Like many of you, I am engaged with thinking through the healthcare proposals and debates and am occasionally frustrated with the scattered focus and the talking past the other guy’s position. So, as a start, I propose a clarification of the questions involved.
As I see it, the overall healthcare discussion is a four-dimensional debate:
1. Ethics: Is health primarily an individual self-responsibility or a collective responsibility? Should I see myself as responsible for my own health decisions and finances, or should we all see ourselves as mutually responsible for our health decisions and finances? This is the debate between the individualist-self-responsibility-egoist axis and the communitarian-collective-responsibility-altruist axis.
2. Civil society: What is the power of voluntary, decentralized institutions such as for-profit physicians, hospitals, and insurance companies and non-profit institutions such as the United Way, the Red Cross, charity hospitals, volunteers and pro bono professionals? Are they sufficient to supply our health care needs, with particular focus on the needs of those who are poorer or less capable? This is the debate between the optimists and the pessimists about the power of voluntary civil society.
3. Politics: What is the proper use of government as a centralized, compulsory institution? Is its role properly limited to protecting our lives, liberties, and property, or is its role properly expanded to include the provision of key values such as health care? This is the debate between the libertarians at one end of the political spectrum and the socialists at the other end.
4. Economics: For any health delivery system, how absolutely and comparably effective will it be at delivering quality, quantity, and innovation in health? This is the debate between those who argue that free markets deliver those goods better and those who argue that governments do.
And some follow-up questions:
Are these the four main issues?
Are there important sub-issues that should be highlighted?
Which of the four is/are most controversial?
Which of the four is/are actually driving the current debates over health care?
Regarding the ethics focus for the debate, a good question is this: What is the difference between being unable to leave your employer (slavery) and being unable to leave your health care provider?
Steve B, being “unable” to leave a voluntary contract for the purposes we are discussing is really just to describe a lack of better alternatives – I think it is unfair to put it in terms of slavery since the person in reality can leave their employer and their health care provider. It just might not be in their best interests.
Steve B, what is up with your spammy website?
Prof. Hicks,
You have described succinctly the Platonic ideal of the Libertarian vs. Socialist debate on healthcare.
In more realistic terms though, the debate actually happening in the United States unfortunately is more like this: is the newly proposed bloated over-regulated monopoly system of healthcare better than the old bloated over-regulated perfect-price-discriminating profit-maximising monopoly system of healthcare and can we pretend it is somehow a moral or philosophical question so as to win the debate and change the policy.
I argue that either the Socialist ideal or the Libertarian ideal for health care would be preferable to the old or new monopoly systems.
Prof Hicks, glad to see you jumping into the health care discussion.
Re the comments by “Pace,” – IMHO, health care hardly resembles a free market now. Oligopolies, if not monopolies, dominate many parts of it. in particular, in many regions, there are only a few health care insurers/ managed care organizations, and often one is dominant. In many regions, there are only a few medical centers/ hospital systems. In general, health care is dominated by large organizations, many for-profit corporations, some ostensibly not-for-profit, some government.
For the most part, there is no balance of power among them. Instead, they often seem to collude at the expense of the public (and of independent health professionals.) For example, medical professional societies stopped enforcing many of their ethical standards fearing federal anti-trust actions against them, after the 1975 Supreme Court decision that prevented Bar Associations from setting fees. On the other hand, there have been almost no successful anti-trust actions against hospitals/ hospital systems, and the government has slept while a few health care insurance companies/ managed care organizations dominate the market. Meanwhile, extensive webs of what we politely have called conflicts of interest entangle most of the large organizations. Medical school faculty are often paid by drug and device companies, and their teaching more resembles marketing than scholarship. A small committee dominated by the AMA and medical specialists gained control of how the government fixes payments to physicians. Board interlocks span all sorts of health care organizations.
We try to chronicle how concentration and abuse of power has wrecked health care in our blog, Health Care Renewal (http://hcrenewal.blogspot.com). We welcome your perusal of the gory details.
So I agree that right now, either a true free market or even a pure socialist approach might be better than what we have now (but not much).
But what about a model built on renewed professionalism on the part of physicians and other health care professionals, and a renewed sense of mission on the part of hospitals and academic medical institutions?
A la Kenneth Arrow, I doubt that a pure free market would work in health care, because patients can rarely act like rational consumers. The scientific basis of health care is too complicated, there is too much uncertainty and ambiguity, and current or anticipated disease is too emotionally compelling for them to be steely rationalists.
In the absence of a free market, might it not be better to trust professionals and institutions who view medicine and health care as a calling (if they can be so renewed), than to trust the government to handle it?
I see #4 as driving the current debate. The most common refrain I hear is, “The system is broken!” From that, apparently, it follows that this “something” must be government-run care. I would like to see the debate steered toward the more fundamental issues raised in #’s 1-3, but I am not optimistic.
Good analogy from Jim Ryan: “Every American has a right to health care. This is because health care is a basic need without which one cannot function. Yet, food and shelter are much more basic needs than health care. …” More at http://philosoblog.blogspot.com/2009/07/national-food-and-shelter-plan-proposal.html. (Thanks to Bob M. for the link)
I think the underlying question is, “Under what circumstances can something created by the volitional act of someone else be considered a right?” Virtually all material values, including basic needs, are created by human beings. If they are “rights,” it follows that each of us has at least some right to the labor of another. Using the word “right” in this sense confounds it with other usages such as the right to self-defense. That right confers no obligation on one to provide for another, only to refrain from molesting them.
In my view, the current health care debate is much muddied by this imprecision in language. Upon hearing that something is a “right,” the listener should request clarification. If something is actively provided by someone, the advocate should be able to identify both the provider and the reason he/she is obligated to provide it.
I agree about the muddied uses of “right,” Terry. I sometimes wonder whether that is intentional, especially by some intellectuals. Muddying the original concept weakens its force.
I read that link provided by Mr. Hicks and was completely blown away. “This is the kind of vision that really gets to the heart of what it means to be an American: to grow the government very, very big so that it can take care of everything instead … That’s the core vision of American values. That’s the American way.” That is exactly what the country was founded against! I agree that the health care system as it now stands is in disarray and needs to be fixed. In my opinion government should not be the institution to take over, but can it help in the reform? It sure can, it should. The government is there to help us, not to take care of us. That is the job of society. Those who have the means whether it be time, money, or skills necessary we can take care of each other.
1. Ethics: Is health primarily an individual self-responsibility or a collective responsibility?
Even if I believe that health is a “self-responsibility” can’t I also believe that I want to help those who may not be able to help themselves? Can’t I also choose to express this through my vote (rather than, say donating money directly), and if so, can’t we choose this as a democracy? In other words– a belief in individual-self responsibility is not incompatible with enacting a health-care system, just as it is not compatible with me calling 911 when my elderly neighbor is having a heart attack, or a firefighter jumping into a burning building to save a child or donating blood to the Red Cross. People can give of themselves out of their “gift-giving” virtue, without treading on the idea of self-responsibility.
Even the most miserly Scrooge feels some responsibility for the well being of someone, somewhere, for some amount of time. This is a question of DEGREE not of absolutes.
We can have this debate without resorting to absolutes and strawmen thusly– Do I want to help these people? Can I afford to? Will I be able to? It’s simply that we do not want to look at the question this way out of fear.