Twenty years ago, I asked a friend’s father why he never bought any new clothes. The man replied, “If I did that, I’d have to work that much longer at a job I hate.” True to form, my friend’s father scrimped and saved on a working-class salary, and retired in his fifties.
Once unheard of, the goal of early retirement is now ubiquitous across the income range. Indeed, the public employees pension system makes news not just because it risks insolvency, but because people working in the private sector are shocked to discover that public employees have a better chance at early retirement than they do.
The numbers confirm the trend. From 1960 to 1990, the percentage of 62-year-old men in the U.S. labor force dropped from 75 to 55; among 58-year-old men from 83 to 72; and among 55-year-old men from 86 to 80. A similar trend has occurred among women. More telling is the change in people’s goals. In 1941, three percent of American men preferred leisure to work; by 1982, that number had shot up to 48 percent.1
Europeans show a similar trend. True, the American experience may be reversing now because of the economic downturn. People will have to work longer. But this fact makes news precisely because it goes against people’s expectations.
Indeed, a story is unfolding in the West about the future of capitalism, one with two main characters, Karl Marx and medical science. Marx believed capitalism’s days were numbered. He might have been right, had medical science not been there to rescue it.
Income inequality is not the issue
To understand how medicine solved the crisis of capitalism, one must first understand the nature of that crisis, which means understanding Marx.
Economic conservatives oppose Marx because they believe he preached income equality. Economic liberals believe the same thing about Marx, which makes them more sympathetic to him. Indeed, many self-described Marxists justify their monikers by supporting total wealth redistribution, thinking they follow in the prophet’s footsteps by doing so.
Both parties are wrong. Marx’s primary goal was not income redistribution but an end to alienation and the division of labor. According to Marx, man is a producer. He wants to produce. In the process he wants to complete himself as a human being. Capitalism, according to Marx, frustrates this longing. Occupational specialization (or the division of labor) condemns a worker to slogging away at one task while ignoring the other facets of his or her being.
For over a century liberals and socialists have condemned the income inequality arising from capitalism while pushing wealth redistribution as the corrective. Yet simply changing the capitalist mode of distribution while preserving the capitalist mode of production would have been unacceptable to Marx. Indeed, Marx scoffed at such efforts, since, despite having a little extra spending money, the poor person would remain stifled, or “estranged” from himself.
Capitalism has built enormous wealth over the past two centuries. It continues to do so. The weakness of liberal political parties, including today’s Democratic Party, remains their inability to generate economic growth. Because conservatives assume Marx is all about income inequality, and because liberals put their stamp of approval on this assumption, conservatives think they can ignore both Marx and the liberals, since economic growth trumps income inequality. To some degree this is true. But to keep capitalism viable, conservatives must also consider the “alienation” problem that Marx raised, which people across the ideological spectrum have forgotten.
Marx once said: “The worker is at home when he’s not working.” Only at home can a worker be a complete person and explore the different facets of his or her being, he argued.
The West exploited the loophole Marx gave it, avoiding social unrest by creating the welfare state and giving workers more time at home. The trend began in the 19th century with eight-hour workdays and weekends off; it continues to this day with family leave for child rearing.
But it was medical science that sealed Marxism’s fate. In 1900, average life expectancy in the U.S. was 47. Today, it is 79. Thanks to better medicine, people retiring in their late fifties and early sixties can hope to live another twenty years, “at home,” escaping the division of labor. No leftist politician has come close to medicine’s record in rescuing humanity.
This outcome was not the result of any concerted plan. When Social Security was passed in 1935, life expectancy was only 62 — three years less than when the benefit kicked in. In addition, the benefit was too small for most people to live on. When Medicare was passed in 1965, life expectancy was 70; thus, recipients were expected, on average, to receive benefits for only five years. The original intention behind these two pieces of legislation was not to help people escape the division of labor for twenty years, but to make life just a little less hard.
