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Is There a Right to Health Care?
by David Kelley, Ph.D.
[Note: Dr. Kelley is the executive director of the
Institute for Objectivist Studies. This paper is
adapted from speeches delivered to the Medical
Action Committee for Education, Association of
American Physicians and Surgeons, National Order of
Women Legislators and Objectivist Club of Michigan.
This paper is copyright by the Institute for
Objectivist Studies, although permission to copy
this material is granted as long as it is copied in
full, including this copyright notice. For more
information, please see the note at the end of this
paper.]
Bill Clinton ran for president last year by
attacking the 1980s as a "decade of greed"--attacking
the leveraged buyouts and hostile takeovers engineered
by Wall Street financiers. I happen think this trend in
the 1980s was a good thing, a productive realignment in
American business. But be that as it may, the irony is
that President Clinton is now proposing a hostile
takeover of his own, a hostile takeover on a scale far
beyond anything that Wall Street capitalists ever
dreamed of, a hostile takeover of one seventh of the
nation's economy.I'm referring, of course, to his
recently announced plan for health care "reform."
The Clinton plan in its present form involves a
massive exercise of coercion against physicians,
employers, and patients alike. Most people will be
forced to do business through health insurance
purchasing cooperatives: government-backed monopolies
that collect payments from consumers and set the terms
on which producers can offer their services. Everyone
will be forced to buy health care through these
monopolies, with employers forced to pay the lion's
share of the bill. Physicians, hospitals, and HMOs will
be prohibited from dealing with patients directly; they
will be forced to offer their services through the
purchasing cooperatives, subject to highly restrictive
rules.
What has brought us to this state of affairs?
Socialism has collapsed in the Soviet Union. The
nations of Western Europe are trying to trim back their
welfare states, desperately looking for ways to
privatize. Yet in this country we are on the brink of a
massive increase in government subsidies and government
controls. Why?
The full story is a long and complicated one, but
the essential cause, I think, is simple. The essential
cause is the assumption that if people have medical
needs which are not being met, it is society's
responsibility to meet them. In the current debate over
health care reform, universal access has become the
unquestioned goal, to which all other considerations
may be sacrificed. The assumption is that the needs of
recipients take precedence over the rights of
physicians, hospitals, insurers and drug companies--the
producers of health care, the people who deliver the
goods--along with the rights of the taxpayers who are
going to have to pay for it. In other words, those with
the ability to provide health care are obliged to
serve, while those with a need for health care are
entitled to make demands.
Indeed, it is often said that the need for health
care constitutes a right. President Clinton campaigned
with the slogan, "Health care should be a right, not a
privilege." Opinion polls regularly show that the
belief in such a right is widespread, even within the
medical profession. The AMA's "Patient's Bill of
Rights" includes the statement that patients have a
"right to essential health care."
If health care is a right, then government is
responsible for seeing that everyone has access to it,
just as the right to property means that government
must protect us against theft. For the past thirty
years, the idea that people have a right to health care
has led to greater and greater government control over
the medical profession and the health care industry.
The needs of the indigent, the needs of the uninsured,
the needs of the elderly, among other groups, have been
put forward as claims on public resources. Government
has responded by subsidizing these groups, and
regulating physicians, insurers, and pharmaceutical
companies on their behalf. Now the Clinton
Administration proposes to make this right universal,
to create a universal entitlement, and to vastly expand
government control.
In this context, I can state my own point in a
sentence: there is no such right. I will show you why
the attempt to implement this alleged right leads in
practice to the suspension of the genuine rights of
doctors, patients, and the public at large. And I will
show why the concept of such a right is corrupt in
theory. I want to stress at the outset the importance
of this issue. The long-term direction of public policy
is not set by electoral politics, or by horse-trading
in Congress, or by this or that court case. In the long
term, at a basic level, public policy is set by ideas--
ideas about things are just and worthy, what rights and
obligations we have as individuals. The idea that
people have a right to health care is inimical to our
genuine liberties. The policies that flow from that
idea are harmful to the interests of doctors and
patients alike. To fight against those policies, we
have to attack their root.
