. In the “Just World”, bad things only happen to bad people and good things only happen to good people. So, be good and you will be safe. Perhaps we need to believe the world is just to avoid that other menace of human psychology – cognitive dissonance. What shall we do if being good is no insurance against misfortune? What kind of world do we inhabit that bad things happen to good people and good things are given to bad people? A corollary of the “Just World” theory, however, is more insidious: — If bad things happen to you, you must be a bad person; if good things happen to you, you must be a good person. I worry that this easy logic of the psyche may often undermine support for community solutions to suffering and collective responsibility for risk. Combined with our national history and cultural bias toward individualism and personal responsibility, it may make for a self-centered brew indeed.

In a blink, we delineate between the “deserving” and the “undeserving” poor. Do we now believe in the deserving and the undeserving sick? Sickness is brought on by poor lifestyle choices, right? Good health behavior - healthy “lifestyles” - will avoid it. If I am healthy – live healthy - why should I pay for the sick? If you get sick, you must have made bad choices. Make good choices and you will be healthy. Be good and you will be safe…

And what of rating categories, separating rather than pooling risks, the most pervasive of which is the age-sensitive rating category? Why would we not pool this risk? Do we think age and its infirmities are a matter of individual responsibility, as well? A risk that should not be shared because it, too, will only happen to those who make bad choices? I guess ours is a culture in denial about aging!

When I speak to groups about health care reform and its political and financial challenges, I maintain that these policy choices are ultimately about social values. The willingness of a community to share risk and responsibility for its members reflects its fundamental values about individual responsibility, the need for security in social systems, and the perception of personal risk. Other industrialized nations’ health systems are mainly funded on an assumption that health risks are shared and so should responsibility for financing them. Last month, the Massachusetts Health Policy Forum presented another dialogue in a series about comparative health systems at the State House. The German Minister of Health, Ulla Schmidt, was invited to describe the German health system through an interview format with Professor Uwe Reinhardt, the internationally-renown health economist from Princeton. Professor Reinhardt and Minister Schmidt discussed the differences in how Germans and Americans may perceive rights and duties vis-à-vis health coverage. They spoke of “social solidarity” among Germans and explained what they meant by that term. They made the point that, “it is not socialism at all; it is really the principle [that] when in trouble, we help each other. We are one nation.” Later Schmidt said, matter-of-factly, that “everybody has the same risk [of getting] sick … when you are really sick it is so expensive that [very few] can pay … you need the other to stand for you … people standing for people is the best sustainability.” And later she added, “The readiness for solidarity depends on affordability.”

I wonder if we Americans believe the same. Perhaps we are getting closer. The Commonwealth Fund recently published a survey conducted by Harris Interactive that found 82% of respondents “believe that the U.S. healthcare system is in need of a complete overhaul.” If we perceive that we all face a risk, then sharing in the costs of protecting against it seems rational. A 30 year old who pays the same health insurance premium as a 60 year-old does not think she is paying for the 60 year old – she is paying incrementally, in advance, for herself. She recognizes that she will become the 60 year old. A community with homogeneous values and a sense of common identity will readily share risk; perceptions of differences among community members undermine this willingness.

The antithesis of the “just world” viewpoint? How about “there, but for the grace of God, go I.” It is not the world that is just or fair. It is we who can choose to be just and fair. We can organize a system for fairness that protects against risks. We can recognize that, but for a handful of adversities, we all face the risk of disability, catastrophic injury, the frailty of aging, the accident of birth that brings genetic infirmity or predisposition to chronic illness. These risks should not be relegated to individual responsibility. We all face the universal risks of illness; we can all share in a universal responsibility to finance healthcare costs; and we can all share in the benefits of universal health care.

I wonder if Americans believe the same.

Jean C. Sullivan, J.D. is a former Deputy Commissioner and General Counsel for MassHealth and currently the Director of the Center for Health Law and Economics and an Associate Vice Chancellor at University of Massachusetts Medical School.

This program aired on August 18, 2008. The audio for this program is not available.

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Martha Bebinger covers health care and other general assignments for WBUR.