Personal Health

Is Health Care a "Right" or a "Moral Responsibility"?

One thing is certain: Health care is not simply a privilege.
I have to admit I often have found the language of health care "rights" off-putting. Yet the idea of health care as a "right" is usually pitted against the idea of health care as a "privilege." Given that choice, I'll circle "right" every time.

Still, when people claim something as a "right," they often sound shrill and demanding. Then someone comes along to remind us that people who have "rights" also have "responsibilities," and the next thing you know, we're off and running in the debate about health care as a "right" vs. health care as a matter of "individual responsibility."

As regular readers know, I believe that when would-be reformers emphasize "individual responsibilities," they shift the burden to the poorest and sickest among us. The numbers are irrefutable: Low-income people are far more likely than other Americans to become obese, smoke, drink to excess and abuse drugs, in part because a healthy lifestyle is expensive, and in part because the stress of being poor -- and "having little control over your life" -- leads many to self-medicate. (For evidence and the full argument, see this recent post.) This is a major reason why the poor are sicker than the rest of us and die prematurely of treatable conditions.

Those conservatives and libertarians who put such emphasis on "individual responsibility" are saying, in effect, that low-income families should learn to take care of themselves.

At the same time, I'm not entirely happy making the argument that the poor have a "right" to expect society to take care of them. It only reinforces the conservative image (so artfully drawn by Ronald Reagan) of an aggrieved, resentful mob of freeloaders dunning the rest of us for having the simple good luck of being relatively healthy and relatively wealthy. "We didn't make them poor," libertarians say. "Why should they have the 'right' to demand so much from us?" Put simply, the language of "rights" doesn't seem the best way to build solidarity. And I believe that social solidarity is key to improving public health.

Given my unease with the language of rights, I was intrigued by a recent post by Shadowfax, an emergency department doctor from the Pacific Northwest who writes a blog titled "Movin' Meat." (Many thanks to Kevin M.D. for calling my attention to this post.) Shadowfax believes in universal health care. Nevertheless, he argues that health care is not a "right," but rather a "moral responsibility for an industrialized country."

He begins his post provocatively: "Health care is not a right. ... I know this will piss off" many readers, "but I wanted to come out and say it for the record. ... My objection may be more semantic than anything else, but words mean things and it is important to be clear in important matters like these."

Anyone who says that words are meaningful has captured my attention. I'm enthralled. After all, words shape how we think about things. Too often, we automatically accept certain words and phrases without realizing that they define the terms of the argument.

Shadowfax then quotes from a reader's comment on his blog: "Jim II said it well in the comments the other day: 'Rights are limitations on government power.'

"Exactly," writes Shadowfax. "When we use the language of 'rights,' we are generally discussing very fundamental liberties, which are conferred on us at birth, and which no government is permitted to take away: free speech; religion and conscience; property; assembly and petition; bodily self-determination; self-defense, and the like. Freedoms. Nowhere in that list is there anything which must be given to you by others. These are freedoms which are yours, not obligations which you are due from somebody else. There is no right to an education, nor to a comfortable retirement, nor to otherwise profit by the sweat of someone else's labor."

Normally, I would object: Americans do have a right to an education. But Shadowfax is defining our "rights" in a very specific sense: Our constitutional rights make us, as individuals, free from something -- usually, interference by government, our neighbors or the majority in our society.

Shadowfax then turns from the idea of rights to what people deserve: "Some societies, ours included, from time to time decide that its citizens, or certain groups of them, should be entitled to certain benefits. Sometimes this (is) justified by the common good -- a well-educated populace serves society well, so we guarantee an education to all children. Sometimes this is derived from humanitarian principles -- children should not go hungry, so we create childhood nutrition programs. Health care would, in my estimation, fall into the category of an entitlement rather than a right. ..."

Here, we are no longer talking about our rights as individuals; instead, Shadowfax is asking us to think collectively about what we all deserve simply by virtue of being human. These are what I would call our "human rights," which are quite different from our constitutional rights as individual citizens.

This is what Jim II is referring to when, after defining "rights" as "limitations on government power," he writes: "That said, I think it is immoral for someone's access to health care, politics, or justice to be dependent on how good a capitalist he or she is. And therefore, I think we should use the government to ensure that people from all economic classes are treated equally in this sense."

In other words, a person's access to medical care should not turn on just how skilled he is as an economic creature. While some of us are smarter, taller and quicker than others, as human beings we are equal.

In the economy, the swift will win the material prizes; but in society, humans possess certain "inalienable" rights to "life, liberty and the pursuit of happiness" simply by virtue of being human. These are different from a citizen's "right" to free speech -- a right that no government can take away. The framers of the Declaration of Independence believed that these "inalienable rights" are bestowed upon us by God. To me, this means that we have moved from the rule of law in the public sphere to the private sphere and those moral rules that begin "Do unto others ..."

When Jim II argues that we should "use the government" to oversee health care, and to "ensure that people from all economic classes are treated equally in this sense," he is saying that government should oversee that moral compact among men and women who recognize each other as equals. Here I would add that, when it comes to the necessities of life, a society that seeks stability and solidarity strives for equality.

