Tuesday, May 17, 2011

The "Right" to Health Care

Last week, Senator Rand Paul of Kentucky offered some controversial thoughts about the medical profession. “With regard to the idea whether or not you have a right to health care,” he said, “you have to realize what that implies. It’s not an abstraction. I’m a physician. That means you have a right to come to my house and conscript me. It means you believe in slavery.”

I posted video of Sen. Paul’s statement on my Facebook page with two comments: “Profoundly philosophical” and “You cannot have a right that requires the labor of other people.”

I’m blessed to have many insightful friends and relatives (and relatives of friends) on both sides of the aisle, and a spirited debate followed. Thank you D.F., T.S., S.I., D.B., P.E., K.O., and E.E.. I wanted to address a few of the points you raised (although for the most part, you already addressed each other!):

Rights can be legal or moral.

The discussion got me thinking about the relationship between the two. IMHO the Declaration of Independence got it right: “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed.”

It’s clear that in the minds of the Founders, rights are more fundamental than government. Rights come from God (or for us atheists, nature). All rights, therefore, are moral rights. Given that governments are instituted to secure rights, it follows that the effectiveness of a government in achieving its raison d’etre can be measured by the extent to which moral rights are also legal rights.

This is not an “honest” argument. Sen. Paul and other libertarians know perfectly well that no one plans to force doctors to provide their services.

I think what you’re saying is that this is a straw man argument, that Sen. Paul is attributing a belief to his opponents that they do not actually hold, for the purpose of refuting it. But actually, it is not a straw man argument – it is a reductio ad absurdum. As such, it is a valid logical construction. The claim is that the argument advanced by the opposing side – that there is a right to health care – would, if taken to its logical conclusion, lead to something absurd – enslavement of doctors.

This particular reductio ad absurdum is one that libertarians take very seriously. It originated with their patron saint, Ayn Rand. There are conflicting reports as to whether Sen. Paul got his name from her. He certainly got his ideas from her. In her 1963 essay, “Man’s Rights”, she wrote, “If some men are entitled by right to the products of the work of others, it means that those others are deprived of rights and condemned to slave labor.” Rand’s essay provides a thorough treatment of the issues involved; I highly recommend reading it in its entirety in her book The Virtue of Selfishness.

In his response to Sen. Paul, Bernie Sanders of Vermont asked doctors whether they consider themselves slaves. He need not have bothered. Sen. Sanders is correct that doctors are not slaves in existing single payer systems. The defining characteristics of slaves – that they are not compensated and cannot quit – do not apply to doctors in the various regulated health care systems of the developed world. In these systems, doctors "merely" have considerable restrictions on their liberty to assign a course of treatment or set the terms of their compensation.

However, this does not refute Sen. Paul’s argument for two reasons. First, Sen. Paul was talking about a universal health care system. Sen. Sanders shifted the discussion to the existing non-universal system in the United States. Second, Sen. Paul did not claim that any particular system provided a right to health care or freedom for doctors; he merely argued that you can’t have both. Consistent with his argument, existing universal systems do not provide patients with a right to health care. We see this in countries where universal health care has been implemented. Bureaucrats dictate the level of service that will be provided. If patients need or want more than decreed, they can pay for it themselves (if that’s allowed) or join a wait list and hope they don’t die before they get treatment. Long wait lists, and occasional unnecessary deaths, are inherent in the single payer systems of Canada, Great Britain, and other semi-socialist countries. The sorry record of single payer systems, and their lack of patient rights, are documented extensively by Goodman, Musgrave, and Herrick in their fine study Lives at Risk: Single-Payer National Health Insurance Around the World. Clearly patients who must pay out of pocket or die waiting do not have a right to health care.

Negative and positive rights are complex and mutually interdependent.

For those just joining us, a negative right imposes an obligation on other people not to do something. For example, your right to life obligates other people not to kill you. A positive right obligates other people to do something. The supposed right to health care is an example of a positive right.

The problem with positive rights is not they are interdependent with negative rights. The problem with positive rights is that they violate negative rights. A system of rights that is contradictory – where some rights violate other rights – cannot be put into practice. Using the example of health care again, a right to health care violates the doctor’s right to liberty. Positive rights can only be consistent with the right to liberty if individuals take on the obligation voluntarily – for example by signing a contract.

It is not fair that the government forces us to see and pay a doctor to obtain a prescription that we already know we need.

I wholeheartedly agree – on the basis of the negative right to liberty. I’d make an exception for antibiotics, since their misuse can violate other people’s negative right to life.

This is merely a semantic argument; health care is better addressed in practical terms.

If you prefer to consider the issue in purely practical terms, I again recommend the Goodman, Musgrave, and Herrick book; it systematically refutes each of the practical arguments for single payer systems. However, I do believe that, as Sen. Paul said, the rights-based argument is not an abstraction. There is a real issue involved because those who promote universal schemes often do so on the basis of a right to health care. What Sen. Paul has shown is that this concept is not intellectually coherent and that therefore a universal health care system cannot be justified on that basis.


  1. Most people, including me, would like to see everyone have access to health care. Many people think that this universal desire is equivalent to a right to health care. But those are two different things, and after much reflection my conclusion is that the failure to distinguish them is at the root of most of the problems with health care systems around the world.

    When health care is considered to be a right, each of us may demand it, and we have no responsibility to provide it for ourselves. Furthermore, there is no limit to how much we can demand, no matter what the cost; can we say that health care is a right but only up to a particular dollar amount? That would be a strange right indeed.

    On the other hand, if you instead think of health care as something we would all like everyone to have, but not as a right, then each of us is still responsible for his or her own health care, but others graciously desire to help us if we cannot handle it on our own. The amount of help we get is determined by how much those others are willing to provide.

    It is clear that the free market is not working properly in health care, but upon close examination I have found that the reasons are because of laws and mindsets that arise exactly from the failure to make this distinction.

  2. Well said, Irwin. You raised a good point that if health care is a right, is there a dollar limit? Goodman et al. pointed out on practically the first page of their book that we could spend the entire Gross Domestic Product on beneficial uses of medical care.