Is Healthcare a “Right” or a “Moral Obligation”?

I have to admit I often have found the language of healthcare “rights” off-putting.  Yet the idea of healthcare as a “right” is usually pitted against the idea of healthcare 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 healthcare as a “right” vs. healthcare 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

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.

46 thoughts on “Is Healthcare a “Right” or a “Moral Obligation”?

  1. As an nation founded in part on Judeo-Christian ethics- rather than health care defined as a “right”-I too prefer the concept of moral or ethical obligation of our nation to provide some level of basic quality affordable health care to all our citizens.
    But too much medical paternalism where the infantilized citizen has no responsibilty for their own health whatsoever is also counter-productive.
    That said, I believe our current excesses of the “free market model” of US health care is both unethical and immoral.
    Dr. Rick Lippin

  2. Rick–
    I believe that people who can take better care of themselves should.
    But as you know, all of the reserach shows that self-destructive behaviors are concentrated among poorer people–many of whom just don’t have the wherewithal–or the hope–to take care of themselves.
    I’m so tired of our society blaming the poor for being poor. They need help rather than condescending criticism.
    Meanwhile, as Dr. Steve
    Schroeder points out, we pour money into improving the health of the upper-middle class and upper-class–needless angioplasties, etc.–rather than putting the money into free smoking cessation clinics, really healthy appetiziing lunches in public schools and other public health measures . ..
    The relatively affluent 55-year-old who is 25 pounds overweight is not our big problem. (And I agree that it’s up to that 55 year old to lose the weight–or not. Ideally his employer might help partially subsidize his gym membership.)
    But our big public health problems are the crack babies, the very fat 11-year-olds living on carbs and fats (because that’s what their families can afford) with no good place to exercise, who will grow up to be truly obese, and the 20-year-old who can’t find a job and has already developed a serious drinking problem which leads him to begin abusing his wife and maybe his kids. . .
    Then there are the vets returning home who aren’t getting the psychiatric help they need. . . .

  3. I understand the argument about enslaving healthcare providers by forcing them to do something in lieu of other more selective and lucrative endeavors, and that is a powerful argument for the moral aspect of universal healthcare versus a right to be inflicted on providers. However, I also see that all humans are relatives of the past generations whose suffering and dying has given the knowledge base that allows healthcare providers to know how to make their livings in the first place. This history and trail of generational suffering to gain the current state of knowledge is also a powerful argument for universal and fair access for all to this knowledge base because everyone’s relatives contributed to this critical knowledge base through their life-death experiences.
    Just a further thought.

  4. Coincidentally, I recently attended several bioethics presentations which addressed this question.(link at my name goes to post with essential primary source material about human rights and health care)
    Health care is enunciated as a right in the Universal Declaration of Human Rights, and this year is the 60th anniversary of that. The US is a signatory.
    Moreover, it is largely argued that the Constitution did not enumerate all rights, allowing for the borad classes of rights to be determined in the context of the times.
    The US is the sole western society without some sort of universal health care.
    And the track record of the VA health care system demonstrates that its patient outcomes are superior to civilian health care, more cost efficient, and more accessible.
    That’s one system already in place that could theorectically be expanded to cover all Americans under a government controlled system. Medicare, on the other hand, has about a 3% administrative overhead, and it could theoretcially be expanded to serve as the single payer source for a universal healthcare system.
    The military health system covers 9 million – active and retired service members and their dependents across all branches.
    Finally, health is a nebulous term, but generally thought to be predicated on the ability of poeple to eat nutritious foods in adequate amounts and safely prepared, drink clean water, breathe clean air, attend work and school, attain and maintain safe shelter and access reliable transportation. So HHS and the extant public health system should always be included in any notion about health care rights and policy/programming.
    From a utilitarian point of view, providing healthcare to everyone makes sense as it maintains a critical level of productive workers and members of society. As health care is denied or is inaccessible, so do communicable disease rates rise and risk to all increase, along with rising catastrophic and complex health care service costs, lower productivity and less effective global market place competition.

  5. No one has a right to health care. The strong do have an obligation to care for the weak – at least in a civilized society.

  6. Since I’ve been preaching about the amorality of economics recently I like casting health care in moral terms.
    However, we still need to de-obfuscate the discussion by making it clear that the goal is universal health care, not insurance.
    Insurance is a means to an end. The USSR didn’t use an insurance scheme to provide universal care, it used socialized medicine.
    Other countries also have mechanisms to provide care that bypass insurance. There is only one purpose to insurance, to spread risk over a large pool of people.
    If the care is universal and the costs are covered by some general collection scheme then there is no need for an insurance layer. The collection scheme provides the risk balancing.
    I realize that in the current climate there is almost no chance of getting universal access to care implemented. Both parties are just fiddling with tax rebates and programs to pay for those currently missed. But there is no reason to make their avoidance of the real goal any easier by falling into their misleading use of words.

