A Necessary Good:
The Right to Medical Care

Years ago, I was a strong proponent of free-market medicine because at the time economic freedom seemed germane to my understanding of all freedom. To believe in anything less than a completely free market in medicine appeared inconsistent with my belief that freedom is the highest value, equal to life itself. I was not oblivious to the problems with the current patchwork of healthcare “solutions” that passes for a system, but thought these problems would best be addressed by reverting to a free market. As a typical ideologue, I was a bit fuzzy as to how the market would provide for the poor, the disabled, or those unlucky souls who were inadequately insured at the time of a medical catastrophe or a pregnancy. Like all good laissez-faire capitalists, I assumed most people would be able to afford adequate care in a laissez-faire society, and those who could not afford such care would turn to voluntary charity, as in the past.

What began my change in thinking was a consideration of the day-to-day struggles of those facing both acute and chronic injuries, diseases, and burdensome and potentially dangerous conditions such as pregnancy. How does someone ill or injured or pregnant go about making ends meet, including meeting one’s family obligations, and at the same time raise funds for one’s medical care? How does one beg, work, heal, rest, and recuperate all at the same time? It seemed to me that seeking and getting charity—begging (or fund-raising, to put it antiseptically)—was the answer until I realized that such work is work and work of an extraordinarily debilitating, if not degrading, kind, especially if one is sick and in pain.

At the outset, I should say that simply stating that this is what people did in the past is not going to cut it. In the past, medical care was very cheap due to a lack of expensive technology, little redress in cases of medical malpractice, low administrative costs, and extremely cheap labor costs below the level of physician. Even if one were to drastically cut the price of malpractice insurance and get rid of much of the corporate and governmental bureaucracy, one would still have medical costs a great deal higher than in the past. It doesn’t cost much to die and suffer and that’s what people frequently did in “the good old days” rather than avail themselves of medical care that they couldn’t afford or did not yet exist. (It should also be added that the biggest day-to-day expense of people living in the West today is housing, a commodity that was dirt cheap in the past when there were far fewer people. Millions of people today spend virtually their entire incomes on rent and food, and have precious little to spend on anything else, including medical care.)

The unwillingness of free and educated people in the modern world to suffer as they did in the past is especially relevant when one considers human childbirth. Women now have a choice whether or not they get pregnant and/or continue a pregnancy, and any society that increases the risk that a pregnant woman will not receive expensive medical care if she needs it (or be reduced to begging in order to get it), will see a huge increase in the use of contraception, sterilization, and abortion.

I have no doubt that the high cost of medical care and the inability of millions to afford it is almost irrelevant to the advocates of free-market medicine. It is irrelevant because for such people freedom as they define it is the highest value. If some people have to die and suffer so that others can maintain their freedom, so be it.

Therefore, laissez-faire capitalists will not change their minds if they are accused of being cold and heartless regarding the fate of the poor and disabled. The only thing that will change their minds is if they are convinced that by their own standard of morality laissez-faire is shown to be inadequate. The only way I can hope to convince them is the way I was convinced: by arriving at a different understanding of what freedom is.

One has to start by carefully considering what it means to be free and of the value of freedom. What is this abstract concept good for? How does the experience of freedom impact one’s day-to-day, moment-to-moment existence?

Freedom is of value when it can be used to achieve other values. It is a means to an end, not an end in itself. Just as there is no sense in being alive if one is in constant, severe pain with little to no hope of that pain ending, there is no sense in being free if one cannot enjoy one’s freedom. The value of freedom to a person overwhelmed with pain is nil.

Libertarians and free-market types of whatever philosophical persuasion love to deride those who argue for positive freedoms. Case in point is the ridicule Franklin Delano Roosevelt’s idea of “freedom from fear” is met with by this crowd. I used to be one of those who ridiculed FDR’s notion. But, on reflection, Roosevelt was right. Freedom is patently absurd, a low value, if not a non-value, to a person ravaged by chronic, debilitating fear. Only when such fear is reduced to a manageable quantity, can a person be “free” in any meaningful sense of the term.

The free marketers would no doubt reply that one cannot legislate such freedom from fear and that in the public, political arena one can only protect a person’s right to be left alone and hope that people, guided by their own self-interest, will find a way to overcome crippling fear (and other debilitating emotions such as pain and anxiety) and get on with the business of living. That is true enough on its face. But one can legislate a safety net that protects a person from economic falls that result in destitution, starvation, exposure to the elements, and a brutishly short life wracked by severe and chronic pain or one that avoids these fates but at the price of one of the greatest deprivations a person can experience—the assault on one’s dignity that occurs when one is reduced to daily and endless begging.

The most important freedom is and always will be the freedom to be left alone, at least when that concept is applied to able-bodied and relatively healthy adults. But one can reasonably argue that freedom means little to one, whether adult or child, who is at risk of imminent death or maiming or is in a state of chronic and especially severe pain or fear. In a very real sense one cannot appreciate freedom or effectively use it when one is crippled by emotions that thwart one’s capacity to exercise one’s faculties and enjoy life. No society, however rich and skilled its members, can possibly provide the means to guarantee that every single person will be able to appreciate freedom or effectively use it, but society, the collective mass of individuals acting through laws and institutions, can create conditions that enable most people most of the time to be in a position to do so.

Libertarians and free-market types also deride the notion of guarantees and entitlements, as if an advocate of a mixed economy is stupid enough to argue for absolute guarantees or entitlements. No, one doesn’t have a “natural” right to medical care—one doesn’t have a “natural” right to anything! Rights are a human construct—none exist in a state of nature. Of course, any lawful provisions for the poor, disabled, etc., are contingent upon those with means having such means. If a wealthy society all of a sudden became poor (meaning most of its members became poor) due to a natural or man-made catastrophe, all bets would be off. It is not in the interest of those who produce little or no wealth to cripple the productive or make them less productive by placing onerous burdens on them.

