In a postscript to Peter Edelman's outstanding cover story, "The Worst Thing Bill Clinton Has Done" (March Atlantic), the Administration has published its rules interpreting the new law's provisions regarding the eligibility of low-income disabled children for Supplementary Security Income cash benefits.
Congress, motivated by the notion of "saving" money from families caring for disabled children and fueled by what have been determined to be inaccurate or unrepresentative anecdotes in the media, had directed that eligibility be restricted for children who already had to show substantial medical evidence of very serious mental and physical impairments. Yet the same Congress gave the Administration considerable discretion regarding how strict the new qualifying test would be.
Through "interim final" Social Security Administration regulations issued in February, the White House opted for the strictest test on the table -- one that not even this Congress directly mandated. President Clinton rejected the viable option urged by a group of bipartisan senators that would have dropped 40,000 children, in favor of a standard that will terminate benefits to a large majority of the 263,000 children to be reviewed shortly. Children in whom mental retardation has been diagnosed will take the biggest hit.
We have not seen the end of the worst thing Bill Clinton has done.
Jonathan M. Stein
Despite his assertion that the new welfare system is even worse than the old one, Peter Edelman offers only more of the same as a remedy: more federally funded job-training programs, child care, health care, and on and on.
In light of rising unmet needs that might result from the new welfare legislation, does Edelman urge readers to volunteer at their local homeless shelters? Does he ask more parents to adopt foster children? Does he admonish more doctors and nurses to offer their services at free clinics? No. He urges us to become lobbyists for more welfare -- to "press for state and local funds" for immigrants, children, and other beneficiaries and to otherwise ensure that the government "doesn't reduce its own investment of funds."
Our thirty-year War on Poverty shows that the government cannot effectively fight poverty. The institutions that can -- indeed, the ones that are succeeding now -- are strong families, neighborhoods, churches, and charities that offer compassion but make tough demands on those seeking help. Reinvigorating these institutions, not funding more government programs, is the task ahead.
Did I miss something? I couldn't find Peter Edelman's rationale to explain how more money and more government will solve welfare problems when exactly the same "cures," although tried repeatedly, have failed over the past several decades. Also, I failed to see any evidence to support the implied contention that elected officials at the local and state levels are less compassionate and less concerned about the well-being of needy citizens than the administrators of gigantic bureaucracies.
Royce B. Crimmin
Jonathan Stein expresses a concern I share. The Social Security Administration's choice of the more restrictive interpretation for the reviews of childhood disability cases is a disappointment.
Terrence Scanlon and Royce Crimmin make variations on the same point -- that I fail to offer meaningful alternatives, that I offer more of the same, and that those cures haven't worked. I may have failed to spell out everything that I think has to happen if we are going to change direction and actually reduce poverty substantially, but I don't think I was offering "more of the same." On the national side we need a serious debate about how globalization and macroeconomic policy affect poverty, about how public policy can ameliorate the huge distributional changes that have occurred over the past fifteen years, and about national spending priorities. I also believe we need tremendous private involvement at the local level, both institutional and individual. I thought I said this in the article. Perhaps the difference between me and Mr. Scanlon is that I think the answer has to be "both and," not "either or." We need more parents to adopt or to be foster parents, we need more volunteers at homeless shelters, and we need more doctors and nurses to volunteer at free clinics. We need the churches and the charities. We need to revitalize neighborhoods, with grassroots leaders at the heart of the effort. But I part company vehemently with anyone who believes that these essential elements of civic involvement will in and of themselves solve the problems.
To Mr. Crimmin I would say that I don't think local elected officials are in general any more or less compassionate than their national counterparts. The choice is not between the administrators of gigantic bureaucracies and elected state or local officials. It is between having some basic national framework of rules, to keep the states from straying too far as they pursue their own localized solutions, and having no safeguards at all.
In his article on physician-assisted suicide, "Whose Right to Die?" (March Atlantic), Ezekiel Emanuel reaches conclusions that are invalid.
