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                    Is There a Right to Health Care?
        
                         by David Kelley, Ph.D.
        
           [Note: Dr. Kelley is the executive director of the
           Institute for Objectivist Studies. This paper is
           adapted from speeches delivered to the Medical
           Action Committee for Education, Association of
           American Physicians and Surgeons, National Order of
           Women Legislators and Objectivist Club of Michigan.
           This paper is copyright by the Institute for
           Objectivist Studies, although permission to copy
           this material is granted as long as it is copied in
           full, including this copyright notice.  For more
           information, please see the note at the end of this
           paper.]
        
        
           Bill Clinton ran for president last year by
        attacking the 1980s as a "decade of greed"--attacking
        the leveraged buyouts and hostile takeovers engineered
        by Wall Street financiers. I happen think this trend in
        the 1980s was a good thing, a productive realignment in
        American business. But be that as it may, the irony is
        that President Clinton is now proposing a hostile
        takeover of his own, a hostile takeover on a scale far
        beyond anything that Wall Street capitalists ever
        dreamed of, a hostile takeover of one seventh of the
        nation's economy.I'm referring, of course, to his
        recently announced plan for health care "reform."
        
           The Clinton plan in its present form involves a
        massive exercise of coercion against physicians,
        employers, and patients alike. Most people will be
        forced to do business through health insurance
        purchasing cooperatives: government-backed monopolies
        that collect payments from consumers and set the terms
        on which producers can offer their services. Everyone
        will be forced to buy health care through these
        monopolies, with employers forced to pay the lion's
        share of the bill. Physicians, hospitals, and HMOs will
        be prohibited from dealing with patients directly; they
        will be forced to offer their services through the
        purchasing cooperatives, subject to highly restrictive
        rules.
        
           What has brought us to this state of affairs?
        Socialism has collapsed in the Soviet Union. The
        nations of Western Europe are trying to trim back their
        welfare states, desperately looking for ways to
        privatize. Yet in this country we are on the brink of a
        massive increase in government subsidies and government
        controls. Why?
        
           The full story is a long and complicated one, but
        the essential cause, I think, is simple. The essential
        cause is the assumption that if people have medical
        needs which are not being met, it is society's
        responsibility to meet them. In the current debate over
        health care reform, universal access has become the
        unquestioned goal, to which all other considerations
        may be sacrificed. The assumption is that the needs of
        recipients take precedence over the rights of
        physicians, hospitals, insurers and drug companies--the
        producers of health care, the people who deliver the
        goods--along with the rights of the taxpayers who are
        going to have to pay for it. In other words, those with
        the ability to provide health care are obliged to
        serve, while those with a need for health care are
        entitled to make demands.
        
           Indeed, it is often said that the need for health
        care constitutes a right. President Clinton campaigned
        with the slogan, "Health care should be a right, not a
        privilege." Opinion polls regularly show that the
        belief in such a right is widespread, even within the
        medical profession. The AMA's "Patient's Bill of
        Rights" includes the statement that patients have a
        "right to essential health care."
        
           If health care is a right, then government is
        responsible for seeing that everyone has access to it,
        just as the right to property means that government
        must protect us against theft. For the past thirty
        years, the idea that people have a right to health care
        has led to greater and greater government control over
        the medical profession and the health care industry.
        The needs of the indigent, the needs of the uninsured,
        the needs of the elderly, among other groups, have been
        put forward as claims on public resources. Government
        has responded by subsidizing these groups, and
        regulating physicians, insurers, and pharmaceutical
        companies on their behalf. Now the Clinton
        Administration proposes to make this right universal,
        to create a universal entitlement, and to vastly expand
        government control.
        
           In this context, I can state my own point in a
        sentence: there is no such right. I will show you why
        the attempt to implement this alleged right leads in
        practice to the suspension of the genuine rights of
        doctors, patients, and the public at large. And I will
        show why the concept of such a right is corrupt in
        theory. I want to stress at the outset the importance
        of this issue. The long-term direction of public policy
        is not set by electoral politics, or by horse-trading
        in Congress, or by this or that court case. In the long
        term, at a basic level, public policy is set by ideas--
        ideas about things are just and worthy, what rights and
        obligations we have as individuals. The idea that
        people have a right to health care is inimical to our
        genuine liberties. The policies that flow from that
        idea are harmful to the interests of doctors and
        patients alike. To fight against those policies, we
        have to attack their root.
        
