I don’t expect much to come of John Holbo’s careful breakdown of the non-philosophy underlying Megan McArdle’s blanket antagonism to all health care proposals, but there’s one point buried in there that’s worth pulling out for its general usefulness.
Namely, that loosely libertarian (e.g., McArdle/Brooksian surface-level libertarianism used mostly to defend fixed programmatic commitments) fears of the unintended consequences of action by the state are empirically and philosophically messed up. They’re not really based on a comprehensive history of the consequences of state action, and they’re not really based on any kind of consistent view of structure-agency interaction. They seem to me to take really very specific kinds of analyses of how 20th Century states engaged in projects, especially high modernist projects, which had many undesirable and perverse effects, and generalize them to a universal law of history. Jane Jacobs and James Scott, to cite two examples of those specific analyses, are talking about concrete episodes and perhaps modestly generalizing them to certain movements, ideologies or specific bureaucratic formations.
I think you can insist on the importance of unintended consequences as a part of a generalized theory of the relationship between structure and agency. I think you can also look at discrete intellectual movements or episodes where important actors believed that they could eliminate or master unintended consequences. Certainly that’s what a lot of rationalist high modernism implied, that good planning inputs based on proper ideological premises could reliably produce exactly the intended systematic changes.
The thing of it is, as John points out, is that if you’re going to argue that unintended consequences follow on any major change or disruption to an existing system, then there are two additional points which have to be made. First, there’s not much of a difference in this sense between the state and other major institutional actors which have some degree of agency over a system or structured practice. If three or four large pharmaceutical firms decide to change the way that they interact with the existing health care system, all sorts of unintended or unanticipated changes may follow. I can’t see any reason why someone like Megan McArdle would be intensely anxious about government and yet be relatively sanguine about industry, civic organizations, and so on, if the issue is that it is impossible to account for or anticipate unintended consequences.
Unless at the end of the day, this is about a near-religious belief that institutions of the market somehow always produce a good unintended consequence. That’s a bit hard to work out if you’re that radical and simplistic a manichean, since either the market is the first condition of human history and therefore produced non-market institutions (whoops! not a good unintended result from that perspective!) or the polity is the first condition and therefore produced the market (whoops! the polity produced a good unintended consequence!). Of course, it’s not a good description of the contemporary American health care system, either, which has been produced by complex interactions between market, state and non-state institutions.
Second, if you’re really interested in the unintended consequences of structure-agency loops on complex systems, you have to allow that many of them may be positive, neutral or be spandrels of some kind or another, as well as being negative or destructive. If you believe that all or even the strong majority of unintended consequences are negative, then you don’t really believe in contingent or unintended outcomes at all. You believe in a kind of declensionist, entropic worldview that holds that everything will in time inevitably go wrong. You’re basically Eeyore. Which is ok, but it is hard to make an Eeyore-style defense of anything, whether it’s the current health care system or anything else. You’re sure it’s all going to go wrong, and in fact, must be sure that the current system is less good than something in the past. If you think the current system is acceptable or worth defending, then you must be sure that unintended consequences sometimes lead to good results, because nobody set out to build exactly the health care system that Americans presently have.
Like John, I’m all for accepting that the gap between intent and practice will inevitably be quite wide, and that in that gap, all sorts of devils can find room to dance. It’s just that those kinds of gaps also have thermals upon which angels fly. The mere existence of such gaps is not a reason to simply squat dully upon the status quo, or unchain the magic market mechanism to come along and sweep us to the promised land, nor is it reason to simply avoid discussion of what we ideally would like to see happen on the grounds that whatever we would like, unintended consequences will ensure that we never get it.