Shadowfax goes on to point out that "our nation has long defined health care as an entitlement for the elderly, the disabled and the very young. We are now involved in a national debate whether this entitlement will be made universal. As you all know, I am an advocate for universal health care. Though there may be an argument for the societal benefit of universal health care, or for the relative cost-efficiency of universal health care, I support it almost entirely for humanitarian reasons. It needs to be paid for, of course, and that will be a challenge, but as a social priority it ranks as absolutely critical in my estimation. ..."

On this point, I don't entirely agree. In my view, there is a very strong argument to be made for the societal benefit of universal health care; if people are not healthy, they cannot be productive and add to the wealth of the nation. And there is an argument for cost-efficiency: If we don't treat patients in a timely fashion, they become sicker, and charity care becomes more expensive. But I would add that even if we are talking about a person who cannot be expected to add to the economic wealth of the nation -- say, a Down syndrome child who will need more care than he can "pay back" over the course of a lifetime -- he is entitled to health care for humanitarian reasons. As health care economist Rashi Fein has said: "We live not just in an economy, but in a society." And as a human being, that child can contribute to society by bringing joy to his family, or by being in a classroom with children who will learn from him.

Shadowfax's argument then takes a shocking turn. Without fanfare, he acknowledges that he has some sympathy for "the common line of argument against universal health care" which declares that, "with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call 'medical care' a right will merely enslave the doctors and thus destroy the quality of medical care in this country. ... It will deliver doctors bound hands and feet to the mercies of the bureaucracy."

Here, Shadowfax is quoting from a speech by Alan Greenspan's moral mentor, Ayn Rand, released by the Ayn Rand Institute in 1993 as a comment on the Clinton health plan.

In that speech, Rand denies that health care is either a right or an entitlement: "Under the American system you have a right to health care if you can pay for it, i.e., if you can earn it by your own action and effort. But nobody has the right to the services of any professional individual or group simply because he wants them and desperately needs them. The very fact that he needs these services so desperately is the proof that he had better respect the freedom, the integrity and the rights of the people who provide them.

"You have a right to work," she continues, "not to rob others of the fruits of their work, not to turn others into sacrificial, rightless animals laboring to fulfill your needs."

If I find the language of "rights" troubling, I find Rand's language terrifying. Shadowfax admits, "There's a lot not to like about this sentiment. But," he argues, "it has some limited validity. ..."

Shadowfax then turns to the predicament of his cohorts -- emergency room doctors. Under law, they are required to at least stabilize patients -- even if those patients cannot pay. And most often, physicians go well beyond stabilizing them; they treat them and even admit them to their hospitals.

"Only problem is," Shadowfax writes, "I and my colleagues are not caring for you out of the goodness of our heart, nor out of charity, but because we are obligated under federal law to do so. While this isn't exactly slavery, this coercion of our work product is essentially compulsory if you work in a U.S. hospital."

What I like about Shadowfax is that he then moves from complaint to a potential solution: "Universal health care, or, more precisely, universal health insurance, might improve upon the current state of affairs by ensuring that doctors are always paid for the services we provide, rather than being obligated to give them away to 15-30% of their patients as we now are. ... The typical emergency physician provides about $180,000 of free services annually," he adds, "just for reference."

I'm not sure that the average ER doc should be paid $180,000 more than he or she is today. (I would agree that, when compared to many specialists, ER docs are not overpaid -- and theirs is a very demanding job. But $180,000 seems a large sum; I don't know whether taxpayers could afford it.) Nevertheless, I agree that the current law regarding ER care is an unfunded mandate -- and one that hospitals located in very poor neighborhoods cannot afford. Moreover when ER doctors feel that they are being forced to deliver free care, many will be resentful. This is understandable, but it does not lead to the best care.

On the other hand, in a society where so many are uninsured, I do believe that physicians have a moral obligation as professionals to provide some charity care. They have taken an oath to put patients' interests ahead of their own. The problem is that the burden falls unfairly on those who are willing to work in emergency rooms or neighborhood clinics while many doctors in private practice simply shun the poor. We need a system that is fairer, both for patients and for doctors.

The answer, as Shadowfax suggests, is universal health insurance that funds emergency room care for everyone who needs it -- and, I would add, health reform that restructures the delivery system so that Americans don't have to go to an emergency room for non-emergency care.

In the end, I agree with Shadowfax that reformers need to think carefully about the language they use: "When advocates of universal health care misuse the language of universal rights to push for health care for all, we fall into the trap of overreaching and provoke a justified pushback, even from some who might be inclined to agree with us. Universal health care is, however, a moral obligation for an industrialized society, and will not result in the apocalyptic consequences promised by the jeremiads."

What I like about calling health care a "moral obligation" is that it presents health care not as a right that "the demanding poor" extort from an adversarial society -- or even as an obligation that the poor impose upon us. Rather, Shadowfax is talking about members of a civilized society recognizing that all humans are vulnerable to disease -- this is something we have in common -- and so willingly pooling their resources to protect each of us against the hazards of fate.
Maggie Mahar is a fellow at the Century Foundation and the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006).
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