However, as medical science pushed life expectancy higher, not by curing people so much as by making it possible for people to live longer with chronic disease, a tidal change occurred. I say a tidal change as opposed to any crashing wave. Waves are obvious and everyone notices them. Debates over tax rates are crashing waves. So are debates over free trade. But the mass breakout from the division of labor went almost unnoticed. Medicine gradually lengthened life; the eligible age for receiving Social Security and Medicare barely changed; Social Security and Medicare benefits gradually increased; and the problem of alienation and the division of labor faded. Average citizens and even a few policy makers missed the event.
Increases in pension and health benefits for government employees also went unnoticed. In the past, average citizens fixated on government employee salaries, with those in the private sector comparing their annual earnings with those in the public sector. The unions understood this, which is one reason they focused more on increasing retirement benefits rather than wages — to fly under radar. As a physician in training during the 1980s, for example, I and other residents compared doctors’ pay in the public and private sectors; we didn’t even thinking of factoring in pension and health benefits. The private sector won hands down, making going into private practice a no-brainer. I observed similar behavior among prospective teachers. Public schools were often more attractive, but largely because they paid more in salary. The pension issue rarely came up. Indeed, at the time, it seemed almost “unmanly” for a 22-year-old to fuss over pension benefits.
Increasingly, people have a new outlook. They pin their hopes on the last twenty to 30 years of life after retiring. Today’s 22-year-olds are acutely conscious of pension benefits. Middle-aged people obsess about the issue. Across the different job categories I often hear people whisper: “What’s your number?” — meaning, how much money do you think you need to save in order to quit. Such money is sometimes called “F—k you” money, which is layman-speak for escaping the division of labor. These middle-aged people also obsess about their health benefits, for if life is geared towards its last 30 years, then people have to stay healthy to enjoy them.
Retirees in the U.S. often get what they’ve been promised. An enormous travel industry exists to take them places. Stifled artists, musicians, writers, and philosophers — people who lacked the chance to express the creative facets of their personalities during their working lives — can pursue higher education. Curiously, some parents can even enjoy parenting for the first time. As one formerly harried, now retired, professional explained to me, he missed watching his children grow up because he was always working; now that he’s retired he can watch his grandchildren grow up.
A new social contract
Iwas already a practicing physician when I began graduate school in political science. One day, a professor of mine yelled at me: “Why should doctors make so much money?!” It seemed unfair to him. Apparently, a Ph.D. is not an antidote to envy.
Since the age of Aristotle, philosophers have tried to devise a social contract that would contain the problem of envy. Democratic capitalism has based its contract on the doctrine of formal equality. In the economic sphere some people will be richer than others, which necessarily leads to an unequal distribution of goods, but everyone has the same right to vote, to run for office, and to express his or her point of view.
Still, economic inequality excites envy, as distributing goods on the basis of class seems unfair. A revision of the social contract took place during the middle of the 20th century, with liberal reformers speaking of “equality of opportunity.” Government leveled the playing field with subsidies, means-tested benefit programs, and new regulations, to neutralize the advantages of class. What arose was a system that distributed goods a bit more on the basis of merit. Yet this scheme also seemed unfair, since nature endows some people with more merit than others. Some people are born with more intelligence or athletic ability; these are random blessings. With neither money nor merit, some people have less chance at the good life, arousing considerable resentment.
Medical progress solved this problem, just as it solved the problem of the division of labor. Indeed, the two solutions are related.
With increased longevity, enjoying the good life need no longer turn on money or merit; instead, it turns on staying healthy, which most people have a shot at doing. If retirement comes early enough, a person can escape the division of labor; along with modest pension and health benefits, and time left to live (another vital commodity provided for by medicine), the person can also enjoy the good life. Although not a guarantee, this is medicine’s reasonable hope.
