Healthcare is an Obligation, Not a Right, Privilege, or Commodity

“In the animal kingdom, the rule is eat or be eaten; in the human kingdom, define or be defined.”

Dr. Thomas Szasz

 

Defining healthcare sparks endless debate, especially in America. Canada seems to have settled on rights, with socialized medicine. The Romanow Report declared that, “Canadians view medicare as a moral enterprise, not a business venture.”

However, the right to stand in line for promised care is itself immoral. In the 2005 Supreme Court of Canada Chaoulli case,  Chief Justice Beverly McLaughlin famously said, “Access to a waitlist is not access to health care.”

Rights

Defenders of rights form a crowd of dignitaries.

Earlier this year, President Biden said, “Health care should be a right, not a privilege, for all Americans.”

Former President Obama celebrated the seventh anniversary of his Affordable Care Act by saying, “We finally declared that in America, health care is not a privilege for a few, but a right for everybody.”

Pope Francis said health “is not a consumer good, but rather a universal right, and therefore access to healthcare services cannot be a privilege.”  Francis moves the right upstream, which begs the question whether healthcare actually delivers health.

Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, declared that “Health is a fundamental human right.”

Rights-talk appeals to natural rights. It assumes they are self-evident. Rights also touch on negative and positive rights: the right to be left alone vs the right to demand something from your neighbour.

Jeremy Bentham, 19th century philosopher, said only the state can confer rights through law. Natural rights confuse the existence of a want with the means of fulfilling it. Bentham called rights “nonsense on stilts.” Those who admire Bentham’s collectivism usually ignore his “nonsense.”

Privilege

By default, those who refuse to pledge allegiance to healthcare rights must be apologists of privilege. However, it is hard to find many saying so explicitly.

Media accused President Trump of calling healthcare a privilege. He said state care was like giving a “bozo with zero experience a management position.”

In 2017, Miss USA was asked onstage whether Affordable Care was a right or a privilege. Caught off guard, she called it a privilege related to her employment — clearly the wrong answer. Media had a fit.

Misplaced Privilege

Privilege, if it existed at all in healthcare, used to lie with the medical profession, not patients. Doctors used to control their own profession.

A physician shared recently how he felt forced to change careers.

“I started a business completely unrelated to medicine that allows me to deliver excellent service, control quality, grow creatively, allows autonomy, and compensates me fairly for taking risks.”

This doctor would still consider it a privilege to care, to help someone in need. But privilege in the sense of service, quality, growth, autonomy, and respect has gone. Planners killed it decades ago leaving us will waitlists and a crisis in primary care.

Commodity

Michael Tanner of the Cato Institute, a libertarian think tank, has argued healthcare is a finite commodity — more like a natural resource than a right.

Since healthcare is a limited resource, choices have to be made. “The question should be: Who get to make those choices?”

Ben Shapiro, political pundit, took the same approach in an article for National Review.

Calling it a right makes no sense to Shapiro:

“But the left believes that declaring necessities rights somehow overcomes the individual rights of others. If you are sick, you now have the right to demand that my wife, who is a doctor, care for you. Is there any limit to this right?”

Political Slogans and Impractical Ideals

In general, rights work best on placards, not so well as policy.

How much healthcare must we provide to satisfy a right to care?

Who satisfies the demand created by the (positive) right?

Should the right to care trump the right to education or police services?

So too for privilege. When we use privilege in policy work, we usually mean entitlement, like an employee benefit, which functions as a right.

If a privilege is not a right, then it is charity, a gift. Charity still inspires some policy discussion, but it lacks the rigour required to ensure care for someone bleeding on the side of the road.

Commodity-talk works for elective care. Rational agents could freely contract for necessary care on their laptop screens. Shopping for CT scans and negotiating elective hip replacement could work for some patients. But it would fail for our most vulnerable, critically-ill patients.

If we focus on payment model, healthcare can be many things: commodity (market pricing of direct or insured care), privilege (employee insurance benefit or targeted funding program), right (of citizenship), or responsibility (medical savings account).

All these labels look from the patient’s perspective. The problem is that the care patients want cannot be forced, bribed, or contracted from physicians and nurses. We have to start on the other side of the bedrail.

Healthcare Is An Obligation

Obligation is omnipresent for all members of society. Even off-grid survivalists feel the pull of obligation when faced with sickness in their family.

The peculiar obligation to care animates medicine, nursing, and all caring professions. Professionals assume obligation to individual patients.

A care relationship extends long after discrete episodes of service. The relationship knows no limit; it can force itself into any part of a professional’s life, unless the responsibility has been ‘handed off’ to another.

In this sense, there is no ’time off’ for the physician. Doctors who try to be completely unavailable off-duty eventually regret their decision.

Obligation eclipses what any policy could capture. Obligations resists codification. A rule designed to capture obligation always misses the mark.

Rules either reduce demands — for example, on-call restrictions for residents. Or they create impossible demands — for example, doctors must accept any patient who enters their practice, if the practice is ‘open.’ If a rule happens to hit the mark, it ignores exceptions by design.

Crushing Obligation

We will always have the poor and sick, and we will always feel obliged to care for them. Instead of fighting over rights or leaving care entirely to markets, we might revisit the old approach of fostering the caring professions.

Every society contains people who feel drawn to care. We need to give them space — privilege — to apply their innate desire, curiosity, and talent.

A provincial budget transforms healthcare into a line item. The modern administrative state then attempts to squeeze efficiency from each line, a drop of juice from reluctant grapes. The innate desire to care gets crushed in the process.

If we were to resurrect obligation, we would need the state to step back and the profession to step up. It seems idealistic, but we have tried everything else.

Whatever we do, we should stop talking about rights, privileges, and commodities when it comes to care. It gets us nowhere.