The Logic of Liberty: Whose Responsibility Is Your Health?
I recently had an (imagined) conversation with my friend Julius, who calls himself a socialist. We met for coffee late on Christmas Eve and spoke about the Senate's vote. Remember: it is not too late to contact your Congressperson to limit the worst excesses of the coming health care bill.
Julius: It's a day of celebration!
Me: I thought you hated Christmas.
Julius: Don't be a putz; you know what I'm talking about. The Senate has finally recognized our rights. It's time to party!
M: A right, eh? So what responsibility is induced by that right?
J: Oh, I'm too happy to be bothered by your technical questions. But I'll play along because you have such a sad face. It will be my Christmas present to you. Besides, the answer is easy: The responsibility is clearly the government's.
M: So it's "easy," is it? Aren't you the one who is always deriding others for their "simple" views of "complex" issues? Anyway, it isn't nearly as easy as you think.
J: My, aren't you the sour one. However, I remain cheerful. Our government has finally joined the international community in recognizing the rights of its citizens to health insurance.
M: Who, then, is the government?
J: The president, our wise Senate, and so on. I told you it was easy.
M: So you claim that just the president and members of Congress, and presumably its attached bureaucracy, is the government?
J: Of course.
M: Then the full responsibility for providing health insurance falls to this small group of people?
J: In a manner of speaking.
M: What manner? Surely, you aren't claiming that these few people will pay the health care expenses out of their own pockets.
J: Of course not. They will administer the costs; that's what I meant.
M: I assumed that's what you meant, but I want to know where those funds are coming from. You claim it is the government's responsibility, but then you say the members of the government won't actually be the ones paying. So it appears the actual responsibility lies elsewhere. Where?
J: Come on, don't be so obtuse. You know that the money will come from taxes.
M: And the taxes will be paid by me and you, and other citizens?
M: So then, what you're saying is that the responsibility is mine, and it is yours.
J: If you want to get technical.
M: I do. It comes to this: we, the citizens, are "the" government, are we not?
J: I guess so.
M: The government is not some abstraction, some far off, beneficent entity, but real people. People like you and me. When you're always crying for "the government" to pay for this or pay for that, what you're really saying, is that I should pay for this, or that I should pay for that. Is that right?
J: Well, yes, I suppose so. But I know you agree with me that since you are a citizen, you have a responsibility to contribute to our society.
M: Unquestionably. I just want to see what the limits of those responsibilities are. Just as I want you to see that when you ask the government for money, you are really asking me for my money.
J: Oh, you can afford it, else you wouldn't be blowing three bucks on this overpriced coffee.
M: Maybe. But let's find out. What new right do you claim that Senate created in their vote?
J: The right to health insurance, naturally.
M: I think you misspeak. Even you would agree that health insurance is not the same as health. Are you sure the "right" you're claiming is health insurance?
J: Everybody knows that health insurance ...
M: Let's not bother with what everybody knows. Let's figure out what we know. You agree, do you not, that having insurance is not equivalent to having health?
J: Not directly.
M: If not "directly," then not at all. Insurance does not bring health, care (from medical specialists and so forth) and certain ways of living do that, am I right?
J: You are. But insurance pays for that care.
M: Once more, you are in a rush to jump to the simple answer. Let's go a little slower. I don't think we have reached an adequate definition of the new right. We need that so that we can figure what responsibilities are induced by that right. We have already agreed that these responsibilities are mine, and yours, so it is well that we understand them.
J: Then the right I mean is health. After all, the Senate was following the Constitution when it said we should promote the "general welfare." Our citizens should be as healthy as possible.
M: I think you should have some more coffee, because you aren't awake yet. You cannot possibly mean what you just said.
J: I do mean it.
M: Then let's discover where the statement "as healthy as possible" leads. To guarantee your optimal health requires that I spare no expense, time, or effort, that I withhold from you no test or treatment, no matter how speculative, that I follow behind you with a safety net, even, lest you fall. Further, since you agreed that each citizen has the same responsibilities, each of us would have to spend the same effort for each other person. We would become a society where all that mattered was health.
J: If I weren't wearing these sunglasses, you'd see me rolling my eyes. You know that the right to optimal health is not what I meant. It was clear that "health" means to be cared for in a manner which is reasonable. If I don't have money, I should be given it so that I can seek care when I need it.
M: It was not clear what you meant; but now we're getting somewhere. However, you left something out, which will be obvious once we decide how much of the responsibility for your health is mine, and how much is yours.
J: I'm not sure I follow you.
M: We already agreed that the responsibility for your health is not solely mine, and that you share some of it. We're just trying to figure your portion. For example, we are as sure as can be that smoking causes a lack of health. Does your right to health require a law mandating you to stop smoking?
J: I could give up smoking. I was going to quit anyway.
M: Good. But how about chips, ice cream, cheap hamburgers, and other artery-clogging foods? These can certainly cause you to lose your health.
J: Dieting is no problem. I'm a little heavy as it is.
M: Drugs -- you know the kind I mean -- are also out. And how about driving a car? That really ups the chances of injury or death.
J: Wait a minute! I clearly have a right to drive!
M: Aren't you always telling me that cars release pollutants into the air? Those can't be good for health.
J: You know what I meant.
M: I didn't. But I think what you're hinting at is that you should be allowed the possibility of compromising your health in exchange for other benefits, or to enjoy the occasional excess. Driving or flying, for instance. Or having Thanksgiving dinner, a hot dog at the ball game, and so on.
