In a previous post, I suggested that the most adequate conception of a purported right to health care is as really consisting of two distinct elements: a distributional right to a fair share of social resources—with the understanding that one’s fair share can depend on the other burdens and misfortunes one faces, so that the sick or otherwise badly-off may be entitled to larger compensatory shares—combined with a paternalistic constraint that requires a portion of the share to be spent on certain kinds of specific goods. (For what it’s worth, I mean to use “paternalistic” neutrally here, freely granting that young people in particular are not wired to make good decisions about low-probability catastrophic events over long time horizons.) I’m not sure whether thinking of it this way has any practical upshot—many of the arguments for health care reform have to do with pragmatic considerations far removed from rights talk—but I operate on the theory that conceptual clarity tends to come in handy sooner or later. Some commenters found this approach fairly counterintuitive, and on reflection I have some added objections of my own, but I want to try to be a little clearer about why I think this is a better way to think about it.
Discussions of a right to care often come down to talk about “saving lives”—which has a certain air of cinematic finality to it. Zoom in and fade out on the kiss, and the last moment of the story lasts a celluloid eternity. Morbid as it feels to keep saying so, though, lives are never really “saved”—just shortened or extended by some finite amount. And a huge amount of medical care is about quality of life, not longevity. Sometimes those two goals are at odds, and the patient has to decide which is more important. To reflect this, when bioethicists want to wade into the hard questions, they are inclined to talk not about “lives saved” but about QALYs (pronounced “Quallies”) or Quality Adjusted Life Years. And I think a great deal of clarity would be gained in discussions of health care if this way of talking became more widespread. Another distorting factor in discussions of health care, I think is the tendency to think of some individual in isolation and just reflect on what we feel we’re morally obligated to do for that person. On most progressive views, though, health is one of many competing goods to which people have positive entitlements, and each person’s right is constrained by the countervailing pull of the equally valid demands of others. So we always need to ask, not whether this person deserves to have his life “saved” (or extended or improved) but how to allocate resources across all the different moral claims on them.
If we switch from “lives saved” talk to QALYs talk, and if we preserve a holistic rather than a case-by-case perspective, I believe the distributive-justice-plus-paternalistic-constraint conception of the health care right becomes much more appealing. At the individual level, it’s easy to get lured into thinking in binary terms of a “right to life”: “Should this person live or die? Live, of course!” If you’re looking at a system of entitlements in which QALYs are one kind of benefit, though, the question “what exactly does the right to health care amount to?” ends up looking quite different—something along the lines of “what is the value of a QALY, bearing in mind the opportunity cost of all the other purposes to which social resources might be devoted?”
Now, for all sorts of purposes, governments do actually have to assign universal dollar values to QALYs for, among other things, regulatory cost-benefit analysis. But I’m enough of a subjectivist that I just don’t think these questions have any general or abstract right answer—which is why the denial of an objective hierarchy of values played the role it did in the last post. The value of longevity, mobility, education, and other goods we might think society ought to provide is the value they have to people. People can, to be sure, make mistakes—they can predict wrongly how happy they will be with a particular tradeoff, and if the mistakes are systematic and common, there may be an argument for paternalism. But these are mistakes relative to their own later assessments: There’s no external or objective standard for whether a college education or a hip replacement or any number of other goods is of greater value to someone. We focus on goods like health care because health is of enormous value and importance to almost everyone. (Whether much of the health care we consume actually provides any value turns out to be a shockingly open question.) But the fact that health, in general, is a good doesn’t tell us how to weigh everyone’s competing claims to specific treatments providing specific increments of longevity or different types of quality of life against every other positive good people might have some right to. So–this is obviously an idealized account, not how actual governments work—the way we decide whether someone is entitled to social provision of the slightly-more-effective-but-much-more-expensive treatment or the second hip replacement or whatever requires weighing the benefit of expending resources on that against the other claims we might satisfy instead. Or, to be sort of stupidly simple about it, suppose you have a limited supply of painkiller and a ward full of people in different degrees of pain. You cannot answer, in isolation, how much of the painkiller this patient has a right to. You can only start to answer the question when you know what sort of pain everybody is in, how much good the drug will do them, and so on.
This need not just be a matter of utilitarian maximizing. It might be that some person has had a very bad life in general, so that fairness requires us to confer a benefit on him even if, at the same cost, we could provide greater benefits to others who have not endured such hardships over their lives as a whole. Alternatively, there might be some upper limit to how much any one person can draw on the common stock, even if the greatest net benefit still comes from spending the marginal dollar on them. I want to be neutral between the many different conceptions of fairness bioethicists defend and argue over. The point is that whatever your standard for weighing interpersonal claims, the question is inherently distributive. And because society is trying to provide a range of heterogeneous goods, and because the benefits conferred by health care are themselves heterogeneous (again, in the simple case, longevity and various aspects of quality), this means trying to compare diverse particular benefits in order to figure out how strong all these different-in-kind claims are on a common resource pool.
Now just for the sake of argument, again as an aid to conceptual clarification, assume away the motivation for paternalism: Suppose you have a society of people who can perfectly well assess their own long-term best interests. If the question of how much health care people are entitled to ends up being inherently distributive in the way I’ve described—if it depends on a judgment about how to fairly confer heterogeneous benefits on members of society given limited resources, where the individual’s subjective valuation is ultimately the only determinant of what counts as a benefit—what grounds could you have for saying that an individual has a right to consume X% of social wealth for the purpose of providing a health benefit, but no right to devote the same share to some alternative use that this person considers a still greater benefit? How to weigh diverse benefits between persons is an extraordinarily hard moral problem—and its intractability one reason I lean libertarian, incidentally. But if, arguendo, we suppose we’re dealing with people who are not subject to the various common biases that lead us into misjudgments about probability and future benefits, then we at least have one metric for determining which use of a given quantity of resources provide the greatest benefit to a single individual: The person’s own subjective report.
