The degree to which humans are capable of being healthy is bound not just by the qualifications and imaginations of skilled clinicians and doctors, but by the way in which medical resources and services can be accessed and distributed under dynamic sociocultural and political climates. That there are major health disparities between ethnic groups and economic classes, as a result of hegemonic, often discriminatory, historical processes, is a core belief held by many researchers in the field of public health such as Amy Gutmann (UPenn’s current czar), who has provided much commentary on the benefits and limitations of equal-access to health care. Loyal opposition, contrasting her thoughts on the equal-access principle, is a doc, Robert M. Sade, who argues that medical care as a right is a contrived ideal, fraught with a host of negative moral implications for both clinicians and their patients – and indeed rattles the foundation of the American free market.
Let’s talk about healthcare sans the machinations of Trumpcare and Obamacare. How do we go about equitably distributing health care services to the public without disrupting, or otherwise restricting, the free market system which the United States has learned to finesse over the years to make it a superpower with near-infinite control in “managing” population health (as if health were cattle to be herded, with some expected to be lost to contagion)? The American healthcare system, if it can be called that, is a clusterfuck in every definition of the word.
The American healthcare system, if it can be called that, is a clusterfuck in every definition of the word.
To illuminate what is meant by “equal-access,” it is first helpful to cite Gutman’s definition: the equal access principle “demands that every person who shares the same type and degree of health” be given an equally effective chance of receiving fitting treatment of equal quality so long as that treatment is universally available; ultimately, equal-access can be seen as a mission to secure equality of opportunity, equal relief from pain, and equal respect. The bulk of the equal-access principle consists of what amounts to a one-class system of health care, such that what is available to one person would be available to another irrespective of social, political, racial, or core economic status. Forgetting for a moment that this shit doesn’t work: As such, a one-class system would not allow those with greater financial resources and thus higher socioeconomic statuses to purchase health services which similarly needy people cannot. This caveat is necessary because, as these sort privileges begin to transmogrify, though their effects might initially be small in incidence—the gulf between qualities of services, over time, could begin to stretch and the underpinnings of equality would erode.
McConnell said coverage does not equal care well last time I checked you have to be covered to see the actual doctor#TrumpDontcare
— WeThePeople🇺🇸🇺🇸 (@PrincessBravato) July 2, 2017
Gutmann sees a need for equal-access proponents to demonstrate why exactly health care is different from other consumer goods; such a claim would work to refocus and resituate health care as a good deserving more protection than other goods and thus a different set of priorities. The essential marrow of healthcare lies in its intricate patchwork of distributive capacity—many health care goods, especially those we deem key to maintaining good health status, are not merely useful, but indeed are necessary, for pursuing most other goods in life such as education and employment. Seen as a pathway, healthcare in this context evolves as a sort of ubiquitous building block from which other core human activities find their sustenance, and us, the ability to live meaningful, productive lives, ultimately deserving prima facie protection, a guard not endowed upon other consumer goods which can be bought and sold.
Dr. Sade, of the Medical University of South Carolina, argues that a man exercises his right to self-sufficiency in large part by having the capacity to produce, cultivate and maintain his economic values—namely in the form of goods and services such as healthcare—as only he sees fit. The main affront presented to an equal-access principle to healthcare comes from the most ardent supporters, such as Sade, of a pure free-market approach to cultivating the healthcare system and civic infrastructure in general. Gutmann argues that if the basic assumption that human preferences are totally subjective are held constant, the market will remain “the best way to order human priorities.” An interesting contrast to this explicit notion of the free market and the equal-access principle being able to coexist is summoned by the Sade, who, before taking on the practical realities of the medical care question, sifts through the notion of health being an inalienable, innate “right,” and how any force taken against true rights, such as those endemic to the free market satellite, are “anti-mind.”
Perhaps Sade’s most compelling point is that, if there is indeed a right to life, the ability exercise one’s own judgment of the best course of action and the capacity to dispose of one’s values, any way one chooses, without coercion from others. Where I differ from Sade is in the latter sentiment which is most intimately tied to the central vignette Sade paints of a loaf of bread (healthcare) being claimed by everyone (namely, the needy who are ill-equipped to purchase it) despite being produced for and by the baker (the doctor who operates within the free market system) who wishes to allocate the bread according to his own self-designs and wishes.
Sade’s argument coagulates in the spirit of rugged individualism and American transcendentalism, harkening back to the spirit of post-American Revolution civil disobedience in saying “nonparticipation may be the only way in which personal values [of free market] can be maintained.” To Sade, our economic values in America are not gifts of nature, but are bestowed upon us as a result of the virtue, spirit and determination of the willful American mind. It is helpful to view Sade’s discourse here as perhaps a red herring with respect to his bread vignette. I believe that bread is fundamentally a product of nature, much as health can be said to be a product of environmental conditions. It is one’s right to healthcare inasmuch as it is one’s right to cultivate nature’s yeast to make bread, for, a doctor is no more independent of his trade, needing patients, than a baker is to his trade, needing consumers, in order to continue his practice and sustain a comfortable life. The main difference here is that the baker almost certainly does not share the same socioeconomic niche as the doctor, nor have the socioeconomic prowess, and Sade fails to provide a reason why the medical profession is deserving of elevated protection in the way that Gutmann explains how healthcare deserves being a part of a protected class of consumer goods.
