“Of course, health care is a right,” my young friend said with a disdainful twist of her face and a shudder that seemed to shake off the unthinkable. “You are a doctor,” she added, reminding me of what I had done for thirty years. “ Surely you agree that health care is a basic human right.”
“Not really,” I said with a casual shrug. She blinked long as if doing so would allow her to hear me say something different. “Rights are intrinsic to the person. You know, the right to do as I want as long as I don’t hurt someone. But health care, if it is a right, involves requiring someone to do something for me. And by definition, that makes the person rendering the care a slave to the person with the right to that care.”
She shuttered again.
I was riding in the back of a pickup truck through the streets of Port au Prince with a group that was half emergency physicians and half graduate students in development. It made for some very interesting and kinetic discussions, the theoreticians versus the pragmatists. And here we were in the middle of one of the most medically deprived populations in the western hemisphere asking the simple question, ‘How can you really help people in need?’
I brought this group to Haiti on the second anniversary of the earthquake to do a general assessment of the progress since those dark days of January 2010 when almost 300,000 people lost their lives. There was no question that emergency help was needed and had been provided by thousands of volunteers who had poured into Haiti in the aftermath of the quake. But how, we were asking, was the transition going towards a stable, sustainable health care system? In pursuit of this answer, it made perfect sense to mix the disaster specialists with the development students and see what we came up with. Again and again our discussions came back to this basic question, “Is health care a human right?”
“It’s simple social justice,“ my PhD student stated with confidence. “People have the right to access to health care.”
“Let’s take that statement apart, if you don’t mind,” I said, trying my best, unsuccessfully, not to be pedantic. “Justice is required when someone has done something wrong to another person. The ‘scales’, so to speak, are out of balance. If someone takes something from me, they have to give it back, or give me something in return to try to ‘make me whole’. And the justice system is charged with doing that task. If through my negligence or greed I take someone’s health from them, of course, I owe them whatever it takes to make them whole. But just by my very existence as a physician, I haven’t taken something from a sick person. By my advantaged position I may have a moral obligation to help people who can’t pay. In fact, that is part of the oath that I took when I became a physician. But to say that I have an obligation is not the same as saying that the other person has a right.”
“But your profession was provided to you with the benefit of government grants and loans. So doesn’t it make sense that they have the right to enforce your obligation to the poor?”
“First, I didn’t go to medical school on government loans. I worked nights and weekends in the blood bank.” I didn’t add the haughty ‘I’ll have you know,’ that I was thinking.
“And even if I had, it would have been a loan that I repaid. So how does that make me indebted to the government?”
“The very fact that you came from a home that had advantages makes you indebted to society. You had parents that made you study and helped you succeed. Some people, typically the poor, don’t have those advantages. Is it right that you should have things that they don’t? And in the case of Haiti, isn’t it true that they are poor and disadvantaged largely due to the history of American imperialism, embargoes, and racism? So isn’t it simple social justice that Americans should be providing health care for the poor of Haiti?” It was clear that she meant this argument to extend to the poor in general.
“That’s an interesting argument that you make,” I said, trying to be open minded about something that I had settled long ago in my own mind. “It is true that I had many advantages, but they were largely due to the decisions and sacrifices that my parents made.
But they didn’t come at the expense of someone else. Life is not a zero sum game. My benefits are not always at the expense of someone else. And it is true that America has not always acted in the best interest of the Haitian people. But it is the obligation of the American government, or any government for that matter, to act for the benefit of their own people. That doesn’t justify some of the racist policies of America’s past, but it does explain some of the trade policies. So while I agree that the American government does owe it to the world to do justice and right the wrongs that it can, I’m not sure that that debt extends to me personally.”
“The government owes to the poor and disadvantaged the right of access to health care, wouldn’t you agree?” It was clear that she cared deeply for the poor and this made perfect sense that a benevolent government would provide for its weaker members. But what I heard was ‘access’, the buzzword that is used throughout the health care debate in America. It was the picture of a doorway to health that someone was blocking. But I could see that the ‘access’ debate was an attempt to shape an argument through defining the terms in such a way that no reasonable defense was tenable.
