As the debate over health care moves from the halls of Congress to town halls across the country, it is time to pause and ask what is private and what is public, what is universal and what is local, about health. Until this is clarified, it is hard to see how a principled solution, indeed any fair solution to the nation’s health care troubles, is possible. Pragmatism is all very well in working out the details of public policy when there is consensus about what we want to achieve—who would want a public policy that doesn’t work and can’t be paid for?—but it cannot settle the question of ends when these are disputed. It cannot weigh conflicting goods against one another, nor suggest the terms of acceptable compromise.
So what is public and what is private about health care? Let me start with what is private. Although an infant, newly born and especially unborn, has an interest in his mother’s health, and children an interest in the health of their parents, spouses in each other’s health, and so forth, one’s own health—that is, the condition of one’s body—is about as private a matter as there is. Viewed negatively, a threat to one’s health is a threat to one’s life. Viewed positively, health is generally an element of personal well-being. American law does not accord individuals absolute ownership of our bodies—there is no right to suicide, for example—but we recoil from physical coercion except to punish or prevent crime. Control over one’s own body is almost a matter of inalienable right, something that cannot be taken away from a person. Common sense suggests that, at least in the long run, no one can be made healthy who does not desire health, and if this is so the implications are well worth pondering. As long as people are at liberty, they will risk their health in various ways and for various reasons: from engaging in dangerous forms of work or play, to eating, drinking, and smoking things they enjoy but that endanger their long-term health, to neglecting their health when in thrall to some other activity, such as love or study. Some of these reasons are better than others, and some might be downright irresponsible, but it is undeniable that choices about health are intertwined with the most important choices we make about how to live our lives, the choices that shape our identity. Americans’ insistence on a substantial element of choice in any health policy thus is not a matter of arbitrary preference or consumer taste; it derives from our sense of the intimately private or personal character of concern for the health of one’s own body and for liberty in its use.
What, then, is the public dimension of health? In part, it arises from the obligations we have to one another, which can be undercut if the health of one party fails. The unborn child dies with his mother if not delivered; the newborn and all young children need constant attention to insure healthy development, and no small part of family life is devoted to providing this. I mentioned the interest of spouses in each other’s health—the traditional wedding vow is explicit about this—but the circle of interest extends throughout the world of human relationships, beyond family and friends. Indeed, employers have an interest in the health of their employees, and, if the media attention to Steve Jobs’ condition is any indication, investors have an interest in the health of those who manage enterprises that bring a good return. In large part, public health involves those matters in which our private health is commonly affected; many diseases are communicable, and the conditions of the physical environment—the availability of clean air and water, of healthy food and of medicine—have always been recognized as matters in need of public attention. In other words, if no one can be made healthy without his own consent, no one can achieve health all by himself, unless in extremely fortunate circumstances. Besides, everyone is utterly dependent on others in childhood, and few even of the generally healthy go through life without ever needing to place themselves during moments of illness in another’s hands. And this indicates a third reason for public involvement: the responsibility we have towards the communities of which we are a part.
If health—and so, by extension health care—has both a private and a public dimension, is there anything universal about it? There is, I think, and it is rooted in universal human nature. On the one hand, there is a universal human right to treatment, recognized in the duty of health professionals not to refuse care to those in need. On the other hand, medical knowledge itself is in principle universal, something proven in practice when doctors and nurses jet across borders to serve those in need. There is a delicate reciprocity between a universal right to health care and the knowledge it takes to supply it. It is, after all, only after the advances of modern medicine have become plain to all that the movement for public provision of health care has arisen; what value is there in a right to a medical guess? But it is essential to modern medicine that its knowledge is experimental and dynamic; even for persistent diseases, new treatments are always being developed and tested, and it is now recognized that diseases themselves change to escape the remedies that attack them. It is not as though health care comes packaged as a fixed supply that can be rationally distributed to those in need; any demand of a right to care must include consideration of how to develop the knowledge to supply that care. Except for the very young and the severely disabled, doesn’t any claim of right to care entail a duty to acquire basic knowledge about how to care for oneself? To what level of knowledge does that duty extend? Does it go beyond knowledge of avoiding disease—basic hygiene, for example—to include knowledge about how to enhance one’s strength?
