Whether health care is a right or a privilege is one of the most intensely debated social questions of the modern era, but phrasing it in this binary way of one or the other masks a deeper problem that is far more complex. The specific issue at hand is the rationing of scarce medical resources. If there were unlimited resources where everyone could achieve the maximum health all the time, we would not have to ask the question, but this is clearly not the case. Glannon argues this requires a theory of "distributive justice" (2005, p. 144), and outlines the four main theories that have emerged from the modern discussion, which are Utilitarian / consequentialist, Libertarian, Communitarian and Egalitarian.
Utilitarian, consequentialist theory is often invoked toward a solution of who deserves health care when there is not enough for everyone, and tries to maximize the social good possible from the given resource endowment. In order to achieve the widest possible public health, we must first recognize that not all needs are the same, which is masked by asking if the resource is a right or a privilege. Either way, some people are in better health than others already, and so do not actually need any more health care than anyone else. Glannon (2005) relates John Rawls' egalitarian theory of distributive justice as the state where "no changes in the expectations of those who are better off can improve the situation of those who are worse off" (145). This parallels an idea from economics called "Pareto optimality," where getting the most out of limited resources means obtaining all good up to the point where no more gain can be achieved without costing one of the parties (Brownstein, 1980, p. 94). What this boils down to is that more good can be achieved by allocating health care resources to those who are in the direst need.
This requires we rank medical conditions and outcomes against each other. Rawls' egalitarianism argues that "inequalities in the distribution of social goods are admissable only if they benefit the least advantaged members of society" (qtd. In Glannon, 2005, p. 145), which Glannon traces back to the original Utilitarianism of Bentham and Mill (145-146). Thus this theory includes the question of whether health care is a right or privilege, and indicates who should get the most even when the answer is "both." If health care is a right, and the claimant is a member of the group with rights, then the member with the most privilege, is the one with the greatest need, rather than the one who can best afford to pay for it. The answer from this point-of-view becomes "yes" to an either-or question.
The problem is more complex because both answers contain more ethical nuance than all of one and none of the other. If health care is a right, not all claims are the same. If health care is a privilege, ability to pay does not necessarily measure need or the greatest good an organization of scarce resources can achieve. If we use a Utilitarian schema to answer the question, and ask what is the greatest good a particular package of health care resources can achieve, we find that the largest benefit may not come about by sharing it all exactly equally across right-holders, or assigning the most to those who can pay if it is a privilege. Those with the highest ability to pay may not have the greatest need, and those in greatest need may very well not be able to earn the same as those who have no need of care because they enjoy perfect health.
The levels of complexity continue to expand. What if two patients claim the same right to treatment when one is far older than the other? Likewise, Glannon asks (2005, p. 151-2), how should we prioritize resources between prevention, treatment and research, especially if withholding medical care actually causes greater need in the future? These considerations can be analyzed using a number of 'net present value' accounting methods but the difficult question of the value of life to different parties at different states of age and well-being remain no matter how we discount the cost of scarce human and medical resources. Nor does such right-or-privilege reductionism answer questions of perceived value of contribution between individuals, as in the case of organ rationing (Glannon, 2005, p. 158). How do we assign value between the potential social contribution of a talented brain surgeon compared to the life of a common laborer? We can take a Utilitarian approach toward maximizing potential good, but we then have to define units that do not always match in the real world.
Gensler places ethical egoism within this Utilitarian
consequentialist framework but opposed to egalitarianism as an extreme where "[e]veryone ought to do whatever maximizes their own self-interest, regardless of how this affects others" (1998, p. 144). This violates the principle of consistency, if ethics dictates that we treat everyone the same. Setting up this type of competition creates the situation where pursuing one's self-interest at the cost of others comes with the price of alienation from the group (Gensler 1998, p. 144) that may undermine the right to the very social benefits a Utilitarian ethic is supposed to allocate. If taking resources away from others in need causes moral pain, there may be no way to achieve pure hedonism without creating a chicken-or-egg problem where the one actually causes the other. Neither either egalitarianism nor egoism solve the problem of the valuation of pain or pleasure between individuals even if we phrase these in terms of individual desire in a purely abstract sense of preference, or pluralistic terms where the greatest good can be measured in specific units that do not match but persist beside each other at the same time (Gensler, 1998, p. 145).
The problem is that phrasing the question in these terms leads to impossible results that demonstrate absurdity when competing answers are both positive. If health care is a right but two people cannot share the same unit, how do we choose for example between an elder who has limited years but demonstrated likelihood of social contribution, and an infant who is powerless to demonstrate the ability to contribute but who may in fact turn out to be a detriment to society? If health care is a privilege based on right to pay, then the sole individual with the greatest privilege should be entitled to consume the entire resource, leaving nothing to those less empowered, but what if the ability to pay empowers the richest to earn more than everyone else? The result is a moral monopoly that the less fortunate cannot apply to each other and thus violates the thinnest principle of fairness or universality. Egoism is easy enough to practice but does not bear the generalizeability and consistency underlying formal moral theories.
Personally, I reject asking such a complex question in these simplistic terms. Imagine a situation where the resource endowment is zero. If someone has to stop doing something else in order to produce a unit of health care, then do I have a right to simply take their output without offering anything in return? So health care bears at the very least the same initial cost of any other productive activity, the price of the foregone output doing something else would have produced. If I could produce the good myself without taking something from anyone else, I very well may choose to pursue that activity. If I cannot, however, I need to produce something in order to compensate the one who did produce the health care I consume. I simply find no way around this core problem of the cost of production. Unless health care can simply be found by anyone without cost to someone else, then I will have to find a way to obtain that without taking away the output of someone else's honest labor.
The question then becomes do both of us have the same cost of producing that good? Once we admit different initial factor endowments say of skill or talent, and then of the ability to acquire training and the tools and practice that complex goods like health care require, then we have to start questioning social systems of inheritance; social class; access to education; and a list of factors that would have to be equal for us to assign price in the same way we would trade an ear of corn for a loaf of bread. Different goods cost different amounts of resources to produce, and providing the necessary 'level playing field' on which to measure their exchange becomes practically impossible in a world where individuals begin with different initial resource endowments. At the same time, investing resources where they may create the most return may require sacrifice on the part of a few, toward benefits they may never receive if the result is greater social welfare. This…