“You are right,” I conceded, “that no one should be denied access to health care. There should be no one preventing someone, anyone, from obtaining health care. You might be surprised to know,” I said, drifting into my professorial tone, “that it is illegal in the US for an emergency physician to ask about a patient’s ability to pay before providing emergency care. So I agree that it would be immoral and unjust to refuse to care for someone until they had proven that they had the means to pay. But that does not mean that they are relieved of the responsibility to pay. Nor does it give them the right through the government to tax me to pay myself for that service.”
“You’re such a Republican,” she said with disgust before she could censor herself. She blushed at revealing her anger with me. I was older, after all, and the leader of the group. It was a conversation stopper, though.
Later she came to me privately. “I’m sorry I called you a Republican,” she said with sincere humility.
“You’re right, you know,” I said, chuckling. “But I never considered it an epithet. Don’t worry,” I reassured her, “we’re on the same side. We both want to make this situation right. We just haven’t settled on the right way to do it yet.”
Dr. Mark Plaster is the founder and executive editor of Emergency Physicians Monthly
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Subscribe to this comment's feedwritten by PhD Student in Question , March 14, 2012
written by Dr. Plaster , March 14, 2012
written by A Real Doctor, Not a PhD , March 14, 2012
written by Darrell Looney , March 14, 2012
written by John Grady , March 14, 2012
written by Dwight Burdick, MD, FACEP , March 15, 2012
I have endeavored to adhere to this concept of obligation throughout my long career. Certainly, if am obligated to provide a service, that service becomes the right of every patient presenting to me.
For my profession, I would point out that whenever Physicians cease respecting our obligation, and instead insist on a privilege, we will inevitably loose our self respect and the respect of our community.
written by Patricia , March 15, 2012
written by Patricia , March 15, 2012
written by Question , March 15, 2012
written by Regular Reader , March 15, 2012
written by Ted Switzer, MD, FACEP , March 16, 2012
In 1986 when Congress passed the Emergency Medical Treatment and Active Labor act (EMTALA), with no provision for compensation, we effectively decided that all people who live in the country have the right to an appropriate medical screening examination and stablization.
So, officially, there is a right to this limited form of health care in the United States. Beyond that, leagally speaking, there is no right per se.
written by Pat Conrad, MD , March 16, 2012
What oath exactly did you take? The Classical Hippocratic Oath does not obligate a physician to treat any and all.
Dr. Plaster, was the oath you took a variation on the Hippocratic one? The Classical Oath does NOT say anything about an obligation to treat regardless of payment, and only prescribes behavior between a physician and patient that have (implied) already entered into a voluntary association.
It is your own choice if anyone took an oath to treat without pay, but let's not confuse that with the original; as a profession, we have blurred the lines for decades and given lip service to something not even in the original oath, which in turn has been used by patients, hospital administrators, insurance companies, the media, and even ourselves to bludgeon us into de facto servitude if and when society deems it.
I enjoyed your well-written, very pointed article, but question this one assertion.
written by Seth , March 18, 2012
written by John Grady , March 18, 2012
written by pjk , March 24, 2012
This entire debate is a DISGRACE! Had the President been HONEST and sold universal health care as a moral imperative that we would all have to chip in to afford, I would have supported his efforts. He could have gotten up before congress and argued that this was the right thing to do, but it will be expensive. Therefore, we are ALL going to have to pay a bit more in taxes to afford this. But no, they created this mandate which is in all likelihood unconstitutional.
So, guess what happened not too long after the bill was passed in regards to its ability to bend the cost of health care down?
http://www.nytimes.com/2010/04/24/health/policy/24health.html?_r=1
oooppps!
I represent some of the largest "safety net" hospitals in the country. These institutions do an amazing job providing health care to poor and underserved communities. Guess what? These same institutions are ALREADY being crushed by the regulatory and compliance costs of the PPACA.
In NY, where I practice, these safety net hospitals are almost 100% dependant on Medicare and Medicaid funding. In NY, The Gov just cut $2.8 Billion dollars from the Medicaid budget. Prior to the passage of the ACA, Gov Patterson and Mayor Bloomberg came out against the new law stating that it would add $1 to $1.5 BILLION in Medicaid costs to NY State.
