Force Versus Choice in Medical Care

Some days ago “Yaakov” left a comment regarding the article, “More political control of medicine comes with higher costs.” That article contains the following paragraph:

[W]hy is it that some people can demand “free” care from hospitals in the first place? After all, people can’t force businesses to give them “free” food or clothing. The reason is that the “Emergency Medical Treatment and Labor Act of 1985 [EMTALA]… requires that hospitals that accept Medicare patients diagnose and treat anyone who comes within two hundred feet of an emergency room, regardless of whether the person can pay for the treatment” (see the article by Lin Zinser and Paul Hsieh, MD, at We should repeal that unjust law and return to a system of voluntary charity.

I decided to post Yaakov’s comment with my reply. Here is the comment:

January 23, 2008 12:39:49 AM MST

Granting for a moment that all of your information is accurate, an issue remains.

If the law is changed, it will become legal for a doctor to watch somebody die in front of him and not spend any effort or money to save the dying person.

Would you go to a doctor who had let a child bleed to death because the child had no insurance? How would you feel if it was your next door neighbor’s kid and your brother was the doctor? Would you want to be that doctor?

This is a country that spent $10 billion on pet medical care. We fly sick kids in from third world countries to do $500,000 operations for free. We will not put up with poor children dying outside hospitals that only admit the rich.

We may go bankrupt, but something significant in our brains is going to have to change before the changes you advocate will be enacted.

My dad and I responded to a similar charge in a follow-up article of February 4. Here I’ll reiterate and expand some of those arguments.

Yaakov’s basic error is to assume that every desirable outcome must and ought to be forced by political controls backed by men with guns. Thus, by this reasoning, if we want doctors to treat bleeding children, we must force doctors to treat them without compensation.

Yaakov’s assumption that good outcomes require political force is clearly false. Indeed, political force interferes with good outcomes. For example, the fact that Soviet economic planners forced people to produce an efficient industrial society did not, in fact, achieve an efficient industrial society. It created mass poverty and starvation.

The fact that various nations impose socialized medicine does not prevent people there from dying from lack of care. Under socialized medicine, it is, in effect, sometimes “legal for a doctor to watch somebody die in front of him and not spend any effort or money to save the dying person.” Under socialized medicine, the practice is not only permitted, it is inevitable. For details, see the section, “Attempted Solutions,” in the article by Zinser and Hsieh.

But let’s examine the central errors of Yaakov’s position in more detail. If Yaakov actually believes his claims, then he should also advocate the following policies:

* If someone comes to Yaakov’s house and claims to need a bed for the night (or the week, or the month), then Yaakov must be forced to provide the comer with a bed without compensation. If Yaakov refuses, he’ll be subjected to severe financial penalties. It should make absolutely no difference whether Yaakov has an extra bed, whether Yaakov has other plans for his beds, whether the comer can afford to rent a bed elsewhere, or whether Yaakov thinks that the comer deserves a free bed.

* If someone comes to Yaakov’s house and claims to need food, clothing, or any other essential item, Yaakov should also be forced to provide those things, without limit, and without compensation.

* Let us assume that Yaakov owns a business. If someone comes to Yaakov claiming to need a job in order to be able to afford the basic necessities of life, then Yaakov must be forced to provide the person with a job, regardless of whether Yaakov can afford the salary, and regardless of whether the person is willing and able to perform any useful work.

* If someone approaches Yaakov and claims to need his car for an essential purpose — such as a trip to the hospital — then Yaakov must be forced to lend his car to the person, without compensation, regardless of whether the person could get transportation elsewhere.

If doctors should be forced to provide service to any comer, regardless of circumstances, then grocers should also be forced to give out free food to anyone who claims to need it, clothing stores should be forced to give away free clothing, and so on.

Imagine the sort of society in which we would live if Yaakov’s policy were consistently imposed. It would be a society in which people competed, not to produce and prosper, but to make themselves as needy as possible. Why get an education, why work, why treat others fairly, if you can just take whatever you want by force?

Recently I quoted a passage from Atlas Shrugged that perfectly sums up the sort of society that Yaakov implicitly advocates:

It didn’t take us long to see how it all worked out. Any man who tried to play straight, had to refuse himself everything. He lost his taste for any pleasure… He felt ashamed of every mouthful of food he swallowed, wondering whose weary nights of overtime had paid for it, knowing that his food was not his by right, miserably wishing to be cheated rather than to cheat… [H]e couldn’t marry or bring children into the world, when he could plan nothing, promise nothing, count on nothing. But the shiftless and the irresponsible had a field day of it. They bred babies… they got more sickness than any doctor could disprove, they ruined their clothing, their furniture, their homes — what the hell, “the family” was paying for it! They found more ways of getting in “need” than the rest of us could ever imagine — they developed a special skill for it, which was the only ability they showed. (pages 619-20)

Forcing people to provide assistance to others, whatever the details, is grossly immoral and a violation of individual rights. The ultimate conclusion is Marx’s dictum, “From each according to his ability, to each according to his need,” with “need” determined by whoever seizes power.