  7. If we can provide education, why can’t we provide healthcare in the same manner? It boils down to how this is funded. It would seem to me that providers would be paid employees, just like teachers and principals and school bus drivers are.

  8. United Protection (AKA Single Payer) health coverage may not BE a right, but it simply IS right.

  9. The ongoing debate about right versus privilege is one that is not likely to be resolved because the terms do not reflect the true issues about healthcare. At the Colorado Medical Society, the physicians selected policy that supports healthcare as a “societal obligation”. Healthcare is not an entitlement; nor is it correct to put it in a judgmental category by claiming it is a moral obligation. Essentially, health care that is not universal jeopardizes both the physical health and economic health of everyone in the community. The best example of this is policy that is directed at universal immunization for children. Despite wide variation in political philosophy, most people support childhood immunization without which we would see devastating recurrent epidemics of polio, diphtheria, smallpox and other diseases that have been almost completely eradicated. Immunizations provide “herd immunity”, which is a protection to the group as a whole by keeping the incidence of exposure negligible. Recognizing that funding, misaligned incentives, overutilization and other barriers are significant hurdles, healthcare as a societal obligation is an absolute imperative.

  10. I would like to offer a couple of thoughts on this.
    Maggie often makes the point about solidarity being a critical value among Canadians and Western Europeans that drives much of their social policy including their approach to financing health insurance with tax dollars. If we could wave a magic wand and import European solidarity and taxpayer financing in order to provide universal health insurance coverage in the U.S., our healthcare system would probably wind up costing at least $150 billion and perhaps, $200 billion more than its current actual annual cost of $2.2 trillion. As Maggie has also written, the claims by single payer advocates that huge amounts of money could be saved on administrative expenses are wildly overstated and, in any case, would only occur once and would do nothing to bend the medical cost growth curve.
    I think two key differences between the U.S. and Western Europe (and Canada) in the way healthcare is practiced and delivered are the litigation environment which drives widespread defensive medicine throughout the system and much more intensive practice patterns in the U.S., especially in hospitals. If we could export our litigation environment and our hospital based practice patterns to other countries, I would bet a lot of money that their healthcare costs would skyrocket. I’m not just talking about end of life care either. People here often feel entitled to everything that medical science and technology can offer no matter how futile the prognosis or how low the probability of success. Indeed, there was an article referenced in Fierce Healthcare a few months back that claimed that the poor actually demand more aggressive treatment at the end of life than other segments of society. Is this what they have a right to and what we should all be expected to pay for? My answer is no.
    We all know about the widespread variations in practice patterns that CMS and other insurers continue to pay for. We know that CMS rewards resource utilization (fee for service) and not value while all other insurers shadow Medicare’s payment policies. Where are the doctors and hospitals on practice pattern variation? Where are they on episode pricing for expensive surgeries? They’re nowhere to be found because sensible reform in these areas would reduce their income, and we can’t have that, can we? I think doctors and hospitals and trial lawyers need to step up. If we could reform our medical dispute resolution system, sharply reduce practice pattern variation, develop episode pricing, at least for expensive surgical procedures, and adopt a more sensible approach to end of life care, then maybe we could actually afford to provide universal health insurance coverage without driving our tax burden through the roof.

