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Is Health Care a Right?

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 President 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 healthcare.  Nevertheless, he argues that healthcare is not a “right,” but rather a “moral responsibility for an industrialized country.”

He begins his post provocatively: “Healthcare is not a right…I know this will piss off” many of my 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. Healthcare 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 healthcare, 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, human 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 which begin “Do unto others . . .”

When Jim II argues we should “use the government” to oversee healthcare, 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 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 healthcare, or for the relative cost-efficiency of universal healthcare, 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 healthcare; 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 Downs’ syndrome child who will need more care than he can “pay back” over the course of a lifetime—he is entitled to healthcare for humanitarian reasons. As healthcare economist Rashie 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.

What of the “Rights” and “Obligations” of Doctors?

Shadowfax’ argument then takes a shocking turn. Without fanfare, he acknowledges that he has some sympathy for “the common line of argument against universal healthcare” 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 healthcare 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 cohort—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, treating them and even admitting 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 US 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 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, and 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 ER 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 ER 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 over-reaching 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 healthcare a “moral obligation” is that it presents healthcare, 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 an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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Francisco Breshearsvaginal tighteningRMichaelGeewizHopi Recent comment authors
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Francisco Breshears
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También estoy en la misma situación y fue un alivio encontrar a alguien con experiencias similares.

vaginal tightening
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I was suggested this website by means of my cousin. I’m not certain whether or not this submit is written via him as no one else know such distinctive about my difficulty. You are amazing! Thanks!

RMichael
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RMichael

Hopi, please recall that Medicare is all but bankrupt. Also, Social Security is about to go belly-up. Every “great social experiment” placed before congress has been, sadly, just another treasure trove for them to loot. They express good intent at the start, but dig into the funds and use them on their pet projects elsewhere, depleating funds intended for other more altruistic activities. What would make anyone believe that congress would not do exactly the same thing with healthcare taxes and funds? The best measure of how some entity will be have tomorrow is how it behaved yesterday. Congress will… Read more »

Geewiz
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Geewiz

Wow, as I understand it then, basically everything in the world is a right! Everyone gets everything that may help society. And I am sure almost anyone can make a case to justify almost any good, service, action, or thought as having some tiny bit of societal benefit to someone.

Hopi
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Hopi

The semantics of “rights” is not the correct basis for the discussion of healthcare. When government provides “free” education, they do so to a limited extent so as to benefit the society as a whole. The same is true of many of the public goods that the government provides. When the government can come to a decision on what is the level of government provided healthcare that will benefit the society as a whole, we shall have such a system. I believe this was done under LBJ for those who survive past the age of 65, perhaps as an inducement… Read more »

dk
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dk

i agree w/the author

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Ms. Sanity
Guest

What an interesting thread. As someone married to a Brit, I’m here to tell you that all of our friends and family (in the UK and elsewhere where they have universal health care) would NOT trade their systems for ours (at least nine out of ten of the ones I’ve talked to/heard about, etc. would not.) The UK system is actually the one that I think is the only likely contender for a system in the US…. e.g. they DO still have “private insurance” and private care, for those that don’t wish to use the NHS for whatever reason. So,… Read more »

MD as HELL
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MD as HELL

This is great! This entire thread is wonderfully entertaining. Those of you who think people are enslaved when compelled provide care are correct. Those of you who think healthcare is a right are nuts. Those of you who think government can do anything better than the private sector are really nuts. Me? I am a 26 year ER doc. Same hospital and same ER. I am not gifted with time or prose, so just a list of inescapable truths: 1. No one has defined “healthcare”. I read about “basic care”, but no one has defined what they wish to provide.… Read more »

Greg
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Greg

It should be a right, just like speech. I am able to speak the truth, but don’t have the right to demand that others pay for my microphone.

Public Health Bugle
Guest

When addressing the argument of universal health care as a right or privilege, I don’t know of an immediate solution other than changing the society’s internal values – basic mental foundation – about health care. It doesn’t matter what external improvements you make on a home, it will collapse if the foundation is not laid properly. A shift in spending priories for the U.S must occur. As of now, the U.S. economy is based on capitalistic views and competitive mind-sets…leading to the recent economic disintegration. Currently, you have a government bending backwards to keep corporations out of a financial crisis… Read more »

Richard Ferreira
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Richard Ferreira

Mr. Hansen offers an interesting comment which is skewed to what many would view as a very fatalistic approach. In the offered comments, basically, he says that death is predetermined at birth and apparently chooses to ignore that the vast majority of infirmities are acquired and not inherited. The costs of healthcare in the first two and last two years of life do consume an inordinate amount of the total healthcare dollar. Is his comment pointing out that these are “wasted” or ill spent and that those dollars should not be spent? Aside from that he offers four questions to… Read more »

Rick Hansen
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Rick Hansen

Looking from the outside in, I find the healthcare industry totally wrapped around its axles. Medicare has been termed as an entitlement program, which begs the question “Why are individuals paying into a system they do not have access to until they are 65?” granted, there is a small percentage of individuals who get Medicare who have not paid into it. Next, with the shortages of providers, universal healthcare coverage will not solve the problems we face today as it will only cobble together the existing system (which is totally broke)and would lead to rationed care and extensive wait times… Read more »

Richard Ferreira
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Richard Ferreira

As a fellow physician (although retired) and as a former health insurance company executive, I want to commend Dr. Friedman for his comments. They are right on point and well stated. I may, as he points out, play with words. His words to describe the financial sector- “parasitic and excessive” are perhaps the best description I have seen and they fit the entire system. To those two words I would add WASTED. He points out that many insurers operate with 20% or greater overhead while Medicaid operates a 4%. I belive that on closer inspection one would discover a much… Read more »

R F Harding, MD
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R F Harding, MD

After reading Dr Friedman’s message, I would like to propose a national formulary be added to his list. There are very many “me too” medicines out there with dubious advantages over their predecessors. The various payors each have their own formulary requiring physicians to keep track of which brand names their patients are eligible to receive. Surely there is enough expertese in the nation to accomplish this.