[This article appeared in the December 1992 issue of Conservative Review, pp. 42-46.]
Health Care as an “Entitlement”: Economic and Moral Aspects
Dwight D. Murphey
Advances in medical technology provide great benefits to mankind, but have also created a major ethical problem. Every year, new and often extremely costly surgical techniques, drugs and medical care devices are introduced to the market. While it is pleasant to think that “All Americans have a right to the best possible health care,” some forms of health care are exorbitantly expensive, so that one must ask whether “all Americans” do indeed have right to expect others to provide them with these extremely expensive services, and indeed whether America is economically able to provide the new medical services to all who live within its boundaries. We are emotionally stricken by the thought of infants born with AIDS or with an addiction to “crack.” The moral issues seem overwhelmingly complex, but Dwight Murphey attempts to introduce some elements of reason to what is a highly emotional but very real problem: Health Care as an “Entitlement.”
The statement that comes trippingly off the tongues of so many Americans today that “all Americans have a right to health care” is a suspect concept. It is so fraught with ambiguity and the possibility for political manipulation that it carries within it the promise of a vast and indeterminate demand upon our means. And it is so indiscriminate in its sweep that it offers the prospect of gross injustice.
This is so despite the fact that good health care is something we very properly want for ourselves and all others. Certainly it is not ignoble to want every American to have the very best care that medical science can provide.
And it is so even though we may agree that the present “health care delivery system” has become misplaced and insufficient from almost any point of view, and sorely needs a better institutional and legal framework.
But the point I would make is that there is quite a difference between something being desirable—even extremely desirable or necessary—and being declared a “right.” The concept of a “right” is a judicial concept, and for every right there is a corresponding obligation, either on the part of other individuals or of the state.
The “Deprivatization” of Needs
During the twentieth century, there has been an on-going process of deprivatizing each of our “needs,” transforming it into a public issue and thereby politicizing it. This process was endorsed by the sociologist C. Wright Mills, one of the founders of the New Left, when he wrote that “it is the political task of the social scientist—as of any liberal educator—continually to translate personal troubles into public issues.”
There was a time when a farmer’s not doing well was a problem for that particular farmer. In the twentieth century, however, the plight of all such farmers has been aggregated into a statistic called “farm failures,” and government has undertaken to provide subsidies and price supports. There is a real question whether all of the billions spent have produced a long-term social good, as compared to having left farm success and failure to the free market.
I remember when, a few years ago, Sen. Edward Kennedy took a trip to northern
, where he discovered the “plight” of the Eskimos. What had until then been their private ail, born out of their choice, made long ago, to live under extreme climatic conditions, was pointed to as a public disgrace, calling for solution by government. Alaska
Examples could be cited endlessly, since there is hardly any part of our lives that is still considered truly private.
Several factors are at work in this politicization. It reflects, as Mills commented, the inherent nature of empirical social science, with its statistical method: individual problems, when aggregated, take on a public dimension. It reflects, too, the dynamic of spend-and-elect politics, as exemplified by such a politician as Senator Kennedy.
Further, it embodies a modern willingness by individuals and families to be no longer completely independent; in many ways, we have come to crave a warm cocoon, guaranteed to us by society at large, and have taken on the psychology of entitlements. Conservatives have long decried this as an excessive seeking of “security” as against “liberty”—and no doubt there is much of that in it; but it can be looked upon more empathetically, too, as a natural seeking by human beings for well-being. The problem, it seems to me, is not in our desire for security (unless it is so excessive as to take away our initiative), but in the means we select for attaining it. The dichotomy between “security” and “liberty” is in part a false one. Free men, after all, often find their freedom enhanced by the provisions they make for security; it’s a rare businessman who would fail to cover his property with casualty insurance. And in part the purpose for which freedom is exercised is to provide security for ourselves and our families.
Still further, the politicization reflects the extent to which Americans have come to accept, almost as the air they breathe, the conceptual worldview of the Left. A society of limited government, operating primarily through a market economy based on private property and free exchange, sees most life as private. We can contrast this with the thinking of, say, Edward Bellamy, the American socialist who a century ago wrote his famous novel Looking Backward about a socialist utopia. In it, everything that anyone wanted would be free for the taking from public storehouses; and everyone, regardless of merit or the extent of his contribution, would have an equal claim. This was “entitlements” thinking in its pure socialist form.