  11. Thank you all very much for your comments.
    This is a good point.
    All of our forebears contributed to the database that gave us modern medicine.
    I’m not sure that this would persuade doctors that
    this is a reason why they should contribute their skills, free of charge. After all, their relatives also contributed. More to the point, in the past many physician/scientists experimented on themselves in their quest for knowledge. And some paid with their lives.
    (I think the straight humanitarian argument is more powerful with most providers.)
    But the fact that “everyone’s relatives contributed to this critical knowledge base through their life-death experiences” is a strong argument for “universal and fair access for all to this knowledge base.”
    I can understand why you want to hold onto the idea of health care as a “right”– and I realize that the INternational definiton of Human Rights defines health care as a “right.”
    But I have to say I like turning the arugment from one about “rights” to one about “moral responsibilty” because this is, I think, really a question of morality. Yes, it is someting that you can legislate, but unless the majority of people truly feel that all human beings deserve health care,
    legislation won’t do the trick.
    And I think that Shadow fax has a point: we lose some people who would agree with us when we cast healthcare in terms of rights. (See Bill’s comment.)
    I agree that “public health” should be at the center any discussion about healthcare “rights”— or our obligaions to others.
    And definitely,as I said in the post, I think you
    can make the argument that society should ensure healthcare for all ib purely utilitarian grounds–talking about productivity, etc.
    Thanks for your comment. I think it illustrates what Shadowfax says– that if we use the language of “rights” we risk losing supporters who would agree with us on purely humanitarian or compassionate terms. As you say, “the strong should care for the weak.” As you seem to understand, the weak did not choose to be weak.
    You write: “Since I’ve been preaching about the amorality of economics recently I like casting health care in moral terms.”
    Yes, that is what I like too. At the end of the day universal healthcare is not an economic problem that has to be justified by arguing that healthcare will lead to greater productivity.
    Our willingness to provide healthcare for all is a matter of morality–and declaring that we really are a civilized society.
    I completely agree that we need to distinguish between health insurance and health care. That has become clearer and clearer to me over the past year, expecially as I attend conferences and hear some reformers talk on and on about the importance of universal coverage, without seeming to be too concerned about whether that converage will provide equal access to high quality care.
    I find that more and more younger doctors coming out of med school would prefer to be on salary– working for large integrated medical center or a hospital– rather than working fee-for-service in small practices where they have all of the headaches of running a small business.
    Today’s it’s an economic model that just doesn’t work very well, particularly given the cost of healthcare IT.
    Some doctors may continue to prefer to work in small practices, but those small practices will probably band together in “virtual networks”–and more and more of their pay is likely to be for keeping a certain number of patients well–and ensuring good outcomes when thsoe patients are sick– rahter than paying them, fee-for service, for the volume of things they do to those patients.
    This isn’t how healthcare evolved in this country because, unlike education, healthcare had a very strong union–really a guild–the AMA.
    And the AMA felt very strongly that every doctor should work for himself and receive all of the profits from his own labor.
    Today, we realize that 21st century medicine must be a team sport. It’s too complicated for doctors to practice solo. They need to collaborate with each other.
    B. Spoon– I too like single-payer. But today 85 percent of Americans have
    private insurance through their employer.
    The only way to move directly to single-payer is to force them all to give up the insurance they have and switch to governemtn -run insurance. (Otherwise the only people in the government’s single-payer plan would be the poor and the unisnured. We need to have those higher-paid employees who have good employer-sponsored coverage in the pool too–otherwise taxpayers won’t be able to afford to fund single-payer.The difference in administrative costs is only a tiny part of total costs.
    This is why I would prefer a plan like Obama’s that gives people a choice between a govt’ plana dn private plans. Ultimately, I’m quite sure more and more people will gravitate toward the public plan which should be able to give them better care at a lower price.
    But we have to let Americans CHOOSE a single-payer (government) plan. If we try to impose it on them, they will revolt. And their Congressmen won’t vote forit.

  12. Lynn–
    I agree that casting the healthcare debate in terms of “right” vs. privilege” makes little sense. I’m not even sure what it would mean to say that healthcare is a “privilege”–it seems to suggest that it is something you earn. Or something that is due to you if you belong to a certain class.
    You argue for healthcare as a social obligation because all of us benefit if we live in a healthy society– and all of us are at risk if members of that society are not receiving care.
    I totally agree—though I’m not sure why you wouldn’t also want to say that it’s a moral obligation.
    For example, if a child with Down’s syndrome doesn’t receive care (as you no doubt know, often they need heart surgery), he is not going to infect the rest of society. So I don’t see the utilitarian argument.
    But I do see the humanitarian argument Insofar as he can live a happly life–assuming he lives with a family who loves him and receives the healthcare he needs– don’t we want to pool our resources to pay for that care? After all, any one of us might have a Down’s syndrome child. That’s what I mean by recognizing each other as equally humna–and equally defenseless against the hazards of fate.

  13. “After all, any one of us might have a Down’s syndrome child. That’s what I mean by recognizing each other as equally human–and equally defenseless against the hazards of fate.”
    Suppose someone is seriously injured while committing a major crime. Or suppose an 85 or 90 year old with severe dementia needs heart bypass surgery or has Stage 4 cancer. I think the concept of a moral obligation to provide everyone with healthcare has its limits, especially when money is a constraining resource and there are numerous other worthwhile public and private priorities that we need to pay for. Every civilized country sets limits one way or another, but nobody seems to want to talk about it in the U.S.
    One of your taskforce members, James Sabin, co-authored a book titled “Setting Limits Fairly.” Perhaps he might want to weigh in on this.

