Government is not reason, it is not eloquence, it is force; like fire, a troublesome servant and a fearful master. Never for a moment should it be left to irresponsible action. -- George Washington, in a speech of January 7, 1790
The moral basis for a right to health care seems almost a dead issue in today's political and legal climate. To claim that health care is not a fundamental right would be political suicide for any party or person seeking election to any legislative body. Even the so-called right wing parties of recent notoriety claim that this right is limited but that it still exists. Philosophically, the issue is not a hotbed of debate either; the view that there exist some kind of right to a decent minimum of health care, or that the principle of beneficence is enough to justify socialized medicine, permeates much of today's philosophical literature. Robert M. Veatch, for example, asserts that "The principle of justice for health care could...be stated as follows : People have a right to needed health care to provide an opportunity for a level of health equal as far as possible to the health of other people." 1 His view is grounded in the concept of justice and rights, with somewhat of a disdain for the principle of autonomy : " I see justice not just as a way to efficiently improve the lot of the least well off by permitting trades ... That would might be efficient and might preserve autonomy, but it would not be justice." 2 Allen E. Buchanan, on the other hand, although coming to the same practical conclusions (the establishment of universal health care), grounds his arguments in the principle of beneficence, and deliberately avoids any talk of the principle of justice: "...advocates of a coercively backed decent minimum [of health care] have operated on the assumption that such a policy must be based on a universal right to a decent minimum. The chief aim of this article is to show that this assumption is false." 3 Most philosophers, with few exceptions, fall into one of these categories, or in between, with disagreement centering mainly on what constitutes a decent minimum or whether a decent minimum is, in fact, enough to discharge the implied duty of beneficence and/or the principle of justice.
There are radically opposing viewpoints, but not as many. According to H. Tristram Engelhardt Jr., for example, "A basic human right to the delivery of health care, even to the delivery of a decent minimum of health care, does not exist." 4 His view is also grounded in the principle of justice, but he takes the principle of beneficence seriously; "It may very well be unfeeling or unsympathetic not to provide [health care to those who need it], it is another thing to show that one owes others such help in a way that would morally authorize state force to redistribute resources." 5 He argues that it is moral to voluntarily provide this helping hand (fulfilling a duty of beneficence), but immoral to use state force to the same end. This leads him to claim later that his "analysis of the principles of autonomy and beneficence and of entitlements to property support a two-tiered system of health care." 6 Noted philosopher Ayn Rand was also of this view, only she went so far as to claim that even a two tiered was immoral, and that the only moral health care system was a fully privatized one.
This is the current state of affairs in the debate over the moral right to health care. Having stated this, I submit that there can be no such thing as a moral right to health care (that there is no moral basis for this right), in the sense that would justify state coercion of non-criminal citizens. This view will be fully developed and justified with an appeal to rule utilitarianism.
Much of the modern debate surrounding the issue of health care rights implicitly assumes that these rights exist and then move the discussion forward to questions of practical implementation. It is this very notion that the moral right to health care exists, however, that the author wishes to question. At the root of any justification of these rights lies the never-questioned, never-doubted belief that it is ethical and good to use state or societal coercion to force those who have appropriate resources to use them in a way that is consistent with the production of universal health care. The issue is one of the morality of coercive beneficence, or alternatively, what constitutes a just action (they are not equivalent). In essence, the main moral question to ask, before any other debate can occur, is not how much money (forcibly wrested by society from private, non-criminal citizens) can be morally devoted to the production of a universal health care system? but rather, is it moral for society to forcibly wrest (i.e. use the power of a gun) resources from private, non-criminal citizens to fund whatever health care system society has in mind?
Before one can even begin to answer such a question, let alone justify the end result, one first has make clear the terms that will used throughout the course of the discussion. The term rights will come up often so I shall define a right to be a morally enforceable claim to a certain object or to do a certain act. Entire books have been written on this topic, but since there seems to be no iron clad definition (see, for example, The Virtue of Selfishness, by Ayn Rand and An Approach to Rights, by Carl Wellman), I will use the one formulated above. In a perfect world this formalization would immediately translate into a legally enforceable claim, but this is not necessary for a discussion of the moral basis of a right to health. In essence the above statement outlines one case when the power of force can be morally used, i.e. the power of force can be morally used when it is defending a right. This is very closely related to the principle of justice as outlined in The Principles of Biomedical Ethics by Beauchamp and Childress. When one thinks of justice terms like fairness, desert and entitlement come to mind. More to the point, one who has a valid claim based in justice has a right, and is therefore due something 7 The foregoing discussion, of course, entirely glosses over the issue of what exactly constitutes a morally enforceable claim or, stated another way, which enforceable claims are just. Once this is determined, the existence or non-existence of a moral right to health care can easily be resolved. More easily defined than rights and justice is the concept of society. I shall merely define it (in this context) as a collection of individual people living within a certain geographical space. There are certain people, of course, who claim that society is something more than this, but most would agree that the term society means at least this much.
