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:
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.
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.
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