  14. With the current attempt to scapegoat Wall Street CEO’s I think the issue of personal responsibility needs to be foremost. And I really think that’s what we’re dancing around with the “right” vs. priveledge issue. I tried earlier to communicate this to you Maggie, but was unsuccessful. I’ll try again.
    Docs see day to day people who have abrogated their personal responsibility. As we all do in small but acceptable ways. We slide through the stop sign, don’t signal, eat bad food, worry too much. But when it becomes disease and we, in this Medical Culture are pressured to DO something, that we may feel a bit reluctant about, not sure of it’s value or appropriateness in the situation, the anger is raw and blame arises. Patients become “dirtballs” for not being more responsible…But we order the CT and antibiotics and hospitalize, when we can see some forethought, some family awareness, some personal responsibility might have saved us the hassle and our own discomfort….
    I appreciate that Dr. Shadowfax was able to see beyond the issue of personal responsibility to societal responsibility.
    No system will guarantee appropriate behavior always. The free market rewards personal risk taking. But personal responsibilty can be shirked no matter, socialism, communism, fascism, captalism. It is all of our jobs to promote this. And it comes down to face to face.
    I am on the side of social responsibility. If we as a society can speak up for our group and be responsible, I can feel comfortable expecting it from my fellow citizens. So, universal coverage for basic services(The Oregon Plan) is my ideal…I don’t know what it will cost. But the current system is degrading.

  15. Wow. Thanks for the link, and thanks for the thoughtful dissection of my post. (It was so long and dense I doubted anybody would even get all the way through it.)
    A couple of clarifications. The figure that ER docs provide $180,000 worth of uncompensated services annually under the EMTALA mandate was derived from a survey of questionable validity, using full “list” prices instead of the more typical negotiated rates. A more realistic figure is closer to $80,000 (figure 1500 hrs/yr * 2 patients/hour * 3 RVU/pt * $45/RVU * 0.20 uninsured patient fraction). Still, if there were no uninsured patients, we might be able to lower our prices a bit as cost-shifting would no longer be necessary.
    Second, I completely agree that there is a societal benefit, and a cost-efficiency case for universal health. But this is analogous to arguing for motorcycle helmet laws because head injuries are expensive. Correct, but it misses the point. Helmet laws are good because the human cost of head injuries is terrible and preventable. Universal health is necessary because of the moral obligation of caring for the vulnerable.
    And understand that I brought up Rand more to disagree with her than anything else. She scares me, too, and my goal was to present an oppositional case. I hope that did come through in the end.
    I’m humbled and flattered that you took the time to review my blog and I’m glad you found much to like. I have been a fan of this blog for quite a while as well. I may be just an ER doc, but I’ve developed quite an interest in health policy wonkery.
    If you’re interested, just the other day I put up an extended defense of medicare.
    And, yes, it is a sad commentary on the state of the discourse that it is ever necessary to defend the most successful and popular government program around…

  16. I certainly agree that health care is not a “right”. As others have correctly pointed out, rights are fundamental freedoms (and thus also fundamental limitations on government powers).
    And to take bold position, it’s not a moral *obligation* either although it can be (and often is) a morally good activity.
    To clarify, providing pro bono or discounted health care can be moral *if* it is done according to one’s genuine values and priorities.
    But it can also be immoral if done for the wrong reasons or to the wrong person. In general, an act of charity can be magnificent and praiseworthy (for instance donating your kidney to a loved one who will appreciate the gift) whereas a similar act would be highly immoral if the recipient were different (e.g. IVDA abuser who would simply trash it).
    Similarly, I think other forms of service such as military service can be moral if done for the right reasons, but immoral if done for the wrong reasons.
    In other words, there’s not a *general and unconditional* moral obligation to provide health care to others. But it is a highly moral and praiseworthy activity in the right context (which is the one most of us are thinking of).

  17. Health care is an obligation by society. However, we are a long way from providing even the basics. I am a hospitalist, and like ED physicians, must treat all comers. We rack up impressive bills with our technologies, and American health care consumers are an entitled lot. In order to change this climate, several things need to happen: 1) Self responsibility must be the norm. The endless cycle of blaming someone else for one’s maladies must stop. 2) We must move away from the litiginous and defensive way we practice medicine, but this will take a huge shift in the American psyche as well. 3) We must come up with an efficent way to deliver care (and sorry, I do NOT believe the VA system is it! Talk to vets and see how easy it is for them to get care!) 4) We must move the focus from disease to maintaining health. 5) Physicians must lead this effort and MUST understand how health care delivery really works.
    Hmm, will this happen in my life time? I doubt it, as we will be too busy paying back the Wall Street debt to fund iniatives in health care….In the mean time, I ‘m preparing for my shift at the hospital, where tonight I will spend a fair amount of time and money on end of life care, end stage treatments of chronic disease, and wonder how people got this sick.

