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.

Racism is alive and well--among Dems

As the growing extent and intensity of public opposition to the Obama Administration’s policies threaten to shut down its agenda, defenders of the Administration have resorted to systematic name calling. The most favored epithet is "racist." No less a personage than former President James Earl Carter last week alleged that most of the opposition to the Obama agenda is due to the President’s partly African origins. It is amazing that those same voters who cast their ballots for the President last year but are opposed to his agenda now suddenly have become transformed from public-spirited citizens into bigots.

Democrats have been calling Republicans racists for years, and it is as false as ever. It was the Republican party, after all, which brought about an end to slavery against powerful Democrat opposition. And it was the southern Democrats who maintained apartheid for a century after emancipation and who opposed civil rights legislation until President John Kennedy reluctantly supported Rev. Martin Luther King Jr.’s efforts to end segregation.

In fact, a greater percentage of Republicans than Democrats supported the omnibus Civil Rights Act of 1964, as such southern "liberals" as William Fulbright and Albert Gore, Sr., and former Ku Klux Klan member Robert Byrd, voted "no.".

Kennedy owed his election in the close 1960 contest to the heavy support of black voters in our largest cities, largely because he won the support of King over Republican Richard Nixon. This came at an opportune time, for growing numbers of suburban dwellers were supporting the Republican party.

In spite of the long history of Democrat racism, party leaders seized upon the opposition to the civil rights bill of the 1964 Republican presidential nominee, Sen. Barry Goldwater. Goldwater had a history of opposition to segregation in his home state of Arizona, having desegregated the National Guard. But he believed that the Constitution prohibited the federal government from regulating matters of state jurisdiction.

That vote won Goldwater only five southern states plus Arizona, as he lost to Lyndon Johnson in a landslide. But his opposition to the civil rights bill was enough to earn the racist tag for his party. When Richard Nixon picked a border state governor as his running mate in 1968, enabling him to win several southern states in a very close election, the racist tag stuck.

It is too bad that, in retrospect, Goldwater’s worst fears were vindicated, as the Great Society corrupted the principle of equality from opportunity to entitlement, with affirmative action, goals and timetables and even racial quotas–racial discrimination in reverse.

The same Lyndon Johnson who, as Senate majority leader in the 1950s watered down Republican-sponsored civil rights legislation, became a "born again" civil rights advocate when the electoral needs of his party dictated the shift. But the shocking–and revealing–fact is that there was no change in principle. Whereas Democrat racism once took the form of favoritism for whites, it easily slid over to favoritism for members of racial minorities.

As former President George W. Bush put it one of his 2000 campaign speeches, the Democrats now preach "the soft bigotry of low expectations." Instead of keeping blacks down by denying them the opportunity to advance of their own merits, Democrats now favor hiring or promoting employees, or admitting students, on the basis of their race or ethnicity.

In what black journalist and author Star Parker identifies as the "government plantation," having what used to be called in the slave and segregated South "one drop of Negro blood" makes all the difference. What previously closed doors for millions now opens them.

But it is a trap. Unearned advantages antagonize those losing out, even as the fact of favoritism is not lost on the supposed beneficiaries. "Soft bigotry" benefits only those who, like the slave masters and racists of old, determine who wins and who loses. The modern bureaucratic state, once thought to be based on merit, now teaches us every day that race trumps character.

When Democrats call their critics "racists," they are engaging in what psychologists identify as "projection." Painfully aware of their racist history, Democrats convince themselves that in their current pose as the friend of racial minorities they alone can be trusted with political power. They imagine that Republicans, who do not pose as friends but actually support equal rights, must be racists too unenlightened to appreciate Democrats’ allegedly good intentions.

Democrats believe that if they call Republicans racists long enough the people will forget about slavery and segregation. But the existence of the race-based government plantation gives the whole show away. Race is the Democrat calling card.

When kindness is against the law

[T]he fruit of the Spirit is love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, self-control; against such there is no law.- St. Paul In the face of domination of the world by the Roman Empire, the most energetic of the Christian apostles asserted that moral virtue was still lawful. Of course, Paul knew that virtues were not widely practiced or held in high regard. Are virtues any more safe to practice now than they were two millenia ago?

This question may strike some as perverse, for are we not living in a society, as Abraham Lincoln once said, "conducing more essentially to the ends of civil and religious liberty than any of which the history of former times tells us[?]" And are we not committed to caring for the less fortunate through vast government programs?

It is true that, while the tribulations of the human condition are not absent in our country, the daily practice of the virtues by millions of people–in families, at work and play, in government and the private sector–make self government not only possible but eminently desirable.

But no blessing can be taken for granted. Virtuous living, like any other great and good thing, requires practice and even habituation. Are there any threats here and now to the continuing beneficial effects of human virtue in our midst?

Let’s focus on the virtue of kindness. Some years back, genuine concern was expressed about the utter lack of kindness implicit in the random acts of violence too often committed in our inner cities, college campuses, places of business and governmental offices. The not entirely playful response by some was to urge everyone to engage in random acts of kindness instead.

No doubt the suggestion was well meant. But a moment’s reflection makes it clear that violence can be discouraged much more by habitual acts of kindness. In a well-governed political community such as ours, it is no accident that people tend to be kinder to each other than in tyrannical regimes in which the rulers treat their subjects as if they were a lower order of being.