Libertarians love to think of the disabled, poor, etc., as parasites, as if they choose deliberately to be in a state where they need to “feed on” those who produce wealth. This is usually not the case. The vast majority of people prefer to live independent and productive lives and will pursue such lives when given the opportunity and the means to do so.

What initially led me to check my premises and move away from a strict adherence to the market in all things were two considerations: first, the meaning of freedom, which I addressed above, but even more widely or fundamentally, a consideration of the values that a rational individual holds and how those values are expressed and promoted in a social setting.

It stood to reason that the first and most important value was life. Once I accepted life as the prime value, I needed to ask myself what is necessary for human life to be created and sustained. What are the requirements of human existence, meaning what are the activities that make human life possible?

This mode of questioning is what I learned by studying Ayn Rand’s philosophy of Objectivism many years ago. But unlike Ayn Rand, I came, after many long, hard years of philosophical thinking, to very different conclusions about what constitutes an ideal society.

An ideal society creates conditions for its members that promote and defend those activities that create and sustain human life. These activities can be broken down into three categories:

1. The physical production and care of people. Without the specialized set of services involved in reproduction and the nurturing of the young, there is obviously no life at all, and not so obviously, no long and healthy lives for those already reared to maturity. A society that does not create conditions that favor childbearing and childrearing will cease to exist once those who do the bulk of reproductive work, women, obtain their freedom and are capable of going on strike. (See my essay Stopping the Engine of the World for more on this issue.)

2. The production of wealth. This involves the production of most goods and services that are consumed and utilized by people to sustain and enhance their lives. This is the realm of the marketplace, the only realm of importance acknowledged by the free marketers.

3. The protection of people and their property. This involves a specialized set of services that maintain public safety and order so people can safely and securely go about the business of producing children and creating wealth. The more foolish of the free marketers believe that this realm can be subsumed under the production of wealth. Anarchists do not understand that the protection of people and property—the rule of law administered by government—stands outside of the marketplace and is what makes the marketplace—at least when understood as a system of manufacture and trade that sustains itself across vast distances, between individuals of widely different cultural, religious, racial, and ethnic backgrounds, and throughout time—possible. No one would dispute that an isolated and tiny enclave of closely knit families engaging in rudimentary barter needs much in the way of government, but that is not, of course, the real world.

The problem with the laissez-faire capitalist, and by extension those who advocate free-market medicine, is that they do not consider anything but point two in their freedom equation. The good life for them results when people are “free” to pursue their self-interest, unencumbered by social mandates of any kind. The only problem with this paradigm is that it will easily lead to perverse incentives and socially disastrous consequences. Such incentives and consequences are readily apparent to anyone thinking outside the laissez-faire box, which is why all advanced, post-industrial societies, without a single exception, have moved far away from anything resembling laissez-faire, especially in regards to medical care.

Here are two perverse incentives that could easily lead to disastrous social consequences. I’m sure there are more, but these two directly bear on the question of whether or not free-market medicine is a moral and practical alternative to today’s medical quandary.

1. In a free market for healthcare, no one, including the disabled, the acutely ill, the severely injured, and pregnant and post-partum women, would be entitled by law to medical care, not even medical care necessary to stave off death or disability. With one exception, however. Those who committed crimes serious enough to warrant imprisonment would be entitled to medical care. They would not need to work or beg for such care. It would be given to them along with their meals, their clothing, and their shelter. The provisioning of the criminal population rather than the law-abiding is just, according to the free marketers, because criminals are deprived of their freedom to produce wealth and the law-abiding have not been.

This argument is specious on its face. Many criminals could not afford medical care if they were free—and not all the law-abiding can produce sufficient wealth at any given time to afford the medical care they need at any given time. In a laissez-faire society, there would be a huge incentive to steal since a person who could not afford needed medical care for himself could guarantee it by committing a crime, and thereby profit either by the theft itself, or by the consequences of being caught (jail time). This is a perverse incentive in the extreme.

2. Another example of a perverse incentive would occur if and when women were deprived of the right to obtain medical care before, during, and after the birth of a child. A free woman who has the right and opportunity to use contraception and/or obtain an abortion will not initiate or continue a pregnancy without knowing in advance that medical care is and will be readily obtainable. Before the twentieth century, women routinely died or were maimed in childbirth. Free women who for the first time in human history can choose not to bear children will make that choice if the medical rug is pulled out from under them. If you want to reduce the number of intelligent, educated, and free women who choose to reproduce, make quality medical care an iffy proposition and that’s exactly what you’ll achieve.

I could also make the obvious point that public investment in care for a pregnant woman saves money in the long run by promoting the birth of healthy children. This should be a no-brainer since scientists now know that the quality of the uterine environment makes a huge difference in the physical health of a newborn baby and that a botched childbirth can produce lasting physical and mental injuries to the newborn. None of this—including the existence of free immunization programs—means anything to the free-market advocate since such a person does not consider the production of people—the future workforce and therefore the most important form of capital available to the economy—to be a social value. This is ideological stupidity since it is a fact, not an opinion, that everyone who lives to old age gains from the existence of healthy and productive younger generations.

To sum up, I will argue that the reason public investment in medical care is good is that it creates the necessary conditions that make a free and ongoing society possible, one where nearly everyone can and will do the productive and/or reproductive work necessary if society is to continue long after they are gone.

Rift Rants