        
                          Liberty vs. Welfare Rights
        
           Let's begin by defining our terms. A right is a
        principle that specifies something which an individual
        should be free to have or do. A right is an
        entitlement, something you possess free and clear,
        something you can exercise without asking anyone else's
        permission. Because it is an entitlement, not a
        privilege or favor, we do not owe anyone else any
        gratitude for their recognition of our rights.
        
           When we speak of rights, we invoke a concept that is
        fundamental to our political system. Our country was
        founded on the principle that individuals possess the
        "inalienable rights to life, liberty, and the pursuit
        of happiness." Along with the right to property, which
        the Founding Fathers also regarded as fundamental,
        these rights are known as liberty rights, because they
        protect the right to act freely. The wording of the
        Declaration of Independence is quite precise in this
        regard. It attributes to us the right to the pursuit of
        happiness, not to happiness per se. Society can't
        guarantee us happiness; that's our own responsibility.
        All it can guarantee is the freedom to pursue it. In
        the same way, the right to life is the right to act
        freely for one's self-preservation. It is not a right
        to be immune from death by natural causes, even an
        untimely death. And the right to property is the right
        to act freely in the effort to acquire wealth, the
        right to buy and sell and keep the fruits of one's
        labor. It is not a right to expect to be given wealth.
        
           The purpose of liberty rights is to protect
        individual autonomy. They leave individuals responsible
        for their own lives, for meeting their own needs. But
        they provide us with the social conditions we need to
        carry out that responsibility: the freedom to act on
        the basis of our own judgment, in pursuit of our own
        ends; and the right to use and dispose of the material
        resources we have acquired by our efforts. These rights
        reflect the assumption that individuals are ends in
        themselves, who may not be used against their will for
        social purposes.
        
           Let us consider what liberty rights mean in regard
        to medical care. If we implemented them fully, patients
        would be free to choose the type of care they want, and
        the particular health care providers they want to see,
        in accordance with their needs and resources. They
        would be free to choose whether they want health
        insurance, and if so, in what amounts. Doctors and
        other providers would be free to offer their services
        on whatever terms they choose. Prices would be governed
        not by government fiat, but by competition in a market.
        Since this is an imaginary state of affairs, no one can
        predict what mix of private practitioners, HMOs, and
        other sorts of health plans would emerge. But market
        forces would tend to ensure that patients have more
        choices than they do now, that they would act more
        responsibly than many do at present, and that they
        would pay actuarially fair prices for health insurance-
        -prices that reflect the actual risks associated with
        their age, physical condition, and lifestyle. No one
        would be able to shift his costs onto someone else. In
        a truly free market, I might add, there would be no tax
        preference for obtaining health insurance through
        employers, so most people would probably buy health
        insurance the way they buy life insurance, auto
        insurance, or homeowners insurance--directly from
        insurance companies. They would not have to fear that
        losing their job, or changing the job, would mean
        losing their coverage.
        
           So that is what liberty rights--the classical rights
        to life, liberty, and property--would mean in practice.
        The so-called "right" to medical care is quite
        different. It is not merely the right to act--i.e., to
        seek medical care, and engage in exchanges with
        providers, free from third party interference. It is a
        right to a good: actual care, regardless of whether one
        can pay for it. The alleged right to medical care is
        one instance of a broader category known as welfare
        rights. Welfare rights in general are rights to goods:
        for example, a right to food, shelter, education, a
        job, etc. This is one basic way in which they are quite
        different from liberty rights, which are rights to
        freedom of action, but don't guarantee that one will
        succeed in obtaining any particular good one may be
        seeking.
        
           Another difference has to do with the obligations
        imposed on other people. Every right imposes some
        obligation on others. Liberty rights impose negative
        obligations: the obligation not to interfere with one's
        liberty. Such rights are secured by laws that prohibit
        murder, theft, rape, fraud, and other crimes. But
        welfare rights impose on others the positive obligation
        to provide the goods in question.
        
