Yesterday’s FT op-ed on the right to health generated a lot of heat in this blog’s comments section.
Several commenters disputed an absolute distinction between the “moral approach”—declaring health to be a human right, and the “pragmatic approach”—directing finite public resources to where they can benefit the most people at a given cost. Justin Krauss said:
I too am skeptical about the wisdom of claiming a “right to health” but I don’t think that such a right AND a more pragmatic approach to healthcare are necessarily mutually exclusive. I can (although I am not sure that I do) believe that health is a “right” while approaching the problem of how to achieve that right in a pragmatic, most benefit for the most people, manner.
The geckonomist questioned the causal link between calling health a human right on the one hand, and inefficient use of public resources on the other. He argued that the real problem is the way that narrow political interests are able to manipulate public funds, “regardless of the underlying moral reason.”
ryan picked up this same thread, asking whether the rights approach is simply being applied selectively, benefiting some groups more than others:
The primary argument you seem to level is that the ‘rights’ approach is applied unequally along disease- and class-specific lines, and that the people advocating that healthcare is a human right are the same people that are really just hungry for big headlines and large commitments to a small but visible sector of the actual needs of developing communities….Your real problem is with the execution, not the intellectual framework, of global public health spending.
Others objected to the notion that a human right implies requiring unlimited resources, and suggested various kinds of limits like “basic needs,” “subsistence,” or “basic health care.”
But none of these concepts are precise enough to yield hard upper limits, they will be different in different countries, and the limits themselves will be the objects of political advocacy for obvious reasons.
Nor is there anything about the “limit” process that keeps the sum of basic needs from exceeding the available resources—in fact, it is highly likely that they will do so.
So the problem is back to the issue of how to decide whose basic needs to satisfy and whose to not satisfy. This will be a political debate, and so once again the most politically skilled and connected will win, which will usually not be the neediest. So the rights approach is inherently unequal — it is not just a matter of execution. And ideas like human rights do matter if they obfuscate the likely outcomes.
It is true the cost-benefit analysis can also be manipulated politically, but it offers at least a chance to lead to a frank and open discussion about effective use of public resources to save as many lives as possible. The ideal that the lives of the poor are worth just as much as the rich is more likely to be realized in the pragmatic approach, ironically, than in the idealism of a human right to health care.
18 Comments
I’m not sure you have said anything new with this reposting.
Pursuing morals claims (in this case the right to health) by pragmatic means is not only possible, but commonplace.
Second arguing that a 100% pragmatic approach to healthcare is more effective is an empircal claim that I don’t think you’ve proven.
Finally using pragamtic arguments against moral claims is rarely persuasive. Furthermore I am not that skeptical about our ability to have “frank and open discussions” about the best pragmatic (or otherwise) means of achieving a moral(or not) objective.
With all this said I am still dubious as to whether healthcare should be considered a right. From a moral point of view I’m simply not sure if its true. Do I really feel obligated to pay for cancer treatment for a person who has a 2-pack a day cigarette addiction? Probably not.
And from a more pragmatic angle I think claiming something to be a right (health) that we so woefully cannot provide may diminish the standing of other rights that we feel more strongly about such as life, free speech, etc.
Now I may not have said anything new with this reply, but at least there will be two of us then.
“So the problem is back to the issue of how to decide whose basic needs to satisfy and whose to not satisfy. This will be a political debate, and so once again the most politically skilled and connected will win, which will usually not be the neediest.”
I do not see why this will be the case. If the law of the land says that everyone should have health insurance (private or public), and then a person dies because he does not have health insurance, there will be a scandal. If there is not such law, then it may be accepted. Clearly the law (the right to health) is pushing the limits towards more people covered.
It is clear though that it may not be feasible to cover all at a very high level of care, but I do not see (really) why putting an objective, a parameter (the real motive of a right to health) would hurt the cause.
It seems that your argument assumes a fix share of resources going to health, and the inefficiency is in the allocation of that share.