For those here who support this new law and ACCESS to health care for all. PLEASE, PLEASE explain to me how a state that just had to cut $2.8 Billion from its Medicaid budget is going to pay for the added costs attendant to this new law?
We will never solve our deficit and debt problems until and unless we confront health care costs head on. Medicare/Medicaid costs are exploding, and will only get worse as the population ages. Congress' heavy handed attempts to control costs by limiting doctor's payouts will not work, as many doctors are already refusing to see new Medicare patients. As a liberal Obama had a unique opportunity to fix this liberal program gone wild. He did not rise to this challenge. Instead the PPACA does nothing to control costs and simply adds another bureaucratic and costly entitlement on top of those we already can't afford. The deficit commission really ducked this one. The PPACA must be repealed and Medicare/Medicaid block funded to the states, or we will never control our debt, even if every dime is simply confiscated from the rich.
written by pjk , March 24, 2012
I realized I was being critical without offering any alternatives to the new law; because I think we all agree that the status quo is unacceptable.
There are ways to insure more people and to bring costs down. Government has established and nurtured a system in which most patients are distantly connected to payment for services. This encourages them to spend without regard to expense. A lack of self-rationing increases demand, which drives up costs. Real progress, however, can be made in states where lawmakers have heaped very expensive mandates on health insurance policies.
In a few states, there are mandates that require policies to include benefits for Oriental medicine. Others require plans to cover hair prostheses. All but four states mandate that insurance cover alcoholism treatment while the majority of states require the same for drug abuse. A benefit for smoking cessation is mandated in six states while port-wine stain elimination is required in two.
In 12 states, insurance policies must include access to acupuncturists. Three states say plans must provide for athletic trainers, and dozens make insurance pay for a variety of marriage, occupational and massage therapists, pastoral counselors and social workers. Four states even require that insurers provide for naturopaths.
There are thousands of mandates at the state level. Most of the mandates cover common benefits or providers, many of the mandates are highly suspect. Few of these are costly by themselves; most increase the price of premiums by less than 1%. But when added together in a plan, insurance coverage becomes considerably higher.
When I was meeting with my clients that run the not for profit hospitals I represent, there were experts who came to us and lectured and demonstrated that getting rid of many of these mandates could lower the cost of premiums by 50%! The mandates are an insult to common sense. A single man does not need an insurance package that covers in vitro fertilization, maternity leave, a midwife, breast reduction or mammogram's. Neither is it necessary for a childless, unmarried woman to have a plan that includes care for a newborn and screening for prostate cancer.
And a teetotaler should have the option of choosing a plan that doesn't have benefits for alcohol and substance abuse.
In many cases, however, they have to pay for such coverage, either through individual policies or employer-provided plans. State legislators could restore good sense to the law and provide a genuine measure of reform by backing off the mandates and letting people buy from an a la carte menu of benefits and providers.
Why should health insurance not be sold across state lines? This lowers the cost for car insurance, why wouldn't it lower the cost for health insurance. This suggestion has been opposed by the democrats. Why?
Also, the costs of medical malpractice is hard to calculate. But, I can tell you from personal experience that Dr's and hospitals routinely order tests and prescribe medications as part of the practice of "defensive medicine". There must be Tort reform that makes sense. I am not advocating caps on damages. People who are injured through the fault of Dr's have a right to compensation without caps. But, I propose taking the cases out of the hands of juries. There should be specialized medical malpractice courts just as there are immigration and tax courts.
These are just some possible ways to lower health care costs and provide access to more individuals.
written by Dr. Theo , March 25, 2012
And what about food? Health care means nothing if you are starving. Everyone should get unlimited groceries and access to restaurants paid by the government.
Clothes? Is not that a basic human need that everyone has a right to? Clothes should be provided for free.
Transportation. Without a reliable car going to work or to the welfare office or to the doctor or to McDonald's becomes nearly impossible. Clearly, owning an automobile is a fundamental right that should be provided by government.
Contraception? Well,...I guess that's been argued enough already.
written by Dr. Alan , June 06, 2012
This argument is not about basic human rights, its about giving free 'stuff' to people who have not earned it - therefore alleviating them of any need to work for it, and hence any desire to work for it.
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