He identifies four "myths" supporting the right to physician-assisted suicide (PAS) and attempts to explode each in its turn. He dismisses the first -- that changes in technology justify rethinking the issue -- on the bizarre basis that similar discussions took place 2,000 years ago. Medical advances during just this century, however, have managed to keep patients alive well beyond the point where fatal diseases would earlier have brought a quick end to a failing body.
He belittles popular support for PAS (Myth No. 2) on the grounds that it is neither broad nor deep, a conclusion he reaches by reinterpreting a fifty-year-old poll. He accepts a more recent poll showing support for PAS, but insists that it applies only to patients experiencing the unremitting physical pain of a terminal illness. He seems unaware -- or unconcerned -- that unremitting pain and terminal illness are just two of many conditions underlying all the passed and proposed legislation considering the issue.
His attempt to explode the third myth is a bit more confusing, in that having arbitrarily accepted unbearable pain as the single exception to a ban on PAS, he says that in the Netherlands pain plays only a minor part in most requests for ending life. In reality intractable pain, the loss of bodily control, and the irreversible and terminal nature of an illness are but several of many triggers for requesting PAS, all of which are tied to fear. It is the fear of having no control in ending their final decline that prompts most patients to request PAS while they are still able. There is ample evidence in both this country and the Netherlands that the mere availability of assistance when needed is enough reassurance for dying patients to forgo precipitous action.
The piece goes on, repeating and amplifying inaccuracies that deserve more exposure and clarification than is available in this short space. The fact, however, is that despite the generally honest and humane nature of most opposition to PAS, denying this option when no other treatment works is simply abandonment of the patient -- an abuse that should be unacceptable.
Robert G. Faber
Ezekiel Emanuel makes several arguments against the legalization of physician-assisted suicide and euthanasia that are lacking in logic, consistency, and compassion.
For example, he writes, "We must not be swayed by a few -- or even a few thousand -- wrenching cases in which such intervention seems unequivocally right." Says who? Can any thoughtful person accept the underlying premise that if, as Emanuel asserts, the number of patients seeking to end their lives because of unremitting and uncontrollable pain is by some measure small, their torment must continue, with any hope for mitigation dependent on the chance availability of physicians willing to risk criminal sanctions? Should there be some magic threshold -- some critical mass of suffering -- that must be attained before society will allow physicians to provide humane relief to individuals, whatever their number, who are in agony?
Emanuel further argues that the legalization of physician-assisted suicide would have the ironic consequence of causing patients who refuse this option to be viewed as responsible for their own suffering. (Of course, the same could be said right now of terminally ill patients who have the legal option of refusing medical treatment but choose not to do so -- a right that, since it lessens the need for physician intervention in ending life humanely, Emanuel mentions with approval if not consistency.) True enough, one way to avoid the unpleasant consequences of opting for one course of action over another is legally to restrict the possibility of choice, but suggesting this in a matter so intensely grave and personal as coping with the final stages of terminal illness runs counter to our ideals of individual freedom and responsibility, which should be honored and preserved even for the very ill.
Stanley L. Spiegel
Robert Faber writes that "fear" drives patients to seek physician-assisted suicide (PAS). We have no empirical evidence supporting this claim. But if it is true, we need to ask whether PAS and euthanasia are the way to treat patients' fear. Surely reassuring them about pain control, home care, spiritual support, and the like is more appropriate than ending their lives. What has happened to our society when people think the proper intervention for anxiety, fear, pain, or lack of control is death?
Declaring that there is a right to euthanasia has become the ultimate trump, a license to ignore data and a means to silence ethical deliberation and debate. Such a right is hardly self-evident or self-justifying. This is precisely the issue the Supreme Court will address, and it is far from a foregone conclusion that the Court will affirm the right. Rational people should be able to end their own lives; suicide should remain decriminalized. But to say that is a far cry from saying that people have a right to have others, namely physicians and pharmacists, help them to end their lives. The ability to commit suicide is what Isaiah Berlin called a "negative liberty" -- a liberty to keep others from interfering with the individual. The right to euthanasia is a positive liberty -- a liberty to have others help to realize an individual's goal. The justifications for negative liberties are widely accepted, and the Bill of Rights is essentially a list of negative liberties; positive liberties are affirmed only when necessary to ensure robust participation in public affairs and to preserve essential opportunities. It is hard to see how granting a right to PAS and euthanasia is necessary to either of those goals.