A right to health, in my view, is indicating that health is more important than other things, and that we should prioritize that sector over others. Again, here, that collective decision (to prioritize health care, at the national and international level) seems a reasonable one: who would not say that we are putting too much resources in producing, say, plasma televisions, expensive cars, computer games, or chip and salsa, than in more worthy causes (say health).
Proclaiming health a right helps, in my view, move the line towards that better allocation.
You keep returning to a concern that the neediest people get helped, rather than money being diverted to people with connections. But isn’t that your own moral compass speaking? In purely economic terms, maybe people who are better at managing money should get more of it, and wee might all be “better of” without the poorest of the poor.
I understand how spending money on ARV treatment is less cost effective than spending on prevention. But what is a “cost effective” argument for spending money on mentally and physically handicapped people among the poor?
Without any moral guide, why single out Amaretch and share her story as you have done? Can you explain your own actions in economic terms?
Prof. Easterly, I agree that there will never be enough money, and that the money that is available is not going to the neediest people if allocated by others.
However, there is not a causal link between health care spending and obtaining a healthy population.
Therefore, I do not believe it is required that governments allocate excessive amounts of scarce resources to the health budget.
Money and efforts would be much better spent in educating all the girls well, and teaching the young people about hygiene, the most important factor in life expectancy stats.
As I learned in a development economics course, best evidence for this = the dirt poor Indian state of Kerala that has obtained in this way first world health & life expectancy statistics (and a first world demography!).
And at the other end of the spectrum, there appears to be the USA, spending twice as much as other developed countries and obtaining at best mediocre results.
Therefore, to provide everybody on this planet with the right to a healthy life, has in my opinion less to do with the health budget than with the provision of an effective education for all members of society.
By the way, I think the right to live already implies the right to live a healthy life. No need to repeat that explicitly.
@Bill
Would it be right to summarize your argument thus:
“Talk about rights as long as you want but, ultimately, there is a budget constraint”
BTW I would like to just put up for discussion the notion of good health as a duty not a right.
Surely the two packs & 12 donuts a day have a duty not to burden our health system by their irresponsible choices (or internalize them by paying higher premiums).
The same goes to parents that do not use their ITNs to protect their children, etc…
The reason why it is necessary for health care to be considered a right is to avoid the sort of pragmatism that says it is more cost effective to cut off treatment for certain patients.
As an economist, I doubt you want to hear this, but really there is no “upper limit” for treatment. If you have empirically established standards for care, you have to follow those for every patient, regardless of their income level or social status. You said that subsidized AIDS treatment is going to middle-income and wealthy patients in the developing world, but do they have access to the same drugs as patients in the West? Is it just as cheap as it is here? Highly doubtful. There’s a myriad of other issues at play here, cutting off funding for treatment before we get into those is incredibly premature.
And to the posters who advocate allocating resources depending on whether the disease was due to poor choices or not, I say that’s rather myopic and foolish. Virtually every disease has a precipitating factor, but overall diseases tend to be more common, more severe, and more costly for the poor. We can complain about the rising obesity rates in poor urban areas, and say that we won’t pay for their weight-related illnesses, but doing so ignores the glaring reality that there are few if any healthy food options in many poor areas. Studies have clearly shown that grocery stores are concentrated in richer areas, while poor communities have food that is cheap, fatty, and salty.
We can’t base allocating health care on “personal responsibility” and “poor choices” unless and until glaring inequalities are first addressed.
Health care is a service provided by other people. For it to be a right means some people have a right to the service of others, even involuntarily, against their will. This is definitely a moral issue. Claiming the right to other people’s lives is wrong.
The only real rights are the rights to freedom *from* others, protection from force, violence, and theft, etc. So, what about the doctors’ “traditional” rights if anyone and everyone can force them to provide care?
@Nadir Q
You raise an interesting point.
Certainly, it would appear that poverty in the USA is associated with worse diets, food choice, etc…
However, with this line of argument one ends up saying that all crimes are committed by society and so on. We’ve all been there before.
