Social Policy, by Richard Titmuss
by Richard Titmuss.
Pantheon. 160 pp. $8.95.
This brief book consists of a group of introductory lectures which the late Richard Titmuss gave in similar form each year to incoming students at the London School of Economics. It is easy to guess that students of social work must have loved them, while the faculty colleagues who edited them into this book treated them with such humble reverence that they did not dare to shape them into a consecutive whole. The resulting book is a paean to the importance of social policy. Despite the discontinuities between the chapters, a tripartite message conies through very clearly: social policy is no mere housekeeping chore concerned with the health of the waifs, strays, and laggards of an industrial society; social policy is the vital part of the economic system because it offers ethical meaning to the system; redistribution is the goal of social policy, but it must be planned meticulously lest it work in the wrong direction, offering more to those who already have more. Give, says the essential Titmuss, give until it stops hurting.
In assigning to social policy the chief responsibility for the redistribution of the material goods and the services provided by the economic system, Titmuss appears to be primarily interested in the effect of this redistribution on those who design and support it. The benefactors are to become the primary beneficiaries of their concern with helping others. Titmuss makes clear that this good moral effect would be dissipated if social policy were designed to augment efficiency instead of purely to redress inequities in distribution. Thus, the originator of social policy is urged not to consider whether or not those who receive the redistributed goods will become, as a result, better able to provide for themselves in the future. The mixture of a gill of poisonous self-interest in a gallon of altruism eats away at its ethical soundness. This view contraverts such ethical philosophers as Maimonides, who wanted donors to be concerned with the future of their benefactions and assigned the highest rank in the hierarchy of charity to that gift which enabled the recipient, ultimately, to manage on his own.
Those who have read Titmuss's earlier book on the donation of blood for medical purposes, The Gift Relationship, will recognize the emphasis on an act of giving which is untarnished by any shadow of practical calculation. The emphasis on redistribution by Titmuss will be familiar also to readers of Daniel P. Moynihan's recent discussion of the connection between Fabian socialism—with its bias against production and in favor of redistribution—and Third World political economics.1
To the familiar chorus of those who accuse industrialization of destroying the quality of human life, Titmuss adds some novel and interesting reflections on the difficulty of pinning down who is exactly responsible for which element of destruction. Titmuss emphasizes that the costs of industrialization are no more uniformly distributed than its benefits. Accordingly, it falls to the maker of social policy to ascertain who pays most for economic activity, and to redress the excess of costs as well as the shortfall of benefits. Titmuss offers his students a choice among three types of equalizers: legal action, private insurance, and publicly-owned redistributive agencies. The last resemble private insurance, but in effect offer subsidized transfer payments from government. Titmuss chooses this kind of public-insurance system over its alternatives, probably because legal action and private insurance enhance the wealth of private non-needy people in the course of helping the poor and the deprived.
To elucidate the difficulties in designing a social policy which can successfully redistribute both the costs and benefits of economic activity, Titmuss cites a study made in 1918 of the laundry problem in the English Midlands. The study revealed a significant difference in household soap costs incurred by families in Manchester, then a dirty city, and Harrogate, a nearby, cleaner city. According to Titmuss, the study indicated that the costs of air pollution fell more heavily on the Manchester population than the Harrogate population because the Manchester people bought more soap. Worse, from the point of view of designing social redistribution, the impact on the Manchester families was itself unequal: the extra soap represented a larger proportional share of a poor family's budget than a wealthier family's. Hence, in planning a proper redistribution, one had to decide who needed help most: those who used the most soap, or those who had the lowest income to begin with. Because the policy-makers of 1918 were unable to make this and other important calculations, Titmuss tells us, the costs of the smoke were allowed to fall where they might. Today, however, he tells us with a sigh of relief, technological progress has made possible the elimination of smoke altogether, and therefore it is unnecessary to allocate the costs and distribute the compensatory benefits.
Would that the problem were so easily addressed. Surely the stacks of Manchester could always have been made to stop belching smoke; one had merely to extinguish the fires beneath them. Who would have paid in unemployment and production lost for the cost of that decision? If, instead of damping down the fires altogether, a conservation-minded government had merely required the installation of expensive remedial equipment, the new costs might have been borne by all the consumers of the products of Manchester through higher prices. If the products then could not be sold at the requisite prices, a differential subsidy might have been borne by all the people in the economic system, through the intermediation of government. But how long can government “subsidize” remedial measures in how many industries? It may turn out that the cost of the new technology, which Titmuss welcomes as a relief from problems in social-cost allocation, is itself too heavy for anyone to bear; the living standard declines. The tradition of Fabian socialism established itself when the British empire was at the zenith of its economic power. To pretend, as do redistributionists of the Titmuss school, that Britain remains sufficiently wealthy to afford redistribution is to mimic a Chekhovian family which refuses to recognize the change in its condition, and continues in aristocratic attitudes long after they have become awkward and, to the playwright, comic.
Even if, however, redistribution were still justifiable on the basis of British wealth, and even if the primary problem in Britain were not, as everyone but the Titmuss school seems to know, the real decline in the level of economic production, the distributionism proposed by Titmuss under government supervision would be difficult to achieve. This is its first weakness. Years of redistributive income taxes, steep inheritance taxes, and a general bias in favor of progressive taxation, have left the Western world with very little change in the degree of concentration of wealth among the population.