What is also missing from Sade’s account is something more than a cursory glance at the health disparities which exist in America and elsewhere and potentially justify the equal-access principle. Ironically, it is likely that the hypothetical baker Sade has created would unable to afford the healthcare proposed by his creator. Any attempt to dismiss healthcare as peripheral to our natural rights seems disingenuous and to be an explicit rejection of one’s right to the agency and self-sufficiency that would be acquired from having the full suite of medical tools necessary to be healthy. And although the producer’s capability to market his product is curtailed under an equal-access principle, the notion that a democracy, by definition, should demand anything less than equality and anything more than what makes one self-sufficient is dubious. As Gutmann says, it seems unduly hypocritical and immensely self-indignant to suggest that a national health care system forcefully takes away the income entitlement of citizens since we, under compulsion and the anti-mind threat of fine and/or imprisonment, contribute tax dollars to the state everyday to support the upkeep of both our communities and our free market in a process that is redistributive and cyclical by nature. The idea that a public good such as healthcare, having both an extrinsic value (its expansive distributive capacity) and an intrinsic value (the tangible, individual need to be free of elevated harm), can act as a shared public good and individual right seems essential to any understanding of the principles of a democratic free market.
One of Sade’s strongest points may rest in his repudiation of the idea that “health is primarily a community or social rather than an individual concern.” At the time of his writing, in the 1970s, it was a nascent idea that there existed myriad risk factors for poor health. Most centrally, overeating, tobacco smoking and alcohol consumption were all variables viewed as risk factors for diseases which, with good will, could be controlled, first and foremost, by the individual. In the 21st Century, through the rise of chronic diseases and the spread of many preventable diseases, including those which are sexually transmitted, we realize more than ever arise from individual decision-making and thus much effort in public health has been made to reduce these outcomes by focusing on malleable individual-level factors. Thus, Sade would seem to be correct in refuting Gutmann’s claim of the equal-access principle being a part of a protocol to forge greater communal cohesion at the diffused levels of culture and economy. To wit, some members of the medical establishment might see the most fruit in the promotion of prevention strategies; however, public health might see more fruit in helping those who are in need of more immediate medical care treatment for existing conditions—treatments which can be afforded to those in need only through an equal-access healthcare system. That these two trends must necessarily be considered mutually exclusive to the other illuminates a broader problem in the discussion at hand.
If insurers refuse to sell equal access and coverage indiv plans, there's no product, no free market! Extorting bad plans.
— Dr Amy Czyz (@amymczyz) June 28, 2017
Sade’s suggestions that a free-market medical care system is the only in which a doctor could be efficient and effective is faulty. Sade points to doctors in Sweden who he said collapsed under the introduction of an equal-access, socialized medical system, becoming indifferent to their work, painting a spurious picture of a future, equalized healthcare nexus in America wherein doctors felt no compulsion to work at the top of their capacity nor the passion to excel and enhance their techniques. Not only is this claim without sufficient evidence and largely anecdotal, it is imbued with the bizarre suggestion that the medical profession is driven not by a utilitarian principle to help as many as people as possible—in other words to act a public servant—but to act as beacon of civil liberties and a defender of the free market, values which exist in the vacuum of Sade’s political philosophy and should be of secondary importance to individuals in whom we routinely place the lives of ourselves and our loved ones. As a public servant, much like a police officer or a fireman, a doctor has a foremost responsibility to perform to his or her maximum capacity in the name of the utility of all. Such an action would seem to enhance, rather than repel, the community capacity for freedom from coercive and compulsory agents.
Ultimately, perhaps the most important point that needs to be reconciled in any consideration of a universal health care system is whether or not the American public would, in a democratic fashion, choose to support the development of an equal-access principle in a medical community that might be antagonistic to such a measure. In order for an equal-access principle to thrive, America would need to hold a discussion about whether the distribution and acquisition of medical goods and health services is a prerogative of the few or of the many; whether we will use the free market system to match corporate goals or to cultivate it to its utilitarian extreme. To give some of the material power of the medical establishment to those in need to decide and manage their own health, might move us forward in the direction of equalizing opportunity. And I believe this can be done without jeopardizing the integrity of the field of medicine:
Returning to Sade’s notion of the right to life, I think it is the right of the American public, every so often, to redraw the moral map and with broad strokes of the brush; to determine what is collectively best for society writ large, much like the revolutionaries that Sade cites did centuries ago, giving us the intellectual curiosity to extract from, and utilize, salubrity for our communal benefit. In the end, any policy regarding an equal-access principle will require capitulations on both sides of the fissure. As a stipulation, I concede that those for and against the equal-access principle must negotiate how liability for voluntary risk should factor into how broad we choose to make the spectrum of access. I believe that a system which at least attempts to equalize access to healthcare, though perhaps leading to some breaches in egalitarian equilibrium, is better than a healthcare system that leaves the decision of resource-allocation to those who, in the end, may be the most heavily incentivized to abuse such a far-reaching, invaluable power as turning the often incoherent language of rights into the lucid expression of a positive health outcome.
A. Guttman, “For and Against Equal Access to Health Care,” in R. Bayer, A. Caplan, N. Daniels (eds.), In Search of Equity (Plenum Press, 1983).
R. Sade, “Medical Care as a Right: A Refutation,” New England Journal of Medicine 285 (1971): 1288-92.
(Lego Nurses photo courtesy of 'Nursing Schools Near Me')