Timothy Lesaca MD
Human rights are generally understood to be universal and egalitarian. They are inalienable, indivisible, and derived from the ideology of natural law which seeks to uphold universally accepted moral principles. Providing comfort and assistance to the physically and emotionally ill is one of those universally accepted moral obligations, yet the question remains whether health care is a human right, or just another commodity to be rationed.
Those who support the idea of health care being a human right can cite several historically honored documents. The Universal Declaration of Human Rights (UDHR), which was adopted in 1948 by the United Nations in response to the mayhem of World War II, identified 30 internationally recognized human rights which subsequently formed the groundwork for human rights policy around the world.
Article 25 of the UDHR states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”
In 1966, the United Nations elaborated on the core principles of the UDHR in the treaty known as the International Covenant on Economic, Social and Cultural Rights (ICESCR). Article 12 of the ICESCR elaborates on the right to health in stating, “The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”
Further advocacy for health care as a human right came from the Declaration of Alma-Ata, a brief document written in 1978 at the International Conference on Primary Health Care. The declaration expressed the need “for action by all governments, all health and development workers, and the world community to protect and promote the health of all people of the world.”
Article 1 of the Declaration of Alma-Ata states: “The Conference strongly reaffirms that health, which is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right.” Almost all of the member nations of the World Health Organization and the United Nations Children’s Fund attended the International Conference on Primary Health Care and supported its right-to-health initiative.
A right to health care is considered a positive right as opposed to a negative right. The classic enumeration of negative rights includes life, liberty, and the pursuit of happiness, and places no societal obligation other than to leave a person alone. Negative rights, therefore, oblige inaction. A positive right, on the other hand, obligates society to take action, and fundamentally requires others to provide either a good or service. Positive rights are “positive” in the sense that they claim for each person the positive assistance of others in fulfilling basic necessities of human well-being. Universal health care would fall into the category of a positive right since its provision would impose an obligation upon others to assist the right-bearers in obtaining needed and appropriate medical services.
Claiming a positive right to health care creates a broad spectrum of societal obligations. These duties include allocating an adequate share of financial resources to health care needs, properly distributing different types of health care services, taking into account the competing claims of different types of needs, and ensuring that each person is entitled to a fair share of such services while balancing the factor of how these services will be paid for. Because a positive right to health care implicates such a vast redistribution of resources and skills, it is arguably difficult to categorize the proper scope and limits of such an entitlement. A positive right to health care therefore inherently possesses the potential to conflict with the negative right to keep and benefit from one’s individual labors, free from the interference of others.
The argument for or against health care as a human right therefore stems from the conflict between positive and negative rights. Positive and negative rights often conflict since the obligations conferred by positive rights can entail infringing upon negative rights. For example, the positive right to any social welfare confers a duty upon the government to find a method to finance such a service, which would likely require raising taxes. A resultant tax increase, however, would infringe upon the negative right to have one’s money taken away.
Further argument against funding health care as a basic human right incorporates the belief that people’s rights to health care is only a negative one. The concept of health care as a negative right obligates that the government only refrains from actively harming people’s health. The other relevant argument is that health care as a positive right is an impossibility, given the practical reality that the health care system can provide service only within the practical limits imposed by resource scarcity and distribution.
Political philosopher Isaiah Berlin skillfully commented upon the distinctions between positive and negative rights in his famous lecture titled Two Concepts of Liberty. Berlin was able to see the delicate balance and interdependence between these ostensibly opposing concepts. He elaborated that negative liberty is concerned with the freedom to pursue interests according to one’s free will and without external interference, while positive liberty addresses the degree to which one can act autonomously in the first place.
Ultimately, it remains an open question whether the positive and negative forms of liberty are two aspects of a common conception of rights or two distinct types of rights that are closely related without being identical. Regarding this distinction, Berlin wrote, “Where it is to be drawn is a matter of argument, indeed of haggling. Men are largely interdependent, and no man’s activity is so completely private as never to obstruct the lives of others in any way.”
The question of whether health care is a human right or a commodity is moot, as it is both a right and a commodity.
Health care is in fact a unique commodity. Beyond being a business and an extension of capitalism, it also is inextricably linked to one of the guiding principles of humanity. If one accepts this as an axiom, then every government and corporate decision regarding allocating the resources of the health care commodity also is a reflection of that entity’s moral perspective. Yet is it reasonable to associate commerce with morality?
In 1925, Mahatma Gandhi published in his weekly newspaper Young India a list of what he referred to as “The Seven Social Sins,” which he identified as contributing to the colonial oppression of India. On that list was the concept of “commerce without morality.” At the time, he was referring to his concerns about the abuse of workers and natural resources, yet in reviewing his writings it is clear that he did not compartmentalize his life. For him, economics together with politics, morality and religion formed an indivisible whole.
A more contemporary perspective on Gandhi’s concern regarding commerce without morality would suggest that every business transaction is a moral challenge to see that both parties are treated fairly. Ignoring this concern creates the risk of economic systems operating without a moral foundation, which would eventually lead to the creation of an immoral society.
I believe that the discussion and debate regarding resource allocation, whether it is on the national or regional level, has become compartmentalized. Simply stated, I am of the opinion that there is insufficient dialogue regarding the moral implications of decisions regarding the allocation of health care resources.
The question of whether health care is in fact a human right seems to have become secondary to the decision-making processes of the organizations that decide the fate of their subscribers.
If Isaiah Berlin is correct, then this is a paradox.
If Gandhi is correct, then this might be immoral.
Both predicaments are avoidable, but it would involve a very personal internal dialogue on whether one truly believes that health care is a positive human right.