Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


Is Medical Care a Right or a Privilege?

By Rob Tenery, MD on December 14, 2016

If health care is a right, it would be a benefit granted to all individuals in a given society, such as protection from bodily harm by an outside source that is beyond one’s control. The responsibility for obtaining and paying for this protection is shouldered by all members of that society. Examples would be the military forces, fireman, and policemen. One could use this argument to support the concept that all individuals are entitled to good health and freedom from disease as a basic right. Unfortunately, the costs and limitations of resources make this concept unachievable.

Health care as a privilege would introduce the concept of option. Just being a member of a particular society would not automatically entitle one to the benefit of health care.

The answer falls somewhere in between. The right to relief from pain and suffering seems universally accepted in civilized societies and would be limited only by the availability of resources. Benefits over and above this fall into the category of privileges.

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.

All integrated societies offer some form of care to their participants. This country’s overflowing emergency rooms and subsidized outpatient clinics serve as testament that patients who are sick or injured are deserving of care to relieve their pain and suffering, at the very least. These benefits, along with certain preventative measures such as selective immunizations, can be lumped into a basic benefits package, and by most, considered a right of our citizens. The rest would be considered as benefits to be utilized based on the measurable criteria of funding, availability, need, and likelihood of benefit.

In an attempt to justify the enormous expenditures directed toward the care of patients in this country, the ethical arguments of “fair opportunity” and “collective protection” have been espoused. These principles, however, could just as easily be applied to larger segments of the population in a financially constrained system, thus justifying rationing on a case-by-case basis.

Under “collective protection” patients are entitled to protection from general threats that are beyond their control, which includes a basic level of health care. It is not necessarily for their own protection, but also to avoid harm to a larger segment of society whom they might contact. “Fair opportunity” does afford individuals the right to develop their skills and pursue goals without undue interference from others, but only if those rights don’t compromise others.

This dilemma is not new to the American public. The need for prioritization in organ transplantation has existed since the technology was first successfully performed on December 23, 1954. Sometimes the decision is made depending on which patient is in the most critical condition and the availability of the needed organ. Sometimes it is based on age—the younger deriving the greatest benefit over the longest time. In the most critical situations, the patient’s financial status has little to do with the decision. With widespread limited resources, an expanding population (especially in the older sector), and growing funding constraints, the concept of allocation has now spread into most other areas of health care delivery.

Although many are reluctant to discuss the subject, there are two levels of health care. With advances in technology, that dichotomy becomes even more apparent. Even in countries that claim to provide nationalized health care, those in power generally fare better than those they govern. Maybe it’s just more personal attention by the providers of health care services, or maybe it’s purchasing care in the “private sector,” as in England, or packing one’s bags and paying for care in another country, as with the oil-rich nations of the Middle East and Canada, whose citizens migrate to the United States.

Keeping up the facade that all health care should be equal has a negative impact on the system. As long as the recourses are available, is it just to deny patients better care if they are willing and able to afford it? The concept discourages innovation. It also encourages the so-called privileged to seek care elsewhere and shifts funds out of the system. A loftier goal is to ensure that everyone has access to a basic level of affordable health care services. That is where countries that offer universal health care have it up on the United States. The difference is that the level of care offered to the masses in most other parts of the world is either substandard or much harder to access.

There are two basic concepts that must be addressed: funding and allocation. One hundred years ago, all funding for health care services came from the patients themselves or went uncollected. Today the broader concept of Gross Domestic Product (GDP) addresses both issues on a larger scale. The term implies that an increase automatically equates to better health care and criteria such as shorter life expectancy and higher infant mortality can be used to root out inefficiencies in the system. Unfortunately other factors such as population make-up and density come into play. More importantly, the concept of using a percentage of the GDP also assigns a dollar value to a human life and changes the argument from a right or a privilege to one of cost–benefit ratio.

Even in the face of this growing complexity, we are drawn back to the fundamental principle upon which this profession was founded: humaneness—the showing of compassion and consideration for our fellow man. Utopian dreams are what raise societies to a higher level. However, it is the cold, hard face of reality that determines which part of those dreams come to fruition.*

* Article excerpted from In Search of Medicine’s Moral Compass, Tenery, R., Goodman, L., The Small Press at Brown Books Publishing, 2011. 





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