Now, certainly there are grounds for thinking it might be socially optimal to insist that people take their share of the common stock in the form of health care rather than other goods. Perhaps, for instance, we want people to stay healthy enough to keep working, or perhaps other people feel uncomfortable seeing people who are sick or disabled, even if the people themselves would be happier staying disabled and putting the cost of treatment to another use. But now we’re not speaking the language of rights anymore. My moral right to health care, on the usual way of speaking about individual rights, is a matter of how having it is good for me. And indeed, one common way of characterizing rights is as trumps against social optimization. So, to pick a clichéd example, we might say that someone has a right not to be chopped up for organs, even though five other people could thereby be saved—the individual right to life (or not to be killed, anyway) trumps the goal of optimizing the total number of lives saved.
There’s a lot going on here, so let me try to step back and provide an overview that disentangles the different issues in play here. There is an argument that even in a world of perfect distributive justice, people would not make wise judgments about how to use their fair shares, justifying intervention to direct more of those resources than some might choose to health care. But that is not, in the ordinary sense, an argument about rights—about what people may claim or demand as a matter of justice. It is an argument for why we should override people’s claims for their own long-term good. There are a variety of reasons we might think it is socially optimal in various ways—because of externalities or economies of scale or whatever—to have social provision of health care, and even to call this a legal right. But this, also, is not an argument about moral rights—about the claims each individual may press as a matter of justice. What we owe each member of society as a matter of right will be a function—we can debate which function, but some function—of the way a treatment is a benefit to that person. And within each person’s life, it is a matter of subjective assessment which use of resources provides the greatest benefit. If it is the benefit a treatment provides that grounds the individual’s claim, then if we agree to bracket all these other considerations in order to focus on this one narrow issue, it is hard to see how it could be that someone would be entitled to some share of social resources in the form of a health benefit, but not to use the very same quantity of resources for a different benefit. From which it follows that the underlying moral right cannot be to a health benefit, but to some share of resources insofar as this provides a benefit.
One way my earlier post may have gone astray is that, while I tried to stress that people’s fair shares may vary over time because the burdens they bear as a result of misfortune give them stronger claims, my approach may have made it sound as though I was imagining everyone as having some fixed quantity of resources they’re entitled to. Moreover, if we look at the way just shares would vary to compensate for bad luck, it may seem that this is a needlessly convoluted way of talking about it, because it ends up looking an awful lot like a right to care superfluously mediated by resources. Consider someone who is born with a seriously disabling condition: On my account, in order to compensate for this, they may be entitled to a greater share so as to enable them to enjoy a quality of life more closely approximating that most others experience. But suppose one day somebody develops a relatively inexpensive treatment that will eliminate this disability. Now, of course, we would say that if they are still entitled to a greater share, it is only as much as would be required to supply the treatment. Isn’t this just a roundabout way of saying they have a right to the treatment?
I think it is not, because the key point is that people’s share claims may vary depending on—among other things—the way those shares contribute to quality of life. If we found some way to elevate people’s quality of life through means other than treatment, then the fair share might be what was required to bring the disabled individual up to the prevailing level by that other means, rather than through treatment. So if you’ll indulge me with another quite fanciful thought experiment: Imagine that at some point in the future, we have developed incredibly convincing shared virtual worlds like the one in the Matrix movies—except, you know, not run by evil robots. Suppose people end up happily and voluntarily spending large portions of their lives in these vivid worlds. Now, perhaps someone is born with an array of very serious physical disabilities that do not affect longevity, but seriously impair his ability to function and enjoy a decent quality of life in the physical world. There are, suppose, highly invasive and extremely expensive treatments that will mitigate these disabilities and restore some function in the physical world. But for much lower cost, we can provide access to these virtual worlds where many people live and work most of the time anyway. Suppose that people with such disabilities are able to enjoy lives as good as anyone else if they have this access, and are happier than people who get the treatments and remain in the physical world. Does this person have a right against society to health care, or has society satisfied its obligations if this person is, by the alternative means of access to the Matrix, the person is provided with the same quality of life enjoyed by everyone else?
I know a lot of readers are thinking this sounds like airy-fairy hypothetical wankery; certainly it’s light years removed from the practical issues of the current health care debate. But these admittedly fantastical thought experiments, precisely because they take us away from the complex tangle of different issues that make those debates so thorny, let us focus more clearly on isolated moral questions. Then, ideally, when we return to the real world, we have a better grasp on each of the individual strands in that tangle and can think more productively about the more practical issues—unlikely as that may seem.
I am acutely aware that this is all a bit muddled; ideally I’d sit down some time and rework all this in a clearer and more rigorous way. But I hope some of those who took issue with the previous post have at least a somewhat clearer sense of what I’m trying to get at. Note, for what it’s worth, that a progressive can probably accept this whole argument without thinking it makes much difference to the contemporary policy argument. None of this, in other words, necessarily has any direct implications for whether the public option or single payer or any other health care regime is a good idea. You can perfectly well say: “Well, forget about an abstract moral right to health care per se; our moral obligation for practical purposes is to provide people with more equitable access to health care than we currently do, and the reason is that it’s more socially optimal, or that people are entitled to share social resources in whatever way gives each a fair shot at a decent quality of life, or whatever other way you want to talk about it.” And then we’ll have all sorts of other things left to debate. But it will probably be a better, clearer debate.