Healthcare Upon Stilts

Today we direct you to an excellent post by Bill Vallicella about the putative “right” to health care. A little while back I mentioned that left-leaning governments tend always toward acting in loco parentis; Bill’s post offers the Democratic health-care initiative as an illustrative example.

Bill makes the important point — seldom acknowledged — that “rights”, particularly as construed on the left side of the aisle, often imply corresponding duties.

We read:

Rights and duties are correlative. My right to X generates in others the duty to either provide me with X or not interfere with my possession or exercise of X. Thus my right to life induces in others the duty or obligation to refrain from injuring or killing me. So if I have a right to health care, then others have the duty to provide me with it. Think about that. But who are those others? The government? The government has no money of its own; its revenue comes from taxing the productive members of society. But why are these productive citizens under any obligation to provide ‘free’ services to anyone? Taxation is by its very nature coercive. How does one justify morally the taking by force of money from one person to give it to another? There is also the practical question of whether the productive will allow themselves to be fleeced.

Indeed, as American liberalism continues to let no crisis “go to waste” in its tilt toward classical fascism — as exemplified by the old slogan “All within the state, nothing outside the state” — we’d better learn to live within the guidelines our leaders recommend as being in everyone’s best interests. After all, if a State, in its paternal beneficence, is going to take on the responsibility for looking after our health, does it not then have the “right” to insist that, as wards and comrades under its sheltering embrace, we have a “duty” to conform to official standards for a safe and healthy lifestyle?

A government big enough and powerful enough to provide one with ‘free’ health care will be in an excellent position to demand ‘appropriate’ behavior from its citizens – and to enforce its demand. Suppose you enjoy risky sports such as motorcycling, hang gliding, mountain climbing and the like. Or perhaps you just like to drink or smoke or eat red meat. A government that pays for the treatment of your injuries and ailments can easily decide, on economic grounds alone, to forbid such activites under the bogus justification, ‘for your own good.’

But even if the government does not outlaw motorcycling, say, they can put a severe dent in your liberty to enjoy such a sport, say, by demanding that a 30% sales tax be slapped on all motorcycle purchases, or by outlawing bikes whose engines exceed a certain displacement, say 180 cc. In the same way that governments levy arbitrary taxes on tobacco products, they can do the same for anything they deem risky or unhealthy.

The situation is analogous to living with one’s parents. It is entirely appropriate for parents to say to a child: ‘As long as you live under our roof, eat at our table, and we pay the bills, then you must abide by our rules. When you are on your own, you may do as you please.’ The difference, of course, is that it is relatively easy to move out on one’s own, but difficult to forsake one’s homeland. Or is Obama yomama?

The nub of the issue is liberty. Do you value it or not?

Read the essay here. You can’t comment at Bill’s anymore, but our com-box is open as always.

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  1. bob koepp says

    I assume that what you and Bill are objecting to is the notion that there is a “natural” right to healthcare. If so, I agree, since I think “natural rights” are pure fiction. But setting aside such philosophical scruples to address the matter of political rights, which flow from certain “fundamental principles” generally thought to underlie political institutions, things are less clear cut.

    For example, one of the fundamental principles supposedly guiding our social-political endeavors is “equality of opportunity.” There’s been a good deal of serious discussion in the past few decades about how opportunity depends on health, and there are strong arguments for the view that a “level playing field” where something approaching equal opportunity can operate requires the provision of at least some healthcare to those who have not fared well in the natural lottery. So, if liberty is about being able to pursue opportunities (a reasonable conjecture, I think), then perhaps “the nub of the issue” is a bit more complicated than Bill and Malcolm think.

    Posted July 29, 2009 at 9:53 am | Permalink
  2. Malcolm says

    Interesting point, Bob, but if we adopt the view that you are suggesting here — that equality of oppportunity implies that society has a positive obligation to provide, on the government’s dime, remediation for every innate inequality — there’ll be no end of it. Indeed, to provide the sort of “level playing field” you suggest for congenital idiots, say, or even the naturally mediocre, we would soon have to move beyond remedial assistance, and begin to handicap the gifted.