The Expansion of Needs
At the same time, aside from the process of deprivatization, there is a psychological phenomenon at work that transforms the nature of human wants.
A few years ago, it was taken for granted by most people buying a new house that the purchasers would put in their own lawn; but slowly it came to be more of an expectation that the builder’s installation of the lawn was part of the expected service that we count on as part of what we get for the purchase price. The same transformation is occurring with respect to lawn and tree spraying; middle class Americans used to buy or rent spreaders and sprayers and do their own yards. But now we see lawn service company trucks running up and down our suburban streets, much in demand.
As our affluence increases, things that we used to do ourselves come to be things we look to others to perform; and what we once thought of as a luxury comes to be felt as a need. This same transformation has occurred, in a rapid and continuing process, in health care (as witness the amount of cosmetic surgery performed today).
But what I have mentioned is prologue to the points I principally want to make. There will be readers who are impatient with what I have said so far, and will think “all of that is so much political and psychological theory. What we need is action.” Accordingly, let’s move on to a more specific statement of the problems inherent in the notion that “all Americans have a right to health care.”
The Ambiguity of the Concept: The Infinite Expandability of Health Care
The shibboleth is simultaneously saying very little and far too much when it speaks of “health care.” The term “health care” is so infinitely expandable that we can’t possibly mean, when we speak of a “right to it,” all that it might encompass.
A recent article entitled “In Health Care, We Want It All” in the Wichita Eagle quoted the head of the counseling center at Wichita State University as saying that “any time you ask the American public what they want with respect to health care, the answer is: ‘Everything.’” The dilemmas contained in the current quandary over health care are reflected in the fact, as the article says, that “we want the choice and technology of the current private system plus the economy and universality of a government-run system.”
It wasn’t long ago that by “health care” we meant a fairly finite set of services: when we were ill we could go to the doctor; when we broke a bone, we could have it set; and we could have surgery for a more-or-less limited variety of reasons.
Even that was considerably more than was meant by “health care” a century, and especially two centuries, ago.
Today, however, what is encompassed by “health care” goes far beyond our expectations of even thirty years ago. Open-heart surgery is commonplace. A friend who had heart surgery at his own expense tells me of a case he came across while in the hospital of a man who had just had his third operation for heart valve replacement at the public expense. Apparently, the three operations, which would have cost a private patient around $60,000 each (including hospital care costs), amounted to repeated valve replacement operations because he took drugs and repeatedly re-infected himself by using “dirty needles.”
Of course, in some cases, advanced medicine actually saves money as well as prevents unnecessary misery. When a woman becomes pregnant, the pregnancy can be monitored with sonograms which make it possible for her to see the image of the fetus on a screen; and potential Downs Syndrome can be detected by a blood test given the mother.
But today’s medicine has extended the reach of life. It moves forward to take the hand of a tiny infant born prematurely to nurture it through precarious months of bare survival; and it stretches itself at the other end of life to prolong the dying process indefinitely for many terminally ill patients. At any other time in history, these patients would simply have died.
The examples I am giving, although sufficient for the purpose, barely scratch the surface. Anyone in medicine can extend them so far as virtually to boggle the mind. Even though we have a long way to go before disease and infirmity are eradicated even in advanced civilization, the scope and technical virtuosity of medicine are unbelievably greater than they were even a few years ago.
What’s more, the process will continue, probably at an accelerated rate. Many of today’s medical adventures are still in the experimental stage, and there are developments that will be coming about—five, ten, twenty, fifty years from now—that we can hardly imagine today.
But a Hard Reality: It’s All Expensive
It isn’t enough to marvel at the variety and extent of today’s health care. We also need to realize that every aspect of it is expensive—often extremely so—, requiring the inputs of research, professional time, and cutting-edge technology.
