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Theres a fundamental argument in the health care debate that has yet to be truly elaborated. The central question is, does our society recognize access to health care as a right or as a privilege? That this question has not been explicitly defined is intriguing as it could very well change the direction of the discourse into a more humanistic direction. That might be the very reason for not framing the health care debate in such a way. After all, rights are very popular, but frowned upon by the power elite as being an undue burden in their quest for a wider profit margin.
As it stands, it looks as though the meritocratic bias of our society predefines access to health care as a privilege. One of my students, echoing the capitalist paradigm, defined health care as a commodity. Like all commodities, health care is subject to supply and demand curves and scarcity. Indeed, this is a strong argument from the perspective of those providing health care and health insurance while trying to secure a profit for themselves and their shareholders. After all, sick people are expensive.
That health care is a commodity is a great descriptor of our current situation. In a health care market the goal is to maximize profits. This is done by cutting the costs of health care providers while at the same time steering health care consumers to the most expensive products. So the people who really need health insurance are more likely to be dropped, denied or subject to exorbitant costs. Those who can afford access to health care are often subject to the most expensive procedures, such as surgery over therapy. This leaves millions of Americans who can only access health services in the emergency room, publicly funded clinics or the extraordinary efforts of charitable organizations. In these instances the costs are passed on to consumers.
If health care is framed as a basic human right, however, then profit motive must take a back seat to universal access, as making the claim that some people have more rights than others is culturally awkward. It is also subject to a different social process, as rights are socially and historically contingent. The founding fathers had no need to elaborate a right to health care. For them, access to health care was almost universal, and quality of care was comparably equitable regardless of class. Its likely that the health care that George Washington received was not much better than that received by anyone else.
But that was before the advent of modern medicine. The medical field has since evolved from an exercise of natural philosophy to a specialized profession of scientific and technological innovation. The miracle of modern medicine has improved the quality of life, but has also contributed increased costs of care. The resulting health care industry can be described as a typology along a horizontal axis of cost and a vertical axis of quality. In such a system some are bound to be left out while others will be privileged.
For a long time this typology was not so pronounced as to inspire the scrutiny of society as a whole. The miracle of modern medicine allowed more people to survive infancy and live into old age. We have since taken it for granted that our children will survive and that we will grow old. However, the cost of this historical revolution is the shift in medical needs from the treatment of infectious disease and injury to the much more expensive chronic diseases that correlate to old age and the limits of medical science.
Large corporations developed to fill the market demand for medical access. These corporations were not motivated by the desire to do well by their fellow man, but rather to turn a profit. In an exercise of free market principles at their best, health insurance companies thrived by guaranteeing access to care for a price. Meanwhile, public clinics and government programs such as Medicare and Medicaid picked up most of the slack among unmarketable old and poor people. This system lasted long enough for insurance companies to become entrenched stakeholders in the medical system, earning them a place at the discussion table for a crisis in which they themselves are complicit.
Now we face a culmination of these dynamics. As usual, the realities do not break down along clear lines of right and wrong. Most people would agree to the simple statement that everyone (except illegal immigrants, but thats another essay) deserves access to health care. The question becomes more complicated when we add factors such as how much access and to which technologiesand who pays for it, the consumer or the tax payer? The fact that there exists an established institutional framework and its requisite capitalist paradigms that wields significant wealth and power is yet another obstacle to meaningful reform and a discursive restraint on radical debate.
Privelege vs. Right
The claim that health care is a commodity is a paradigm of privilege that denies the concept of an individual right to health care. After all, individual rights are not for sale. This constraint predetermines the direction of the debate and ultimately the outcome of reform.
A privilege is, by definition, something that is bestowed upon individuals through some social process. The sociology of privilege is based either on merit or inheritance and is a defining feature of status. Achieved status, or status based on presumed merit, is the default discursive formation in American society. Being of high status is assumed to be based on some individual quality, work ethic, drive or competence. Therefore, any privileges corresponding to status is deserved. Those who do not have such privileges may be offered some charitable entitlement, or they may simply be written off as undeserving.
Yet status is also ascribed, or inherited based on factors such as the socio-economic position of ones parents, ones race or gender, ones biological contingencies or limitations. Being born without a congenital health defect privileges one to easier access to health care just as being born to wealthy parents does.