Liberty vs. Welfare Rights
Let's begin by defining our terms. A right is a
principle that specifies something which an individual
should be free to have or do. A right is an
entitlement, something you possess free and clear,
something you can exercise without asking anyone else's
permission. Because it is an entitlement, not a
privilege or favor, we do not owe anyone else any
gratitude for their recognition of our rights.
When we speak of rights, we invoke a concept that is
fundamental to our political system. Our country was
founded on the principle that individuals possess the
"inalienable rights to life, liberty, and the pursuit
of happiness." Along with the right to property, which
the Founding Fathers also regarded as fundamental,
these rights are known as liberty rights, because they
protect the right to act freely. The wording of the
Declaration of Independence is quite precise in this
regard. It attributes to us the right to the pursuit of
happiness, not to happiness per se. Society can't
guarantee us happiness; that's our own responsibility.
All it can guarantee is the freedom to pursue it. In
the same way, the right to life is the right to act
freely for one's self-preservation. It is not a right
to be immune from death by natural causes, even an
untimely death. And the right to property is the right
to act freely in the effort to acquire wealth, the
right to buy and sell and keep the fruits of one's
labor. It is not a right to expect to be given wealth.
The purpose of liberty rights is to protect
individual autonomy. They leave individuals responsible
for their own lives, for meeting their own needs. But
they provide us with the social conditions we need to
carry out that responsibility: the freedom to act on
the basis of our own judgment, in pursuit of our own
ends; and the right to use and dispose of the material
resources we have acquired by our efforts. These rights
reflect the assumption that individuals are ends in
themselves, who may not be used against their will for
social purposes.
Let us consider what liberty rights mean in regard
to medical care. If we implemented them fully, patients
would be free to choose the type of care they want, and
the particular health care providers they want to see,
in accordance with their needs and resources. They
would be free to choose whether they want health
insurance, and if so, in what amounts. Doctors and
other providers would be free to offer their services
on whatever terms they choose. Prices would be governed
not by government fiat, but by competition in a market.
Since this is an imaginary state of affairs, no one can
predict what mix of private practitioners, HMOs, and
other sorts of health plans would emerge. But market
forces would tend to ensure that patients have more
choices than they do now, that they would act more
responsibly than many do at present, and that they
would pay actuarially fair prices for health insurance-
-prices that reflect the actual risks associated with
their age, physical condition, and lifestyle. No one
would be able to shift his costs onto someone else. In
a truly free market, I might add, there would be no tax
preference for obtaining health insurance through
employers, so most people would probably buy health
insurance the way they buy life insurance, auto
insurance, or homeowners insurance--directly from
insurance companies. They would not have to fear that
losing their job, or changing the job, would mean
losing their coverage.
So that is what liberty rights--the classical rights
to life, liberty, and property--would mean in practice.
The so-called "right" to medical care is quite
different. It is not merely the right to act--i.e., to
seek medical care, and engage in exchanges with
providers, free from third party interference. It is a
right to a good: actual care, regardless of whether one
can pay for it. The alleged right to medical care is
one instance of a broader category known as welfare
rights. Welfare rights in general are rights to goods:
for example, a right to food, shelter, education, a
job, etc. This is one basic way in which they are quite
different from liberty rights, which are rights to
freedom of action, but don't guarantee that one will
succeed in obtaining any particular good one may be
seeking.
Another difference has to do with the obligations
imposed on other people. Every right imposes some
obligation on others. Liberty rights impose negative
obligations: the obligation not to interfere with one's
liberty. Such rights are secured by laws that prohibit
murder, theft, rape, fraud, and other crimes. But
welfare rights impose on others the positive obligation
to provide the goods in question.
Health care does not grow on trees or fall from the
sky. The assertion of a right to medical care does not
guarantee that there is going to be any health care to
distribute. The partisans of these rights demand, with
air of moral righteousness, that everyone have access
to this good. But a demand does not create anything.