But if modern medicine and a right of access to medical care have a universal dimension, there is much about health and care that is inevitably local. Different cultures and communities have different diets, and these have various consequences for people’s health, sometimes in surprising ways, that are not readily transferable. The French taste for wine with daily meals has been shown to explain their low incidence of heart disease. Leaving aside the question of forming and reforming people’s tastes, it would prove difficult to transfer French eating and drinking habits to an automobile-based culture like the American without creating new risks. Climates and terrain vary, with direct effects on human health and indirect effects through differences in agriculture and commerce. We know enough already about genetically based disease to suspect that different populations need supple and adaptable medical care that is attentive to individual characteristics. Moreover, dietary rules and practices are governed or at least influenced for vast populations by religion, which of course varies across the globe and even around our country; this is just one way in which religion affects health care and health. From invasive examination to various forms of treatment, what counts as standard medical practice in one community may cross religious strictures in another. All religions address questions of life and death, and since a large proportion of modern medical expense is associated with care of the dying, it makes no small difference how a people understands death and its inevitability. And religion, through its encouragement of charity, often provides the motive for individual service in professions like nursing and the spark that distinguishes mere treatment from genuine care. Indeed, whether or not religion is the motive, it is generally true that steady care over the course of a lifetime depends on a particular community in which there are human bonds. A merely universal right to treatment invites bureaucratic indifference, not personal attention.
Where are politics and economics in the midst of all these considerations? Of course most of the current debate is about these in one way or another, and addressing everything that is being said would exceed the confines of this short essay. Even here, however, a few basic points can be made. Because individuals take such an interest in their own health and in the health of their loved ones and families, it makes sense to recognize the nexus of interest in health provision. Of course, this is complex: When a doctor’s fee is dependent on satisfying the patient, there is an incentive to care, but also an incentive to please in a situation where genuine care often requires administering unpleasant medicine. Markets are famously adept at matching consumers’ needs and choices with suppliers’ products and skills—and notoriously clumsy about weeding out those who prey on short-term fears or make fraudulent offers in situations where consumer knowledge is scarce. In medicine, genuine need and ability to pay are often mismatched, and the traditional supply of the deficit by charity—in terms of service and monetary gift—probably does not fit most economic models. The current crisis is not exactly a crisis of care—Medicaid pays for the poor, and laws forbid the denial of treatment—but a crisis of cost and insurance. As economist Arthur Laffer has recently suggested, there are policy proposals that can address these issues while respecting the principles discussed above. Of course the dynamic state of medical knowledge introduces further wrinkles into economic calculations, for experience shows that monetary incentives often succeed in summoning the creativity that devises new treatment, but providing these incentives is something few markets can bear. Isn’t it an open secret that the American market for new drugs, and the willingness of our current system to sustain their prices, is an important engine of medical advancement in recent years—and a sort of gift of American largesse to medical health throughout the world?
As for politics, it is inevitable in the formulation of policy, especially when consensus not only has not congealed but in many respects seems unlikely to any time soon. Americans are not agreed on whether abortion is the unjust taking of a human life or an acceptable medical procedure like any other—and, especially when seen in relation to a whole range of issues concerning human reproduction and the character of death and dying, this means we have fundamental disagreements about what constitutes health and well-being that no merely technical solution can paper over, whether it is bureaucratic or market-based. Since modern health care costs encompass so great a percentage of all economic activity, decisions about the health system necessarily entail decisions about the structure of the whole economy, so even on the question of ends more is involved than health alone. And in the complex structure of American federalism and constitutionalism, where attention to health is traditionally a matter for the police power of the states and receives no mention in the enumeration of the powers of Congress, and where even today medical licenses are issued by the states and most laws defining legal duties are state laws, the politics of health care reform will necessarily be complicated, as indeed should be the case if all voices are to be heard and all interests considered.
These last remarks suggest why the debate over health care in America has proceeded in the way it has, to the frustration of many of the parties directly involved and perhaps to the American people as a whole—but I don’t think they negate the need for some clarity of principle on the issue. Indeed, I think that many of the debates taking place involve one or another of the principles I’ve tried to sketch—the value of individual choice, for example, or the justice of some sort of universal coverage, or the need to preserve the dynamic of medical progress—but “inside the Beltway” the principles get hidden in the instrumental details and are not openly expressed. I don’t suppose that greater clarity about principles will resolve the debate; indeed, it might have the opposite effect of exposing the depth of disagreement. But I think it would help reestablish an atmosphere of good faith, in which each side can acknowledge the legitimacy of the concerns of the other and openly challenge their errors. That, it seems to me, is the precondition for healthy political deliberation.