Indeed, when slavery was legal in America, even the most benevolent slave master was free to indulge his whims. Thomas Jefferson, a slave master himself, wrote, "The whole commerce between master and slave is a perpetual exercise of the most boisterous passions, the most unremitting despotism on the one part, and degrading submissions on the other."

Classical philosophy and Christianity both teach that friendship is the cement that holds societies together. The Greek philosopher Aristotle observed that democratic societies, which are based on the principle of equality, are more conducive to friendship than any other. Jesus taught us where we can to make friends out of enemies.

Those of us living today, as Lincoln observed in 1838, "toiled not in the acquirement or establishment of [these fundamental blessings]." As in antebellum days, so in ours, we have the obligation to pass moral virtue on to our descendants.

The most fundamental threat to the lawfulness of the most gracious virtues lies in widespread rejection of what Jefferson called "the moral law.". Clearly, portrayal of gratuitous sex and violence in the popular arts does not teach kindness. For if other persons are merely the objects of one’s unbridled will, no kindness will be shown except by accident or cold calculation.

The rebel, the person with "an attitude," has been glorified in movies and television for years. More, the Constitution and laws of the country have been perverted by the special protections that have been carved out for anyone who does as he pleases with no regard for the rights of others. We are enjoined by elites to be kind to such obnoxious persons rather than expecting them to be kind to us.

The massive government programs that take the responsibility of caring for the needy from families, friends and neighborhoods and assign it to impersonal bureaucracies have made kindness almost unnecessary. Kindness depends on reciprocity as well as good intentions, for people more freely come to the aid of others when they know that, if circumstances were reversed, they could count on that aid. In fact, we are coerced into being compassionate by the law. Is that kind?

There is no law against kindness or the other virtues, but we are living on the edge, so to speak, pushing matters to such an extreme that, as Alfie was inclined to believe in the popular song of that name, "only fools are kind" and "it is wise to be cruel."

Socialized medicine: inefficient, unfair

Recently a message was sent to President Barack Obama’s supporters under his name that urged them to get behind his proposal for universal health care and castigated his critics. I share with him a desire to reform our health care system, but along lines completely different from those which he only vaguely explained. It is not very helpful, as Obama did, to sum up health reform in terms of "core principles" (reduced costs, guaranteed choice, and quality care for every American) when the means employed to fulfill them are unspecified. Nor does it help to oversimplify the issue, as he did, by equating support of the dreaded "status quo" with "half measures and empty talk."

Obama stigmatized critics, moreover, for "spread[ing] fear and confusion about the changes we seek." And then he proceeded to spread genuine "fear and confusion" about "spiraling health care costs" and failed to acknowledge how much government programs such as Medicare and Medicaid have contributed to those rising costs.

The President told the story of his late mother's battle with ovarian cancer, "spending too much time worrying about whether her health insurance would cover her bills," which is very moving but also verging on exploitation. Ovarian cancer presents a major challenge which even the most lavish health insurance cannot mount. No government program can end these worries.

We are responsible for our health. I'm no less mindful than Obama of the persons without health care, but dealing with that deficiency does not require socialism. As his opponent, John McCain, advocated last year, substantial tax credits for health savings accounts will help people who lack employer or government plans.

Before there was massive government involvement in health care, and before third-party payers dominated the field, costs were actually more manageable. Forty years ago my oldest son needed surgery that cost us, a young married couple of modest income, $500. I am sure it would cost many times more than that today, not only because of inflation but because of the proliferation of third-party plans, which shield consumers from the true cost of their care.

In any case, there is no more reason to socialize health care costs than the cost of food, transportation or housing. Obama may not want us to know that what he is proposing is socialism, but many of us don't need to have it spelled out. It is not fear-mongering to point to the experience of nations that already have government care, which entails artificial caps on costs and rationing. Only a free marketplace can bring consumers and providers together and enable them to agree to reasonable terms.

The President is only worsening the current difficulties by proposing more of the same government intervention. We must oppose him in order to preserve, and even return to, the limited government bequeathed to us by our founding fathers.

As a friend of many years has reminded me, however, for millions of Americans justice is central to the health care debate. He wrote: "We will end up with ‘socialized’ medicine unless our people are convinced that justice and fairness are better served, and good medicine is better provided, in a non-socialized system of health care. Many good Americans are willing to accept lesser care (up to a point) if they are persuaded that the promised new system would be more just and fair for each and all of us."

I think he is right. Liberals believe they have a monopoly on justice and fairness, erroneously equating equality of condition with equality of rights. The truth is, the free market exemplifies reciprocity in exchange, a form of justice, as doctors and hospitals provide a service for which they deserve to be paid, and patients deserve a say over costs. They have that say now for virtually all other commodities (automobiles now conspicuously excluded, thanks to President Obama), which makes them largely affordable.

But there is no justice in making some Americans subsidize the health care of others, nor is it fair to deny people health care because some bureaucrat decides that their needs aren’t as worthy as someone else’s. Imagine if food production, distribution and sales were socialized, and the government determined what we ought to be eating!

The American idea of justice is not, as Obama evidently believes, "From each according to his ability to each according to his need." Rather, it is our right to govern ourselves. It is better, as the early Pilgrims learned the hard way, for each person and/or family to use their abilities to provide for their needs. Justice and utility are in perfect alignment.