           Health care does not grow on trees or fall from the
        sky. The assertion of a right to medical care does not
        guarantee that there is going to be any health care to
        distribute. The partisans of these rights demand, with
        air of moral righteousness, that everyone have access
        to this good. But a demand does not create anything.
        Health care has to be produced by someone, and paid for
        by someone. One of the major arguments offered by
        supporters of a right to health care is that health
        care is an essential need. What good are our other
        liberties, they ask, if we cannot get medical treatment
        for illness? But we must ask, in return: why does need
        give someone a right? Fifty years ago, people whose
        kidneys were failing needed dialysis every bit as much
        as they do today, but there were no dialysis machines.
        Did they have a right to protection against kidney
        failure? Was Mother Nature violating their rights by
        making their kidneys fail without a remedy? It makes no
        sense to say that need itself confers a right unless
        someone else has the ability to meet that need. So any
        "right" to medical care imposes on someone the
        obligation to provide care to those who cannot provide
        it for themselves.
        
           If I have such a right, some other person or group
        has the involuntary, unchosen obligation to provide it.
        I stress the word "involuntary." A right is an
        entitlement. If I have a right to medical care, then I
        am entitled to the time, the effort, the ability, the
        wealth, of whoever is going to be forced to provide
        that care. In other words, I own a piece of the
        taxpayers who subsidize me. I own a piece of the
        doctors who tend to me. The notion of a right to
        medical care goes far beyond any notion of charity. A
        doctor who waives his bill because I am indigent is
        offering a free gift; he retains his autonomy, and I
        owe him gratitude. But if I have a right to care, then
        he is merely giving me my due, and I owe him nothing.
        If others are forced to serve me in the name of my
        right to care, then they are being used regardless of
        their will as a means to my welfare. I am stressing
        this point because many people do not appreciate that
        the very concept of welfare rights, including the right
        to health care, is incompatible with the view of
        individuals as ends in themselves.
        
           I might add that the difference between charity and
        rights is very well understood by the advocates of a
        right to health care. One of their main arguments for
        using the language of rights is that it removes the
        stigma associated with charity. A right is something
        for which you don't owe anyone any gratitude. But
        notice the contradiction. The reason for proposing such
        a right in the first place is the claim that certain
        people cannot provide for themselves, and are thus
        dependent on other people for their medical care. The
        advocates of a right to health care then turn around
        and insist on using the concept of rights to disguise
        the fact of dependence, to allow the recipients of
        government subsidies to pretend that they are getting
        something they earned.
        
           It is also worth noting that the Supreme Court has
        never recognized a constitutional basis for any welfare
        right, including the right to medical care. The Court
        recognizes that the concept of rights embodied in our
        legal system is the concept of liberty rights. Welfare
        rights are a product of later movements to expand the
        role of government beyond the original conception of
        its role. In our constitutional system, there is no
        requirement that the federal government provide health
        care. Health care entitlements, unlike fundamental
        rights like freedom of speech, have to be invented by
        legislators.
        
        
                   Effects of a Right to Health Care
        
           Unfortunately, our legislators have been equal to
        the challenge. They have invented such entitlements in
        spades. And that leads me to my next point. When
        government attemopts to implement a right to health
        care, the result will be the abrogation of liberty
        rights. As with money, bad rights drive out good ones.
        Let's review the major consequences of implementing a
        right to medical care. I am going to use illustrations
        from our current situation, but these consequences
        follow inevitably from any approach: single payer,
        managed competition, whatever.
        
        1)   To begin with, of course, the government has to
          tax some people to pay for medical subsidies offered
          to those it considers to be in need. So the first
          consequence of implementing a "right" to medical care
          is forced transfers of wealth from taxpayers to the
          clientele of programs like Medicare and Medicaid. And
          this will inflate the demand for health care
          services. Offering free or heavily subsidized care is
          inevitably going to increase overall use of the
          health care system.
        