Health care has to be produced by someone, and paid for
by someone. One of the major arguments offered by
supporters of a right to health care is that health
care is an essential need. What good are our other
liberties, they ask, if we cannot get medical treatment
for illness? But we must ask, in return: why does need
give someone a right? Fifty years ago, people whose
kidneys were failing needed dialysis every bit as much
as they do today, but there were no dialysis machines.
Did they have a right to protection against kidney
failure? Was Mother Nature violating their rights by
making their kidneys fail without a remedy? It makes no
sense to say that need itself confers a right unless
someone else has the ability to meet that need. So any
"right" to medical care imposes on someone the
obligation to provide care to those who cannot provide
it for themselves.
If I have such a right, some other person or group
has the involuntary, unchosen obligation to provide it.
I stress the word "involuntary." A right is an
entitlement. If I have a right to medical care, then I
am entitled to the time, the effort, the ability, the
wealth, of whoever is going to be forced to provide
that care. In other words, I own a piece of the
taxpayers who subsidize me. I own a piece of the
doctors who tend to me. The notion of a right to
medical care goes far beyond any notion of charity. A
doctor who waives his bill because I am indigent is
offering a free gift; he retains his autonomy, and I
owe him gratitude. But if I have a right to care, then
he is merely giving me my due, and I owe him nothing.
If others are forced to serve me in the name of my
right to care, then they are being used regardless of
their will as a means to my welfare. I am stressing
this point because many people do not appreciate that
the very concept of welfare rights, including the right
to health care, is incompatible with the view of
individuals as ends in themselves.
I might add that the difference between charity and
rights is very well understood by the advocates of a
right to health care. One of their main arguments for
using the language of rights is that it removes the
stigma associated with charity. A right is something
for which you don't owe anyone any gratitude. But
notice the contradiction. The reason for proposing such
a right in the first place is the claim that certain
people cannot provide for themselves, and are thus
dependent on other people for their medical care. The
advocates of a right to health care then turn around
and insist on using the concept of rights to disguise
the fact of dependence, to allow the recipients of
government subsidies to pretend that they are getting
something they earned.
It is also worth noting that the Supreme Court has
never recognized a constitutional basis for any welfare
right, including the right to medical care. The Court
recognizes that the concept of rights embodied in our
legal system is the concept of liberty rights. Welfare
rights are a product of later movements to expand the
role of government beyond the original conception of
its role. In our constitutional system, there is no
requirement that the federal government provide health
care. Health care entitlements, unlike fundamental
rights like freedom of speech, have to be invented by
legislators.
Effects of a Right to Health Care
Unfortunately, our legislators have been equal to
the challenge. They have invented such entitlements in
spades. And that leads me to my next point. When
government attemopts to implement a right to health
care, the result will be the abrogation of liberty
rights. As with money, bad rights drive out good ones.
Let's review the major consequences of implementing a
right to medical care. I am going to use illustrations
from our current situation, but these consequences
follow inevitably from any approach: single payer,
managed competition, whatever.
1) To begin with, of course, the government has to
tax some people to pay for medical subsidies offered
to those it considers to be in need. So the first
consequence of implementing a "right" to medical care
is forced transfers of wealth from taxpayers to the
clientele of programs like Medicare and Medicaid. And
this will inflate the demand for health care
services. Offering free or heavily subsidized care is
inevitably going to increase overall use of the
health care system.
Figures from the early years of the Medicaid
program indicate the vast increase in demand that can
result. According to a Brookings Institution study,
in 1964, before Medicaid went into effect, those
above the poverty line saw physicians about 20
percent more frequently than did the poor; by 1975,
the poor were visiting physicians 18 percent more
often than the nonpoor. Again, before Medicaid, those
with low incomes had only half as many surgical
procedures as those with middle-class incomes; by
1970, the rate for low-income people was 40% higher
than for those with middle class incomes.[1] When
Medicare was instituted in 1966, the House Ways and
Means Committee estimated that by 1990, allowing for
inflation, the program would cost $12 billion; the
actual figure was $107 billion.[2] (Government
forecasts of the costs of entitlement programs are
never accurate. In many cases, like this one, they do
not even get the order of magnitude correct.)
