One very, er, healthy aspect of the debate about Paul Ryan’s proposals for Medicare (and the entire budget for that matter) is that it has stimulated a long-needed reality-based debate about the role of government. It has shaken some of us out of lazy ideology into more pragmatic choices. For the moment, though, let me take a stab at the Big Picture and work back from there. In 2011 we live in a world even our parents could barely dream of. We have the medical capacity to bring Gabby Giffords back to life even after a bullet has gone straight through her brain; we have the scientific ability to model a retrovirus on computers and get to real world treatments in years rather than 418px-Tree_of_Knowledge decades; we are able to give wounded soldiers new limbs and tell cancer patients that hope is real and not be lying. We can map the human genome and devise revolutionary new treatments for previously fatal conditions; and we can extend life beyond any previous human generation’s imagination. Remember all those old black and white movies where you saw scenes in which the father of a sick child simply says “we don’t have the money for the operation.” And little Johnny dies. How far away that passive stoicism now seems. Within a few decades, what was once taken as fate is now rejected as a moral obscenity. Because, given what we have achieved in those decades,  it is a moral obscenity. We are all physical beings and we are never as equal as when we face sickness and mortality. Because we have so feasted on the tree of knowledge, it becomes morally intolerable to prevent its fruit from being given to all. At the same time, as a matter of economics and mathematics, we also know at the back of our minds that we simply cannot give it to all – because these breakthroughs involve huge investment, highly trained experts, and inherently expensive technology. And as the options for health grow, we are forced to make choices that were previously out of our grasp, and those choices make us, in some way, gods. We collectively decide who can live for how long and who can die – because for the first time in human history we really have that choice. In fact, we have no escape from that choice. Healthcare is no longer triage, where sickness and death is the norm; it is an open-ended, blurry range of positive choices, where wellness is the expectation. At some point, then, we have to ration. You see this in socialized systems as well as hybrid ones. In Britain, the National Health Service confronts medical opportunities unknown when it was set up sixty years ago. And so, as the years went by, you saw more waiting lists and more de facto rationing – or a spending splurge under Blair and Brown that was simply unsustainable, and ended in piles of debt. Nonetheless, Cameron is refusing to cut from the NHS – which makes the cuts elsewhere all the more draconian. Why? Because he is a decent chap who has seen family illness upfront, and cannot really deny his fellow human beings the ability to rescue their infant from early death or cure a loved mother or keep someone with HIV or Parkinson’s as healthy as possible. In the US, you see the same process – but where no single entity gets to dictate the outcome. The result? Each agent passes the buck to everyone else – from insurance companies to doctors and hospitals to patients and back to government and then back again. And so instead of rationing by government, we have soaring healthcare costs as the least worst option. We can try to find efficiencies to make these god-like choices less onerous, but it often feels like running down an up escalator. We’re lucky if we merely stay in the same place. In fact, we have long since been going backward – hence the alarming projections of healthcare spending essentially crowding out every other economic or government activity in a few years’ time. We can try to increase efficiencies – and the ACA has not been fully credited with the many good ideas and experiments buried inside it. Or we can do what Ryan proposes, which is essentially severing the whole idea of an entitlement to good health, and turn it into a simple lump sum for seniors, after which they have to pay for themselves or have less health or longevity. Ezra Klein is right to remind us of the distinction here.

Only the ACA is really trying to deliver more efficiency; the Ryan plan simply shifts the responsibility for someone’s health after a given point from government to individuals.

Both proposals therefore make some sense to me. But Obama’s is both more humane and less ambitious in its attempt to solve the basic dilemma. My fear is that the ACA’s admirable experiments in cost control, even if they work, simply will not save enough money to alter the basic reality. And so we can either tackle the widening discrepancy between our expectations and our means politically through a government appointed rationing board or economically through the market. The market feels more manageable and at the same time more callous to me – because to make these choices consciously through the political process turns politics into a citizenry’s version of Sophie’s Choice. Yes: at some point, if you really wanted to hyperbolize and demonize such proposals, you could call these decisions “death panels” for those without great wealth. But the alternative is really hidden death panels, where the market makes the cut, and not the government.

My fiscally conservative mind sees some variation of the Ryan option as the only long-term viable one. You just, at some point, choke off the supply and force human beings to go without. And that’s where my Christian-informed conscience rears its benign head. As a human being, I find it extremely hard to deny another human being the ability and means to cure their sickness, if it is available. Health, one recognizes, is not like other goods; it is the precondition for all such goods. Going without chemotherapy is not like going without an iPad 2, or a car. There is, in other words, an inherent tragedy here. Accepting that tragedy is the first step to trying to ameliorate it. Because we can ony ameliorate this dilemma; we cannot resolve it.

We are humans; but we have no choice now but to play God. And people wonder why in Genesis, partaking of the tree of knowledge is regarded as a fall. This is our fate as truly modern humans.

I don’t really think it’s a fate we can ultimately handle.

(Painting: The Tree of Knowledge by Lucas Cranach.)