Let's Design an Institution

At this point, we have an account of good reasons. We also know that it applies to reasons for individuals and to reasons for communities. Thus, our guiding questions in taking choices often are how we see our past and who we want to be, as persons but also as a people.

What do these rather abstract conclusions entail for the design of a concrete institution? The best way to bring them to life will be to consider an example in detail. So let's design an institution together.

Suppose, political groups in a given state propose the creation of a new institution, public healthcare. To simplify, we consider a dichotomous choice. Either all pay privately for all their care or all pay collectively for everyone's care. In our private scenario, there hence are no state-funded emergency rooms, no infant vaccination campaigns, nor any of the other basic public health services that, to my knowledge, any contemporary state offers at least in larger cities. Healthcare is fully private. How could the proposed alterna-tive, fully public healthcare, further the public good? More precisely, what would be reasons to create this institution and what do these reasons imply for the institution's design?

In a political debate about the choice between all private versus all public healthcare, a proponent of universal care might see a variety of goods at stake and hence offer a variety of reasons. Table 6.1 lists some reasons and sorts them into Anscombe's three categories. These are mere examples; the list is by no means exhaustive. In the row below, you find the accusations that such a proponent might level against people who fail to see the proposed reasons as reasons. In the bottom row are the goods that, following the reasons in that column, will be realized through public care. Let's go through the details, starting with the reasons.

All three columns seem to offer plausible pro tanto reasons—whether or not you ultimately agree with any given one. Their purpose is neither to show that all states should have universal healthcare nor to evaluate particular reasons, but only to illustrate the form of correct reasoning about institutions.