The moral issues of health care reform

According to Eugene Robinson, progressives "wonder how health care reform came to be defined not as a moral issue...but as a 'big government takeover,' complete with 'death panels.'" While he doesn't elaborate, perhaps because he takes it for granted, on the moral case for reform, Robinson, or the progressives he writes for, mistake their opposition if they assume that resistance to the alleged "takeover" isn't also a moral issue. Health care itself is an issue that reveals two competing moral systems in play.

Let's assume that the moral case for reform is that no one should go without needed or even helpful medical treatments simply because they can't afford them, or are uninsured. The moral case is usually stated most succinctly as an assertion of a human right to health care. The Heartland Institute, publisher of The Patriot's Toolbox, challenges that assertion in its policy paper on health care, in terms that are moral in their own right.

A right is a claim to be treated in a certain way by others, which places an obligation on others to act in certain ways. Negative rights -- such as the rights to 'life, liberty and the pursuit of happiness' proclaimed in the Declaration of Independence -- are rights to be free from interference and coercion by others. Positive rights -- such as a claim to free or subsidized health care -- are claims to the service, involuntary if necessary, of others. Positive rights therefore bring the risk of contradicting the freedom rights of others.

A 'right to health care' does not appear in the U.S. Constitution or its Bill of Rights, or in any state constitution, or in the writings of the Founding Fathers or the British intellectual tradition from which they drew their inspiration. This was not an oversight. Positive rights may require that goods and services be produced involuntarily, under the penalty of law. Historically, this has not been an efficient or just way to produce goods and services.

From the Heartland perspective, it is for all intents and purposes immoral to coerce someone into providing or subsidizing services for someone else. A different moral code, however, might recognize a general and individual obligation to assist in providing needed or helpful services to everyone within a polity, or to the entire human race. If perpetuating life for everyone is a compelling public good, it can't be immoral or unjust to require each person to contribute to securing services for all. There's an answer to this argument, though, which Heartland, to their credit, doesn't express: some people should go without health care because they don't deserve it. The Toolbox actually asserts that "The Uninsured Typically Get Good Health Care" when they need it, but the fundamental denial of a right to health care, it could be said, should make whether they get good care or not a matter of indifference to the principled opponent of implicitly coercive positive rights. That position assumes a moral imperative on each person to make arrangements for his or her own care without imposing on other people. If you can't manage it, you can hope for charity, but you shouldn't take it for granted, and you ought to be ashamed of your own inadequacy if you have to ask.

The question of rights, their sources and their authority, raises questions about the essence of morality. I've been pondering the meaning of morality for a while in an attempt to distinguish morality from ethics. One of my ideas is that morality is a general condition or state of being rather than a code of rules, so that the crucial moral question, at least according to one moral system, is whether you deserve something -- life or death, reward or punishment, etc. Consider the wounded Little Bill's protest in that essential moral text, the movie Unforgiven, when William Munny prepares to finish him off. "I don't deserve this," the sheriff insists, "I was building a house!" Many in the audience will think differently, because they know that Little Bill had tortured Munny's friend Ned to death. In their view, Little Bill deserves death for that act. Little Bill thinks differently in part because he knew Ned to be one of a band of assassins killing cowboys for money. From his perspective, Ned deserves death, though we know that Ned never actually shot a cowboy, and therefore Little Bill himself doesn't deserve to be shot. Munny himself expresses a third viewpoint. A sympathetic audience might want him to answer that Little Bill deserves death for what he did to Ned, and Munny has already said that he would kill the sheriff for that reason. However, when challenged by Little Bill, Munny answers, "Deserve's got nothing to do with it." He has asserted an amoral position, admitting that he has acted purely for personal revenge. Unforgiven is mainly concerned with the entanglement of morality, justice and revenge -- the assassins are avenging a prostitute disfigured by a cowboy, but by raising the question of "deserve" it may point us toward the essence of morality, or at least the essence of one moral code. For some advocates of universal health care and single-payer provision, asserting a right to health care may be the same as saying we deserve it simply by virtue of being human or at least citizens of a civilized nation. For others, deserve's got nothing to do with it, and a person can never disqualify himself from entitlement to health care. But for those for whom deserve's got everything to do with everything, the simple assertion of a universal human right to health care, not to mention a maximized lifespan, sounds like an amoral if not immoral claim by the undeserving on the deserving. For such people, just as the beginning of wisdom is the fear of Hell and the realization that a sinner belongs there, the beginning of virtue is the recognition that you don't deserve to live, or at least don't deserve a good life, unless you earn your own way. Some others might agree with the proposition while questioning whether some who think they deserve a good life actually do so, while a hedonist or utilitarian for whom the only bad thing is suffering would grow impatient with the whole deserve question. Because the health care issue throws the question of suffering into the balance, the moral stakes are nearly as high as you could ask for short of war. In the long view, the crucial question is whether compromise is possible among the conflicting moralities in play, or whether some large faction of Americans will remain convinced, whatever the outcome, that the country has gone in an immoral, unforgivable direction.