Is health reform a matter of justice?

(Author: Robert F. Sasseen) Is affordable healthcare for all a question of individual rights, or a requirement of the common good? The public debate in the US seems to assume that it is both. It is not my purpose here to examine what reforms are necessary or wise, but to identify some of the issues of justice implicit in the debate Is There a Natural and Individual Right to Health Care?

Most believe that the US healthcare system needs reform. Why? Because it has become too expensive and too many are left out. All seem to agree on that. So the public debate is focused on how to fix the system, not whether it needs fixing. It is asserted that 46 million Americans do not have access to health care. Strictly speaking, that's not true. Millions of them could, but choose not to purchase health insurance. But let's not quibble over the word "access." In the USA, the door to health care is open to all in the sense that no law prohibits entry to anyone. It remains open even to those who choose for whatever reason not to enter. But isn't the door effectively closed to all who choose not to enter because they can't afford to pay the cost of the care available inside the door? Don't they have an individual and natural right to the care they need? If every individual is by nature entitled to affordable health care as a matter of individual right, then is it not the duty of government to make sure that health care is available to each and all? Indeed, this is the view of some who argue for a national healthcare system established, managed, and regulated by the Federal Government. They argue that it alone is big enough, powerful enough, and wealthy enough to provide affordable (and equal?) health care for everyone.

A question of justice arises with respect to things to which I am entitled by positive law, natural right, or divine command. If there is no entitlement , my lacking a good I desire (say, a room with a view) is not an injustice. Nor would it be just to tax another to pay for that room. But what of life's necessities? Am I not entitled to food, clothing, shelter, education, and healthcare? If so, doesn't justice require that another help provide them for me, at least if I am a child, or poor and destitute through no fault of my own?

Perhaps. But first, what is the ground of that entitlement? No question of an individual right arises if there is no entitlement to the good which is lacking? Some believe that my entitlement arises from my natural right to life, liberty, and the pursuit of happiness. If I have a natural right to life, do I not also have a right to the things necessary to preserve my life and to achieve the happiness I naturally seek ? Is that not logical? Seems so. But how does my right become another's duty to help me?

Classical Liberalism (e.g., in Hobbes and Locke) struggled with that question, not quite successfully in my opinion. In that view, the duty of another to assist me arises from the transformation of my natural rights into civil rights through the "social contract" and the laws established by a legitimate government to maintain the "state of society." In the "state of nature," there are no natural duties arising from my natural right to seek the goods I need. My natural neediness is not the ground of another's duty to help me. My natural right to acquire the goods I want leads to the war of each against each. The goods we need are naturally scarce, there is no natural law, and no executive power capable of enforcing it if there were such a law. I am not naturally my brother's keeper. Thus life in that state of nature is "solitary, poor, nasty, brutish, and short." The purpose of the "social contract," and consequently the duty of government, is to put an end to that war and to establish the conditions, (primarily law and order), which are necessary for the security, peace, progress, and prosperity of society as a whole.

St. Paul once admonished the Thessalonians that "if anyone will not work, let him not eat" [2 Th. 3.10]. Fathers once admonished their children that "the world doesn't owe you a living. Neither does your neighbor. It is your responsibility to provide for yourself and your family." That was a salutary teaching consistent with the harsh facts of life, the natural rights teaching of our Declaration of Independence, and the preservation of freedom and limited government in a democratic republic.

Is Affordable Health Care a Requirement of the Common Good?

What about all those who can't provide life's necessities for themselves? What about the "widow and the orphan," the poor, the handicapped, the disabled, the defeated, the downtrodden, the "marginalized," and all those who suffer "the slings and arrows of outrageous fortune"? If they have no natural and individual right to health care, are they to be left to suffer and die?

Of course not! Compassion forbids it, as does Charity. But compassion is not a virtue, and charity is not the same thing as justice. The "Good Samaritan" aided that particular victim. He did not organize a political party to demand that government create a program to aid all victims everywhere. It is good for society to foster the development of compassion, charity, and the cardinal virtues in its members. But the question we are exploring is whether universal health care is a requirement of justice and therefore a duty of government to establish and to guarantee. Government may have that duty. But according to the originators of the modern natural rights doctrine, its foundation is not in the natural right of needy individuals to life, liberty, property, and the pursuit of happiness. That duty, however, may be inherent in the nature of society and the purpose government."

Now we wish to consider whether the provision of affordable health care for all is a requirement of the common good.

Essential elements of the common good are succinctly stated in the Preamble to the Constitution of the United States: Its purpose is "to form a more perfect union, establish justice, insure domestic tranquility, promote the general welfare, provide for the common defense, and secure the blessings of liberty to ourselves and our posterity." Health is a good thing. Sickness is a bad thing. We naturally seek the first and wish to avoid the second. Health care is necessary for both. My own health is my private good. A healthy population is a public good. An adequate system of health care open to all is a common good, part and parcel of the general welfare. It is therefore a proper function of government to promote its establishment and to govern it operation through appropriate laws.