The alternative is liberty. Each individual has the right to decide how to live his own life and use his own resources. In a system of individual rights, individuals often choose, by their own volition and good will toward others, to help others in need. However, such individuals also tend to make sure that their charitable donations are spent well to help those who deserve it without encouraging dependency.

Yaakov offers the sympathetic case of a child bleeding to death. Of all the people I’ve met, including Christians, Muslims, atheists, Republicans, Democrats, and so on, not a single one of them (save criminals) would hesitate to take every conceivable step to save a child in such circumstances. I also know a number of doctors, and they deserve far better than Yaakov’s unjust insinuation that they will not help those innocently in desperate need unless they are forced to do so. Typically doctors are among the first ones to rush to the scene of an emergency.

Even in our semi-free market, all sorts of charitable organizations exist specifically to help children. For instance, my dad is a Shriner:

Shriners Hospitals for Children relies on the generosity of donors to help us continue our mission of providing specialized pediatric care at no charge, conducting innovative research and providing world-class teaching programs for physicians and other health care professionals.

In a truly free market, I suspect that most hospitals and clinics would offer charitable services. Because marginal costs often are much lower than average costs (due to the high costs of facilities and machinery), many health providers would also offer sliding scales for payment options.

But don’t parents bear any responsibility for raising their children? If parents were, in normal circumstances (as opposed to cases of rare, expensive problems), required to pay their health bills, perhaps parents would think twice about having children that they cannot afford to support. Perhaps parents would take better care of their children, reducing the chances of needing a trip to the emergency room. Perhaps in non-emergency situations parents would seek out less-expensive care options, such as regular doctors’ offices. Perhaps more parents would purchase health insurance. Perhaps more parents would realize that they have to save money for health expenses, just as they have to save money for the rent and groceries. Perhaps more parents would take out short-term loans to pay off health expenses. Why should doctors (but not any other professional class) be forced to pay for parental irresponsibility?

But let us consider even less sympathetic cases as well. What about the people who could pay for their health care but choose to freeload? To take another example, one cycle proceeds as follows: an impoverished alcoholic, in rough shape because of a lifetime of bad choices and irresponsible behavior, drinks himself into unconsciousness, so somebody calls an ambulance, which takes the drunk to a hospital, which then must spend many thousands of dollars drying the guy out and fixing his self-induced medical ailments. Repeat this process every few weeks. Does Yaakov really believe that hospitals should be forced to treat, without compensation and without limit, chronic alcoholics, drug addicts, and gangsters who live by violence?

If we could attain a free society, that would imply a healthier culture in which such problems would be reduced. However, assuming the persistence of such problems, I do not doubt that a variety of charitable programs would be available even for such hard cases (as they are today). However, if I were running such a program, I would also impose very strict conditions for assistance. Alcoholics and drug addicts would have to clean up their lives, and criminals would have to work and live under controlled conditions. Charity in such cases should focus on rehabilitation and should avoid enabling self-destructive lifestyles.

Not only do existing rules encourage irresponsibility, they also harm the responsible. Not surprisingly, it is the unjust, immoral policy that Yaakov advocates that is responsible for depriving some people of health care. As Zinser and Hsieh point out:

[A]s a result of EMTALA, hospitals are closing emergency rooms. According to the American College of Emergency Physicians, from 1993 to 2003, while the U.S. population grew by 12 percent, emergency room visits grew by 27 percent — from 90 million to 114 million visits. In that same period, however, 425 emergency rooms closed (14 percent of the ERs that existed in 1993), along with 703 hospitals and nearly 200,000 beds. More close every year.

By mandating that doctors and hospitals treat patients at a financial loss, EMTALA violates the rights of doctors and hospitals to set the terms of their business. Consequently, doctors who are unwilling to lose money or who are tired of treating dishonest patients withdraw from emergency rooms. This leads to more overcrowding, longer waiting times, and, in some cases, the closing of ERs. As the remaining ERs become still more overcrowded and understaffed, the quality of emergency room services necessarily declines, harming honest patients who have genuine emergencies.

As Zinser and Hsieh argue, the problems with modern medicine are caused by the imposition of political force. Today, many immoral political policies impose force, violating the rights of doctors, patients, and insurers. A just system, and a system that offers the best medical care, is one in which the rights of doctors, patients, and other parties are consistently protected.