The effort to ignore the realities of economic production constitutes the second major weakness of redistribution as the main goal of humane social policy. Titmuss, more particularly in his book on blood, would substitute ethical considerations for economic calculations; this moral hubris may be charming, as in Titmuss's descriptions of his treatment for terminal cancer by the National Health Service, or scary, as in the aspects of that treatment which he chooses to ignore. Clearly a man of great personal courage, Titmuss speaks of the impact of waiting for cobalt treatment at a large, British hospital in company with other disease victims. His fellow patients covered the gamut of British caste and class, yet they were treated in order of arrival, not in descending level of status. Titmuss is buoyed by the feeling that the National Health System has been able to cut down the hedges of the repressive British social pattern, and that he, as a supporter of that system, may take a small measure of pride in the achievement.
So much for the charming. The scary part comes when Titmuss reflects on the extremely expensive character of cobalt treatment. In his case alone, the National Health scheme paid for 17 hours of treatment at a cost of £10 per minute. What Titmuss celebrates here is far more than equality of treatment; it is equal access to a very expensive form of treatment. If Britain's economic system were unable to bear the cost of the cobalt, the laboratories, the equipment, and the personal services required to give the treatment, the result would be a mere equality of poverty of little significance, spiritual or otherwise, to anyone.
A third difficulty with the redistributive goal involves the very question of morality itself. Is the sense of duty and achievement for Titmuss and his associates truly an ennobling experience, or is it merely a form of moral smugness? Just as Maimonides praised most highly those who were concerned to render self-sustaining their unfortunate brethren, he put on one of the lower rungs of the hierarchy those who were motivated primarily to derive pleasure or satisfaction from their benefactions. An air of piety attaches itself to the distributionists and to the purgatorial process which Titmuss urges on his followers, a process of stripping off from redistribution any accidental benefit that might be enjoyed by those not entirely entitled to be the objects of social policy. It is surely commonplace in pietistic social movements to learn that the more practitioners are urged to cleanse themselves of material gratification from the policy they adopt, the more likely they are to derive instead an even more stifling moral gratification. If the Titmuss brand of redistribution does indeed rest its case on ethical grounds, that case rests on ambiguity. The purer the self-denial in material terms, the more likely it is to become a tyrannical righteousness, perhaps even a secular form of theocracy.
Finally, a fourth difficulty in the path of redistribution presents itself with special force to the American reader of Titmuss: the anti-American bias. At first this seems to be carelessness, or unfamiliarity with the American scene; then, as one reads further, the anti-Americanism seems a personal peculiarity; still further, and the anti-Americanism becomes the logical extension of the Titmuss position. For the United States, as Titmuss imagines it, is his Horrible Example—a nation wallowing in market economics unmodified by progressive humanitarianism, a nation obsessed with the shortcomings of government activity and purblind to the defects of the profit motive. Just as, in Elizabethan England, when dynastic wars were ending with the ascension of the house of Henry Tudor, Niccolo Machiavelli served as the Horrible Example of a politicized, secular kingship and encouraged Englishmen to accept the divine rights of the new line, so the Titmuss view of America serves to instruct waverers in the dangers of ignoring Fabian altruism in the political economy.
The enthusiasm with which Titmuss pounces on his instructive example sometimes causes him to loosen his grip on the facts. Thus, on the second page of Social Policy, the following arresting statement occurs: “It is not widely known that during the first six months of 1971 more people were murdered in New York than all the American soldiers killed in Vietnam during the same six months.” The statement becomes even more arresting when a bit of research reveals that the Department of Defense reported 1,105 Americans killed in combat during the first six months of 1971. The New York City Police Department lists but 651 homicides during the same period. Since murders are only a subclass of homicides, the Titmuss discrepancy is even bigger than it appears to be, and inspires queasy feelings about other statistics in Titmuss's lectures. Decrying the redistributive efforts of private insurance against social risks like workmen's compensation (the American practice), Titmuss claims that private insurance involves administrative costs of 30 to 40 per cent of premium income, while public insurance involves only 5 to 10 per cent in administrative costs One wonders whether Titmuss quotes the figures correctly or whether they cover comparable activities.
The references to the United States, which abound in the book, contain faulty observations as well as imprecise or doubtful facts. Titmuss writes: “Voluntary hospitals in the United States, for example, have public wards for indigents which tend to be full of black people. This can be contrasted with the integrated wards and outpatient departments of British hospitals under the National Health Service.” The public wards of the voluntary hospital nearest me are, in fact, nearly empty, thanks to Blue Cross and Medicare; the semi-private accommodations are integrated. But the major racial difference between my city and London results from the fact that the non-white population in my city approaches 40 per cent; London's is much smaller. Didn't Titmuss observe the difference?
When I was a very minor functionary in the government's overseas information office in 1942, we blamed Hollywood for many of the mistaken notions then current abroad about the American reality. Reading Titmuss, I find it easier to believe that Americans are imagined to have horns because these pointy protuberances are needed to pin together the inconsistencies in the hubristic Fabian conscience.
1 “The United States in Opposition,” COMMENTARY, March 1975.