OPINION:
Much of the discussion about the Affordable Care Act (ACA) has dealt with costs, unintended effects or constitutionality, which are all crucially important. But there has not been much mention of the deeper philosophical issues the ACA raises, such as its effects on human autonomy and dignity, both of which are endangered by the usurpation of personal health care choice by a government bureaucracy.
A patient’s interests in his own health, comfort and financial security as well as the well-being of his loved ones are multifaceted, complex and known only to him. As such, choices regarding health care are among the most intimately personal choices one can make, and making those choices oneself is essential to maintaining and expressing one’s autonomy. Government intervention in the health care system will lessen the ability of people to make their own choices to promote their own interests and to preserve their dignity as autonomous persons.
Under the ACA, bureaucrats will play a more significant role than ever in rationing scarce medical resources. Of course, scarcity is not the fault of the government (although price controls make it worse). The market must allocate scarce medical resources, too, but it will do so according to the price mechanism, which critics say is unfair or arbitrary. While any allocation of scarce resources is likely to have tragic aspects - especially in the case of medical resources - there is no more ethical way to allocate them than the market. The price mechanism incorporates the choices of many, while bureaucracy represents the choices of few, which is truly unfair and arbitrary.
The issue is not whether choices must be made - for they must - but rather who should make them. In a market system, the patient can assess the value of different treatments compared to other uses for his resources. Perhaps he will decline the recommended treatment, even if he can afford it, in order to leave more money for his children or to take a cruise in the final months of his life. Or maybe he will sell his house to pay for another month on life support - and with his beloved grandchildren. In a market setting, he alone is responsible for the benefits, costs and other consequences; the choice is his, no matter how imprudent others may judge it to be.
In some cases, the patient will not be able to afford his preferred treatment, but there may be less expensive options that also will be of benefit. In a market system, this is the patient’s choice, just as it’s his choice what size house to buy, what model car to lease, what size TV to own. Past choices will expand or constrain his present options; a person who spends his income recklessly throughout his life should not expect sympathy when he cannot afford top-of-the-line treatment at the end of it. The same applies to lifestyle choices: If a person chooses to smoke, for instance, he increases his risk of cancer, and in a market system, he would be held responsible for the costs of that choice.
In a market system, those are his choices, whereas under a state-controlled plan, treatment decisions might be made or limited according to considerations of efficiency. (Our current health care system, dominated by insurance companies, has some elements of this, too.) Not every person can receive premium treatment, but this fact is because of scarcity of resources, not the way in which they are allocated or distributed. Under a plan like the ACA, the choice of who gets premium treatment - if anybody - will be arbitrary, made by some distant bureaucracy, with little, if any, role for choice on the part of the patient.
The beauty of the market is that it coordinates individuals’ choices to allow each person to pursue his goals, including those regarding health care, consistently with all others doing the same. If many people want the same scarce medical technology or procedure, the market solves the problem impersonally by rationing it on the basis of price, based on the choices countless individuals made in their own interests. A market-based approach to health care preserves an individual’s dignity by guaranteeing the expression of his autonomy and control over his intimately personal health care choices. The alternative is choice by bureaucracy, in which the worth of one person’s life, health and dignity is traded off against those of others according to a formula that, by its very nature, cannot accommodate these incalculable concepts.
Mark D. White is a professor at the College of Staten Island/CUNY and author of “Kantian Ethics and Economics: Autonomy, Dignity, and Character” (Stanford University Press, 2011).
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