By structuring the social contract such that the good life is back-loaded, coming during a person’s retirement years, the problem posed by class and merit fades. Much of longevity turns on genes — and chance. Rich people can die young. Even smart and athletic people can die young. Poor, dumb, and untalented people have the same shot at longevity as rich and talented people, especially with medicine to help. If the good life turns on escaping the division of labor at age 55 and living another 30 years, as opposed to having the wealth and talent to get those goods early in life, then poor and untalented people have a chance at the good life. No reason to be envious. All one has to do is survive.
The new social contract has an inherent stability that the other contracts lacked. Under the old contracts, many have-nots knew they were destined to remain have-nots while still in their twenties. Filled with resentment, these people caused trouble, in some cases revolution. Under the new system, young have-nots have a reasonable chance of becoming haves; all they have to do is make it to age 55, when the benefits kick in.
The new social contract tracks medicine’s other influences on how we view life. Sociology looks at the life of an individual person as a series of social and emotional phases. For example, adulthood is broken down into several phases, including romance and building a career. Medicine, on the other hand, views the life’s arc of an individual as one long process called “aging.” People lose one percent of their brain function every year after age 30. Other organ systems exhibit similar decline. In medicine, adulthood is interpreted biologically rather than sociologically or psychologically. The social sciences have increasingly assimilated medicine’s approach to the lifecycle, as books on aging sit next to books on adulthood in college libraries.
A relevant application of the new thinking can be found in a recent and controversial Lancet article.2 Determining who under a system of medical rationing should get priority, the authors conclude that those with the most potential for “quality of life” should take precedence, with quality of life turning on three simple variables: age, life expectancy, and level of infirmity. The more subtle elements are removed from consideration. Quality of life turns on biology.
As with the new social contract, class and merit are eliminated from the equation. Indeed, Ezekiel Emanuel, one of the article’s authors, emphasizes this as a major advantage of the rationing plan. The old variables that went into determining the distribution of goods, and that aroused resentment — class, merit, race, and gender — are replaced with biological variables that even a poor, dumb, and untalented person can excel at. When a human being’s life quality is judged solely according to scientific markers, such as age, weight, and the ability to ambulate, the result is a lottery system of justice that traditional have-nots can live with, for now they have a lottery ticket.
The terms of the new social contract are simple: The longer one lives, the more happiness one gets, because the goods in life are back-loaded. Yet won’t people resent it if they find themselves too sick to enjoy retirement? What if they lose out under the new rationing plan because they have a chronic disease?
Medicine has a solution to this problem. It has contributed to the rise of a healthy lifestyle ideology that justifies and explains disease, thereby deflecting people’s anger. Popular medicine tells people that they have only themselves to blame if they fall ill and miss out during old age, because of their bad lifestyle habits. Do you drink alcohol, overeat, or under-exercise? If so, you only have yourself to blame for losing out; you didn’t play by the rules; it’s your fault that you didn’t live long enough to reap the benefits of the social contract.
Although the link between bad lifestyle habits and disease is often more association rather than direct causation, and therefore not scientifically justified, laypeople make the leap in their minds nonetheless, and doctors rarely disabuse them of their prejudices. Thus, in one fell swoop, medical science not only neutralizes the resentment of the have-nots, by making them feel responsible for their plight, but also helps to circumvent social unrest, since, by the time the have-nots realize they are have-nots, they’re too sick to revolt — or just plain dead.
If, as marx wrote, revolutions happen because man is a frustrated producer, then how has the capitalist West forestalled a revolt? Some Marxists argue that the West purposely changed man from a producer into a consumer, thereby deforming class consciousness. People will tolerate living stifled lives, the Marxists argue, if they can buy baubles to entertain themselves with. Indeed, the more people fuss over the differences between product labels, the better it is for capitalism, bemoan some Marxists.
Even if this were true, the era of obsessive consumption may be coming to an end. Many Americans are in debt. With persistent inflation, chronic high unemployment, and stagnant wages, consumption may not return to its earlier levels. Indeed, economists recognize consumption as having been one of the four major drivers of American economic growth over the last 50 years, along with investment, exports, and government intervention. Their plans for America’s economic future typically factor in consumption’s decline.