It was mentioned before that the question to ask in the debate on health care rights was: is it moral for society to forcibly wrest (i.e. use the power of a gun) resources from private, non-criminal citizens to fund whatever health care system society has in mind?. The position of Robert M. Veatch (and he is typical of those who share his views; differences mainly arise in issues of practical implementation, not in the main philosophical viewpoint) , in his essay "Justice, the Basic Social Contract and Health Care", is clear: "The principle of justice for health care could...be stated as follows : People have a right to needed health care to provide an opportunity for a level of health equal as far as possible to the health of other people." Let us examine what the implications of this assertion are in full.
Health care is not free, and appropriate resources must be obtained before any such system can be built. It is the method that Mr. Veatch suggests (the use of state force) for acquiring these resources that leads to one of the most fundamental, underlying assumptions of the above position : that private, individual property does not exist. This becomes clear when the concept of owner is emphasized: the owner of a resource is the person or persons who have ultimate moral authority over its use. The "moral" qualifier, in this case, is important; a burglar might take your telephone, and may do it in such a way that you will no longer have any practical say in how it is used, but you are still the owner, since you are the one who has moral authority over its use. This notion is closely tied to concept of property rights. Stated another way, one can say that the owner of an object is the person who has the moral right to use that object as he sees fit. Following this line of logic, and this definition of owner, one can see that if society has the final word on the use of certain resources, if it can morally dictate their use, then by definition society owns these resources. Furthermore, this conclusion is not changed by the fact that individuals may possess property throughout theirs lives. A right to a certain piece of property, with no accompanying right to use it whenever one chooses, is not a right at all. The opposite of possessing something by right is possessing something by permission and, in fact, this is the nature of all forms of possession in a society that claims the moral right to forcibly wrest resources from individual citizens. Individuals control property by permission of society (since society holds the final authority over its use), which can be revoked, or changed at any time. Without invoking any moral judgment, this is the form of society that Mr. Veatch envisions. Moreover, since society as a strict entity does not exist as such, but is merely a collection of individuals, what the above position translates into in practice is the moral right of some people to forcibly wrest property (such as money) from other people.
Mr. Veatch's position could perhaps be justified if it could be shown that society as a whole were the rightful owner of these resources. To show that the above position is not justified, however, one has to demonstrate that individual people have ultimate moral authority over the property they have earned or produced. This is fairly easy to do using a few basic facts about the nature of human survival.
Few would argue that in order to survive for any significant length of time, people must produce the necessities of life. They must produce their shelter (by building huts, cabins, houses or skyrise apartment buildings), they must produce their food (by planting crops or hunting animals), and they must produce their clothing (animal skins, cotton dresses, blue jeans). Production is the key word here; without production, men and women would die after their first winter, flood, volcanic eruption, tornado, or any natural disaster. The fruits of production are the necessities and resources of life. Furthermore, this fact of reality is unaltered by the existence of trade. The development of trade is the natural next step when the methods of production become more and more refined. Men and women may produce more of a certain resource then they strictly need, and so trade with other men and women to obtain other resources that they may not have. In time, things get to the point where certain people devote themselves entirely to the production of one resource, in order to trade their surplus for their entire necessities of life. More to the point, to say that this type of human survival is a societal concern shows a misunderstanding of the term society. "Society" does not produce food; farmers do. "Society" does not produce clothes; tailors do. "Society" does not make money; people do. To say, then, that these people do not have the moral right to these resources (clothing, food, money), and ultimate authority over how they are used, whether they are traded or destroyed or saved in their original form, is to say that people do not have the right to support their own lives. When the moral right to own property is denied, the moral right to life is denied as well. If people keep the resources they earn "by permission", then they live "by permission" as well. Without bothering to argue the good and bad consequences of denying people a right to life (as utilitarianism requires), I will simply assert that, because the right to private property - the right to ownership - is inseparable from an individual's right to life, people must be given the final, ultimate word over the resources they have earned. To put this in terms of the principles of justice : it cannot be just to use force to take property away from the people who have earned it. It follows that there cannot be any moral right to another person's property. This automatically precludes the existence of moral positive rights (i.e. rights to a certain object owned by someone else). This also eliminates from the realm of moral consideration Mr. Veatch's version of justice to which his claim to morality hinges. In other words, the views expressed by Veatch are fundamentally unjust. In fact, there is a specific name for the policy he advocates : it is called theft. 8
Moreover, since Veatch's claim is not grounded in justice (despite his assertion that it is), it becomes nothing more than an attempt to justify the policy of enforced beneficence. In this respect, his views are very similar to those of Allen E. Buchanan's, who asserts explicitly that his policy of a decent minimum standard of health care is not based on any right as such, but on the idea that stealing resources from individual people is moral if it is done in the name of the principle of beneficence.