    There is a clear difference, I think, between an “equality of opportunity” that insists only that society refrain from unfairly placing obstacles in peoples’ way, and one that positively mandates public largesse to the innately (or even voluntarily, in the case of various self-destructive lifestyle choices) disadvantaged; what you suggest here seems closer to requiring equality of outcomes, not opportunity. Under such a system every inequality of outcome, after all, would surely be used as evidence of unequal opportunity, and as justification for further costly remediation. (This is, of course, happening already.) An Olympic foot-race assumes equality of opportunity; were I to demand that since I am 53 and have a bad left knee I should be allowed to start from the halfway mark, it would hardly seem fair to the others.

    But all of this notwithstanding, we should not lose sight of what is perhaps the most important point here: the necessary curtailment of liberty we assume when we choose to live in our parents’ house.

    Posted July 29, 2009 at 11:23 am | Permalink
  3. bob koepp says

    Malcolm –
    While any principle of virtue can become vicious when interpreted in an extreme manner (cf. Aristotle), that doesn’t count against moderate forms of principlism. While I can’t endorse everything they say on the topic of opportunity, I think Amartya Sen and Norman Daniels cannot be dismissed as knee-jerk liberals.

    Posted July 29, 2009 at 11:44 am | Permalink
  4. Malcolm says


    Well, what’s being proposed here — nationalizing a major industry, in a time of economic malaise, in order to offer a public entitlement at a cost of a trillion dollars — might indeed be to interpret a principle of virtue in an extreme manner.

    Posted July 29, 2009 at 12:13 pm | Permalink
  5. jack says

    Well, if government is the instantiation of a social contract, and it is supposed to be responsive to the will of the people, and the will of the people, as expressed by its duly elected representatives, is to create a public health care safety net (which I personally am in need of), then what precisely is the objection? Indeed, do we not pool together our individual resources for the common defense? Do we not pool our individual resources to provide for the efficiency and safety of our transportation systems, our roads, and sidewalks? Do we not pool our individual resources to provide for police, for fireman, and for health inspectors? for social services, for education, for water distribution? if we do all that, how is it that a government, expressing the will of the people through our representatives (the theory upon which our nation rests), that wishes to pay for health care by taxation (as all these other essential services are paid for through taxes), any more tyrannical or fascist that a government that provides for these other services, but not health care?

    For myself, I want national health care, and I want it now. For me. For my family. For my community. For all those people who I personally know who’ve gotten f*cked by their insurance companies, and for all those people I personally know in countries with national health care who get the care they need when they need it, and would hesitate to come to the US for that reason alone.

    All this talk or rights and abstract principles getting everyone knotted up inside, I ask them to let go of ideology and ask a simple question. Does it work?

    Posted July 29, 2009 at 2:45 pm | Permalink
  6. Malcolm says

    Hi Jack,

    The will of the people is traditionally the object of a great deal of manipulation by their duly elected representatives, so it is good, I think, if there are gadflies and Devil’s advocates out there who are willing to point out that superficially attractive proposals may not turn out, in practice, to pay off as advertised.

    Indeed, we do pool our resources to pay for a great many things, perhaps already more than we ought. The hallmark of fascism is a tendency toward greater statism in all things — rather than a tendency, whenever possible, to diminish the role of government. As is pointed out above, the more the government, acting in loco parentis, assumes responsibility for every one of life’s blessings, the more it is in a position to regulate the behavior of the “children” living under its roof.

    Fascism is certainly not incompatible with the “will of the people”; if America chooses to become a fascist nation, we will. (If you want to see what Fascism in America looked like, read up on the Wilson administration, or the N.R.A. under FDR and Hugh Johnson.) As Mencken said, “Democracy is the idea that the people know what they want, and deserve to get it good and hard.” The purpose of civil debate is to try to exert a rational influence on the will of the people; if this health-care agenda is perhaps not such a great idea, as a great many reasonable people think for a variety of good reasons, then people ought to be told.

    As for people in places with socialized medicine getting care “when they need it”, in many cases they aren’t, and die waiting for treatment they could have had far more quickly here. As for being hesitant to come here, they are of course welcome NOT to; the last thing we need is to put in a taxpayer-subsidized healthcare system that then becomes a buffet for every sick person on Earth. And I think you will find that there are in fact a great many people from places like Canada who come here precisely for the opposite reason – that they can buy superb care here right away, rather than enduring long and potentially lethal waits at home.

    As for your question: “does it work?”: as you say, that is an empirical question, not an ideological one. There are many reasons to imagine it may not.

    Posted July 29, 2009 at 4:14 pm | Permalink
  7. bob koepp says

    While I imagine it’s the current furor over a national healthcare plan that provoked Bill’s post, it was the idea of a right to healthcare that he claimed to be criticizing — not very cogently, in my opinion.