Without a culture of consumption to “deform class consciousness,” how will the capitalist West forestall a revolt among people still mired in the division of labor, years away from retirement? After all, as Marx predicted, the division of labor has grown more intense in the U.S. as capitalism has advanced. Americans work longer hours than ever before. At the same time, they want to be complete human beings. A classic example is the single mother who works ten hours a day, but who also desires to be a good parent, and perhaps have a romantic life too. Working and having “no life” is stressful, yet so also is working and trying to have a life.
Medicine has a solution to this problem, and it is a solution that both Marxists and conservatives detest, albeit for different reasons: psychoactive medication. “Stress,” the “juggling of too many balls at once,” the “job worries,” and the “I can’t sleep; I’ve got too many things on my mind” — all popular code phrases that capture everyday American life before retirement — are increasingly managed with psychoactive medication.
Prescription trends don’t lie. In the U.S., the rate of antidepressant treatment has increased from roughly six percent in 1996 to over ten percent in 2005, or from thirteen million to 27 million people.3 An additional five percent of Americans are on anti-anxiety drugs, such as Valium and Librium. At least fifteen percent of Americans are on mood-modifying drugs; some studies put it closer to twenty percent.
In addition, 60 million Americans suffer from insomnia. A quarter of all Americans use a sleeping pill or sleep aid at night.4 Finally, 90 million Americans reportedly suffer from chronic pain, with eight million of these people under treatment, often with psychoactive drugs such as narcotics and antidepressants, in part to manage the chronic pain, but also to manage the stress and unhappiness in life that exacerbate that pain.
Many Americans on psychoactive medication fit the official criteria for clinical depression, anxiety, or some other psychiatric disorder, but many Americans also do not. A broad continuum in American medicine stretches from true mental illness to everyday life trouble — the kind of trouble that a “stressed out” person might suffer, working ten hours a day, worrying about job security while also unhappy with work, and trying to find time for oneself. That the majority of people on antidepressants do not suffer from true clinical depression has been well documented. 5 In addition to psychoactive medication, there is the parallel world of psychotherapy to help ease people’s stress and unhappiness, in which 30 percent of Americans now participate.
The distribution patterns of psychoactive drug use support my picture of an overworked and “alienated” population dreaming of retirement and their escape from the division of labor. In the U.S., the most commonly prescribed drugs in the age 20 to 59 category are antidepressants, with analgesics running a close second. In some studies, antidepressant use peaks in the fifties. These people are working. In the age 60 and over category, however, the most commonly prescribed drugs are cholesterol-lowering medications.6 Retirement, it seems, is good for one’s mental health.
It’s not just that seniors are taking plenty of antidepressants, but taking even more cholesterol-lowering drugs. The rate of antidepressant use in depressed seniors is similar to that in depressed middle-aged Americans, but the prevalence of depression among middle-aged Americans is much greater. For example, the rate of dysthymia, or chronic low-level depression, increases dramatically among adult Americans starting in the early thirties, peaking in the age 45 to 59 age group, only to fall precipitously after age 60.7 Indeed, seniors have the lowest incidence of dysthymia among all age groups. Major depression exhibits a similar trend, with the incidence greatest among women age 18 to 45. Similar trends exist for anxiety disorders, with a peak incidence somewhere between early adulthood and middle age.8
Especially telling is the increased rate of prescription therapy for young adults with depression. Despite the fact that most American seniors have health insurance in the form of Medicare, and therefore access to doctors and prescription drugs, their rate of antidepressant prescription in cases of self-reported depression has decreased over the last decade, while young adults, who make up a large portion of the uninsured, and for whom getting care is often no easy thing, are the only age group to show an increasing rate of antidepressant prescriptions for self-reported depression. 9 That young adults exhibit this trend despite the hurdles put before them suggests a serious mental health issue.