I submit that this position is a moral obscenity, and shall proceed to justify that assertion with the moral theory of rule utilitarianism. In essence, rule utilitarianism asserts that the moral action is the one that conforms to a specific rule or policy that has been previously justified by the principle of utility, or the principle of maximizing "good" consequences over "evil" consequences (i.e. the moral policy is the one that produces the most "good" consequences and produces the least "evil" consequences). This somewhat formal definition glosses over the problem of what exactly constitutes the "good"; the standard varies from theory to theory, all of which can be labeled as utilitarian. The author shall choose to call "human life" (its quality and its existence) the standard of the good in this particular context; it is as reasonable a standard as any, and it seems almost axiomatic that in any calculation of the "good", human life must be given an extremely prominent place. It is a small step from there to the assertion that " human life" is the "good".
The ultimate question of rule utilitarianism is, in the words of Beauchamp and Walters, "What good and evil consequences will result generally from this sort of action?" Let us ask, therefore: What would happen if some people, in general, routinely stole property and resources from other people, in the name of the principle of beneficence, in order to pay for a universalized system of health care? To be perfectly fair, this would definitely have some good consequences. People unlucky enough to be stricken sick, and who could not normally afford private health care, provided by people who have devoted their resources towards this end, would not have to rely on private charities for their well being. From the standpoint of human life, and taken strictly by itself, this is, of course, a desirable outcome. Who would have a reason to say that it is not? This is, in itself, however, no justification, and when the impact of this policy on society in general is examined closely, things begin to change.
As implied before, the opinion stated above essentially amounts to morally endorsed theft. What sort of evil consequences does this type of policy generate? Firstly, if such a policy is adopted strictly on the basis of the principle of beneficence - as it must be, since I have shown that there is no moral right to another person's property - there can be no objective standards to decide when "enough" resources have been stolen. There was some talk, previously, of assuring a decent minimum standard of health care as a theoretical limit on the power of moral expropriation, but that in itself is an undefinable term. Beyond prescribing soap for disease prevention and a bottle of aspirin a year, what exactly is a "decent minimum"? Can a $1,000,000 medical procedure be considered part of a "decent minimum" health care plan, and guaranteed to all when the need arises? If not, what principle dictates that the setting of broken bones be put under the same heading?