    As for “what’s being proposed,” it depends a great deal on who is doing the proposing. Not that anyone is paying attention to yours truly, but my proposal for a national healthcare plan is quite simple. Underwrite the provision of what was “standard of practice” 20 years ago to anybody who, given our current knowledge of safety and efficacy, is likely to benefit from the healthcare in question. If you wanted anything beyond that, you’d have to arrange for some other sort of finance mechanism — on your own dime or with assistance you were able to persuade others to provide. I’d bet all my future earnings that this would result in a healthier population and a drastic reduction in the portion of GDP being fed to the medical-industrial complex.

    Posted July 29, 2009 at 4:22 pm | Permalink
  8. Malcolm says

    I don’t understand, Bob. What’s the idea of the 20-years-ago part?

    Posted July 29, 2009 at 4:24 pm | Permalink
  9. bob koepp says

    Patents have expired. The latest interventions, fresh from the labs, which more likely than not offer only marginal improvements compared to what was available 20 years ago, would not be part of the “universal plan.” In other words, basic healthcare would not be state-of-the-art. What is state-of-the-art today might become basic healthcare 20 years down the road. (And I’m actually in favor a a slight complification… If a newly minted intervention can demonstrate a favorable cost/benefit profile relative to the 20-year-old “standard”, it could be accepted under the “universal plan” umbrella now.)

    When I’ve suggested this sort of thing in open fora, I’ve been roundly condemned by those representing the healthcare professions, pharma and medical device manufacturers, as well as patient rights advocates. I take that as evidence that I’m making sense.

    Posted July 29, 2009 at 4:51 pm | Permalink
  10. Malcolm says

    Certainly not an idea I’ve heard before, Bob. Are you sure that 20-year-old remedies and equipment will still even be available? And if so, that it will be cheaper?

    Posted July 29, 2009 at 5:56 pm | Permalink
  11. bob koepp says

    Malcolm – The 20-year standard is pretty arbitrary, though it does encompass the 17-year life-expectancy of most patents. Even in that context, there’s a great deal of arbitrariness, since most patents are in their dotage by the time they are marketed. (That, and not just greed, is one reason such large premiums are charged for drugs still under patent. There’s usually just a short time in which to recoup development costs.) The point of setting such a standard is that it would moot much of the debate about the cost of a national plan, and provide for a standard of care that, while not ideal, would improve the lot of many millions of our fellow citizens who are uninsured. Also, I offer this simply as a “starting point”, a system that could be operational fairly quickly. The hard part about implementing it isn’t logistical, but emotional. And yes, the technology of 20 years ago is readily available.

    Posted July 29, 2009 at 8:10 pm | Permalink
  12. jack says

    Bob’s suggestion is reasonable. We have an irrational obsession with “progress” in medicine. The fact is, we’ve come quite far already.

    Practically, it might be hard to implement. Lots of patents out there. Say on springs in a bed mechanism…

    Posted July 30, 2009 at 12:03 pm | Permalink
  13. jack says

    Am I to understand Malcolm right that he is suggesting that we should not have socialized medicine in the U.S. because it might be too attractive to immigrants? Sheez.

    Posted July 30, 2009 at 12:08 pm | Permalink
  14. Malcolm says

    “Sheez”? Are you kidding? With a staggering economy, do we really want to set up yet another attractive and enormously costly public entitlement and offer it to the whole world? Who do you think pays for this stuff?

    Here’s an even more attractive proposal, then: why not just have the Treasury Department put free public-access ATMs at the border, and be done with it?

    Posted July 30, 2009 at 1:38 pm | Permalink
  15. jack says

    Malcolm, that’s stupid and you know it.

    Could just as well say, f*** law and order. Its too expensive to maintain and only encourages immigration to the U.S. Or say, you know, those folks across the border might just like clean air and water enough to sneak across the border. So lets not do anything for our own good.

    Its not an entitlement program. What a load of wash. Its a collective decision to invest in our collective health. Immigration is immigration. A nation should control the flow of immigration, not limit what it is willing to do for its citizens out of fear that it will make citizenship or residency too attractive to potential immigrants.

    No, the only institution that the people control and own and have an absolute voice in *is* the state. It is the *people’s* institution. Private enterprises, even publicly traded ones, are not accountable in the same way to the general public. Insanity! Where would we be without the state? Where would we be without government? Inanity!