             Figures from the early years of the Medicaid
          program indicate the vast increase in demand that can
          result. According to a Brookings Institution study,
          in 1964, before Medicaid went into effect, those
          above the poverty line saw physicians about 20
          percent more frequently than did the poor; by 1975,
          the poor were visiting physicians 18 percent more
          often than the nonpoor. Again, before Medicaid, those
          with low incomes had only half as many surgical
          procedures as those with middle-class incomes; by
          1970, the rate for low-income people was 40% higher
          than for those with middle class incomes.[1] When
          Medicare was instituted in 1966, the House Ways and
          Means Committee estimated that by 1990, allowing for
          inflation, the program would cost $12 billion; the
          actual figure was $107 billion.[2] (Government
          forecasts of the costs of entitlement programs are
          never accurate. In many cases, like this one, they do
          not even get the order of magnitude correct.)
        
        2)  The cost explosion leads to the second major
          consequence of implementing a "right" to medical
          care: restrictions on the freedom of health care
          providers. During the debate over health care policy
          in the 1960s, proponents of Medicare and Medicaid
          assured doctors that they only wanted to pay for
          indigent care, and had no intention of regulating the
          profession. Abraham Ribicoff, then Secretary of
          Health, Education, and Welfare, said: "It should be
          absolutely no concern to a physician where a patient
          gets the money."[3]
        
             But of course the surge in demand for medical care
          led to rapid price increases, along with abuses of
          the system by clients of the government programs as
          well as by unscrupulous doctors and hospitals. These
          problems had to be addressed somehow, and the result
          was a growing web of controls: Professional Standards
          Review Organizations, diagnosis-related groups,
          restrictions on balance billing, utilization reviews.
          Under the managed care systems that have proliferated
          in the effort to control costs, physicians have less
          and less autonomy to act on their own best judgment
          about what is best for the patient. Dr. Maurice
          Sislen has written: "A huge, complex, policing system
          has taken the place of what used to be the doctor's
          responsibility to his patient. Probably only a
          practicing physician can fully appreciate the
          magnitude of the economic waste and moral degradation
          involved."[4]
        
        3)   A third major consequence of implementing a right
          to health care is the increased burden imposed on
          consumers of health care--the ones who were
          originally not in need of government subsidies. As
          taxpayers, of course, they have to pay for all the
          programs; that's point 1. But as consumers, they are
          also affected by all the distortions of the market
          which these programs create. Everyone pays the higher
          prices caused by the inflation of demand for medical
          services, together with the increased costs of
          regulation and paperwork. As people are priced out of
          the system, they are forced into managed care systems
          that limit their choices of doctors.
        
             Health insurance stipulations by states raise the
          cost of insurance, and discourage employers from
          hiring certain kinds of workers. For example,
          "community rating" laws require insurance companies
          to offer policies for the same price to all people,
          regardless of age, lifestyle, or physical condition.
          Since the actual risks depend on these factors, what
          community rating means is that the young pay higher
          prices to subsidize the elderly, the well subsidize
          the sick, and those with healthy lifestyles subsidize
          those with unhealthy ones. As an indication of the
          kind of subsidy involved, community rating in New
          York nearly tripled the cost of insurance for a 30-
          year-old male.[5]
        
        4)   Yet another consequence is a growing demand for
          equality in health care. If something is a human
          right, after all, then it should be protected equally
          for all persons. Our system is based on the idea of
          equality before the law. Now if we plug into this
          system the additional idea that we all have a legal
          right to some good like health care, the natural
          inference is that we all ought to receive that good
          on a more or less equal footing. For example, in a
          1989 survey for the Harvard Community Health Plan,
          90% of the respondents said that everyone should have
          "a right to the best possible health care--as good as
          a millionaire." Here's another example, a statement
          by Horace Deets, the Executive Director of the
          American Association of Retired Persons: "Ultimately,
          we must recognize that health care is not a
          commodity. Those with more resources should not be
          able to purchase services while those with less do
          without. Health care is a social good that should be
          available to every person without regard to his
          resources."[6] And the Clinton plan is clearly
          egalitarian. One of the explicit goals of the
          proposal is to eliminate any "two-tier" system in
          which some people are able to buy more or better
          health care than others.
        