In any case, the number of dying patients who have unremitting pain or who want to die and are physically incapable of killing themselves is very small -- a few thousand of the 2.3 million Americans who die each year. Again, something is wrong with a society that finds itself ready to declare a constitutional right with profound dangers for millions of people to ensure the proper care of a few thousands.
Legalizing PAS and euthanasia would remove the burden of proof from those who want to perform these procedures and place it on those who want to restrict them. This subtle but important change would mean that patients and physicians would no longer have to demonstrate that everything had been done to ensure optimal care of the dying patient in order to justify euthanasia. PAS and euthanasia should be exceptional not because there should be "some critical mass of suffering,"as Stanley Spiegel says, but because everything should be done to relieve suffering. This can occur only if PAS and euthanasia remain illegal.
It is always nice to have a positive review of one's book ( "China's Strategic Culture" by Warren I. Cohen, March Atlantic). And I don't want to sound ungrateful. But Professor Cohen's review of my Cultural Realism contains two crucial misinterpretations of my work that may lead readers to believe that my views on how to deal with rising Chinese power are close to his. They are not.
In the first he says I contend that "China's willingness to use force has grown with the improvement in its capability. It is more likely to be confrontational as it grows stronger." This is not at all what I argue. I am very careful to point out (on page 257) that once in a crisis, China is more likely to resort to military force when its relative capabilities improve -- a conclusion based on the data set I had at the time. Put another way, when China is not involved in a crisis, an improvement in its power does not necessarily lead it to act more aggressively.
This is not the same as saying that when China's relative capabilities improve, it becomes more aggressive. Indeed, data from the Correlates of War project at the University of Michigan suggest the opposite. As China's relative share of world power resources has increased since 1949, its involvement in militarized interstate disputes has declined. From 1945 to 1992, according to these data, the United States was the most dispute-prone major power, followed by China.
The second misinterpretation concerns the theoretical thrust of my argument. The book criticizes Western and Chinese analysts alike for essentializing China's strategic culture as uniquely peaceful. Strategic cultures may be deeply socialized, but because they are constructed and institutionalized world views, they are, in principle, changeable. I argue, therefore, against essentializing any state's strategic culture. Professor Cohen replaces an essentialist view of Chinese pacifism with an essentialist view of Chinese aggressiveness. He rules out any possibility of change, even with democratization in China.
My argument does not lead to this conclusion. Indeed, as I point out in the book, the existence of a democratic security community in Western Europe, an area that was once the site of bloody interstate wars, suggests that realpolitik strategic cultures are not immutable. I happen to believe that a democratic China will probably be "kinder and gentler," because it will probably be treated more kindly and gently by other democracies. I also believe that China's increasing involvement in international institutions has constrained and possibly altered some of the realpolitik impulses of the Chinese state. Some Chinese officials are not only beginning to talk the talk of multilateralism but also starting to walk the walk. The emerging debate in the United States over the "China threat" has so far missed any nuanced understanding of the interactive effects of China's diplomacy and international institutions. Whatever multilateralist voices exist now in China's policy process are likely to be drowned out by hard-line reactions to a simplistic U.S. neo-containment strategy.
Alastair Iain Johnston
I regret that Professor Johnston feels that I have misinterpreted parts of his argument. He and I differ in our assessment of contemporary Chinese international behavior and how the United States might best respond, and I hope that his more sanguine view of future Chinese performance will prove correct. I see little evidence, however, for such optimism in the actions that China has taken since he wrote his very important book.
The Atlantic Monthly. All rights reserved.
The Atlantic Monthly; June 1997; Letters; Volume 279, No. 6; pages 10-19.