Rights, on the other hand, are much trickier matters. By virtue of Americas cultural canon, such as the Declaration of Independence, the Federalist Papers and the Constitution human rights are inherent just by virtue of being American (or as some might suggest, human). As such, human rights cannot be denied an individual based on status without some established and limited system of due process.
In the United States the claim to rights is easy to postulate when those rights can be identified in personal terms. The right of the individual to speak or to worship, or even to gather with other individuals is easily defensible. Such rights do not require an investment on the part of others for exercise. The right to free speech does not have attached to it a corresponding right to be listened to, in other words.
Other rights, however, require a commitment on the part of others if the individual is to exercise them. The right to due process including a jury of ones peers, for instance, requires others to take on the responsibility of serving for jury duty. The right to privacy infers a responsibility to keep out of other peoples affairs. A more abstract right that most of us would recognize is the right to an education. But in order to exercise that right a sacrifice (one might argue a responsibility) must be made on the part of the community in the form of taxes, land acquisition and the childs time spent away from parents and out of the marketplace. Such rights, however, often come with a certain amount of contention as we debate just how much the community is to sacrifice as compared to what the community can expect to get in return.
Thomas Jefferson did us no favors in defining these inalienable rights so eloquently as life, liberty and the pursuit of happiness. All three such rights require some expense on the part of the community if they are to be manifest in the individual. For instance, it could be argued that one must have access to meaningful work at a living wage to enjoy life, real freedom and the opportunity to happiness. However, what is the responsibility of the community, of the society, of government, in assuring such access?
Health care fits nicely into this paradigm. Inequalities in access to health care certainly correlate to inequalities in life expectations, the liberty that comes with good health and unfettered ability to pursue ones own ends. Those with enough resources have a privileged advantage to these rights. However, rights should not be subject to ones socio-economic status. Rights are inherent in the individual, not in their social position.
Toward a Right of Health Care
Health care was not an issue for our founding fathers. Before the advent of a germ theory there was not much polarity in access to this right as there was for other matters addressed by the founders, such as speech, assembly, privacy. Consequently, health care is not neatly defined in our 220 year old Constitution. The founders recognized, however, that as times change so does our concept of rights. Thats why our Bill of Rights included the 9th Amendment, which ensured that the rights listed in the Constitution are not the beginning or the end of the story?
Since the advent of modern medicine, contemporary statesmen have come to recognize the importance of health care to the satisfaction of individual rights. Many governments and charters formally recognize access to health care as a human right. Not the least of these charters is the Universal Declaration of Human Rights, Article 25. As a signatory to the UN Charter the United States is bound by our own Constitution to recognize the right to health care.
Yet this does not stop others, like Theodore Dalrymple, to suggest that there is no such right. In his Wall Street Journal editorial Dalrymple, a pseudonym for British physician Dr. Anthony Daniels, states:
Whenever I deny the existence of a right to health care to a Briton who asserts it, he replies, So
you think it is all right for people to be left to die in the street? When I then ask my interlocutor whether he can think of any reason why people should not be left to die in the street, other than that they have a right to health care, he is generally reduced to silence. He cannot think of one.
I have one! How about the Hippocratic Oath: I will treat without exception all who seek my ministrations. Or how about this version of the Oath, I will remember that I remain a member of society, with special obligations to all my fell human beings Shouldnt we expect a physician to accept an oath taken in their profession as binding? Perhaps Im asking too much from Dr. Daniels.
How about the story of the Good Samaritan? Well, Im sure Dr. Daniels doesnt wear a WWJD bracelet.
How about the fact that it is universally, morally repugnant to allow the sick to suffer and die without giving whatever succor and aid at our disposal? According to the American Journal of Public health an estimated 45,000 deaths a year are associated with lack of health insurance. The study found that those who do not have insurance are 40% more likely to die from their illnesses than those who are insured. This study offers the moral equivalent to Dr. Daniels people dying in the street.
Jefferson declared that human rights are self-evident, endowed by our creator, that they are inalienable. This was nice rhetoric, but Jefferson was wrong. Rights are a social process of the people demanding that those in power treat them with dignity, and asserting such through whatever means available. As the chronicle of human history demonstrates, the struggle for human rights is ongoing and expanding. It is time to assert a basic and fundamental right to health care.
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