        5)   The fifth consequence--the last one I'll mention--
          is the collectivization of health care, and of health
          itself. Just as a mixed economy treats wealth as a
          collective asset, which the government is free to
          dispose of as it sees fit for "the common good," so a
          collectivized health care system treats the health of
          its members as a collective asset. Under this regime,
          physicians no longer work for their patients, with
          the overriding responsibility to act in their
          interests. Instead, physicians are agents of
          "society" who must decide the amount and the kind of
          care they give an individual patient by reference to
          social needs, such as the need to control costs in
          the system as a whole. Indeed, even the individual in
          such a system is urged to protect his own health not
          because it is in his self-interest, but because he
          has a responsibility to society not to impose too
          many costs on it.
        
           To summarize, then, a political system that tries to
        implement a right to health care will necessarily
        involve: forced transfers of wealth to pay for
        programs, loss of freedom for health care providers,
        higher prices and more restricted access by all
        consumers, a trend toward egalitarianism, and the
        collectivization of health care. These consequences are
        not accidental. They follow necessarily from the nature
        of the alleged right.
        
        
                              Clinton Plan
        
           The same is true of the Clinton Administration's
        plan--true on a much larger scale. This plan will be
        far more destructive of our liberties than anything we
        have experienced so far.
        
           The plan calls for a further extension of health
        care subsidies: to those who are currently uninsured,
        and to those who have health coverage less extensive
        than the proposed standard package of benefits. Where
        are these subsidies going to come from? The
        Administration has rejected the so-called "single-payer
        system"--that is, overtly socialized medicine, in which
        the government pays all the bills--because it knows
        that the government cannot pay all the bills. The
        necessary tax increases would be politically
        impossible. So the Clinton plan calls for a nominally
        private system in which regulations force some people
        to subsidize others.
        
           At the heart of the plan are the health alliances:
        government-protected monopolies in each area which will
        collect premiums and negotiate with health care
        providers to offer acceptable plans. Everyone who lives
        in a given area will be forced to obtain health
        insurance through their local monopoly health alliance.
        Health care providers--private practitioners, HMOs, and
        others--cannot deal directly with individuals. They can
        offer their services only through the health alliances,
        subject to the conditions it imposes.
        
           One such condition is guaranteed access: every plan
        must be willing to accept any individual who wants it;
        no one may be excluded for any reason. Another
        condition is community rating: the price of the plan
        must be the same for everyone. Now think about what
        effects this will have on incentives. If I know that
        when I get sick I will be able to enroll in any plan I
        want, at a price that does not reflect my condition,
        then I have no reason to obtain health insurance when I
        am well. If people are free to choose whether or not to
        obtain and pay for a policy, the only people enrolling
        will be the sick, and costs will go through the roof.
        So the system works only if everyone is forced to
        participate. That is exactly what the proposal
        requires, and although the details of the proposal keep
        changing, this is one point that cannot change.
        
           At the national level, the system will be governed
        by a National Health Board whose two main functions
        will be to determine the standard package of minimum
        benefits, and to set global budgets. The global budgets
        will force the health alliances to impose what amount
        to price controls on medical providers. And the
        standard package of benefits will be set by interest
        group lobbying, as every group in the health care field
        will try to get its services included in the package.
        For example, the current definition of the package
        includes mental health and substance abuse counseling.
        You may feel that you do not need insurance for these
        services, but you are going to pay for them.
        
           In short, the plan will require a massive exercise
        of coercion against individuals, far beyond anything we
        have seen so far. Which brings me back to the
        fundamental issue.
        
        
                           Moral Foundations
        
           In all the ways I have described, any attempt to
        implement a "right" to health care necessarily
        sacrifices our genuine rights of liberty. We have to
        choose between liberty rights and welfare rights. They
        are logically incompatible. It is because I believe in
        the rights of liberty that I say there is no such thing
        as a right to health care. So I want to end by
        explaining why I think the rights of liberty are
        paramount, and by trying to anticipate some of the
        questions and objections you may have.
        
           The rights of liberty are paramount because
        individuals are ends in themselves. We are not
        instruments of society, or possessions of society. And
        if we are ends in ourselves, we have the right to be
        ends for ourselves: to hold our own lives and happiness
        as our highest values, not to be sacrificed for
        anything else.
        
