What determines opportunities for a long and healthy life?

This post is about the reasons why opportunities for people to live long and healthy lives are much greater in some countries than in others. In the preceding post the prospect of a long and healthy life was identified as one of five basic goods of a flourishing human.

So, which are the countries in which an individual chosen at random would be likely to have the best prospects of a long and healthy life? The OECD’s Better Life Index gives top ratings on health to Canada, New Zealand, Australia, Israel and Ireland. The health indicator used in that index may not be reliable, however, because it incorporates self-reported health along with life expectancy at birth to take account of the quality of life as well as its length. Self-reported health seems to be unduly influenced by cultural factors. For example, while life expectancy in Japan is among the highest in the world (more than 2 years greater than in Canada) less than 40% of people in Japan rate their health as good or very good (the comparable figure for Canada is 88%). 

Objective evidence published in The Lancet articles on Global Burden of Disease indicate that the difference between life expectancy and healthy life expectancy (the number of years people can expect to live in good health) is about the same in Japan and Canada (13 years for females and 10 years for males).

The Lancet study, which covers 195 countries and territories, indicates that healthy life expectancy (HALE) is highest in Singapore and Japan, but also relatively high in other high income countries. 

HALE is strongly correlated with life expectancy (LE). The difference between HALE and LE rises somewhat as LE rises: on average from 6.4 years for a country with LE of 50 years, to 10.8 years for one with an LE of 80 years. The difference is typically about 2 years greater for females than males, but LE for females is about 5 years greater than for males in middle and higher income countries.

The accompanying graph shows that substantial increases in HALE have occurred in many countries since 1990. The increases have generally been most pronounced in countries with relatively low life expectancy.

There seems to be little support for concerns that additional years of life are frequently not worth living. For countries with low LE in 1990, average increases in LE of 12 years were associated with increases in HALE of 10.5 years. For countries that already had high life expectancy in 1990, average increases in LE of 5 years were associated with increases in HALE of 3.7 years. It seems likely that many individuals would consider an additional year of life to be preferable to the alternative, even if accompanied by some ill-health.

Research seeking to explain differences in longevity among countries suggests that health care spending, higher income and education have beneficial impacts. An OECD study of 35 countries (mostly high-income) found that health expenditure made the greatest contribution to increased longevity (42 months) over the period 1990 to 2010, followed by education (15 months) income growth (13 months) and reduced smoking (5 months). The study found the impact of increased health spending to vary between countries, with relatively small gains in longevity experienced in the U.S. despite large increases in health care spending.

War and violent crime have a major impact on life expectancy in some parts of the world. For example, life expectancy among men who live in the north of Mexico apparently declined by about 3 years in the period 2005 to 2010 as a result of an increase in the homicide rate associated with drug wars.

Some of the important drivers of increased longevity have a common cause: health care spending has tended to account for a higher share of GDP as per capita GDP has risen. Econometric studies have suggested that this increased spending may be driven largely by demographic and technological factors, but income growth makes it possible.

The more fundamental determinants of opportunities for a long and happy lives are the factors contributing to the economic development that has led to high average income levels. There are virtuous circles involved in this process. As previously discussed on this blog, a plausible story of economic development also needs to take account of virtuous circles involved in interactions between culture and economic freedom. Where culture and economic freedom support markets, people have added incentives to gain reputations as being worthy of trust others in order to obtain the benefits of mutually beneficial exchanges. As people become more trustworthy and trusting, and more respectful of the rights others, they could be expected to support greater economic freedom. Economic freedom, and a culture supporting innovation, result in further economic development and economic development promotes a culture supporting greater economic and personal freedom. As part of this process, improvements in population health could be expected to contribute to higher labour productivity and further enhance income levels.

The economic development story outlined above implies that we should expect healthy life expectancy (HALE) to be higher, on average, in countries with higher levels of economic and personal freedom. In order to test that, HALE data for 155 countries have been matched with data from the Fraser Institute’s Human Freedom Index. The chart below shows that average HALE is about 10 years greater for the countries in the fourth quartile, with the highest freedom levels, than for countries in the first quartile, with the lowest freedom levels.

