“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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