Insomnia reveals a similar trend. One study has shown the younger the population, the greater the relative increase in the use of sleep aids over the last decade. From 1998 to 2006, the use of sleep aids in the U.S. increased 50 percent in the general population; among 25- to 34-year-olds it doubled; among 18- to 23-year-olds it tripled.10
These statistics mirror observations of everyday life in America. Many young and middle-aged adults drag themselves to work, follow rules and regulations, worry much of the day, and then go home, where they have just enough energy to drink a beer and watch television, or search on the web under “retirement planning” to partake of a little dreaming. Young and middle-aged women, in particular, feel the division of labor, torn as they are between their need to work and their desire to be with their families.
Many conservatives dislike the trend toward an increased reliance on psychoactive drugs. They believe these drugs are a substitute for character, and prevent the building of character. Marxists distrust psychoactive drugs for the same reason they distrust religion; they see them as an opiate for the masses. Strange bedfellows. The former support capitalism; the latter hate it; and yet both distrust a major means by which capitalism today sustains itself.
The future of capitalism
Ibelieve in capitalism. Many of this journal’s readers do, too. Then why am I writing as if we can learn something from Marx?
The fact that such a question is certain to be asked is in itself indicative of weakness typically more rooted in left-wing thinking. The intelligent conservative does not ask to be given reasons why he should read Marx and the Marxists. He reads them because they are important, and because they are on the other side. He learns from them and is sometime warned by them. The intelligent conservative makes use of Marxist insights, but for his own purposes. He learns from his adversaries about the strengths and weakness of his own position — and of theirs.
The leftist, on the other hand — though with some notable exceptions — has a strong tendency to neglect his adversaries and to dismiss even their most influential writings. Although conservatives should and do read Marx and Foucault, leftists often think they have nothing to learn from Tocqueville and Burke. Indeed, they often greet these writers with a sneer, which is why they consistently misunderstand and underestimate the forces opposed to them.
Marx is important to study because the medical solution to the problem of alienation and the division of labor is showing signs of unraveling at the very moment that problem is intensifying.
Many Americans today work long hours. The eight-hour workday is rare. Many Americans also work weekends. Spouses typically work. Indeed, people now spend so much time at work that they sometimes have “work spouses.”
Moreover, the division of labor is intensifying, causing work in some fields to become less rewarding. The change in the professions is particularly troubling, as revolutions begin not in the peasant and working classes, but typically in the professional and technical class. The U.S. has largely been spared labor unrest in this quarter, primarily because the professions have been walled off from capitalism. For much of the 20th century, the medical, legal, and academic professions, for example, were small islands of feudalism in a capitalist sea. Doctors, lawyers, and professors organized themselves; their pay structure resisted the laws of supply and demand; their work was varied and interesting, and came with a high degree of autonomy and self-supervision; their work gave them an opportunity to be creative and express the different facets of their personalities.
This is less the case now. A doctor who once could enjoy talking to patients at length now focuses on performing one procedure well, every day, to make a living. The division of labor in medicine is extreme. In addition, less than one-third of American doctors now go into private practice.11 Most physicians work for a salary in a traditional business structure where they can be hired and fired, as workers in the conventional capitalist economy are.
A lawyer who once had the luxury of exploring different projects now may spend an entire career on asbestos litigation, thereby facing the same extreme division of labor as doctors do. The legal profession has created a new and growing “proletarian” tier, as lawyers unable to find regular jobs increasingly work as “coders,” where a lawyer stares at a computer screen eight hours a day, checking off on documents that flash by.12 He or she is not much more than a glorified assembly-line worker — although with aspirations and expectations of being much more.
The academy has also added a “proletarian” tier, as the majority of professors in the U.S. are now adjuncts, or teach “course per contract.” These professors are paid an academic version of minimum wage; their responsibility is to teach, not to act on their creative inclinations in research. They, too, in their own way, are assembly-line workers — but again, with aspirations and expectations of being much more.