Conclusions

The countries in which a person chosen at random seems likely to have the best prospects of having a long and healthy life are characterised by high average income levels. Estimates of healthy life expectancy (HALE) published in The Lancet’s global burden of disease project are highest in Singapore and Japan. Since 1990, there have been substantial increases in HALE in most countries.

Health spending, income growth and education have contributed substantially to increased longevity. The more fundamental determinants of opportunities for people to have long and healthy lives are the cultural and institutional factors that have contributed to economic development. Evidence that high HALE is associated with high levels of human freedom supports an economic development story taking account of virtuous circles involving market freedom, cultures supporting freedom and health improvements.

What are the basic goods of a flourishing human?

A good place to begin is with the discussion of the basic goods of “the good life”, by Robert and Edward Skidelsky in their book How Much is Enough (2012). The relevant discussion is in Chapter 6, entitled ‘Elements of the Good Life’. I published a somewhat critical review of the book on this blog some years ago, but I saw some merit in the authors discussion of human flourishing.

The authors adopt the following criteria to identify basic goods:

Universality: not specific to eras or cultures;

Finality: not just serving as a means to a more basic good;

Sui generis: not incorporated in some other good;

Indispensability: lack of the good leads to loss or harm.

I accept those criteria.

The authors identify the following seven basic goods:

• Health: ‘‘the full functioning of the body, the perfection of our animal natures”.
• Security: ‘‘an individual’s justified expectation that his life will continue more or less in its accustomed course, undisturbed by war, crime, revolution or major social and economic upheavals”.
• Respect: an individual’s feeling that others ‘‘regard his views and interests as worthy of consideration, as things not to be ignored or trampled on”.
• Personality: ‘‘the ability to frame and execute a plan of life reflective of one’s tastes, temperament and conception of the good”.
• Harmony with Nature: ‘‘a sense of kinship with animals, plants, and landscapes”.
• Friendship: ‘‘all robust, affectionate relationships”, including work relationships etc. as well as family relationships.
• Leisure: “that which we do for its own sake”, not just time off work.

That list summarises 17 pages of discussion, so it may not do justice to the authors’ deliberations. Nevertheless, it provides a basis to consider whether items have been identified appropriately, and whether anything important has been left out.

Health is obviously an essential characteristic of a flourishing human. The authors want to discourage “an obsession with longevity”, but it is reasonable to assert that flourishing involves living healthily for the term of one’s natural life.

Security is important, but it serves as a means to other goods, including a long and healthy life and psychological well-being (an important omission from the authors’ list of basic goods).

Having others respect of one’s views and interests feels good, but it isn’t indispensable to individual flourishing. Respect for one’s natural rights (life, liberty and property) is certainly indispensable, but serves as a means to other goods, including the ability to live a long and healthy life, interact with others for mutual benefit, and to the acquire human and physical capital that contributes to flourishing.

“Personality” does not seem to capture adequately the ability to frame and execute a plan of life reflective of one’s tastes, temperament and conception of the good. The authors use the term personality, rather than autonomy or practical reason, because it implies “spontaneity, individuality and spirit”. Those aspects of personality could be more appropriately incorporated under psychological well-being. The basic good corresponding to framing and executing a plan of life seems to me to be best described as accepting responsibility for self-direction.

Living in harmony with nature is important to human flourishing, and not just because of environmental impacts on human health and well-being. As I see it, the motivation for living in harmony with nature stems from deep-seated intuitions about our kinship with other living things.

Friendship doesn’t seem the most appropriate word to capture the wide variety of relationships that the authors put under this heading. The relevant basic good seems to me to be positive relationships.

Leisure is usually thought of as time off work, rather than engagement in doing things for their own sake. Martin Seligman uses the term ‘engagement’ to refer to the relevant basic good in his book Flourish (2011).

The other four elements of well-being identified in Seligman’s PERMA acronym (discussed here) are positive emotion, relationships, meaning and achievement. Of these, Skidelsky and Skidelsky only directly acknowledge relationships as an element of the good life. It seems to me that positive emotion and a sense of achievement are essential characteristics of a flourishing human.

Meaning requires a little more discussion. Seligman defines ‘meaning’ as belonging to and serving something that you believe is bigger than the self. This makes sense if serving the self means pursuit of personal pleasure. Those who see their lives as meaningful could be expected to value more things in life than their own pleasure.