2) The cost explosion leads to the second major
consequence of implementing a "right" to medical
care: restrictions on the freedom of health care
providers. During the debate over health care policy
in the 1960s, proponents of Medicare and Medicaid
assured doctors that they only wanted to pay for
indigent care, and had no intention of regulating the
profession. Abraham Ribicoff, then Secretary of
Health, Education, and Welfare, said: "It should be
absolutely no concern to a physician where a patient
gets the money."[3]
But of course the surge in demand for medical care
led to rapid price increases, along with abuses of
the system by clients of the government programs as
well as by unscrupulous doctors and hospitals. These
problems had to be addressed somehow, and the result
was a growing web of controls: Professional Standards
Review Organizations, diagnosis-related groups,
restrictions on balance billing, utilization reviews.
Under the managed care systems that have proliferated
in the effort to control costs, physicians have less
and less autonomy to act on their own best judgment
about what is best for the patient. Dr. Maurice
Sislen has written: "A huge, complex, policing system
has taken the place of what used to be the doctor's
responsibility to his patient. Probably only a
practicing physician can fully appreciate the
magnitude of the economic waste and moral degradation
involved."[4]
3) A third major consequence of implementing a right
to health care is the increased burden imposed on
consumers of health care--the ones who were
originally not in need of government subsidies. As
taxpayers, of course, they have to pay for all the
programs; that's point 1. But as consumers, they are
also affected by all the distortions of the market
which these programs create. Everyone pays the higher
prices caused by the inflation of demand for medical
services, together with the increased costs of
regulation and paperwork. As people are priced out of
the system, they are forced into managed care systems
that limit their choices of doctors.
Health insurance stipulations by states raise the
cost of insurance, and discourage employers from
hiring certain kinds of workers. For example,
"community rating" laws require insurance companies
to offer policies for the same price to all people,
regardless of age, lifestyle, or physical condition.
Since the actual risks depend on these factors, what
community rating means is that the young pay higher
prices to subsidize the elderly, the well subsidize
the sick, and those with healthy lifestyles subsidize
those with unhealthy ones. As an indication of the
kind of subsidy involved, community rating in New
York nearly tripled the cost of insurance for a 30-
year-old male.[5]
4) Yet another consequence is a growing demand for
equality in health care. If something is a human
right, after all, then it should be protected equally
for all persons. Our system is based on the idea of
equality before the law. Now if we plug into this
system the additional idea that we all have a legal
right to some good like health care, the natural
inference is that we all ought to receive that good
on a more or less equal footing. For example, in a
1989 survey for the Harvard Community Health Plan,
90% of the respondents said that everyone should have
"a right to the best possible health care--as good as
a millionaire." Here's another example, a statement
by Horace Deets, the Executive Director of the
American Association of Retired Persons: "Ultimately,
we must recognize that health care is not a
commodity. Those with more resources should not be
able to purchase services while those with less do
without. Health care is a social good that should be
available to every person without regard to his
resources."[6] And the Clinton plan is clearly
egalitarian. One of the explicit goals of the
proposal is to eliminate any "two-tier" system in
which some people are able to buy more or better
health care than others.
5) The fifth consequence--the last one I'll mention--
is the collectivization of health care, and of health
itself. Just as a mixed economy treats wealth as a
collective asset, which the government is free to
dispose of as it sees fit for "the common good," so a
collectivized health care system treats the health of
its members as a collective asset. Under this regime,
physicians no longer work for their patients, with
the overriding responsibility to act in their
interests. Instead, physicians are agents of
"society" who must decide the amount and the kind of
care they give an individual patient by reference to
social needs, such as the need to control costs in
the system as a whole. Indeed, even the individual in
such a system is urged to protect his own health not
because it is in his self-interest, but because he
has a responsibility to society not to impose too
many costs on it.
