Health Care & Compulsion

President Barack Obama's signature on the health insurance reform bill at the White House, March 23, 2010. The President signed the bill with 22 different pens. (Photo credit: Wikipedia)

The United States Supreme Court will soon be ruling on the constitutionality of the Affordable Care Act. This ruling will, of course, settle the legality of the matter-at least until it is challenged. While the constitutionality (or lack thereof) of the act is certainly interesting, my main interest as a philosopher is the ethics of the matter.

While the law is 2,400 pages long, I will just focus on the ethics of a key part, namely that the law requires people to purchase health care insurance. Opponents of the law assert that this is the first federal law that requires citizens to purchase a product and they typically assert  that this goes beyond the legitimate power of the state. Proponents of the law retort by arguing that the state is acting legitimately. As such, a key moral issue is whether or not the state has the right to compel citizens to buy a product in general and insurance in particular.

On the face of it, the idea that the state has a right to compel people to buy a product seems to be absurd-even when such a purchase would be a good idea. After all, buying and consuming fresh fruits and vegetables is a good idea, yet one would be hard pressed to present an argument in favor of compelling this by law (the Broccoli and Orange Act, perhaps).

To present a more substantial argument, I will begin by noting that I favor a a presumption in favor of liberty. That is, the burden of proof is upon the state to show that the intrusion on liberty is legitimately warranted. While spelling out the various conditions under which intrusion would be warranted goes beyond the scope of this essay, one obvious justification is that the intrusion prevents an individual or group from inflicting unjust harm onto others. Thus, the restrictions on murder, theft and defective products are warranted. Intrusion that are done merely for the good of a person would not be justified, at least if we follow John Stuart Mill’s classic arguments regarding liberty. After all, if I am sovereign over my self, then the state (and others) have no moral right to intrude on my actions when they impact only me. As such, while the state can justly prevent me from selling tainted broccoli, it would not seem warranted in compelling me to eat broccoli-despite the fact that doing so would be good for me. This line of reasoning, interestingly enough, would also forbid the state from making the use of marijuana illegal and would also make laws forbidding same sex marriage morally wrong since they impose on liberty solely to impose a specific religious/moral view rather than to prevent people from harming one another. In fact, the principle that the state cannot compel except to prevent harm would entail a host of libertarian positions on various issues-something that should be duly considered when using such a principle.

Of course, it could be argued that while the state has a right to compel people to not do various things even when they are not harmful to others, it does not have the right to compel people to take positive action. That is, the state can be justified in telling me what not to do, but it has no legitimate right to tell me what to do. As might be imagined, this approach is often taken by folks who want the state to compel people to not do various things (like smoke marijuana or marry someone of the same sex) but who are against this specific act.

While justifying specific acts of compulsion can be challenging, this approach does seem consistent. After all, the principle is that the state cannot compel taking action and can only compel people to not do things. As such, while the state can, for example, forbid abortion, it cannot morally  compel people to buy health insurance.

Naturally, if this principle is used to argue that forcing people to buy insurance is wrong, it must be applied consistently-namely that the state is wrong to compel action and it can only forbid. This would entail that compelling young men to sign up for selective service is wrong. It would also entail that compelling people to pay taxes is wrong. Forcing automakers to include seat belts, air bags, and brakes would also be wrong. Forcing women to undergo an ultrasound before getting an abortion would be wrong. So would forcing children to attend school. Compelling people to serve on a jury would also be wrong.  And so on. Naturally, this might have considerable appeal to some people, but this path would seem to take us into the realm of the absurd (although some, such as the anarchists, would say we are already there and doing this would take us out of the absurd).

The obvious counter is to insist on narrowing the principle from “the state has no moral right to compel” to “the state has no moral right to compel people to buy a specific product.” The challenge, of course, lies in justifying this principle. As might be imagined, the reply that “the state has not done this before, so doing it is wrong” is not a good argument. After all, the mere fact that something has not been done before is no indication of whether it is good, bad or indifferent. This sort of “reasoning” could be seen as a variant on the appeal to tradition fallacy, in that the idea is not that something is good because it is a tradition but that something is bad because it is not.

What, then, is needed is something that shows that the state lacks the legitimate authority to morally compel people to have health insurance while it does possess a right to compel people to do things. The challenge is to show a relevant difference between the insurance case and the other cases in which state compulsion is (allegedly) morally acceptable. The obvious thing to point to is that the state would be forcing people to buy a  product. However, the mere fact that this is different does not entail that it is a relevant difference that make this specific compulsion wrong. After all, the state does compel us to pay for Medicare, Medicaid and Social Security and is thus compelling us to buy what amounts to health and retirement insurance.

Naturally, it could be argued (as some have) that the state should not do this-that being forced to pay for Medicare, Medicaid and Social Security involves an unjust compulsion and thus the state should not do this. This view would allow someone to consistently oppose the Affordable Health Care Act’s compulsion to buy health insurance but at an obvious price-namely the need to be opposed to these three things.  As such, those who do not want to be rid of these things will need another line of attack.

The most fruitful one is that the the health care coverage is a private product rather than a state product. This, of course, does provide a significant difference between the state’s “products” and health care coverage. Of course, it does not provide an argument against the state compelling people to pay into a national health care insurance (as it does with the current national health care insurances, Medicare and Medicaid). As such, focusing on the fact that the product is a private one would seem to help shore up the view that the state should instead compel people to buy national health care-after all, this seems to be well within the legitimate power of the state (at least as it is currently conceived).

Nations other than the United States do, of course, have national health care. Of course, this sort of thing is presented as a worse demon than forcing people to buy private insurance. But this is a matter for another time.