So, here are the basic goods that I would expect a flourishing human to have:

1.  The prospect of a long and healthy life.
2. Wise and well-informed self-direction.
3.  Positive relationships with family, friends, colleagues, acquaintances and trading partners.
4. Psychological well-being: emotional stability, positive emotion, satisfaction with material living standards, engagement in doing things for their own sake and learning new things, perception of life as meaningful, a sense of accomplishment, optimism, resilience, vitality, integrity, and self-respect.
5. Living in harmony with nature.

What do I plan to do with this list? My interest is in the factors that lead to differences in opportunities for human flourishing in different countries. For example, which are the countries where some person chosen at random is likely to have the best prospects of a long and healthy life? How can we explain why the prospects for that individual are better in those countries?

Such questions will be explored in later posts.

What is it important to know about freedom, liberty and natural rights?

Dear readers, this article summarises the conclusions of a series of recent posts on this blog relating to freedom, liberty and natural rights.

It might help you in reading the article to think of it as an outline of the chapter on freedom in a book about freedom, progress and human flourishing. It would help me if you could provide comments below, or by email, on whether you think the article captures adequately what it is important to know about liberty.

The meaning of freedom, liberty and rights. 

Freedom sounds good, but the meaning of the word depends on context. For example, when people talk about freedom from fear, or freedom from want, they may have something important to say about human flourishing, but it isn’t necessary related to personal freedom or economic freedom, which are aspects of liberty. My focus in this post is on liberty.

Liberty has a more precise meaning than freedom. I adopt Friedrich Hayek’s definition of liberty as “a state in which coercion of some by others is reduced as much as is possible in society”. In the civic republican tradition, liberty is sometimes defined more broadly to encompass political freedoms, including the right to political participation. To avoid confusion, however, I think it best to stick with Hayek’s definition.

Rights refer to things that one is morally or legally entitled to do or have. As with freedom, the precise meaning depends on context and qualifier words. A negative right is a right not to be subjected to an action of another person or group whereas a positive right is an entitlement to have another person or group do something. The Universal Declaration of Human Rights encompasses not only the negative right to liberty and positive legal rights (including political freedom) but also economic and social aspirations that cannot necessarily be met by anything that a person or group might do.   

My focus here is on natural rights, including the rights to life, liberty and the pursuit of happiness - as famously proclaimed in the United States Declaration of Independence. The inclusion of “pursuit of happiness” as a right in the Declaration might appear to be redundant since pursuit of happiness is encompassed in our understanding of liberty. In 18^th century America, however, an inalienable right to liberty could have been interpreted in civic republican terms. At that time, pursuit of happiness was widely perceived as the activity of human flourishing, as perceived by Aristotle. (Further explanation is provided in an earlier post.)

Liberty is worth having.

Anyone who lives in a liberal democracy should ask themselves from time to time what it would be like to live without liberty. What would your life be like if you lived in a country where you didn’t have freedom of religion, where you could be jailed for expressing views not approved of by political leaders, where you could be subject to arbitrary arrest, where your property could be arbitrarily seized by the government, or where your freedom to  move around was restricted? Such countries are still easy to find.

The right to freedom of speech is particularly important because free speech helps to protect liberty more generally. Some restrictions on freedom of speech have long been widely accepted as desirable, for example to discourage incitement to violence. However, recent efforts in some liberal democracies to make it a crime to offend others based on identity characteristics - such as ethnicity, religion or gender - have potential to curtail freedom of speech substantially. Even when people strive to be respectful in the way they present their views, some people with opposing viewpoints are likely to claim to be offended if they can thereby stifle debate on controversial topics.

Norms of liberty make it possible for individuals to flourish in different ways.

As explained by Douglas Rasmussen and Douglas Den Uyl: 

“Individual rights are … needed to solve a problem that is uniquely social, political and legal. … How do we allow for the possibility that individuals might flourish in different ways … without creating inherent moral conflict in … the structure that is provided by the political/legal order? How do we find a political/legal order that will in principle not require that the human flourishing of any person or group be given structural preference over others? How do we protect the possibility that each may flourish while at the same time provide principles that regulate the conduct of all?”  (Norms of Liberty, 2005, p 78).