  18. Is having children a right or a privilege for those that can afford it? I say that because our Medicaid system allows women to have as many children as they like, and many take full advantage of that.

  19. Health care as a moral obligation

    Maggie Mahar expounds on Shadowfax’s assertion that health care is a moral obligation, rather than a right.
    It’s an excellent, detailed piece that you should read in its entirety.
    Re-casting the question in terms of “obligations” rather than “rights” is

  20. One downside you don’t mention about Employing Physicians. They are then legally allowed to unionize. A real functioning, work slowdown/stoppage union. If you think the AMA is a guild. You ain’t seen nothing yet and yes it would be a team sport. The physicians on one team with exponentially increased bargaining power and all on the same side.

  21. I think one could argue that healthcare is a moral obligation in that everyone should have health insurance and access to health care. However, it’s not as straightforward as that. I also think we have a moral obligation as a society to live within our means and to try to pass on to the next generation a world and an economy that will enable them to live at least as well and, hopefully, better than we did.
    When it comes to healthcare, it means we need to set limits and we need to set them in a fair and ethical manner. It means that the treatment strategy for an elderly person with severe dementia who also has heart disease or cancer should not be the same as for an otherwise healthy middle age person with heart disease or cancer. Personally, I like QALY metrics conceptually. We implicitly apply these all the time in other aspects of life including the development of environmental regulations. For example, how much in air pollution mitigation costs should we impose on business and consumers in order to avoid one premature cancer death? I’m sorry but human life does not have infinite value in a real world of finite resources and I reject the notion that only God can decide when the end of life comes. While humane comfort care should always be in order at the end of life, I don’t think we have a moral obligation to throw everything that medical science has to offer in end of life situations when the prognosis is grim and the patient has already lived well beyond a normal lifespan.
    Finally, on the general subject of taxpayers helping the poor whether it’s with health insurance, food stamps, housing vouchers, welfare or whatever, I think a lot of people are more than willing to help those who were simply dealt a bad hand in life such as a child born with a severe physical or mental handicap or someone who is badly injured in an accident that is not their fault. By contrast, people who just made poor or dumb choices generate less sympathy rightly or wrongly.

  22. Quite a debate raging here, and a scary one at that.
    “I’m sorry but human life does not have infinite value in a real world of finite resources and I reject the notion that only God can decide when the end of life comes.”
    We as a society DO place infinite value on human life. Some examples: There’s no statue of limitations on murder. Airlies offer bereavement fares. Police escort funeral processions. Deceased are revered and respected… even those that were despised in life. We reach out to the poor, sick and hungry in less priveleged parts of the world because we value human life, and we value it a great deal.
    Should the woman with dementia not have her cancer or heart ailment treated? Even if it won’t prolong her life? Well of course she should because we, as a society will learn and advance our treatment for other cancers and heart ailments.
    My husband was a burn patient. I read a book called “Burn Unit” and it contained a fascinating history of burns. My husband was treated for his injuries because, throughout many generations, other burned people, people who could not be saved, were treated and what was learned was processed and retained for the future…this is the evolution of treating burn injuries…no doubt the evolution of almost everything in medicine.
    If we’re not going to treat people who “can’t be saved” anyway, then what’s the point of all this advancement.
    I think it’s ultimately up to the patient or their sound-minded next of kin whether or not they’re going to treat dementia grandmother’s heart disease or cancer. That’s not something that should be decided through legislation in a free country.
    Somebody asked if having a child was a right or priveledge…maybe not if you live in China. I would say it’s a right “liberty and the pursuit of happyness.”
    Driving a car is a priveldge.