    And until I see your data on how bad public health systems actually are, your opinion is just that. an opinon.

    Posted July 30, 2009 at 6:16 pm | Permalink
  16. jack says

    Anyway, that flood of Canadians coming over our borders is really worrisome. I’d better call my senators before they make a big mistake.

    Posted July 30, 2009 at 7:03 pm | Permalink
  17. bob koepp says

    Sheez! For the record, I don’t think the state is benign, and I don’t think it is the only conceivable “actor” in making decent health care available to citizens. But for people who would rather be coerced than voluntarily treat each other in a civilized manner, I suppose state action is better than none at all.

    Posted July 30, 2009 at 8:50 pm | Permalink
  18. jack says

    The conservative stance on health reform is an odd perversion of the slogan, “Give me liberty, or give me universal health care.” Don’t you think?

    Of course, we force people in all kinds of places in the U.S. to buy insurance- car insurance, and that money goes into the pockets of private companies. In practicality (since self-insurance is out of the reach of most) that means being obligated to fork over to a private interest. I’d rather fork over to the government itself.

    Posted July 30, 2009 at 10:03 pm | Permalink
  19. Malcolm says


    You said that you were worried that immigrants wouldn’t come to the US unless we offered them socialized medicine.

    I replied that in my opinion the fact that we weren’t offering handsome enough medical entitlements to induce even higher levels of immigration — when in my opinion we could do with less immigration anyway — was hardly an argument in favor of socializing medicine. If they don’t want to come, that’s fine; they can stay home. We have plenty of people here already. I’m certainly not about to wring my hands at the prospect of the US not being attractive enough to immigrants, as you seem to be. We already take in far more immigrants than any country on earth.

    You then twisted that to suggest that I wanted to reject the idea of taxpayer-funded medical services for all because “it might be too attractive to immigrants”, which is not what I said. At no time did I argue that the US should “limit what it is willing to do for its citizens out of fear that it will make citizenship or residency too attractive to potential immigrants.” Please stop putting words in my mouth. We should do what we think best for our citizenry, as you say. Controlling our borders is a separate issue.

    To be fair, you did ask “Am I to understand Malcolm right…?”

    The answer is no, you didn’t.

    And nowhere did I express concern about a “flood” of Canadians. You seem to have missed the point there as well, which is that Canadians, faced with long and potentially deadly waits for service, have been coming here to get better care faster. The gist of that was not that we are inundated with Canadians poaching health care (they pay for it, after all), but simply, rather, to illustrate that their own vaunted government-run system isn’t working all that well.

    Next you caricature me as wanting to abolish all government, which is absurd, then sing paeans to the beneficence and obedient responsiveness of the State (likewise), meanwhile suggesting that corporations are answerable to nobody at all — as if they did not rely upon attracting and retaining customers in a free and competitive market for their very survival. Free-market competition drives efficiency and innovation. Government agencies, which can run at a loss and simply draw money from the public till, are under no such pressure, and are notoriously bloated and wasteful.

    We force people to buy car insurance because people routinely harm innocent others with their cars, and we need to be sure that they are able to provide compensation for the damages they cause. Health care is different. And if you still don’t understand the inverse relation between statism and individual liberty, we probably won’t make much progress here.

    Your comments are welcome, but please simmer down, and stop the straw-man stuff.

    Posted July 30, 2009 at 10:52 pm | Permalink
  20. greg says

    I’m sorry, but I just don’t see what’s being meaningfully argued in Bill’s post, or your commentary on it. The entire post seems to reduce down to the basic debate between classical liberalism (negative-rights, keep the government away) and modern liberalism (positive-rights, involve the government in constructive social contributions). Which is an old and important debate, fine. But the entire substance of the post seems to be “I am a classical liberalist”. Great. Preach to the choir. But this is just an assertion of political identity. What’s the argument?

    Yes, positive rights imply a duty to provide those rights, which requires time, attention and resources from some (likely government-influenced) part of society. And yes, that creates the opportunity for government-decreed restrictions. But unless you adopt the uncompromisingly pure position that government shouldn’t provide *anything at all*, the question is when do we or don’t we accept this services / restrictions balance. And this question is argued on a case-by-case basis. In other words, “government can’t provide X because it might then dictate our behavior under X” isn’t a valid argument unless you reject positive rights outright. And again, you can very well make that rejection, but then you’re just asserting your basic political affiliation. You’re not making an argument *for* that affiliation. And I’m missing what’s important in that.