A discussion of views of other authors who have also advanced metanormative arguments for individual rights was posted on this blog some years ago.

 

Moral intuitions support natural rights.

Natural rights are inherent in human nature. They have traditionally been seen to be endowed by God, but widely-held intuitions about natural rights can also be explained in terms of the evolution of the ethics of respect. Moral intuitions that it is good to respect the lives and autonomy of others provide support for norms of liberty that maximize the opportunities available for all to flourish. As discussed in a recent post, it seems reasonable to suppose that the ethics of respect evolved because of the benefits that voluntary cooperation for mutual benefit brought to individuals and communities.  

Those who seek to deny the existence of natural rights tend to argue that individual rights are bestowed by governments, so it is legitimate for governments to remove them if that serves what they see as the “greater good”. There are times when individual rights do need to be compromised (e.g. via compulsory land acquisition) to prevent a community being held to ransom by an individual, but this should not be done lightly and fair compensation should be provided.

Respect for the rights of others has been advocated as an ideal since ancient times.

In ancient Greece, the poems of Hesiod, which appear to date from the 8^th or 7^th century BCE, urge people to comply with rules of just conduct rather than to seek to benefit via predation. In his poem, Works and Days, Hesiod advises his brother Perses, to “put away all notions of violence” for “fish, and wild animals, and the flying birds” may “feed on each other, since there is no idea of justice among them,” but “to men [Zeus] gave justice,” which is the “best thing they have.”  Hesiod condemns both force and fraud: the grabbing of goods either by “force of hands” or by “cleverness of … tongue.” (Further discussion here.)

Perceptions of natural law have not always supported universal human flourishing.

Aristotle (384-322 BCE) was the great philosopher of individual human flourishing. His emphasis on the natural capacity of humans to use reason to guide themselves and exercise appropriate moderation in their behaviour provides a basis for understanding human flourishing to be an essentially self-directed activity.

Nevertheless, Aristotle argued that it was natural to make slaves of defeated enemies. He viewed the system of conquest and slavery as a natural system governed by internal sources of change. By identifying the whole system as natural he was able to disregard the use of force at the heart of it.

The perception of what was natural of Cicero, the Roman statesman, lawyer and philosopher who lived from 106 BC- 43 BC, was more supportive of liberty. He argued that “nature made us just that we might participate our goods with each other, and supply each others’ wants”.

(Further discussion here and here.)

Reason and spontaneous legal processes both played a part in recognition of natural rights.

Beliefs and values supporting natural rights of individuals to life, property and liberty seem to have travelled from Cicero to the modern world through both the spontaneous evolution of rules and evolution of reasoning about the natural law. Those different transmission processes interacted. There were periods when reasoning about natural law held back recognition of individual rights to participate in mutually beneficial activities e.g. lending and borrowing. Eventually, however, reasoning about natural law reinforced and extended individual rights recognised under common law. (Further discussion here and here).

Rule of law protects natural rights and enables people to live in peace.

From the 12th century onwards, with the advent of centralised monarchies in Europe, homicide came to be viewed as an offence against the crown, rather than a civil matter. That enabled societies to avoid the violence associated with do-it-yourself justice. More effective justice systems penalised plunder, and thereby promoted peacefulness and improved incentives for mutually beneficial exchange.  

Evolution of the rule of law provided greater protection to natural rights by requiring people to refrain from initiating or threatening any forceful interference with other individuals or their property.  (Further discussion here.)

Systems of government preferment are an infringement of natural liberty.

Adam Smith argued that it was an unjust infringement of natural liberty for the powers of government to be used to assist some economic groups at the expense of others. Smith’s ideal of everyone being free to pursue their own interests in their own way is consistent with Francis Hutcheson’s earlier explanation of the right to natural liberty in terms of pursuit of happiness. (See this post).

In The Law, published in 1850, Frédéric Bastiat foresaw the potential for the universal franchise to endanger natural rights. He was concerned about the use of the power of the state by some groups to seize and consume the products of the labour of others. Legislation that seriously endangers natural rights is difficult to reconcile with rules of just conduct that have evolved to foster mutually beneficial interactions. (See discussion here.)

The right political participation should be viewed as a natural right.