To summarize, then, a political system that tries to
implement a right to health care will necessarily
involve: forced transfers of wealth to pay for
programs, loss of freedom for health care providers,
higher prices and more restricted access by all
consumers, a trend toward egalitarianism, and the
collectivization of health care. These consequences are
not accidental. They follow necessarily from the nature
of the alleged right.
Clinton Plan
The same is true of the Clinton Administration's
plan--true on a much larger scale. This plan will be
far more destructive of our liberties than anything we
have experienced so far.
The plan calls for a further extension of health
care subsidies: to those who are currently uninsured,
and to those who have health coverage less extensive
than the proposed standard package of benefits. Where
are these subsidies going to come from? The
Administration has rejected the so-called "single-payer
system"--that is, overtly socialized medicine, in which
the government pays all the bills--because it knows
that the government cannot pay all the bills. The
necessary tax increases would be politically
impossible. So the Clinton plan calls for a nominally
private system in which regulations force some people
to subsidize others.
At the heart of the plan are the health alliances:
government-protected monopolies in each area which will
collect premiums and negotiate with health care
providers to offer acceptable plans. Everyone who lives
in a given area will be forced to obtain health
insurance through their local monopoly health alliance.
Health care providers--private practitioners, HMOs, and
others--cannot deal directly with individuals. They can
offer their services only through the health alliances,
subject to the conditions it imposes.
One such condition is guaranteed access: every plan
must be willing to accept any individual who wants it;
no one may be excluded for any reason. Another
condition is community rating: the price of the plan
must be the same for everyone. Now think about what
effects this will have on incentives. If I know that
when I get sick I will be able to enroll in any plan I
want, at a price that does not reflect my condition,
then I have no reason to obtain health insurance when I
am well. If people are free to choose whether or not to
obtain and pay for a policy, the only people enrolling
will be the sick, and costs will go through the roof.
So the system works only if everyone is forced to
participate. That is exactly what the proposal
requires, and although the details of the proposal keep
changing, this is one point that cannot change.
At the national level, the system will be governed
by a National Health Board whose two main functions
will be to determine the standard package of minimum
benefits, and to set global budgets. The global budgets
will force the health alliances to impose what amount
to price controls on medical providers. And the
standard package of benefits will be set by interest
group lobbying, as every group in the health care field
will try to get its services included in the package.
For example, the current definition of the package
includes mental health and substance abuse counseling.
You may feel that you do not need insurance for these
services, but you are going to pay for them.
In short, the plan will require a massive exercise
of coercion against individuals, far beyond anything we
have seen so far. Which brings me back to the
fundamental issue.
Moral Foundations
In all the ways I have described, any attempt to
implement a "right" to health care necessarily
sacrifices our genuine rights of liberty. We have to
choose between liberty rights and welfare rights. They
are logically incompatible. It is because I believe in
the rights of liberty that I say there is no such thing
as a right to health care. So I want to end by
explaining why I think the rights of liberty are
paramount, and by trying to anticipate some of the
questions and objections you may have.
The rights of liberty are paramount because
individuals are ends in themselves. We are not
instruments of society, or possessions of society. And
if we are ends in ourselves, we have the right to be
ends for ourselves: to hold our own lives and happiness
as our highest values, not to be sacrificed for
anything else.
I think many people are afraid to assert their
rights and interests as individuals, afraid to assert
these rights and interests as moral absolutes, because
they are afraid of being labelled selfish. So it is
vital that we draw certain distinctions. What I am
advocating is not selfishness in the conventional
sense: the vain, self-centered, grasping pursuit of
pleasure, riches, prestige, or power. Genuine happiness
results from a life of productive achievement, of
stable relationships with friends and family, of
peaceful exchange with others. The pursuit of our self-
interest in this sense requires that we act in
accordance with moral standards of rationality,
responsibility, honesty, and fairness. If we understand
the self and its interests in terms of these values,
then I am happy to acknowledge that I am advocating
selfishness.
