Paternalism, autonomy, and milk

Progressive-minded people love to ridicule the internal inconsistency of right-wing social conservatives. Conservatives’ defining values are limited government, individual liberty, and privacy…but one of their core goals is federal government control over private medical decisions. They deify individual choice and (the myth of) meritocracy…but are also unapologetically anti-choice, giddily dooming poor pregnant women and teenage girls to lives where structural poverty obliterates individual merit.

Yet, the socially progressive worldview also contains a core contradiction: Understanding that meritocracy is a myth and poor people are not at fault for their situations…but believing ardently in the need for governmental control over poor people’s behavior. Progressives recognize the humanity of the less fortunate. They lament poor people’s limited autonomy in the face of widespread discrimination, low wages, environmental and legal injustice, low-quality education, and community violence…but they further limit personal autonomy via paternalistic welfare programs.

Recently, I opined to a fellow bleeding-heart liberal about the wisdom of cash payments to poor people in lieu of behavioral regulation via in-kind welfare. The topic has been abundantly-researched and well-documented in the media: Unconditional cash payments to poor people are “surprisingly” more effective. Since gaining attention some two decades ago, the idea has spread around the globe.

My companion disagreed. When she worked checkout at a grocery store long ago, people on food stamps who had a grocery bill higher than their food stamp card balance would routinely tell her to “put back the milk”. She glanced at me with a horrified facial expression, seeking commiseration.

But, I’m the opposite of horrified. I can easily think of numerous rational reasons to “put back the milk” in favor of boxes of processed food, beginning with this:

We heavily subsidize a food that 45% of food stamp recipients can’t even digest. (Lactose intolerance affects approximately 75% of African-Americans, 50% of Hispanics, 100% of East Asians and Native Americans, and 20% of Anglos. Food stamp recipients are 26% African-American, 10% Hispanic, 4% East Asian and Native American, 40% white, and 20% unknown ethnicity.) Lactose intolerance causes intestinal pain, diarrhea, bloating, and vomiting. Many people don’t know they are lactose intolerant but may have a subconscious aversion to milk, drinking it medicinally because, in the swamp of endlessly-conflicting nutritional advice, many voices insist it’s good for you. Years ago, my Asian husband suffered intractable Irritable Bowel Syndrome for which he took medication and sometimes skipped work…until it dawned on us that my dairy-centric meal plan was making him sick.

Rich white people wrote the economic rules. And, they wrote them from their non-universal perspective. Bias is invisible to those that hold it. Even as Anglo-America’s age-old faith in the virtuousness of milk has lately been shaken by science, those of us upon whose distant ancestors evolution bestowed the lactase enzyme will be the last to fold. Debate over continued government subsidy of the dairy industry reveals how milk takes on quasi moral significance in our culture.

Other valid reasons to put back the milk:

  • Kids in school. All children of parents on food stamps automatically get free milk at school, via the USDA’s 80-year-old Special Milk Program (other kids pay $0.25 to $0.65 per half pint). So, putting the milk back doesn’t mean denying nutrition to kids — at least on weekdays during the school year. And, for adults, the health benefit of cow milk over vegetables is no longer supported by science.
  • Spoils quickly. Because milk goes bad quickly and poor people fastidiously avoid food waste, they may only buy milk when they’re confident that in-town schedules guarantee it’ll get used up quickly. Similar to how financial credit serves to smooth income, and layers of exquisite knotted carpets in an otherwise bare Bedouin tent serve to store wealth, so packaged food serves to smooth food consumption. When my next payday is uncertain, I’m financially and nutritionally better off with calories stored as non-perishable food in the cupboard.
  • Not filling. When food is scarce, it’s rational to buy food with the highest satiety index per dollar (usually also the highest calories per dollar). Like it or not, that means cheap carbs. We should fix food insecurity, and fix the systemic issues making processed carbs cheap — not expect hungry people to behave irrationally, or to take a long-horizon view of nutrition when they’re trapped in a short-horizon survival game.
  • Alternate source. If I check out with eggs, flour, chocolate, and butter, the grocery store clerk will often remark, “You forgot the sugar!” (for the brownies I must surely be making tonight). Cognitive bias blinds him to the possibility that I already have sugar at home. Similarly, putting milk back may mean there’s already milk in the fridge that should be finished first in order to not waste money. It may mean that cheaper milk can be gotten at a food bank, so food stamps are better used for non-milk items. Or, it may mean that another family member with their own funds can get the milk.