J: It seems reasonable.
M: It isn't. It doesn't follow from your responsibility to maintain your health. If you believe that you have a responsibility, just as you say I have, for your health, then we should make it illegal for you to engage in behaviors that would affect your health adversely. If not, then you are asking to get away with whatever you like, and have society pay the bills to patch you up.
J: OK, I understand. What if I agree to wave my right to health in those cases where my lack of health was directly attributable to my own behavior? But then you'll have to agree to restore me to health when the cause was external.
M: The first part of your bargain is acceptable. I'm not sure about the second. Can you explain it more fully?
J: Suppose I, out of the blue, develop cancer and I can't pay for treatment. That kind of thing.
M: I notice you start with a dread disease, an extreme. Let's start at a lower level where we are less apt to make a mistake. I'll instead suppose you develop a planter's wart, which is certainly a departure from health. Should I be required to pay for its removal?
J: Maybe not.
M: How about we put the wart on your nose. Should I pay to have it cut away and restore your good looks?
J: Well ...
M: Or suppose you developed a hangnail. Or zits. How much should I contribute to your acne wash funds?
J: Nobody is asking you to pay for trivials!
M: Aren't you? OK, suppose you only thought you had cancer and you sought care. But it turned out to be nothing, a false alarm. Should I pay for your hypochondria?
J: It isn't always easy to know when to go to the doctor. Better safe than sorry.
M: Perhaps, but that's an evasion. Should I pay? After all, even if I agree to pay for your care when the cause of your lack of health was external, in this case there was no lack of health. If you insist I pay, then this isn't a right to health you're claiming, but an entirely new right. We can call it a right to "peace of mind."
J: There is mental health, you know.
M: Of course there is. But your mistaken doctor visit cannot possibly weaken your mental health; if anything, it strengthens it.
J: I'm sensitive.
M: Don't I know it. But should I pay? You still haven't answered.
J: I guess not. However, now you must answer: Will you pay for my real cancer?
M: First answer this: Is your cancer treatable of fatal?
J: If it makes any difference, fatal.
M: OK, you have incurable cancer, for which, by definition, there is no treatment. All medical costs are thus solely for your comfort, because you cannot be saved.
J: I suppose so.
M: Then can't you see that you have invented for yourself the "right" to be comfortable?
J: Why should I be in pain?
M: Indeed. But if you are and you're going to die, why should I pay for your comfort? I mean, why should I legally have that responsibility? I might, of course, desire to alleviate your suffering out of compassion.
J: Ha! What do you conservatives know about compassion?
M: I'm surprised that you think such a blatant non-sequitur answers me. Surely you can see how unlimited and ridiculous a 'right' to comfort can be; there would be no end of applications for the lack of it.
J: I suppose you shouldn't be forced to pay. And now I see why you wanted to differentiate between types of cancer. But since I've agreed with you that I should be responsible for small departures from my own health or for my comfort, let's suppose my cancer is treatable. Cancer is clearly different than indigestion, a common cold, and so on, and if left untreated it will kill me. I say that you should pay for my care. And since I'm on to you, I do not mean those costs that are not associated with the treatment of the disease. I'll even beat you to the joke and say that I will pay for my own Jello in the hospital.
M: You're learning, Julius. But tell me this: Do you have the money to pay for the treatment? If you do, then you already know that you have no solid reason for demanding my money. Shall we amend your scenario and say that you haven't the funds to pay?
J: Grudgingly. I don't like the idea of having to pay for the whole thing myself, even if I have the funds. It could turn out that paying bankrupts me.
M: Then why not buy insurance? You could write a contract to indemnify yourself, even against trivials.
J: Aha! You think you have scored a point, but we are back to the beginning. You have talked yourself into a circle! If you agree to pay for my externally caused departures from health, why not just pay for my health insurance, and save yourself some money?
M: Someday I'm going to have to teach you math; then at least you'll be able to calculate a decent tip for our waitress. Look -- pool all the costs of care from each citizen whose lack of health was external. It is cheaper to pay for this care directly and to not add the overhead associated with insurance. After all, the costs of care must still be paid by the insurer, plus we must pay him for administering the fund. If you insist on me funding your insurance, you are creating yet another "right," this one for underwriters to make a profit.
J: That doesn't make any sense, since you just suggested that I buy insurance for myself!
M: Even though you don't celebrate, I'm buying you a calculator for Christmas. Insurance is like buying a lottery ticket that you hope doesn't win: if your ticket comes in, you win a lot of money, but also a lot of sickness. The reason to buy insurance is if you estimate the probability of being paid (that is, of you getting sick) is high. For some people, buying insurance is a bad bet. The way you live makes it a good one.
J: Very funny. However, I'll concede that I don't understand the math, but since I know you, I'll accept it -- for now. I am smart enough to follow an argument, though. You still haven't admitted that you should be responsible to pay for care when I, and others less fortunate than myself, lack the funds.
M: And if I pay, what do you owe me? Do those who accept funds owe a debt to society that they have the responsibility to repay? Should they be required, legally, to honor their debt? Don't answer by invoking a new 'right' to dignity, because then you'd have to explain how my dignity is unaffected by giving away my money for free.
J: Of course people shouldn't have to pay you back!
J: Because you have more money.
M: And that's what makes you a socialist.