  23. Lisa:
    Thanks for providing your input.
    I would agree with you that we put value on human life, but that value is conditional, based on the circumstances.
    For example, the value of bereavement fares may have been reduced, due to the profitability problems airlines are facing.
    To say that the choice of treatment should reside with the patient or next of kin without any concern about the effectiveness and the cost to the insurer or the taxpayer is a bit arrogant, imo.
    To place this in a religious context, man was made in God’s image.
    Man is not God, and thus, his worth is substantial, but not infinite.
    To claim otherwise would be idolizing man.
    Don Levit

  24. “next of kin without any concern about the effectiveness and the cost to the insurer or the taxpayer is a bit arrogant, imo.”
    I have more faith in folks than that, I don’t think patients/next of kin make foolish choices and I think effectiveness and cost are factors they would include when reaching a decision…maybe not so much cost but effectiveness for sure. There were many, MANY procedures and tests offered to my husband (blank check, wouldn’t have cost us a red cent) that we declined repeatedly because they offered no relief and would have been pointless and painful.

  25. That is to say I think when folks are given a choice I believe they’ll make the right one.
    By the way for anyone that’s followed any of my posts here and/or has read my book, I’m going back to my old job, same one I had when my husband got hurt. (applause*applause) Laissez Les Bon Temps Roulez

  26. Lisa:
    Let’s assume you made “responsible” decisions in what seemed to be a very difficult situation.
    If so, I applaud your reasoning and ethics.
    I don’t think your sample of one is an accurate indicator of how the general population would respond.
    Are you suggesting that the insurance company should pay out whatever the patient requests, because it should believe the patient is as responsible and ethical as you?
    Don Levit

  27. Lisa,
    With all due respect, I think there are many millions of people in our country, especially among the elderly, lower income and less educated who are what doctors call passive patients. That is, they will basically go along with whatever treatment strategy their doctor recommends, especially if they don’t have to pay anything for it. Moreover, in end of life situations, middle class children will often insist that everything possible be done for their loved one including ventilators and feeding tubes even when their loved one doesn’t want that care but can no longer communicate that fact and there is no living will or advance directive. At least part of the children’s motivation is that they have not yet come to grips with their own mortality. Every developed country sets limits one way or another whether it’s restricting the supply of expensive imaging equipment and hospital beds, refusing to pay for treatments deemed too expensive based on QALY metrics or other criteria, denying invasive treatments to people based on age or just making people wait longer for treatment than they would here. Your comments implicitly reject the notion that resources are finite and that there are numerous other worthwhile public and private priorities that we need to pay for. Moreover, as I said in my earlier comment, I also think we as a society have a moral obligation to live within our means for the benefit of the next generation if nothing else. We simply cannot afford to provide every intervention that might be marginally useful to everyone who might want it.

  28. Barry, Don…do you want some nameless, faceless bureaucrat deciding what care you recieve when you’re sick or hurt? Deciding whether you live or die? I don’t. There was an example of this a couple months ago in our recent paper. Here in Texas families don’t get to decide whether their loved one lives or dies. A teenage girl, due to a surgical error, was left in vegetative state. The hospital decided not to prolong her life, against the family’s wished. Family got a lawyer, got their daughter out of the hospital, and she’s home today and she’s not a vegetable. The medical error didn’t kill her, but the law almost did.

  29. Thanks for your comments–
    Let me begin to respond regarding extending life–
    Barry: You ask “Suppose someone is seriously injured while committing a major crime. Or suppose an 85 or 90 year old with severe dementia needs heart bypass surgery or has Stage 4 cancer. ”
    First we just aren’t doing bypass operations on severely demented 85 or 90 year olds. That isn’t happening.
    We are, however, keeping some people alive whose quality of life is very very low. A major problem here is that many people in this country are reglious–and at this point in time, separate of church and state seems to be dissolving.
    Both presidental candidates frequently speak in relgious terms.
    This makes it very hard (probably impossible) to pass laws protecting doctors or hospitals who don’t do everything possible to extend life (partiicualrly if that’s what the family wants.)
    The fact that the government intervened in the Terry Schiavo case tells you what we’re up against.
    I really wish everyone was asked to fill out a living will– maybe forms can be made available along with income tax forms. And people could send it in with their taxes where it would be filed somewhere that it could easily be found in an emergency.
    Of course you couldn’t force people to do a living will. But making it easy and available would be a start And I think that most people in this country agree that the individual has a right to decide whether he wants extreme measures used to keep him alive.
    Though we have to accept the fact that, in this country, some people will want extreme measures . .
    On the criminal who is injured in the course of committing an accident. Of course you treat him. What are you going to do, let him bleed to death on teh sidewalk?
    You treat him, and then you try him and if found guilty you put him in prison. That’s the rule of law.