Some of us believe such a view is paternalistic (we, the anointed ones, can make good choices for them); impractical (whatever happened to the budget constraint?); unsustainable (ultimately behavior change is needed) ; and riddled with moral hazard (many cheat the system).
Certainly a lot has to do with poor education. In Washington DC, for example, 30 percent of the population is functionally illiterate (according to FT)
So what is needed are better schools, education on lifestyle choices, prevention, and behavior change.
Creating the right web of monetary incentives must be a key element. I strongly believe poor people are not stupid, and will make the right choices if given half a chance.
But I grant you this is an empirical question.
I think it is important to distinguish between health and healthcare in this discussion. Behavior and health-related choices are significant details in the health of any population, which no healthcare program can correct for. Unfortunately, both are vulnerable to political manipulation.
Maybe it is not necessary that approaching health policy and health development assistance from a human rights framework undermine effective use of resources – but it often does. Bill have given the example of the misallocation of AIDS program funds (excess spending on treatment relative to prevention). I’d add excess spending on AIDS relative to other illnesses and activities where you can get much bigger “bang for the buck” like treatment of diarrhea and pneumonia (big killers of children, significantly cheaper to treat, and prevent, then AIDS).
I could give pages of examples of this in action. I have never been able to figure out why this predictable dynamic unfolds, but it does, again and again.
It seems to go something like this:
A human rights frame (similar to the universal frame) for promoting attention and spending on health – is often accompanied by effort to get governments to committ to these values. These committments get recorded in global venues and also in domestic foundational legislation. Sometimes in a country’s constitution (as in a number of Latam countries).
However much is available, resouces for health are still always scarce. In order to achieve good “value for money” in health governments must prioritize in some way: among services (using partly cost effectiveness) and among populations. Human rights (and universal) framing undermines prioritization. It undermines it by giving health policy makers an easier “out” for not prioritizing. Also, even in countries where they have prioritized, groups that want more (of whatever) can use the human rights (or universal) frame (and government committments) to push the government to giving more to their issue. This often works – and undermines rational use of funds. It very often shifts spending to less cost effective uses, and because middle and upper income groups are more organized, vocal and efficatious, it often shifts spending towards the things they value. And away from services that are needed by the poor.
Colombia right now is experiencing exactly this phenomenon – as their ability to NOT spend on costly treatments (excluded from the insurance package) has been undermined by court cases by higher income people. The judges feel compelled by the constitutional committment to universal healthcare to rule in favor of expanding the package to cover the uncovered treatments. And, as a result, they can subsidize insurance for fewer and fewer poor people.
The human rights frame is nice when it is being used to get governments who are spending way too little on health to allocate more. However, the formal committments to health human rights do a lot of damage, and we should take it into account.
The Hastings Center has just published a fascinating paper by John Arras and Elizabeth Fenton on precisely this topic, which I commend to everyone.
Bioethics and Human Rights: Access to Health-Related Goods.
http://www.thehastingscenter.org/Publications/HCR/Detail.aspx?id=3880&terms=arras+and+%23filename+*.html
We can use monetary incentives and education to promote “right” decisions. But what constitutes a right decision?
Suppose smokers were to be required by law to sign the following:
1. I understand smoking cause lung cancer
2. I understand that by choosing to smoke I am willingly incurring this risk
3. I understand that were I do develop lung cancer related to smoking treatment will cost up to $40,000 (or whatever)
4. I understand the State will not pay this bill
5. I understand that without treatment I am likely to die sooner than with treatment.
Chances are many people would still choose to smoke and sign the form. After all, we make similar decisions everyday when we drive a car, ride a horse, engage in dangerous sports, consume drugs, etc…
Moreover, this might be construed as a perfectly rational choice. For example, a bullfighter puts his life at risk everyday, and earns a handsome premium for that. Are we responsible if he gets injured?
And yet collectively, even if smokers or bullfighters signed clauses like the one above, we cannot keep the end of the bargain by denying treatment when the inevitable outcome arises. And for good reason.