           I think many people are afraid to assert their
        rights and interests as individuals, afraid to assert
        these rights and interests as moral absolutes, because
        they are afraid of being labelled selfish. So it is
        vital that we draw certain distinctions. What I am
        advocating is not selfishness in the conventional
        sense: the vain, self-centered, grasping pursuit of
        pleasure, riches, prestige, or power. Genuine happiness
        results from a life of productive achievement, of
        stable relationships with friends and family, of
        peaceful exchange with others. The pursuit of our self-
        interest in this sense requires that we act in
        accordance with moral standards of rationality,
        responsibility, honesty, and fairness. If we understand
        the self and its interests in terms of these values,
        then I am happy to acknowledge that I am advocating
        selfishness.
        
           We have to draw the same distinctions when we think
        about altruism. For it is, in the end, the moral code
        of altruism that makes people think that need is
        primary, that need gives one a right to the ability and
        effort of others. In the conventional sense, altruism
        means kindness, generosity, charity, a willingness to
        help others. These are certainly virtues, so long as
        they do not involve the sacrifice of other values, and
        so long as they are a matter of personal choice, not a
        duty imposed from without. I might note in this regard
        that physicians have historically been extremely
        generous with their time.
        
           In a deeper, philosophical sense, however, altruism
        is the principle that one person's need is an absolute
        claim on others, a claim that overrides their interests
        and rights. For example, Dr. Edmund Pellegrino has
        asserted, in an article for _JAMA_, "A medical need in
        itself constitutes a  moral claim on those equipped to
        help."[7] This principle has often been asserted by
        thinkers who are opposed to individualism, and it is
        the basis for the doctrine of welfare rights. It is the
        reason why advocates of government involvement in
        health care can take for granted that the needs of
        patients are primary, and that everyone else can be
        forced to provide for those needs.
        
           No rational basis for this principle has ever been
        offered. The fact is that our needs have to be
        satisfied by production, not by taking from others. And
        production comes from those who take responsibility for
        their lives, who apply their minds to the challenges we
        face in nature and find new ways of meeting those
        challenges. Ayn Rand said it best, in her novel _The
        Fountainhead_: "Men have been taught that the highest
        virtue is not to achieve, but to give. Yet one cannot
        give that which has not been created. Creation comes
        before distribution--or there will be nothing to
        distribute. The need of the creator comes before the
        need of any possible beneficiary."[8] The creator's
        need, in any field, is the freedom to act, the freedom
        to dispose of the fruits of his labor as he chooses,
        and the freedom to interact with others on a voluntary
        basis, by trade and mutual exchange.
        
           That freedom is a vital need, not only for doctors
        but for patients. It is only in a context of freedom
        that one person's need is not a threat to others. It is
        only in a context of freedom that genuine benevolence
        among people is possible. It is only in a context of
        freedom that the medical progress which has brought so
        many benefits to all of us can continue.
        
           The problems of our current system were caused by
        government. More government is not the solution. But we
        must oppose the expansion of government control in
        principle, by rejecting spurious claims of a "right" to
        health care, and insisting on our genuine rights to
        life, liberty, property, and the pursuit of happiness.
        
        
                               REFERENCES
        
        1 Karen Davis and Cathy Schoen, _Health and the War on
        Poverty_ (Washington: Brookings Institution, 1978),
        cited in Terree P. Wasley, _What Has Government Done to
        Our Health Care?_ (Washington: Cato Institute, 1992),
        61
        
        2 Steven Hayward and Erik Peterson, "The Medicare
        Monster," _REASON_, Jan 1993, 20
        
        3 Quoted in Leonard Peikoff, "Doctors and the Police
        State, _The Objectivist Newsletter_, June 1962, Special
        Supplement
        
        4 _The Wall Street Journal_, Jan. 10, 1990
        
        5 Michael Tanner, "Laboratory Failure: States Are No
        Model for Health Care Reform," _Policy Analysis_ #197,
        September 23, 1993 (Washington: Cato Institute, 1993)
        
        6 Letter to the Editor, _The Wall Street Journal_, Dec.
        23, 1992
        
        7 Edmund D. Pellegrino, MD, "Altruism, Self-Interest,
        and Medical Ethics," _Journal of the American Medical
        Association_, 258, Oct. 19, 1987, 1939
        
        8 Ayn Rand, _The Fountainhead_ (New York: Bobbs
        Merrill, 1943), 712
        
        
        
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