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Health Care: a Human Right or a Privilege?
by Dr. Emanuel Paparella
2013-10-07 08:29:22
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I often teach a course on Biomedical Ethics at the Barry University Adult Education Program. For the last three years, given the raging debates on health care here in the US and much of the third world, I have made sure that such a class includes at a minimum a one hour discussion of the issue of Universal Health Care and Human Rights. The debate that ensues is usually a spirited one between those who defend Health Care as a privilege and those who consider it a universal human right. The former usually  end up taking that position based on sheer ignorance of ethical norms or sheer selfishness. The same people would never give up their health policy, exactly because they consider it an earned privilege. None of the congressmen and senators who are against Obama Care have given up their health policy. They consider it their due and privilege.

This bizarre scenario is presently unfolding in the US Congress with the Republican extremists (usually Tea Party members or Libertarian fanatics which now comprise some one third of the party) who wish to revoke  the so called Obama Care law, never mind that it is presently the law of the land approved by both Houses and signed by the President, and has been adjudicated constitutional by the Supreme Court. It’s Ayn Rand’s “virtue of selfishness” scenario on steroid which must have Aristotle and his virtue theory turning in his grave. As I have repeatedly told my friends and colleagues (at least those who listen): if Barack Obama had done nothing else than institute universal health coverage, he would go down in history as a great president, for he has put us on a par with the all the other democracies and industrialized capitalistic nations of the world who provide health care to all their people.

But to go back to my biomedical classes, before the discussion is tabled, I usually dedicate a whole four hour class in clearing the underbrush, so to speak, that is to say, in gathering the historical record and the various attitudes toward the issue and defining the terms. I’d like to review some of those with the Ovi readership and my future students, given that I’ll be teaching another such class in 10 days or so.

Historically, the promotion and protection of human rights as embodied in the United Nations Universal Declaration of Human Rights draws upon human rights principles, including those on the health and well-being of populations. Those principles of ethical conduct in health care can be traced all the way back to the father of medicine Hippocrates. In the spirit of the Hippocratic Oath which every medical doctors still take in order to be certified as such, human rights and health care ethics complement each other when applied together in efforts to improve public health. I then go on to the social encyclicals of the Catholic Popes in the last one hundred years or so, mostly concerned with distributive universal social justice. The present Pope has recently addressed this urgent issue as I have already pointed out in a separate article.

So the question naturally arises: how do we define public health care and what exactly is a human right? Traditionally, human rights norms are meant to guide the actions of governments. For example, the World Medical Association adopted the Helsinki Code in 1964. This code is the precursor to the field of bioethics, which encompasses research in life sciences as well as the ethics of health practice. In the United States, bioethics, as developed in the late 1960s and early 1970s, emphasized the central priority of individual autonomy, reflecting the individualism of American culture, in contrast to the social solidarity characteristic of many other cultures. A key feature of ethical guidelines, as recently evidenced with stem cell research and HIV vaccines, is that they can be rapidly adjusted or drafted to meet evolving scientific and human challenges, allowing for regional or national variation as needed.

By contrast, human rights norms and standards tend to be drafted by government representatives, negotiated in political forums, and incorporated in the body of international law in the form of international treaties that impose legal obligations on the governments that ratify them. Although these processes allow human rights law a permanency and legitimacy useful for engaging governments and institutions of power, there is less flexibility and less rapid adaptation possible than with ethical guidelines. The 1948 Universal Declaration of Human Rights, although significantly shaped through the diplomatic skills of American Eleanor Roosevelt, reflects the principles of many cultures and traditions and the consensus achieved among governments of what rights should exist.

The public origins of, and accountability for observance of, human rights highlights the value of human rights to public health concerns. For instance, the International Covenant on Economic, Social, and Cultural Rights recognizes in article 12 “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” and establishes associated governmental responsibilities. These responsibilities include reducing infant mortality; improving environmental and industrial health; preventing, treating, and controlling epidemic, endemic, occupational, and other diseases; and ensuring the availability of medical care in the event of sickness. Other rights relevant to the health and well-being of populations include access to such goods and services as information, food, clothing, housing, and safe workplaces, as well as environmental rights to clean water and air. An evolving notion of a right to development, constituted from these and other rights, requires governmental initiatives for protection of public health interests relevant to the environment and for promoting the economic development that generates resources for individual and public health and for environmental protection and enhancement.