  30. “I really wish everyone was asked to fill out a living will”
    Not only do I completely agree with this but I’ve been pounding on it since I started participating in healthcare blogs in early 2006. My preferred approach would be to encourage people to execute a living will as part of the process of enrolling in Medicare, Medicaid, and employer provided health insurance or health insurance obtained in the individual market. As you say, a central database that would be easily accessible to medical professionals should store the information and process updates and changes. If there is no living will and no family member, friend or relative empowered to make medical decisions for patients who no longer can, I think the default protocol should allow doctors to apply common sense depending on circumstances.
    If doctors in Western Europe and Canada had to operate with our litigation environment and our demanding, entitled patient base, I think their costs would be far higher than they currently are no matter how good they are at primary care and prevention.
    I think one can always find examples of unusual cases where people make miraculous recoveries to the astonishment of medical professionals. That does not mean that patients should be able to demand any treatment they think might be marginally useful no matter how expensive and even if doctors don’t think it would do any good. Of course, if you would like to spend your own money on such treatments, go right ahead. I say again that every country sets limits on healthcare one way or another. We need to as well but we need to do it in a fairer and more ethical manner than ability to pay.

  31. The most recent issue of the AARP Bulletin has an interesting article titled “Million-Dollar Medicines” which is about the high cost of specialty drugs. I will pass on a small segment of it which is relevant to this discussion. Here it is:
    Some drugs are highly effective but others offer what Caplan (Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania) calls “limited and debatable” benefits – extending life by weeks or months – at a cost of $200,000 for treatment. Now doctors who once took pride in not knowing or considering the price of a therapy “are recognizing that discussing the cost of a drug should be an important part of providing good care,” says Neal J. Meropol, M.D., an oncologist with the Fox Chase Cancer Center in Philadelphia.
    He says the medical community is moving to a cost-effectiveness approach that will weight a drug’s cost against a year of quality life. “There is a groundswell of demand now for studies that tell the physician how much bang you get for your buck with these drugs,” Meropol says.
    This is good news and long overdue, in my opinion.

  32. What great comments on a very good post. I too think the question is way oversimplified when it is defined as a right or responsibility. It’s not either/or, but rather both as well as a moral imperative for a society that likes to think of itself as civilized. People have a basic responsibility to look after themselves and their families, but they also have a right to decent care when they are ill or injured.
    Every day in my work covering the news for low-income populations, I come across story after story about adults and kids dying or suffering from problems that are treatable.
    If you want to look at it from an economic standpoint, those unable to get decent medical treatment or advise are going to be less and less productive. This harms our economy.
    But the bigger issue is morality. We can only be judge as good as we treat the least among us.
    Thanks for a nice discussion.

  33. Colin & Barry–
    thanks for your comments–
    Colin– I agree, a society should be judged by how we treat the least among us.
    It’s good that you’re reporting on what happens to low-income people. For a long time, we’ve been essentially ignoring the poor in the country. They’ve become almost invisible . .
    As we move into very hard economic times, sometimes has to be throwing a spotlight on what is happening to the poor . .
    I wish that doctors would turn their backs on these marginally effective drugs, even for people who can afford to pay for them.
    That is the only way drugmakers will get the messag: we need to have them focus their resources on developing affordable, effective drugs, not bleeding-edge drugs that might given someone an extra couple of months . . .

  34. Like most liberals, the cause and effect relationships are turned around and the arguements are illogical. Government mandated healthcare will always be inadequate. Innovations and hard work should be rewarded by the ability to profit. We as humans can and should donate to charity based healthcare options for those who choose not to take care of themselves. St judes is much more effective than any government run facility and the red cross is far superior to FEMA. I have never understood why lilberals feel better about having the government take money by force than to have it given freely. Conservatives dont think that we shouldn’t care for others we just dont believe the government shaking down workers is the way to accomplish anything. Do you like how what the government did to the mortgage industry? Social Security? anything? I want to choose and monitor what charities I fund, the government takes money and then uses it for many unacceptable causes.
    You have the right at any time to send your money to whatever you feel is important just dont tell me what to do with mine.
    Like most liberal points of view facts never get in the way of your opinions

  35. Elilzabeth-
    I have to disagree. Both the posts on this blog and many of the comments are filled with well-reserched facts.
    As for the government not being able to produce successful programs . . .
    Medicare is far from perfect, but it’s a very popular program.
    As for FEMA–well we know how the director of FEMA was chosen.

  36. Glad to see this article from the standpoint of people supporting universal care. Too often I hear “health care is a right,” and it makes me cringe.
    A true right can be exercised, in my opinion, without requiring the taking of life, liberty and property from others.
    With that definition (about which I’m sure there will be disagreement), health care is NOT a right.
    However, I do believe it something that an affluent and compassionate society should strive to provide. Even if health care isn’t a right, I’d like to think as a society we’re better than allowing people to get really sick or go bankrupt because they are lower income and uninsured/underinsured.