If so, this would suggest regulation. But should we ban smoking? And what about bullfighting (animal rights aside)? My answer would be yes to the former no to the latter.
The former is much more prevalent and costly to society. The latter is a rarity and typically handled by private insurance.
And yet a universal approach would probably ban all life threatening activities, even when these are perfectly rational, such as driving a car. This is patently non nonsensical (but requiring seat belts is not).
I leave it to readers to opine about euthanasia, suicide and so on. After all, smoking could be construed as a partial or slow suicide. And dangerous sports as a stochastic form of suicide.
My point is that universal rules regarding rights and duties are rarely if ever helpful when moral dilemmas are the order of the day.
Ultimately, our morality and our legislation is the outcome of a political process. One partly motivated by cost benefit considerations. Given scarcity of resources this is always, of necessity, going to be the case. As such rights based argument are inherently unhelpful.
First to this new format is giving me an eye sore, I have to squint to see the comment box.
Anyhow, first to Mike H:
“Health care is a service provided by other people. For it to be a right means some people have a right to the service of others, even involuntarily, against their will. This is definitely a moral issue. Claiming the right to other people’s lives is wrong.”
Doctors already are obligated to stabilize patients in emergency situations, even if it’s for free and/or something they don’t want to do. And even more importantly, there are countless doctors who go beyond simple stabilization by providing free checkups, free tests, free treatment to those who can’t afford it. It’s certainly not enough, but if they didn’t do this, there would be far more health problems in this country.
We as a society have already laid a claim on health providers, we expect and want them to provide a basic service for the poor, but the problem is that healthcare providers are also expected to shoulder all the costs under the current system. A far more ethical and reasonable approach would be for us to all share the costs of those people who can’t afford care, that way the burden isn’t on one group of people.
Now, that’s not me advocating one system or another, personally, I think allowing providers to get tax breaks when they work for the poor would help tremendously, but it’s important that we as a society acknowledge two things:
1) We acknowledge that the kind of care given to the poor under the current system is inadequate and
2) We realize that it’s unfair to offset the cost of caring for the poor to health care providers.
If you try to address those two issues, but still don’t want to call that “a right to health care”, then that’s totally fine with me. Call it what you want, just address those two issues and I think we’ll be on our way to getting a more equitable system.
Why Bill is right: In economic terms, a ‘right’ is a good whose price is infinite. Nothing really has an infinite price, including my life (casting the earth into perpetual poverty to save my life, for example, would not be worth it). In real life we have to make difficult and delicate tradeoffs, such as between current and future health (treatment vs. prevention), and asserting that one of those has an infinite price guarantees that we get the tradeoff wrong — meaning that pain and death happen which could have been avoided if the tradeoff had been struck differently. Stay strong in the face of the critics, Bill; you are right on target.
While there may be a moral obligation for individuals to care for the poor (whether their health care or other needs), there is nothing “moral” about government aid. Morality implies individual choice; government only operates by coercion and force
Paul,
Obama is making an appeal to a different view of government that it should be a reflection of a society’s values and one of those values should be social solidarity. One of the problems with the relations between gov’t and its citizens in the US is that everyone wants to get more out of it than it is putting into it. That and a lack of Congressional discipline explains our huge deficits. Obama wants to return to a time when the better off felt a social obligation to “give back to the less fortunate. Not coincidentally, this is also a basic principle of risk pooling. The lucky subsidize the unlucky.
Re rights based approaches, my objections are practical. As much as I believe in social solidarity, I am against rights based approaches to health. In countries where I have worked where rights based approaches were in vogue (SA, Nigeria, Kenya) they became a barrier to making serious choices on where to invest scarce health resources.
Here is a link to the ungated version of the paper I mentioned above
Bioethics and Human Rights: Access to Health-Related Goods by John Arras and Elizabeth Fenton
http://fenton.elizabeth.googlepages.com/elizabethfenton