There are two camps in America: those who think that health care is a right and those who think that it’s a privilege. Well, perhaps that’s a bit of an oversimplification, but bear with me. Given these two respective positions, what are we to make of the health inequalities that are well documented in the United States? First, we must acknowledge that health is the product of multiple factors such as lifestyle, genetics, and access to health care. In general, these may be lumped into two categories as well: individual-level factors and system-level factors. Both levels may also be sub-divided into modifiable and non-modifiable factors. For instance, we cannot modify the circumstances of our birth, but we can decide whether or not to smoke. Again, bear with my gross oversimplification. Similarly, we can change certain aspects of the health care system, but we cannot change the fact that we must operate under the constraint of limited resources.
Okay. Now that all of that’s on the table, we return to the question: What are we to make of health inequalities in the U.S.? To the extent that the inequalities are the result of modifiable individual-level factors, we may feel no obligation. People who choose to smoke are taking the risk of getting lung cancer. People who chose not to smoke and get lung cancer anyway may seem to some of us to be more “deserving” of treatment. Others may not make such distinctions. But generally, where personal responsibility can be identified, we feel less of an obligation to help. In fact, some of us take this to the extreme, excusing our self-interested behavior by creating things for which to blame the person in need. The homeless we pass at the intersection are “lazy” or “lack self-control”, which resulted in them becoming alcoholics who don’t bother to get a job. Once we make that leap, we feel justified in not sparing them a dollar. If we were confronted with their reality that they were abused as a child, had a genetic predisposition to mental illness, or some other circumstance beyond their control, we would likely find it much harder to squelch our pity.
At the heart of all of this is the notion of “fairness.” Everyone has some conception of the term, but it varies from person to person. The group that believes health care is a right is more likely to support an approach that maximizes the number of people who have access to health care. It’s purely utilitarian. The group that believes health care is a privilege is more likely to support an approach that maximizes the number of “deserving” people who have access to health care. And, as above, those who deserve it are typically those who either have access to care already, or who need access to care and are without it through absolutely no fault of their own. For many people, especially those who have access to care, there are very few uninsured sick people who appear blameless. It’s utilitarianism infused with judgment. Not that that judgment is wrong, mind you.
For more on this topic, you should read a recent article by Blackser, Rigby and Espey, which inspired this post. They conducted a fascinating study of the public’s values surrounding fairness concerning health inequalities.
Brad Wright is a health policy postdoctoral fellow who blogs at Wright on Health.
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