  37. Tim–
    Thanks very much. You wrote:
    “I’d like to think than as a society we’re better than allowing people to get really sick or go bankrupt because they are lower income and uninsured/underinsured.”
    I agree completely. And I think it’s very important to think about healthcare collectively “as a compassionate, civilized society” rather than individually (“my right”.)
    Countries that have much better health care systems think collectively.

  38. “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.”
    Thank you for pointing this out Maggie. More clarity and important perspective like this educates many of us and helps bring into consciousness and action how we live out our so called moral principles that prevailing voices in society likes to harp about but lacking in energy to realize.

  39. Health care is a right, who pays for it?

    Senator Obama has gone on record saying that health care is a right. Bad move, pandering to his base. Dr. Wes warns that this is a slippery slope that will dwarf the current housing crisis.

  40. It’s both a right and a moral obligation.
    The U.S. system would cost less if it was universal health care, studies have shown. Most other countries concur with this premise.

  41. Your analysis has several deficiencies. First, you improperly characterize the rights question. The analysis refers to positive versus negative rights. The 14th amendment refers to certain inalienable rights (life, liberty, and pursuit of happiness). These are negative rights: persons are protected from infringement of such rights by government. Moreover, a government, through various amendments and legislative acts, decides additional negative and positive rights. Those additional negative rights include freedom of speech, freedom of religion, and the like. Moreover, the positive rights are those entitlements afforded to persons by the government.
    The difference between negative rights and positive rights is this: our government must respect one’s negative rights, while our government has the responsibility to allocate positive rights to each individual equitably. The Constitution does not provide for the positive right to health care. However, our legislature has provided persons in our nation with a positive right to a medical screening exam in an emergency room for purposes of stabilization (EMTALA). In contrast, a patient cannot demand medical care from a physician in a private office or clinic, for example. The non-ER physician has a right to refuse to treat a patient, thereby not creating a patient-physician relationship.
    Thus, our government must furnish a reasonable means for hospitals and physicians to comply with EMTALA. But to require physicians and hospitals to comply with this positive right, and not provide a fair structure in which to do so, is unreasonable. Note all the confusions of the current EMTALA rule, and its poorly defined parameters.
    What is the upshot here? Healthcare is an entitlement insomuch as our legislature decides. Currently, there is no law that makes healthcare a right to all persons; this statement embodies the current health care debate. This begs the question: should healthcare be an absolute, positive right? My answer is no. Let me explain.
    Health care is a shared responsibility, just like all entitlements. Any government entitlement, if dispensed without caution, will run out. (Consider social security.) Currently, our nation does not have unlimited financial or health care resources. A resource cannot be a positive right if the resources are so limited that it is not possible for every person in the nation to have access to it. To characterize health care otherwise is unrealistic and short sighted. Claiming that all persons have a positive right to our current health care system deprives physicians of personal and professional autonomy. You basically say “You must treat this patient, and not demand pay.” No other business industry is expected to comply with such a request. I find it interesting that you have some special authority to state that an ER physician should not have to be paid for his or her services. Also, I find it interesting that you can say that physicians should engage in some charity work. To require ER physicians to work without the ability to demand payment would no longer be charity work, but rather become compulsory work. Again, no other business industry is given such demands. We don’t tell insurance agencies to insure everyone even if they don’t want to. We don’t require retailers to give some of your clothes away. We don’t require educators to teach without pay, or lawyers to represent without pay. We know that charity is conducted in these fields, but our government does not require it.
    Your comment that the poor are more prone to disease is interesting, and may or may not be true. But I fail to understand your conclusion from this. Should we, as a society, remove all financial responsibility from a person that he or she has diabetes, or obesity, or drug abuse, or coronary artery disease, because he or she is poor? I do not follow your logic. You merely state that the poor have more problems, then conclude that they need health care more, and therefore they have a right to it.
    To conclude, to describe health care as a right, removes financial responsibility from the individual, which drains our health care resources, and ends up being an empty statement without any reference to a plan or scheme to provide universal health care to all persons. On the other hand,to describe health care as a responsibility places the onus on each individual, as well as on our government, to seek reasonable solutions and hopefully a means to pay for it.
    To take the professional autonomy from physicians will deplete the physician pool and make health care more scarce. This will make your statement of health care being a right more and more of a fantasy, because a scarce resource cannot be a positive right if it cannot be provided to everyone.