It is necessary to make some distinctions here. The Preamble to the US Constitution does not grant the Federal Government a specific power to do anything. Its specific powers are enumerated in the body of the Constitution. Other powers (over education for example) belong to the nature of government in general, but are not included in that enumeration. They are reserved to the States or to the People (Article 10). This fact is relevant to the determination of the proper role of the Federal Government with respect to our healthcare system. It is also necessary to understand the distinction between the power to govern, to regulate, to manage, and to administer; as well as the difference between laws, rules, and regulations.

Few would deny that an adequate system of healthcare is part of the general welfare. Most would agree that it is legitimate for government to promote its development and to enact appropriate laws governing its operations. Some laws might be very controversial. For example, laws prohibiting discrimination against illegal aliens, deliberate killing, experimentation on humans, cloning, eugenic cleansing, abortion, embryonic stem-cell research, euthanasia, "mercy killing,"or doctor-assisted suicide. But few contest the right, or even the duty of government to pass laws of that nature--i.e., laws as distinguished from rules and regulations. It is a proper function of government to govern, but not necessarily to manage or administer the country's healthcare system.

It is conceivable that the common good may, in some circumstances, require the government itself to establish and manage a healthcare system, or to "nationalize" an essentially private one. Some believe that "socialized medicine" is the best way to go. But it is a question worth considering whether such a system is compatible with liberty, with the duty of government "to secure the blessings of liberty to ourselves and our posterity." There are several essential elements in the common good. It is the duty of government to attend to them all and not to sacrifice one to another. That requires prudence and moderation in the government and in the people.

Who Benefits? Who decides?

Women and children first” shouted the captain of the sinking ship. “First treat the slightly wounded” ordered the field commander in desperate and immediate need of more soldiers. (Some military doctors wanted to treat the severely wounded first, to prevent their dying.) As to the availability of health care in general, some demand affirmative action for minorities and a “preferential option for the poor” in the name of justice and human dignity. They are many and needy. A few insist that priority should be given to those who most benefit society. Others hold that equal treatment is the proper principle. They differ whether equality means equal eligibility for each person, or proportionally equal financial support “to each according to his need.” Still others take a more pragmatic approach that others reject as inadequate and insensitive. “First, don't bankrupt the country. Second, don't take over the healthcare system or usurp powers not constitutionally authorized. Respect the proper role of state and local governments, as well as private, intermediary associations. Third, require all to purchase private health insurance open to all, and remove restrictions on the insurance industry that inhibit competition and restrict its territory. (Government should be insurer of last resort for the deserving poor.) Fourth, focus health care on the condition and futures of the different age groups. Provide health education and preventive care for all; remedial and curative care for children and adults who can be restored to useful life; only palliative care for the rest--particularly for seniors running out of gas. No extraordinary procedures or inordinately expensive measures for any person who can't pay for them.“

It is impossible to avoid rationing and setting priorities so long as health care is a scarce good and the demand is virtually without limit. Such issues are in substantial part questions of distributive justice. But who is to decide? Some of them are decided in the market place by what insurers and sellers of health care can afford to offer, and buyers can afford to purchase. Some are decided by government, in the subsidies or funding it provides and in the general laws and regulations it establishes for health care. Some are decided by the doctor and patient together. Many American's prefer that rationing decisions be made as close to home as possible--between the patient and his doctor.

It is characteristically human to “want something for nothing,“ ”to have our cake and eat it too,“ to have ”third-party payers“ for the goods we want. There is never enough money to do everything we desire. Choices must be made and priorities set, not only within the world of health care but between other elements of the common good. Universal healthcare may be very desirable, but self-defense and victory in war more imperative. Government must decide among competing goods and competing “values.” The struggle for power and deliberation about what is best are the very stuff of politics. We want the People to decide, and that is why we favor democracy. “Power to the People!“"

"Justice is the advantage of the stronger“ asserted the ancient Sophist. The law declares what is just and unjust. The winner of the struggle for power is by definition the stronger and makes the laws according to the “values“ of her class or his winning coalition. It is no surprise that too often those “values“ both rationalize and favor the interests of the winners in the struggle for power. Contemporary Liberalism offers no defense against such a cynical view of justice and politics. At bottom, that is its own view.

"Don't tax me. Don't tax thee. Tax that rich man behind the tree!” If there aren't enough of those, keep borrowing or printing the necessary money until the bubble bursts and the economy collapses, hopefully sometime in the distant future. “Do not suffer today what can be put off till tomorrow.“ That appears to be the natural way of democracy.


Much is at stake in this healthcare debate. The dominant opinion of justice and what it requires of government is one of the main causes of its form and policies. The view that justice requires government to guarantee or provide universal and affordable health care is a particular instance of the Marxist principle of justice. ("From each according to his ability, to each according to his needs.") The triumph of that view of justice could eventually bring in its wake the tyranny inherent in the Marxist principle, as our experience of Communism demonstrates.