Last summer, I sent Milton Friedman a comic strip I had cut out of the paper that quoted his saying that “there ain’t no such thing as a free lunch.” Friedman wrote me back, with commendable humility, to tell me that the saying really didn’t originate with him; a researcher at the Hoover Institution has traced it back as far as the middle of the first century.
The saying deserves to have been around, and to stay around, a long time, because it expresses one of the fundamental truths of economics: that all economic goods are scarce. It is part and parcel of the human condition that there are very few “free goods.” Virtually everything we need, and certainly everything we develop through human effort, involves scarcity. Ronald Nash has quoted the late British economist Arthur Shenfield as saying that “everything still has a cost, but everyone is tempted, even urged, to behave as if there is no cost or as if the cost will be borne by somebody else. This is one of the most corrosive effects of collectivism on the moral character of people.”
The plain fact is that if by “health care” we mean all that medical science can now provide and will come to provide in the future, we can’t possibly afford to declare it a limitless “right” for all people that has to be paid for by other members of society. Without very real limitations on the concept that we are now so easily bandying about in our reference to health care as an entitlement, we are talking about services that will cost literally trillions of dollars. Furthermore, the cost is as infinitely expandable as the thing itself.
But do we know, or even bother to think about, what a more restrained reference to “health care” would entail? The very idea of limitations upon it introduces a difficulty that the current shibboleth “all Americans have a right to health care” is too facile to concern itself with. Those who use the shibboleth are essentially irresponsible, talking nonsense—and demagogic nonsense at that, since it sounds good and is politically appealing, but can’t possibly be translated into practicable policy in the form stated. What a responsible version might be would be that “we desire to provide all Americans with a certain defined amount of health care.” But somehow that loses its ring—hardly the stuff from which bumper stickers are made.
Make no mistake about it, though: the “health care” spoken of in the shibboleth isn’t something that can be easily narrowed to a practicable dimension. Try telling today’s public that the health care to which everyone is “entitled” doesn’t include keeping a “crack baby” alive… or providing a liver transplant to all who need it… or putting an emphysema patient on a respirator. Then just stand back and witness the explosion, the cries of heartlessness, the media’s appeals to pity for the always-present cases of suffering.
Limitations on the entitlement concept will be hard enough, almost impossible, to make for their own sake, if for no other reason than the humanitarian claims that will inevitably press against them. The very idea of limitation is even less achievable, however, when political and ideological considerations are taken into account. Once the whole psychology of “entitlement” is introduced, there is an acknowledged moral demand for more and more.
This is a demand that politicians either won’t want to try to buck or won’t be able to contend against even if they desire to. (In keeping with the shape of things since the 1930s, we can well imagine a politics in which Democrats will always call for more care, while Republicans will hang back, looking ungenerous and uncaring—just as they’ve put themselves in the position of always wanting a somewhat lower minimum wage than the Democrats have. It’s a prescription for a continuing
’s Law of Politics, by which irresponsible politicians force out those who are less irresponsible.) So long as there remains a single “rich taxpayer’s” pocket to be picked, the pressures will be well-nigh irresistible. Gresham
“Social Justice” (Perhaps)—But Unjust in Every Other Way
I have already spoken of the enormous variability of “health care.” Now let’s consider the equal variability of human risk-taking behavior.
To the extent that we guarantee everybody the same health care, we’re saying, in effect, that “we’re going to entitle you to the same care regardless of what your behavior leads you into, and make everybody else pay for it regardless of what their own behavior may be.”
As for myself, I live a basically sedentary existence. I’m one of those who hates exercise, and who spends his time at a word processor, or reading, or standing before a class. I’ve managed so far to ignore the “exercise craze,” and I look at sweaty joggers with a certain condescension, thinking them exhibitionists. There will come a time, probably, when this will cost me, and my doctor will tell me what a toll my sedentary life has taken. Then I’ll have a good many medical expenses—which the joggers would be required to help pay for if we were all guaranteed the same care regardless of what we do.
Many years ago when I was a teenager, it seemed self-evident to me that smoking couldn’t be good for you, so I’ve never smoked. Various chain-smokers in the family (all wonderful people) have died from emphysema. What was self-evident to me was ignored by them. In a system of equal entitlements, we’ll all pay for their emphysema-related expenses.