Many philosophers and political scientists attempt to resolve the above difficulties by claiming that any policy of morally sanctioned theft will be properly tempered by financial considerations. It is realized, the argument goes, that people live by the property they earn, and so, when all of "society's" resources are redistributed, it will be made sure that, in the end, everyone possesses enough to live on. It is this consideration that supposedly defines the aforementioned decent minimum standard of health care. Usually such a scheme involves differentiating between a luxury and a necessity of life. Theft can only be morally justified when the resource involved is a luxury (to the person you're stealing it from) and not a strict necessity of life (so the argument goes). This statement becomes dubious when it is realized that almost everything we take for granted in today's civilization is a luxury. Certainly cars, buses, ice cream, pants, shirts, televisions, radios, telephones, computers, non-leaky homes, leaky homes, three meals a day, soft drinks, coffee, tea, sugar, milk, juice, hats, music, theatre, movies and books are all luxuries in the strict sense of the term. In fact, if one wants to be technical, everything above a piece of raw meat, a bear skin, and a cave is a luxury. So what moral principle would prevent the reduction of mankind to the material state of medieval serfs, in the name of a decent minimum standard of health care, if a "decent minimum" can basically mean whatever anyone wants it to mean? Even Mr. Veatch states that "society would rather arbitrarily set some fixed amount of the total resources for health care [italics mine]" 9. This leaves the door wide open for any potential dictator with a yen to cure the country to impose his views on competent people who may not agree with him. By forcing his views competent people, this potential dictator becomes a forcible arbitrator of ideas. The free exchange of ideas is an absolute necessity in a free society. If a free society is the most conducive to human life (as seems to be the case; the bloodiest societies on earth tend to be those that dispense with human freedom), and if human life is a standard of the good, then one must conclude that the very concept of enforced beneficence brings about major evil consequences. Moreover, it seems fairly obvious that the evil consequences stemming from this coercion outweigh the possible good it might accomplish, since we are talking of the total deprivation of liberty of huge numbers of citizens as opposed to the lack of health of a few people who cannot afford private health care. In light of all this, it is obvious that the most general rule to adopt in this case, that is, the rule which offers the most utility, is: do not enforce the principle of beneficence. Stated in a more specific way, this rule reads: do not steal from other people, even in the name of beneficence. The principles of justice and autonomy must outweigh all others.
This view is not shared by many people in the philosophical community. The views of H. Tristram Engelhardt Jr. come close; as stated before, he believes that "A basic human right to the delivery of health care, even to the delivery of a decent minimum of health care, does not exist. " His sees enforced beneficence as fundamentally unjust, but he still takes the principle of beneficence seriously : "It may very well be unfeeling or unsympathetic not to provide [health care to those who need it]; it is another thing to show that one owes others such help in a way that would morally authorize state force to redistribute resources." As far as can be gathered from his writings he supports a voluntary two-tired system of health care. The issue of whether it is moral to help those in need, without being forced to, is a matter for another debate. The key concept here is that Engelhardt does not believe in enforced beneficence, and, in this sense, I have implicitly defended his position above.
In conclusion, after a rigorous evaluation of the good and evil consequences of adopting a policy of institutionalized theft, or enforced beneficence, it is evident from an appeal to the principle of utility and an adoption of human life (quality and existence) as a standard of the good, that such general actions fail the test of utility, cannot morally be made into a rule, and hence is not moral in general. To be brief, there is no moral basis for the "right" to health care. Since absolute private property can be defended on the basis of the right to life, any policy that advocates the forcible wresting of resources from individual citizens is excluded from the realm of moral consideration and of justice.
Robert M. Veatch, "Justice, the Basic Social Contract and Health Care" in Contemporary Issues in Bioethics, Tom L. Beauchamp and LeRoy Walters, Wadsworth Inc., 1994) p. 694
Ibid p. 694
Allen E. Buchanan, "The Right to a Decent Minimum of Health Care" in Contemporary Issues in Bioethics, Tom L. Beauchamp and LeRoy Walters, Wadsworth Inc., 1994) p. 696
H. Tristram Engelhardt, Jr., "Rights to Health Care" in Contemporary Issues in Bioethics, Tom L. Beauchamp and LeRoy Walters, Wadsworth Inc., 1994) p. 701
Ibid p. 702
Ibid p. 705
Tom L. Beauchamp and James F Childress, Principles of Biomedical Ethics, (Oxford, Oxford University Press, 1994) p. 327
Ayn Rand, The Virtue of Selfishness, (New York, The New American Library Inc., 1964) p. 92-100
Robert M. Veatch, "Justice, the Basic Social Contract and Health Care" in Contemporary Issues in Bioethics, Tom L. Beauchamp and LeRoy Walters, Wadsworth Inc., 1994) p. 694
Beauchamp, Tom L. and LeRoy Walters. Contemporary Issues in Bioethics. Belmont, Wadsworth Inc., 1994.
Beauchamp, Tom L. and James F Childress. Principles of Biomedical Ethics. Oxford, Oxford University Press, 1994.
Rand, Ayn. The Virtue of Selfishness. New York, The New American Library Inc., 1964
Wellman, Carl. An Approach to Rights. Dordrecht, Kluwer Academic Publishers, 1997.