Health Care, Rights, and Obligations

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Matt Skene has a very thoughtful post on the intersection of issues related to rights and obligations and recent health care debates. I disagree with a number of Matt's assumptions. I think we do have positive obligations, and I do think they simply are there without our taking them on. I don't think rights determine obligations but the other way around. Perhaps most salient, I don't think we can distinguish between obligations and moral goodness. I think we simply have an obligation to do what's morally best (and yes, I know that that means that pretty much everyone on this planet is thoroughly immoral, but that's not exactly a new view; it's historic Christian doctrine).

But I think there's a lot worth thinking about in Matt's post. His general approach is libertarian. He starts with natural negative rights and argues for no positive rights. In other words, certain things are wrong to do to me, because I have a right for you not to do them, but I have no rights for you to do positively good things on my behalf, just for you not to do bad things to me. But such a view doesn't imply that there aren't moral reasons to do positive things on behalf of other people.

In particular, there are reasons why it might be the morally best thing to do to help those who are less fortunate to obtain good medical care. Matt doesn't think I have an obligation to alleviate the suffering of people I have no other connection with, but he does think it's morally good to do so. It's also self-interestedly good for me to develop the character traits that such acts help develop in me. He's open to, but not convinced by, the argument that it would be in our best interests to contract with one another to institute such obligations by common consent, as we do with building highways. It depends on whether we'd all be better off with it.

Matt suggests an interesting possibility, though. You can donate money to your utility company to offset the costs of low-income utility customers. Presumably this goes to heating assistance aid, which is given to recipients of food stamps once a year and paid directly to the utility company. I'm not sure how else the utility companies would know who counts as low-income. But if we did a similar thing with insurance companies, there might be enough money from those who, like progressives on this issue, think they have an obligation to pay for others' insurance and from some of those who, like Matt, think it's a morally good thing to do. Could that cover everything Medicaid and other public health insurance does? It's worth seeing how much it covers.

I tend to doubt it, since most people who think the government should tax us more to pay for benefits to low-income people are not inclined to give money when it's voluntary (consider our current president as a prime example), but maybe enough people who don't share such views will give the money voluntarily while resisting it when it's government-controlled (as, apparently, Dick Cheney does with a huge percentage of his income). But it's being done with utilities. Why not try it with health insurance and see where it goes? There might even be enough votes in Congress after the 2010 election.


Hi there! I’m puzzled by the interface between obligations and voluntary donations. I do wonder how we can tell what’s morally best from what’s ‘second-best’, or why people might seek to maximise their disposable income so as to contribute to a greater extent to their favourite charity. Does Dick Cheney have demonstrably superior epistemic access to an objective hierarchy of worthy causes compared to everyone else?

I'm making no claim about whether Dick Cheney does this well. I'm also not taking a stance on whether he does it from good motivations. It is publicly available information that he gives a huge percentage of his income to charities, some of which achieve goals that he doesn't think the government should be pursuing but that he apparently considers worthy goals.

As for how we tell what's morally best from what's morally second-best, how is that much different from telling what's right and what's wrong? We consider the moral factors that bear on the situation, and we evaluate which option seems best. It's almost certain that in some situations we won't be able to discriminate finely enough to have any idea, but I'm not arguing that we should maximize the actual consequences the way a utilitarian would. I'm simply saying that we have an obligation to be as good a person as we can be, to do as good a job as we can in terms of our actions, to be motivated by the best considerations we can be, and so on.

I’m not sure it’s ‘wrong’ to support the second-worthiest cause, except in so far as this entails that finite resources are diverted from the worthiest cause, if such there is. Perhaps the objectives of all prima facie worthy charities can only be satisfied simultaneously by a Descartes-omnipotent God.

But we are certainly juggling finite resources, and - unless we’re just mistaking misanthropy for philanthropy - there’s a distinction to be made between (a) depriving people of resources, and (b) furthering worthy objectives. People want ‘value for money’ and if a government is seen as corrupt, inefficient and wasteful, it may make sense to give directly to dedicated, well-managed charities with low admin costs.

But the best-managed charities are not necessarily those that pursue the worthiest causes: The efficiency of a mechanism for pursuing a set of objectives is a separate question to what those objectives ought to be. I think Mr Cheney would have furthered a worthwhile cause had he tried to reduce inefficiency and corruption in the US administration in the first place.

I wouldn't say that it's very wrong to choose the second-best over the best, but I do think it's wrong.

I'm not saying that we ought to choose the best when the best is impossible. There's no need to invoke Descartes-omnipotence here. I just think we ought to do the best we can do, and if there's no best because there are plenty of equally-good options then we don't have one thing that it's our obligation to do, but we ought to pursue one of the possibilities that leaves no better option unpursued.

It's possible that reforming government waste and undoing government corruption may well be a better pursuit than giving to the best charity, or perhaps we should do both. It's quite possible that Dick Cheney didn't advocate enough for that when he had the ear of the president (a vice-president has no actual power except as a tie-breaking vote in the Senate; he was highly influential but only as a glorified advisor, not as a direct decision-maker). He did advocate for less expenditures on domestic policy matters, as he always has.

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