I won’t even comment on the kinds of voluntary behavior that lead so many to contract AIDS, since it just isn’t regarded as ideologically acceptable to tie that behavior to their disease.
A more wholesome example will be that of my brother. For many years, he loved to fly “ultralites,” floating on gossamer wings over
. Then he built himself a “gyrocopter,” hardly more than a chair with a pole on the back of it, a small motor, and rotating blades at the top of the pole. The last time I talked with him, by phone four years ago, he told me “I’m getting a motorcycle again.” I joked with him about how “one of these days I’ll get a call from Joyce telling me you’ve done yourself in.” And that’s just what happened; three weeks later the call came, except that it wasn’t the motorcycling that got him, it was a motor failure with the gyrocopter. Since I love my brother, it isn’t out of any desire to be unkind to his memory that I observe that he deliberately chose to set out on high-risk behavior. Most of us would respect his courage and spirit of adventure, and he certainly had the right to engage in high-risk forms of recreation. The suddenness of his death meant that there weren’t any medical bills. But what if he had managed to paralyze himself from the neck down? Is it just that everyone else should be required to pay for that? Tucson
This last question is what I’ve been leading up to: the question of justice. In a redistributionist, Bellamy-like world, perhaps no thought need be given to distributive justice in the old sense of the term, when it suggested “to each according to his due.” The old story about the ants that put food away for the winter while the grasshopper did nothing used to voice a vitally important moral point: that we are responsible for, and ultimately ought to bear the consequences of, our own chosen course of conduct.
The Concept of “Social Justice”
We have substituted an egalitarian “social justice” that deigns to be “non-judgmental” about conduct. No wonder the dark shadow of Irresponsibility looms so large over the world! Since to me this Irresponsibility is one of the major facts in the late twentieth century American cultural crisis, discoloring much of our national life, I consider it anything but a negligible factor.
If we go to “health care as an entitlement” in anything other than a limited sense, we continue, in a major way, to reverse the morality that ought to govern men’s relations with one another: we’ll continue the process of throwing a warm comforter over irresponsibility, while making those who act responsibly pay. I deny the justice of that. It becomes especially important to note this moral skewing when we consider that the health care entitlement can become an enormous vehicle for the redistribution of wealth.
None of this is to say that there is no justification for the public provision, up to a point, of common amenities. There are important reasons for a “commons” (the sharing of some space and services) as part of the theory precisely of an individualistic society.
Part of this is a matter of sheer practicability, even though libertarians in their flirtation with anarcho-capitalism have wished to deny it; certain “public space,” such as streets and parks, makes it more, not less, possible for the free individual to live his life of freedom. This plays a role as part of the framework for a free society.
Nor is there a theft of wealth from some, to give to others, inherent in such a provision, since it is true, as Henry George argued a century ago, that a certain portion of everybody’s wealth is an “unearned increment.” George made the point primarily with regard to the value of land, which often appreciates not because of something the owner has done but because an increasing population has grown up around it. The point applies more generally, too: no matter what effort and talent we bring to something, we stand in effect on the shoulders of countless others who came before us or who may even be our contemporaries. This means that some taxation to provide for common amenities should not be counted as an invalid redistribution.
But although this is true, the idea of a “commons” or of “common amenities” (which is inherent in a generalized provision for health care) can be carried to the point of destroying a society’s primary emphasis on private property, individual effort and economic freedom. (This is why socialists, not just Henry George, have long been fond of talking about “unearned increments.”) Taken to an extreme, it is a vehicle for socialism.
One of the things that impels libertarians to deny the validity of common amenities altogether is the fact that there is no “bright line” demarcation separating how much is acceptable and how much unacceptable to a free society. The absence of a “bright line” separating the two means that those who care about a free society need always to remain alert to differences in degree. It is precisely such an alertness that I am urging in this article. To that end, we need to be suspicious of the shibboleth that “every American has a right to health care.” Despite its evident appeal, it contains ambiguities, injustices and opportunities for abuse that can take us far from what is most appropriate to a free society.