In a world in which hunger, poverty, and environmental degradation are all too evident, it would be unrealistic to demand governmental remedies on the basis of their international human rights commitments alone, but these commitments do provide a useful framework for shaping national laws and policies.

The first goal ought to be to institutionalize the systemic and routine application of human rights perspectives to all health sector actions. In many, if not all, societies, the poor or marginalized benefit too little from public health initiatives. The Pope has addressed this issue recently lamenting the neglect and marginalization of the poor in public health. One would hope that so called “good Catholics” such as Paul Ryan are listening, unless they wish to start their own separate Church together with their separate party.

Be that as it may, ongoing efforts are required to reduce social inequalities in health, including in the receipt of health care, health service financing, and allocation of health care resources. Most importantly the health care bill, Obama Care, as it stands should be vehemently defended and proclaimed. These efforts should include adequate health infrastructure and personnel, in particular where poverty levels are highest, and policies or practices to eliminate gender, racial/ethnic, and other forms of discrimination, as they may affect access to and use of services.

Another important goal ought to be to strengthen and extend public health functions to create the basic conditions necessary to achieve health and well-being. Health sector contributions to these efforts include establishing programs for clean water and sanitation, food and drug safety, tobacco control, and health education and disseminating information about and setting standards for safe workplaces, housing, transportation, and environmental conditions.

Equitable financing is also extremely important for a rights-based agenda for public health. Principles of proportionality to achieve the human rights goal of “the highest attainable standard of physical and mental health” require that individuals with the least resources pay the least, both in absolute terms and as a proportion of their total resources. This requirement also means that a lack of personal resources should not prevent an individual from receiving services that are recommended on the basis of prevailing norms and scientific knowledge.

Moreover, we ought to ensure that health care services can be provided effectively in response to the major causes of preventable health conditions, particularly among the poor and disadvantaged. Health institutions, however financed, will need to make systematic and sustained efforts to develop infrastructure to provide equitable services. These efforts include identifying and reducing the obstacles that keep disadvantaged groups from receiving the full benefits of health initiatives—obstacles such as discrimination on the basis of language, race/ethnicity, gender, and sexual orientation.

Finally we ought to monitor, advocate, and take action to confront the human rights implications of development policies in all sectors that affect health, drawing on the World Health Organization’s description of health as a state of “physical, mental and social well-being.”  Ethics and philosophical reflection ought to provides a basis for a broad spectrum of actions and may complement the actions originating from human rights perspectives, for indeed, human rights and ethics in health care are closely linked, both conceptually and operationally.

What we have to constantly keep in mind, and Pope Francis has reiterated this in his last pronouncements on solidarity and justice toward the poor, is that human rights are not earned as a privilege for the rich, powerful and talented, but are intrinsic part of being born human. One does not earn human rights, one is born with them. In more constitutional parlance, those rights are inalienable; no government on earth can confer them or violate them, even if sadly they in fact do violate them.

In both the US and the EU much lip service is paid to inalienable human rights, but one wonders if the concept is well understood. For it were, there would be more compliance, not to speak of compassion and empathy toward the poor, in evidence. Socrates declared “that knowledge is virtue,” that if one truly knows the good, one will do the good. If Socrates is correct, then we must conclude from the present scenario that there exists an abysmal lack of knowledge on the concepts of inalienable human rights and distributive justice. But the problem may be a deeper one: perhaps it is not so much lack of knowledge but lack of sensibility toward an issue that continues to cry to heaven for attention. Jesus Christ perhaps said it best: “let those who have ears, let them hear.”


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Leah Sellers2013-10-07 22:02:46
Dear Brother Emanuel,
Wonderfully and Logically expressed and laid out, Sir.
Thank you !

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