Moral intuitions supporting the right to political participation presumably evolved because human flourishing has always required individuals to participate actively with others in decisions relating to provision of collective goods. Such involvement is less active in modern societies in which many collective goods are provided by remote government agencies and citizen involvement usually involves little more than voting.

The exercise of voting rights provides citizens with some protection against tyranny, but increasing numbers of people in the liberal democracies nevertheless feel unhappy about the outcomes of democratic political processes. That unhappiness may stem to an important extent from unrealistic expectations of what political processes can deliver. It seems likely to increase as low productivity growth reduces government revenues and demographic change increases political demands on governments.

Technological advances that enhance opportunities to seek mutual benefit in cooperative enterprises offer hope that people will in future be able to exercise their natural political rights in ways that give them more involvement in decisions that affect them.

(More discussion here and here.)

For liberty to prevail the ‘real constitution’ must be pro-liberty.

It is illusory to think of political institutions as external to society. The rules of the game exist only insofar as they are continually maintained in existence by human agents acting in certain systematic ways. The constitution of a free society is a pattern of interactions in which people give one another incentives to act and keep acting in ways that tend to maintain liberty. It is not the rules per se that gets disputes resolved, but rather the incentive structure that makes the system’s administrators likely to act in accordance with such rules.

Sheldon Richman defines the real constitution as the set of dispositions that influence what most people will accept as legitimate actions by the politicians and bureaucrats who make up the government. He derives support for this concept from Roderick Long’s observation that “government is not some sort of automatic robot standing outside the social order it serves; its existence depends on ongoing cooperation, both from the members of the government and from the populace it governs”.

It follows that for liberty to prevail the real constitution must be pro-liberty. As a corollary, tyranny cannot persist in any jurisdiction when the real constitution is pro-liberty.

Can any of the positive rights listed in the UDHR be considered natural rights?

A statement made last year by Michelle Bachelet, the UN High Commissioner for Human Rights, marking the 70^th anniversary of the Universal Declaration of Human Rights (UDHR) prompted me to take another look at it  In her statement, Ms Bachelet suggested that the UDHR has “withstood the tests of the passing years” and “has passed from being an aspirational treatise into a set of standards that has permeated virtually every area of international law”.

The UDHR is not a document that I look at often. My reason for largely neglecting the document has been the perception that it is aspirational, and involves a large element of wishful thinking. Ms Bachelet’s suggestion to the contrary reminded that Friedrich Hayek had asserted that by proclaiming social and economic aspirations to be rights, the UDHR was playing “an irresponsible game with the concept of ‘right’ which could result only in destroying the respect for it” (Law, Legislation and Liberty, p 105).

After re-reading the UDHR, there are a couple of points I would like to make about it.

First, Hayek was right!

Hayek’s warning about the confusion of the concept of right in the UDHR was appropriate. For example, consider Article 15:

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

Article 15 seems to tell everyone that the world owes them a living. But who will pay? Nature has different imperatives. Human flourishing depends on what people can do individually and collectively to help themselves and each other. Governments may help by defending the natural rights that enable people to better their own condition and help others. Although they often promise to ensure that everyone has an adequate standard of living, governments can’t themselves generate the wealth needed to keep such promises.

Governments can redistribute wealth, but their redistribution efforts tend to discourage wealth creation. What happens when redistribution is pushed too far is obvious from the recent experience of Venezuela. The policies followed by the Venezuelan government were presumably intended to contribute to the human flourishing aspirations underlying Article 15, but they have had the opposite effect of impoverishing many people in that country. The incoming Venezuelan representative on the UN human rights council would do us all a favour if he or she could acknowledge the consequences of the Venezuelan government’s efforts to comply with Article 15.

The UDHR would have provided a more coherent defence of human rights if its framers had given more attention to the insights of Frédéric Bastiat about natural rights and the role of law. In The Law, published in 1850, Bastiat makes the point that everyone has a natural right to defend their person, their liberty and their property, and asserts that the law should be viewed as “the collective organization of the individual right to lawful defense”:

“When law and force keep a person within the bounds of justice, they impose nothing but a mere negation. They oblige him only to abstain from harming others. They violate neither his personality, his liberty, nor his property. They safeguard all of these. They are defensive; they defend equally the rights of all”.