In today’s America, there is increasingly only capital and labor. The professions, the government job — all the old sinecures that let people avoid capitalism even while praising it — are either being eliminated or brought under the umbrella of capitalism.
Two centuries ago, in the age of Weber’s Protestant capitalist and Tocqueville’s individualist, this might have been less of a concern, since the culture then emphasized working more than the nature of any particular work. As Tocqueville notes, all jobs were considered equally honorable in 19th-century America, so long as the job was legal and the profit was large; few people spoke of career “fulfillment” and the need to express one’s “individuality” through work. This gave all jobs an air of resemblance. Today, Americans have different expectations. They don’t want to just labor. They want to labor in interesting ways. A job that avoids the division of labor is highly prized.
With work hours lengthening among the employed, and the division of labor intensifying, people’s great hope for salvation lies in early retirement — hence, the drive to retire in one’s fifties or early sixties. But the economic downturn makes this harder to do. Almost dialectically, medicine has solved the problem of alienation and the division of labor by increasing longevity, but has also sown the seeds of that solution’s demise, for society cannot pay for the very pensions and health benefits that the new longevity demands.
Granted that one can learn from Marx, without agreeing with his main argument, what is it that one can learn? It is that people can live with income inequality, and, indeed, many kinds of inequality, but they can’t live knowing that their life will forever be drudgery. On the major budget issue of the day — how to reform entitlements — policy makers face a choice between keeping the age of eligibility the same while means-testing benefits, or raising the age of eligibility while keeping benefits available to all, as they are now. Given the central role of retirement in Western society today as a means to escape the division of labor and to preserve social peace, every effort should be made to keep the age of eligibility the same, even if it requires means-testing benefits.
The stimulus of American life has always been money. American technique grew up and developed so that money might be made faster. Everything that brings in money develops, and everything that does not bring money degenerates and wilts away. On this principle America has raised itself to a high degree of welfare, leaving most of the world far behind. Yet the country is now facing its own reductio ad absurdum. It has everything needed for material contentment, yet it has come to pass that much of its population lives in a state of unrest. People fear they will have to choose between the basic good things in life — work, love, raising children, and self-development in the future. They look to retirement as their one chance in life at having it all. They want those last 30 years. They need those last 30 years. In the future, the stimulus of America will not be money but time.
1 Dora Costa, “The Evolution of Retirement,” American Economic Review 88:2 (1998). .
2 Govind Persad, Alan Wertheimer, and Ezekiel Emanuel, “Principles for allocation of scarce medical interventions,” Lancet 373 (Jan 31, 2009).
3 Mark Olfson and Steven C. Marcus, “National patterns in antidepressant medical treatment,” Archives of General Psychiatry 66:8 (2009).
4 Robin Lloyd, “Sleep Deprivation: The Great American Myth,” Live Science (March 23, 2006).
5 See Ronald W. Dworkin, Artificial Happiness (Basic Books, 2006). .
6gu Qiuping, et al., “Prescription Drug Use Continues to Increase,” nchs Data Brief 42 (September 2010).
7 “Dysthymic Disorder Among Adults,” available at www.nimh.nih.gov (accessed January 5, 2012).
8 Lee N. Robins and Darrel A. Regier, eds., Psychiatric Disorders in America (Free Press, 1991).
9 Jeffrey Harman, Mark Edlund, and John Fortney, “Trends in Antidepressant Utilization from 2001 to 2004,” Psychiatric Services 60:5 (May 2009).
10 Allison Russo, et al., “Prescription Sleep Aid Use in Young Adults,” report prepared by Thomson-Reuters (October 2008).
11 “Physician Employment Trends Will Force Payers, Hospitals and Vendors to Revise Business Strategies, According to Accenture Survey,” Accenture press release (June 13, 2011).
12 Vanessa O’Connell, “The Rise of the Temp Lawyer,” Wall Street Journal (June 15, 2011).