We have to draw the same distinctions when we think
about altruism. For it is, in the end, the moral code
of altruism that makes people think that need is
primary, that need gives one a right to the ability and
effort of others. In the conventional sense, altruism
means kindness, generosity, charity, a willingness to
help others. These are certainly virtues, so long as
they do not involve the sacrifice of other values, and
so long as they are a matter of personal choice, not a
duty imposed from without. I might note in this regard
that physicians have historically been extremely
generous with their time.
In a deeper, philosophical sense, however, altruism
is the principle that one person's need is an absolute
claim on others, a claim that overrides their interests
and rights. For example, Dr. Edmund Pellegrino has
asserted, in an article for _JAMA_, "A medical need in
itself constitutes a moral claim on those equipped to
help."[7] This principle has often been asserted by
thinkers who are opposed to individualism, and it is
the basis for the doctrine of welfare rights. It is the
reason why advocates of government involvement in
health care can take for granted that the needs of
patients are primary, and that everyone else can be
forced to provide for those needs.
No rational basis for this principle has ever been
offered. The fact is that our needs have to be
satisfied by production, not by taking from others. And
production comes from those who take responsibility for
their lives, who apply their minds to the challenges we
face in nature and find new ways of meeting those
challenges. Ayn Rand said it best, in her novel _The
Fountainhead_: "Men have been taught that the highest
virtue is not to achieve, but to give. Yet one cannot
give that which has not been created. Creation comes
before distribution--or there will be nothing to
distribute. The need of the creator comes before the
need of any possible beneficiary."[8] The creator's
need, in any field, is the freedom to act, the freedom
to dispose of the fruits of his labor as he chooses,
and the freedom to interact with others on a voluntary
basis, by trade and mutual exchange.
That freedom is a vital need, not only for doctors
but for patients. It is only in a context of freedom
that one person's need is not a threat to others. It is
only in a context of freedom that genuine benevolence
among people is possible. It is only in a context of
freedom that the medical progress which has brought so
many benefits to all of us can continue.
The problems of our current system were caused by
government. More government is not the solution. But we
must oppose the expansion of government control in
principle, by rejecting spurious claims of a "right" to
health care, and insisting on our genuine rights to
life, liberty, property, and the pursuit of happiness.
REFERENCES
1 Karen Davis and Cathy Schoen, _Health and the War on
Poverty_ (Washington: Brookings Institution, 1978),
cited in Terree P. Wasley, _What Has Government Done to
Our Health Care?_ (Washington: Cato Institute, 1992),
61
2 Steven Hayward and Erik Peterson, "The Medicare
Monster," _REASON_, Jan 1993, 20
3 Quoted in Leonard Peikoff, "Doctors and the Police
State, _The Objectivist Newsletter_, June 1962, Special
Supplement
4 _The Wall Street Journal_, Jan. 10, 1990
5 Michael Tanner, "Laboratory Failure: States Are No
Model for Health Care Reform," _Policy Analysis_ #197,
September 23, 1993 (Washington: Cato Institute, 1993)
6 Letter to the Editor, _The Wall Street Journal_, Dec.
23, 1992
7 Edmund D. Pellegrino, MD, "Altruism, Self-Interest,
and Medical Ethics," _Journal of the American Medical
Association_, 258, Oct. 19, 1987, 1939
8 Ayn Rand, _The Fountainhead_ (New York: Bobbs
Merrill, 1943), 712
Institute for Objectivist Studies
Founded in early 1990, the Institute for Objectivist
Studies has become a widely recognized center for
research and education on Objectivism, the philosophy
originated by Ayn Rand, author of _The Fountainhead_
and _Atlas Shrugged_, among other works of fiction and
non-fiction. Objectivism is a secular world view which
stresses reason, individualism, respect for
achievement, and liberty.
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For more information, contact:
Donald Heath, Director of Operations
Institute for Objectivist Studies
82 Washington St., Suite 207
Poughkeepsie, NY 12601
phone: (914) 471-6100, fax: (914) 471-6195
Email: MCI:IOS, MCI:588-5921 or IOS@mcimail.com
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