The point is that if you don’t conduct an in-depth interview, you cannot reasonably judge such a decision. If you’re a social progressive, your overarching philosophy demands that you respect the decision-making capacity of individuals and recognize that nobody wants to be hungry or unhealthy. We should all cultivate “sonder” — a neologism defined by the Dictionary of Obscure Sorrows as “the realization that each random passerby is living a life as vivid and complex as your own — populated with their own ambitions, friends, routines, worries and inherited craziness — an epic story that continues invisibly around you like an anthill sprawling deep underground, with elaborate passageways to thousands of other lives that you’ll never know existed, in which you might appear only once, as an extra sipping coffee in the background, as a blur of traffic passing on the highway, as a lighted window at dusk.” Arms-length judgment and condescension have no place in the liberal person’s worldview.

Cash payments work better than in-kind welfare services. They are cheaper to administer and more effective at alleviating poverty. The body of research that showed this is, incidentally, the ground that supports the “universal basic income” idea — a new policy darling of the left. Paying people a subsistence income frees them from taking the first dead-end job that comes along, and it enables them to make economically efficient investments in more productive activities. Advocates believe (supported by ample evidence) that most recipients wouldn’t use the income to sit around idly. So, we see that left-wing progressives’ inability to transfer conclusions from one domain (cash payments labeled “universal basic income”) to another (cash payments labeled “welfare”) echoes that same silo problem among right-wing ideologues.

A well-meaning friend bought me $40 of groceries. He chose what items to buy, paternalistically believing he knows what’s best. But if I had control of $40 in cash, I would have used it at a store where it went further, and bought foods that work best in my body and in small quantities that I have no chance of wasting given what’s already sitting in my fridge. I would have kept some of it to fund my dying dog’s pain medication. Still, I am grateful for the gesture and the food (including a delicious quart of milk, which I happily drink with a grateful nod to my Germanic cow-herding ancestors). My friend’s understandable desire for his charity money to be used efficiently translated into the money being used somewhat inefficiently. Without walking in a poor person’s shoes, you simply cannot know what is best.

Emergency food stamp benefits of $194 per month can only be used in grocery stores and farmer’s markets. With $150 free cash instead, I could get my car approved for carshare service — i.e., craft my own proverbial fishing pole, rather than depend on handouts of fish. This inefficiency of in-kind payments is what leads to people standing idly outside of low-income grocery stores, offering to buy groceries with food stamps in exchange for cash. Conditional welfare payments create economically inefficient gray markets. Participants lose time, money, dignity, and autonomy.

If I don’t make it out of the black hole of poverty, I will likely spend my last $5 on coffee rather than a final meal — buying a few crucial hours of hunger abatement and mental focus, and thus a last-ditch chance to happen upon a fishing pole. To a thoughtless and callously paternalistic observer, that dogged resourcefulness might look like a stupid choice.

Another friend recounts driving past an apparently-homeless man smoking a cigarette. My friend viciously rails about how stupid poor people are, “wasting money on cigarettes that cost $12 a pack”. I rail back at how unimaginative he is, presuming that anyone smoking a cigarette purchased it and did so without a valid reason. The man could have been gifted the cigarette by a passer-by, cleverly bartered for it, or bought it loose for next to nothing. If he bought it, it could be a once-in-forever indulgence, a substitute for medication he can’t afford, or a strategic means of managing gnawing hunger. Until you ask, you don’t know. The wise person — and the person whose political identity rests on belief in the complex and structural drivers of poverty and the recognition that there are hapless geniuses stuck in homeless shelters and lucky idiots inhabiting corporate board rooms — must reserve judgment.

None of this should feel so unrelatable. Nearly half of Americans will apply for a means-tested welfare program at some point in our lives. Of course, because of the stigma, many of us don’t know for sure who among our acquaintances and colleagues has done so. But a reasonable level of observational awareness would make it evident.

The medical field practices “paternalism in the name of autonomy”. By definition, illness involves some diminished capacity. Paternalistic medical treatments aim to restore patients’ autonomy. Admirably, physicians hand-wring over this issue, uncomfortable with the possible excesses of paternalism while keenly focused on their mission to preserve and restore autonomy. Social policy advocates should take a page from medical ethics. It would be wise to frame paternalism in social welfare as a means to an autonomous end — an ethically-challenging means to be employed only in limited circumstances and with great caution.