Second, some of the positive rights in the UDHR are worth supporting.

I am referring to various legal rights relating to natural justice, or procedural fairness, and the right of political participation in Article 21:

“Everyone has the right to take part in the government of his country, directly or through freely chosen representatives”.

People who live in liberal democracies tend to take that right that for granted, and many are even disillusioned about it, but it is a right that people seek persistently when it is denied to them. Tyrants understand that well; although they often claim to be adored by citizens, they are rarely willing to allow their popularity to be fairly tested in fair elections. The recent protests in Hong Kong show that the right to political participation is keenly sought even when people live under a regime that, for the time being, provides individuals with greater economic freedom than is enjoyed in most liberal democracies.

Friedrich Hayek argued in favour of recognition of such political rights in the following terms:

“Since we are all made to support the organization of government, we have by the principles determining that organization certain rights which are commonly called political rights. The existence of the compulsory organization of government and its rules of organization does create a claim in justice to shares in the services of government, and may even justify a claim for an equal share in determining what government shall do” (LLL, p 102).

Is political participation a natural right?

It seems to me that the right to political participation should be viewed as a natural right for much the same reasons as I have argued that humans have a natural right to exercise the self-direction that is central to their flourishing. It is part of human nature to seek mutual benefit by participating actively with others in decisions relating to provision of collective goods because provision of such goods is, and has always been, necessary to human flourishing. As Aristotle said, “man is by nature a political animal”.

The context in which Aristotle made that observation is worth quoting because what he described seems to an essentially voluntary process of people coming together for mutual benefit:

“When several villages are united in a single complete community, large enough to be nearly or quite self-sufficing, the state comes into existence, originating in the bare needs of life, and continuing in existence for the sake of a good life. And therefore, if the earlier forms of society are natural, so is the state, for it is the end of them, and the nature of a thing is its end. For what each thing is when fully developed, we call its nature, whether we are speaking of a man, a horse, or a family. Besides, the final cause and end of a thing is the best, and to be self-sufficing is the end and the best.

Hence it is evident that the state is a creation of nature, and that man is by nature a political animal” (Politics, Book 1, Part 2).

The political participation of a citizen in a liberal democracy, which usually doesn’t involve much more than voting, has little in common with the participation of citizens in the functioning of the city states that Aristotle wrote about. Perhaps that helps to explain the disillusionment that many currently feel about the exercise of their democratic rights. Responses to surveys suggest that many people want more involvement in decisions that affect them.

Many people are also unhappy about the outcomes of democratic political processes. In my view that unhappiness stems to an important extent from inflated expectations generated by UDHR and other authorities which assert that people have the right to expect politicians to deliver them a standard of living they consider to be adequate. Another important source of disillusionment is the ‘plunder’ that Frédéric Bastiat foresaw as a likely outcome of the universal franchise. Bastiat was referring to the use of the power of the state by some to seize and consume the products of the labour of others. These days economists refer to that as rent seeking and usually consider it to be a major obstacle to productivity growth.

It seems likely in the decades ahead, that low productivity growth will reduce the rate of growth in government revenues in many democratic countries, at the same time as an increase in the proportion of elderly people places increased political demands on governments. Consequently, governments are likely to be forced to reduce their involvement in provision of services that can be supplied either privately, or via voluntary cooperative activity.

Fortunately, as I have previously discussed, technology is developing in ways that are likely to enhance our opportunities to seek mutual benefit in cooperative enterprises.

Conclusions

The right to political participation should be viewed as a natural right which evolved because human flourishing required individuals to participate actively with others in decisions relating to provision of collective goods. Such involvement is less active in modern societies in which many collective goods are provided by remote government agencies.

The positive right to political participation is nevertheless an important right recognised in the UDHR. It differs from social and economic aspirations - that are also claimed to be rights in the UDHR - because it is a right that governments can comply with. The exercise of voting rights provides citizens with some protection against tyranny.

The disillusionment that many people in the liberal democracies feel about the exercise of their democratic rights seems likely to increase as low productivity growth reduces government revenues and demographic change increases political demands on governments. Technological advances that enhance opportunities to seek mutual benefit in cooperative enterprises offer hope that people will in future be able to exercise their natural political rights in ways that give them more involvement in decisions that affect them.