Should We Aim For Equality or Autonomy in Healthcare?

Posted on March 31, 2008
Filed Under Fixing American Healthcare, Healthcare economics |

In a previous post we considered the first of three questions we must resolve before we can decide on any plan to fix American healthcare, namely, the question of whether the healthcare system should be universal.

In this post we will take up the second question: Should our healthcare system be designed to enforce equality, or should it instead permit Americans to exercise their autonomy as individuals?

Note that this question becomes relevant only because the answer to the first question (should the healthcare system be universal?) is “yes.” If we don’t have a universal healthcare system, then by definition we won’t have the option, much less the means, of trying to enforce equality. But once we decide on a universal system (i.e., a publicly-funded system of providing healthcare to everybody), then equality - equal access to healthcare services for everybody - seems not only the fair and logical next step, but also at first glance a very good thing.

The very fact that equality of access seems so naturally desirable - and thus will be very difficult to turn aside - is what makes the notion of a universal healthcare system so disagreeable to DrRich and many others, and is what makes the necessity of a universal system so fundamentally distressing. As it happens, the mere fact that this issue will have to be debated threatens the very nature of the American compact.

We should note right away that there is nothing inherent about a publicly-funded system of healthcare that demands equal access to all healthcare services. The only equal access demanded by such a system is equal access to whichever healthcare services are publicly-funded. That is, universal healthcare does not necessarily preclude individuals from supplementing publicly-funded services with their own resources. To achieve equal access to all healthcare services (and not just the services that are publicly-funded), we would have to actively restrict individuals from exercising their rights of individual autonomy.

To say this another way, ensuring the overall equality of access to healthcare services turns out to be not a positive good (i.e., granting the populace a boon they otherwise might not have), but instead turns out to be a negative restriction of rights.

The right that will have to be restricted is not a trivial one, like, for instance, the right to board an airplane without undergoing a body search. Let’s be clear on what we would be restricting here: We would be denying individuals the right to spend their own money on their own health.

Health - avoiding illness, disability and death - itself has a high intrinsic value, and restricting an individual’s right to use their available resources to maintain their health will have a high personal cost. But the cost will be much higher than just to individuals.

If We the People cede to our government the power to restrict us in this way, we will be abrogating the very foundation of our culture. We will be saying we no longer hold as self-evident our unalienable rights to life, liberty and the pursuit of happiness.

Our founders, recognizing the human condition, consciously tried to establish a system of government that would guarantee individuals the liberty necessary to pursue for themselves the best achievable outcomes, and that would maintain a reasonably level playing field (i.e., as level as practicable) on which they could pursue it. As imperfectly realized as it may be, this effort has made the United States everything that it has become.

It is beyond disturbing that we seem ready to abandon our foundational principle, especially since it will be for no good reason. We would be empowering our government to abridge our personal liberties, all in a vain attempt to achieve something that our founders recognized could never be achieved and should not be sought - an equality of outcomes

Why an equality in outcomes is not achievable.

Achieving equality in healthcare services is simply not feasible; it can’t be done. At least not in America.

Any healthcare system we devise will simply fail if we try to restrain people of means from exercising their fiscal freedom. Restraining this freedom does not work in Canada (whose efforts to enforce a universal system has created a powerful flow of wealthier Canadian patients to healthcare facilities in American border states), nor in Britain (which has given up altogether its attempts to restrict people from seeking healthcare outside the National Health Service, and has allowed a shadow self-pay healthcare system to develop). It certainly won’t work in America.

If we were to attempt to enforce equal healthcare across the population (and at the same time achieve the necessary limits on public spending), the demand among many Americans for more healthcare than the bureaucracy allows will inevitably stimulate a response from creative entrepreneurs. Some of the offerings one could imagine might include black market healthcare, overseas medical tourism, converting mothballed Soviet aircraft carriers to off-shore healthcare Meccas, or (following the example of the gaming industry) building Mayo Clinic equivalents on Native American reservations. (DrRich assumes here that retainer practices will long since have been declared illegal, fraudulent, and heretical, and will no longer be an option for American patients.)

Why an equality in outcomes should not be sought.

It is axiomatic that whenever a society becomes dedicated to achieving a perfect equality of outcomes (any outcome), the power of the individual is greatly diminished and the power of the central authority is greatly strengthened. This, simply, is because achieving equal outcomes demands that the central authority must have the power to take whatever commodity is being equalized from individuals whom it deems undeserving, and give to other individuals whom it deems more deserving. While actually achieving equal outcomes is never really possible, societies that doggedly pursue this end ultimately become tyrannical. This axiom our founders understood perfectly.

If we insist on perfect equality under our universal healthcare system, and forcibly prevent individuals from pursuing their own medical happiness, we will fundamentally redefine what it means to be an American. We will change the essential character of our culture - and of our government.

We should not take this path without careful reflection on what it actually means, both for us and for the generations that follow us.

What should we seek to do, then?

Since insisting on enforced equality in healthcare will undermine the founding principles of our culture, and won’t work besides, a better solution would be to first acknowledge that fact, and then to devise a system that - while incorporating universal access to publicly-funded healthcare - honors the autonomy of individuals to provide for their own well-being, in a way that maintains an acceptable degree of social equity. Such solutions can be imagined.

They will never even be imagined though, let alone achieved, if we allow our political leaders to lure us down the “obvious” path of enforced equality in healthcare, at the cost of individual autonomy. If this is the kind of change we opt for, we’ll be changing America in much more fundamental ways than by just altering our healthcare system.

In a later post we will take up the third and final question we must answer before figuring out how to fix American healthcare: Where’s the rationing?

Note: This is the fourth in a series of posts that discuss healthcare economics, and the three basic questions we will have to answer before we can devise a way to fix American healthcare. The first post in this series can be found here.

Comments

One Response to “Should We Aim For Equality or Autonomy in Healthcare?”

  1. Trusted.MD Network on April 1st, 2008 9:50 am

    Survey indicates majority of physicians favor universsl coverage-but what kind?…

    A recent survey claims that more than 50% of physicians (over 80% of psychiatrists for some reason) indicated they favor universal medical coverage. The research is in the April Issue of the Annals of Internal Medicine-subscription required

    I believe…

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