By LUCAS RESTREPO, MD

“The primary ethical issue of modern medicine and public health is the outcome gap,” write Paul Farmer and Nicole Gastineau Campos in an essay published in 2004. Entrenched in “growing social inequalities,” this gap is immediately evident to every physician: poverty is inversely proportional to health. “The growing gap,” they elaborate, “constitutes the chief human rights challenge of the 21^st century.” The proliferation of people who never experience abuse of their civil rights, but lack access to medical care, has damaging societal implications: “what does it mean when an African-American neonate does not have ready access to a neonatal intensive care unit?” The answer is that “[w]henever more effective technologies are introduced there will be, in the absence of an equity plan, a growing outcome gap.”

Around the country, this gap is exploding. Surviving an illness may sometimes depend on the good will of kids. I kid you not. Carlos Olivas, Jr., a 12 year-old  boy, in view that Arizona’s cuts to Medicare meant certain death to a man who he had never met named Francisco Felix, decided to help, raising money in the street. Carlos’ empathy toward Mr Felix―at least in part―originates from the thought of finding his father (who has cirrhosis) in a similar situation.

A sense of responsibility toward others, as exhibited by this young man, is the foundation of all societies. Carlos is an exemplary citizen, proof that the Social Contract is an intuitive concept. His behavior is strictly rational: today, I’m strong and can help the weak; tomorrow, when I’m not as strong, someone will help me.

Strength means being able to confront the powerful. A strong government is concerned with the defense of the weak, as there is no need or merit in defending the strong. Carlos didn’t need induction to deduce that “might is not a right at all.”

Jan Brewer, Arizona’s Governor, has a different view. Based on a cost-effective analysis, she announced that Arizona’s local government will not try to save the lives of almost 100 citizens, including Mr Felix. As result of this calculus, two persons have died.

It is a blatant injustice to die so that accountants can balance a budget. These persons were abandoned by a government that ―at its most minimal expression―is supposed to protect them. When confronted about the fate of those denied transplants, Brewer, an advocate of States’ autonomy, rejoined: “ask the federal government.”

Keep AZ Safe, a website founded by the local government to shield their new immigration law against litigation, has collected so far $1.506.511 in donations from 32.593 people. This exceeds by $100.000 the cuts to Arizona’s transplant program. Frugal in the protection of life, overindulgent in the defense of the indefensible.

“Cost effectiveness are in fact ideological constructs,” assert Farmer and Gastineau Campos.

Farmer and Gastineau Campos also remind us that the poor “do not live in another planet,” which can’t be said of David Schweikert, another Arizona politician elected to the House of Representatives. In an interview with Eliot Spitzer, he agreed in principle that uninsured individuals receiving medical care in the Emergency Department should pay for their care. However, when Spitzer argued that a mandate to purchase insurance derives from the same principle, Schweikert replied that the mandate contradicts “the right as an American of being dumb.” I couldn’t find that right in the U.S. Constitution. Stupidity is generally regarded as an embarrassing and perilous shortcoming, rather than something that needs to be advocated or praised. Moreover, one can deduce from Schweikert’s wisdom, without logical fault, that the mandate is a smart thing to do, given that it runs contrary to being dumb. In spite of logic and Schwikert’s commendable concern for the rights of his electorate, the fact remains that stupidity isn’t why so many individuals lack health insurance.

Most uninsured people can’t afford premiums or co-pays, are unemployed, or not eligible for Medicare or Medicaid. Age, gender, area of residence, and race are unequivocal contributing factors. Reducing the problem to colorful remarks is unlikely to solve the problem, and sounds rather contemptuous.

I don’t like the mandate either, nor do most people who are polled. That is why it’s called mandate. No one likes to be told what to do. Hence, it isn’t surprising that the mechanism that will pay for health care reform is the least popular part of the bill. However, I am able of appreciating the merits and disadvantages of the mandate without evoking the imagery of concentration camps. The rational basis for the mandate is elegantly discussed by Rahul Rajkumar and Harold Pollack elsewhere.

Typically, the malaise generated by the mandate dwells on concerns about “personal” freedom – no matter how irresponsible or destructive it may be to others. We suppose that our own freedom is the only one that counts, pretending that our actions have no consequences upon others, near or far. This reminds me of a story recounted by Karl Popper about a man who expressed indignation over a court’s decision to restrain his freedom, to which the judge overseeing the case remarked: “the freedom of the movement of your fists is limited by the position of your neighbor’s nose.” The legislators of health care reform failed to explain that choosing not to purchase health insurance hurts fellow citizens. Liberty without responsibility is inherently antisocial.

Being dumb is not a right. Neither is being smart, but acting intelligently is more prudent than acting stupidly. Repealing health care reform without an alternative leaves 50.7 million people uninsured. And you, reader, will have to pay anyway when they become sick, which is a shame because many illnesses can be prevented or ameliorated. Greater clarity is needed if repeal is seriously contemplated by the House majority:

Repealing health care reform means that your insurance can be cancelled if you get sick.

Repealing health care means that people with preexisting illnesses won’t afford health insurance.

Repealing health care means that insurance companies will invest in health care about half of their earnings, instead of the 85% required by law.

Repealing health care means that we will neglect curbing the cost of your own health care.

More importantly, repealing health care means that the wealthiest country in the world will decide that its citizens have the right to receive health care only if they have money, perpetuating a two-tier system of rights based entirely on social class. The destitute will always pursue equality through any possible means. And history shows that these means, sometimes, are dangerously dumb.

You can help Mr Francisco Felix and others in need of transplant by clicking here.

Lucas Restrepo, MD, is a neurologist at the UCLA Medical Center (Los Angeles, California) and the Barrow Neurological Institute (Phoenix, Arizona). He received his medical degree from the Health Science Institute in Colombia, South America, and completed his residency training at Georgetown University in 2000 and fellowship at Johns Hopkins Hospital in 2002. His research interests include the pathophysiology and treatment of acute ischemic stroke, and the application of proteomic platforms to the diagnosis of Alzheimer’s disease. More information at: http://www.stroke.ucla.edu/staff/Restrepo_L/