The Right to Medical Care
A Government that Controls Medical Spending Controls the Length of Your Life
SEPTEMBER 01, 1997 by SHELDON RICHMAN
The idea of a right to medical care is so blithely tossed around that most people never take time to ponder the rather serious consequences that would flow from it. It is a classic pseudo-right. A pseudo-right is any claim expressed in rights language that would expand the power of the state at the expense of genuine rights.
The “right to medical care” is seductive. People not accustomed to dissecting political discourse will think of the benefits of having their medical services provided “free” or at a guaranteed affordable price. More sophisticated people may see the proposal as a giant insurance system and feel that there can be no danger in it. If all citizens pay and all have access to care when they need it, what could be wrong?
Well, a lot could be wrong. Let’s start with something basic: for a right to be genuine, it has to be capable of being exercised without anyone’s affirmative cooperation. The full exercise of my right of self-ownership requires you to do nothing except refrain from killing or assaulting me. The full exercise of my property rights requires you to do nothing except refrain from taking what is mine. You have no positive, enforceable obligations to me, apart from any you accept through contract.
That principle of nonobligation is an excellent test to which we can submit any proffered right. How does the right to medical care hold up? Leaving out self-treatment, it is difficult to see how there can be such a right. Medical care, unlike air, is not found superabundant in nature. It is produced by someone who spends resources to acquire expertise and education. It requires the use of instruments and drugs, which have to be manufactured by someone. Who is to provide these things? Does the provider have any choice in the matter? What if he refuses? Should he be forced? If so, how shall we distinguish that person from an indentured servant or slave?
Since the “right to medical care” requires an affirmative obligation, it fails the rights test. Put simply, that “right” cannot coexist with the right to be left alone.
Implementation of the “right” does not typically entail forcing doctors, nurses, and manufacturers of medical instruments and pharmaceuticals to provide their services at gunpoint. So what I have said above may not seem germane. But it is, because although providers are not compelled, the taxpayers are. Taxation is somewhat less egregious than conscription, but it is still compulsion. Appropriating people’s earnings is tantamount to appropriating their time and labor. Since the compulsion of taxation is spread across large numbers of people, it is less noticeable than the conscription of medical personnel. But it doesn’t fundamentally change what’s going on.
That is only the beginning of what’s wrong with trying to enforce a right to medical care. Imagine for a moment a right to apples. That may sound nice, but an immediate problem arises. How many apples? Scarcity is the natural condition, which means that at any given moment our wishes exceed the supply of the things we want. (Freedom and free markets have this knack for loosening nature’s rather strict bonds of scarcity.) Declaring such a right would be an efficient way of emptying the shelves of apples. And let us ignore the significant question of who would produce apples if we all had a right to them.
We might decide to trust people to take only what they need. But that doesn’t get us out of trouble. Even if we assume a population of considerate people, “need,” in this context, is a subjective notion. You can probably live without apples; so in one sense, you need none. But if we expand the concept of “need” a little, we open the gates to endless disagreement over who needs how many apples. I may think I need many more than you. There is no way to resolve a dispute of that nature. Well, there is one way: the state can ration apples. We could trust the government to scientifically determine how many apples each of us needs. And if you believe that, you will also believe that the ruling party won’t manage to get more apples than the rest of us.
Government control of apples might be no more than an inconvenience. Government control of medical care would be life threatening. Yet what is the alternative once a “right to medical care” is declared? There is no way all people can have all the medical care they wish to have if it is (that is, appears to be) costless. The government will have to decide who gets what. How many of us would take comfort in that?
Here is the crux of the issue. The right to medical care must mean—no exceptions—the power of government, in principle, to determine who gets what. It may not exercise that power immediately. But given the economics of the matter, it will, sooner or later. I submit that this has nothing to do with rights and everything to do with control, literally, of people’s lives.
I do not exaggerate. A major ethical issue these days involves the “right to die,” or the right to assisted suicide. That is overshadowing one that may be more consequential, the so-called “duty to die.” Some years ago, then-Colorado Governor Richard Lamm argued that old people should know when it is time to quit this earth in favor of younger people. (The civil libertarian Nat Hentoff wrote recently that Lamm is, inexplicably, a devotee of exercise.) John Hardwig, a medical ethicist and social philosopher, has now picked up the cause of the duty to die. He writes that medical advances and an “individualist culture” may have many people believing that “they have a right to medical care and a right to live, despite the burdens and costs to our families and society.” He adds that “there may be a fairly common responsibility to end one’s life in the absence of any terminal illness . . . a duty to die even when one would prefer to live.”
For our purposes we need not address whether an old person should preserve his heirs’ inheritance rather than spend it on medical care. At the moment, that is a private, not a political, matter of how one spends one’s own money. (The inheritance tax could have consequences for such a decision.) What is relevant is how that ethical issue is transformed when government controls medical spending via “the right to health care.” The Lamm-Hardwig line would be translated into a rather unpleasant public policy: the withholding of care for the elderly in the name of “making room” for the young. The government giveth rights; the government taketh them away. As a matter of public policy, might not the politicians and bureaucrats decide that heart transplants, knee replacements, and mastectomies for octogenarians are a waste of money? This sort of thing is not considered beyond the pale in the increasingly fragile welfare states of western Europe.
All of this is a rather roundabout way of identifying the worst aspect of the “right to medical care”: the tethering of the citizen to the state. For all the criticism that is leveled at Medicare and proposals to reform medical care in general, too little attention has gone to that uncomfortable fact. If government controls medical spending, it controls you, including the very length of your life.
We may correlate the progress of mankind with the extent of its independence from the state. To put it mildly, national health insurance would be a setback.
Yet that is the direction in which we move. New regulations governing the portability of insurance policies and coverage of existing conditions all portend creeping comprehensive control. The newest cause, uninsured children, does the same. Ludwig von Mises explained why in his Critique of Interventionism. One regulation creates problems, which are used to justify the next intervention. For example, if Congress says mental-health benefits have to be equal to medical benefits, the cost of insurance will go up. That will then be the excuse to force young people who don’t wish to pay those premiums to buy insurance. Next on the agenda will be price controls on doctors and insurance companies. When companies flee the straitjacketed market, the government will step in. This is not conspiracy. It’s logic.
It all starts with an innocuous phrase, the right to medical care. Language is a potent thing. Let us handle it with care.