    Regarding healthcare, I think there’s little value in arguing whether or not it’s truly a right. Issues like this are more about practicalities than abstract ideology. The reason why we have a huge national debate going on over healthcare, and not “more important” issues like food and shelter, is that our current systems for food and shelter aren’t dragging down our economy, driving masses of people into bankruptcy, putting American business at a competitive disadvantage, or otherwise inhibiting our social and economic growth at a dizzying rate with no end in sight. I mean, the current state of healthcare in this country is *massively* problematic. I think most people can agree on that (the correct solution, and how the government relates to it, of course, being another debate). It doesn’t matter that food and shelter are more fundamental needs. The “right” or “desire” or “need” (or whatever you want to call it) for effective healthcare matters more because it addresses a legitimately serious national problem. And if someone concludes that the right answer is a government-supplied program, there’s nothing inconsistent in that.
    Note that this comment is not addressing whether government-issued healthcare is a good solution or not. The whole point is that I don’t think either you or Bill are really arguing that either. But I want to just throw one volley into that arena: it’s disingenuous to argue that existing socialized programs are comparatively flawed as if this is a well-accepted, non-controversial position. Canada’s a particularly good example: most arguments of Canadian “health pilgrimages” to the US that I’m aware of are anecdotal and unsupported by anything remotely resembling real data. This study found that under 1 in 1,000 Canadians have come to the US for health services (I’m not aware of any study regarding American coming to Canada, which of course also happens). I’d be very wary of using the particular issue as part of the larger healthcare argument, as it’s far from accepted and quite possibly specious.

    Posted July 31, 2009 at 1:20 pm | Permalink
  21. Malcolm says

    Thanks, Greg; that’s an excellent contribution.

    You’re right: health care is certainly a clamant problem here, as it is just about everywhere. But you do somewhat miss the point of Bill’s post, which is simply to address the question of whether there is some kind of natural “right” to taxpayer-funded healthcare, which seems to be axiomatic in some quarters. That may seem irrelevant to you, but it is a major rallying cry for vocal segments of the population, and it is arrant nonsense. As you say, it is up to us to decide whether a government-supplied solution is best, and there is nothing inconsistent about arguing that it may be. But it is certainly not written into the laws of Nature that it must be so. There are good reasons to be leery of it, and we will have a better chance of avoiding rash and ultimately foolish decisions if we keep them in mind. That’s all I am saying here.

    Let me be clear: I want good healthcare, like everyone else, and I am willing to pay for it. The question before us is how it should be administered, and how it should be paid for. It is an extremely difficult issue, and the purpose of this post was only to remind people that glib assertions about “rights” are unsupportable — rights are nothing more than a matter of social consensus, and such a consensus does not yet exist — and that there are reasons to be wary of having the government run such an important and enormous operation, as opposed to private enterprise. Not least of those reasons is the tradeoff between collectivism and individual liberty, which is seldom, if ever, acknowledged by proponents of nationlization, but which is amply demonstrated by history.

    It may be, as Paul Krugman argues in today’s Times, that the system already works as well as it does only because the government has assumed the responsibility for providing care to so many of the poor and elderly through Medicare and Medicaid. But Social Security, Medicare, and Medicaid entitlements are already stretched far beyond their limits, and it is certainly reasonable to ask if adding the enormous additional cost of extending them to the rest of the population, particularly before we get our economy on a more solid footing, is a wise move. Perhaps incremental adjustments would be wiser in the short term — the current administration seems to be in an awful hurry, and we have just seen, with the trillion-dollar bailout, that when government decisions are made in haste in an atmosphere of crisis, the results are sloppy, to put it mildly.

    As for socialized medicine elsewhere, it is unarguably the case that it is far from optimal, and in particular that there are often long and sometimes deadly waits for services. I haven’t hard data to back up the rate at which desperate Canadians come here to buy medical services, and for that I apologize, but I will do some poking around of my own.

    Posted July 31, 2009 at 2:05 pm | Permalink
  22. Malcolm says

    Purely anecdotal, this clip, but worth a peek.

    Posted July 31, 2009 at 3:08 pm | Permalink
  23. Malcolm says

    This is of interest also. 18 weeks!

    Posted July 31, 2009 at 3:10 pm | Permalink