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Markkula Center for Applied Ethics

A Right or a Privilege? How to Practically and Ethically Reconcile Two Opposing Views of Health Care

Charles E. Binkley, MD

Charles Binkley (@CharlesBinkley) is the director of Bioethics at the Markkula Center for Applied Ethics. Views are his own.

The unsettled debate in our country over whether health care is a right or a privilege is almost certainly at the heart of why our health care system is one of the costliest in the world, and also one of the worst in terms of quality and outcomes, ranking last among peer countries. President Trump has been explicit about his belief that health care is a privilege and should not be given to those who cannot or do not earn or pay for it. His administration has made this conviction clear with its numerous attempts to dismantle the Affordable Care Act (ACA).

In contrast, President-elect Biden has been equally clear in his belief that health care is a right and not a privilege. He is not alone in this conviction. Article 25 of the United Nations Universal Declaration of Human Rights lists medical care as a basic human right. In addition, Pope Francis has spoken out that health care is not “a consumer good, but rather a universal right.”

So, what is at the root of this fundamental difference over health care? Are those who believe that health care is a privilege willing to stand by and watch other humans suffer and die just because those suffering cannot afford medical care? Most agree that humans have a basic moral responsibility to save other humans from suffering and death, but the question is always, “At what cost?”

Should we help a drowning person?

Take the example of the drowning person. A woman walks by and sees a man drowning in a shallow lake. Entering the lake and assisting the man would mean that she gets wet, gets her clothes dirty, and makes her late for work. Not helping the drowning man would mean that he suffers and dies. But what if the lake is frozen and the ice is fragile? What if the lake is deep and the woman can’t swim? The moral question is how much personal burden are we willing to accept in order to end another human’s suffering and save their life?

Those who believe that heath care is a privilege would say none, or at most very, very little. Those who believe that health care is a right would say that society should shoulder some degree of burden in order to alleviate the suffering and preserve the lives of others. Therefore, the debate over whether health care is a right or a privilege really comes down to how much burden society is willing to accept in order to provide health care to those who lack it. Put in practical terms: are those with money willing to give part of their money to those who don’t have money in order to alleviate their suffering and prevent their death?

How to reconcile right and privilege

How can these two radically different views of health care ever be reconciled? There may be a way.

Markkula Center for Applied Ethics Board Chair Dick Levy and I recently proposed a model of health care that is practical, ethical, and satisfies both those who believe health care is a right, and those who believe it is a privilege.

It works like this. By eliminating spending on health care that has never been shown to improve human health and wellness, that money can be used to extend to everyone health care that has been shown to improve human health and wellness. Interventions, treatments, and medications that have been shown to improve human health are often called “high-value care” whereas those that have not are called “low-value care.”

Let me give an example. One classic is a procedure called knee arthroscopy. This procedure can be used to treat many conditions, one of which is to treat arthritis of the knee. The procedure involves making a few incisions on the knee, placing a camera into the joint, and “cleaning” out debris. It’s an outpatient procedure with minimal pain and a short recovery. What makes this straightforward procedure “low value?” It just doesn’t provide any benefit to patients with osteoarthritis. There is no improvement in joint movement, no decrease in pain, nor improvement in function after the procedure. And it’s expensive. The two largest drivers of health care costs are physicians and hospitals. Who makes money off of knee arthroscopy? Physicians and hospitals.

By eliminating low-value care and using the money saved to pay for high-value care, the same amount of money could pay for more people to receive health care. What’s more, there would be no greater cost to those who believe health care is a privilege. What about those who want to have a knee arthroscopy for osteoarthritis, even if it doesn’t decrease pain or improve movement or function? If you can pay out of pocket for the procedure and can find a physician and hospital willing to perform it, then go for it. However, don’t take money from high-value interventions such as childhood vaccinations, mammograms, and diabetes management to pay for an arthroscopy that doesn’t make any difference in overall health.

This hybrid approach is likely the best that can be done to reconcile these two differing views of health care. Ethics is full of trade-offs wherein each party gives up something and gains something. The “rights camp” would get health care coverage for everyone and the “privilege camp” would not have to spend any more money for procedures that improve health.

In the end, needless human suffering and death would be dramatically reduced. That is a moral value which everyone can agree on.

Dec 7, 2020