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The Creeping Takeover of Medical Care, Part 2


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In Part I we saw that the right to medical care is a pseudo right. It cannot be a real right because it conflicts with rights that stand the test of authenticity. But that is only the beginning of what’s wrong with trying to enforce a right to medical care.

Imagine for a moment a right to apples. That may sound nice, but an immediate problem arises. How many apples does each of us have a right to? Scarcity is the natural condition, which means that at any given moment our wishes exceed the supply of the things we want. (Freedom has a knack for loosening nature’s rather strict bonds of scarcity.) Declaring such a right would quickly empty the shelves of apples, making a mockery of our “right.” The shelves would not be soon replenished, for who would produce apples if we all have a right to them? (Not a right to trade with apple vendors, but a right to the apples themselves.)

We might decide to trust people to take only what they need. But that doesn’t get us out of trouble. Even if we assume a population of kind people, “need,” in this context, is very subjective. You can probably live without apples; so in a strict sense, you need none. But if we expand the concept of “need” a little, we open the gates to endless disagreement over who needs how many apples.

I may think I need many more apples than you need. There is no way to resolve a dispute of that nature. The state could ration apples. We could trust the government to scientifically determine how many apples each of us needs. And if you have faith in that process, you will also believe that the ruling party won’t manage to get more apples than the rest of us.

Now substitute “medical care” for “apples.” Government control of apples might be no more than an inconvenience. Government control of medical care can be deadly. Yet what is the alternative once a “right to medical care” is declared? There is no way all people can have all the medical care they would want if it is (that is, if it appears to be) costless. The government will have to decide who gets what.

Thus, the right to medical care must mean — no exceptions — the power of government, in principle, to determine who gets what. It may not exercise that power immediately. But given the economics of the matter, sooner or later it will. That has nothing to do with freedom and rights and everything to do with control, literally, of people’s lives.

I do not exaggerate. A major ethical issue these days involves the “right to die,” or the right to assisted suicide. That is overshadowing one that may be more consequential, the so-called “duty to die.” Some years ago, then Colorado Gov. Richard Lamm argued that old people should know when it is time to quit this earth in favor of younger people. (The civil libertarian Nat Hentoff wrote recently that Lamm is, inexplicably, a devotee of exercise, presumably to lengthen his life.)

John Hardwig, a medical ethicist and social philosopher, has now picked up the cause of the duty to die. He writes that medical advances and an “individualist culture” have many people believing that “they have a right to medical care and a right to live, despite the burdens and costs to our families and society.” He adds that “there may be a fairly common responsibility to end one’s life in the absence of any terminal illness . . . a duty to die even when one would prefer to live.”

We need not address here whether an old person should preserve his heirs’ inheritance rather than spend it on medical care. For the time being, that is a private, not a political, matter of how one spends one’s own money. (The inheritance tax could have consequences for such a decision.) What is relevant is how that ethical issue is transformed when government controls medical spending via “the right to health care.” The Lamm-Hardwig line would be translated into a rather unpleasant public policy: the withholding of care from the elderly in the name of “making room” for the young. (Elderly political leaders no doubt would be excepted.)

As a matter of public policy, might not the politicians and bureaucrats decide that heart transplants, knee replacements, and mastectomies for octogenarians are a waste of money that could be used to treat younger people? This sort of thing is not considered beyond the pale in the increasingly fragile welfare states of Western Europe.

If government finances medical care, such public policies are inevitable. Money is limited. The presumption will be that “government money” would be spent wisely and not squandered. Tough choices will have to be made. Politicians and bureaucrats will make them.

What starts as a right to medical care ends as the authority of the state to say who lives and who dies.

A vastly neglected aspect of the “right to medical care” is that it will necessarily tether the citizen to the state. For all the criticism that is leveled at Medicare and proposals to reform medicine in general, too little attention has gone to that uncomfortable fact. If government controls medical spending, it controls you, including the very length of your life. The Clintons promoted their reforms with the slogan “health care that is always there.” But that was a fraud. Congress can change the rules at any time. What is covered and thus allowed today could be disallowed tomorrow.

We may correlate the progress of mankind with the extent of its independence from the state. National health insurance would be a major setback.

Yet that is the direction in which we are moving. With the defeat of Clintoncare, the U.S. Congress is taking the piecemeal route to national health insurance. Clinton endorsed that approach recently when he said, “If what I tried before won’t work, maybe we can do it another way. That’s what we’ve tried to do, a step at a time until eventually we finish this.” As noted earlier, new regulations governing the portability of insurance policies and coverage of existing conditions all portend creeping comprehensive control. The newest causes — uninsured children and the exclusion of coverage on the basis of genetic testing — do the same. Ludwig von Mises explained why in his Critique of Interventionism. One regulation creates problems, which are used to justify the next intervention.

For example, if Congress says mental health benefits have to be equal to medical benefits, the cost of insurance will go up. That will then be the excuse to force young people who don’t wish to pay those premiums to buy insurance. Next on the agenda will be price controls on doctors and insurance companies. When companies flee the straitjacketed market, the government will step in.

Mises showed that there is an alternative to burgeoning regulation: repeal of the regulations that caused the problems in the first place. Getting rid of all existing regulations on the medical and insurance industries (including licensing and drug regulations) would work the same wonders that free markets have worked in other parts of our society.

Language is potent. The “right to medical care” lulls people into a sense of security and an acceptance of government largess. But like an insect that looks benign and sends out a sweet scent, that “right” turns out to be something quite deadly: a grant of power to the state to say who gets and who doesn’t get life-saving services. There is no way out of this short of the separation of medicine and state. There is no single public interest, and even if there were, the public-choice school of political economy has shown that the state is not capable of serving it. The “right to medical care” is a loaded gun aimed at the people. In the name of life and liberty, we must reject it.

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    Sheldon Richman is former vice president and editor at The Future of Freedom Foundation and editor of FFF's monthly journal, Future of Freedom. For 15 years he was editor of The Freeman, published by the Foundation for Economic Education in Irvington, New York. He is the author of FFF's award-winning book Separating School & State: How to Liberate America's Families; Your Money or Your Life: Why We Must Abolish the Income Tax; and Tethered Citizens: Time to Repeal the Welfare State. Calling for the abolition, not the reform, of public schooling. Separating School & State has become a landmark book in both libertarian and educational circles. In his column in the Financial Times, Michael Prowse wrote: "I recommend a subversive tract, Separating School & State by Sheldon Richman of the Cato Institute, a Washington think tank... . I also think that Mr. Richman is right to fear that state education undermines personal responsibility..." Sheldon's articles on economic policy, education, civil liberties, American history, foreign policy, and the Middle East have appeared in the Washington Post, Wall Street Journal, American Scholar, Chicago Tribune, USA Today, Washington Times, The American Conservative, Insight, Cato Policy Report, Journal of Economic Development, The Freeman, The World & I, Reason, Washington Report on Middle East Affairs, Middle East Policy, Liberty magazine, and other publications. He is a contributor to the The Concise Encyclopedia of Economics. A former newspaper reporter and senior editor at the Cato Institute and the Institute for Humane Studies, Sheldon is a graduate of Temple University in Philadelphia. He blogs at Free Association. Send him e-mail.