Market-Based Reforms in Health Care are Both Practical and Morally Sound

Plato , The Laws, trans. Saunders T. J. (Harmonsworth, England: Penguin, 1970): At 457–458.

Aristotle , Politics, trans. Baker E. (Oxford: Oxford University Press, 1946): At I, 126a-b.

Cicero , De Officiis, in Cicero on Moral Obligations, trans. Higginbotham J. (Berkeley, CA: University of California Press, 1967): At 92.

These objections to markets are cited by Walsh A. J. , “Commercial Medicine and the Ethics of the Profit Motive,” Journal of Value Inquiry 40, nos. 2–3 (2006): 341–357, at 344.

Margaret Thatcher's views are cited by Ronald Munson, Raising the Dead: Organ Transplantation and Society (Oxford: Oxford University Press, 2002): At 112.

This quotation is from San Bernardino of Siena;

cited by Raymond De Roover , San Bernardino of Siena and Sant'antonino of Florence: The Two Great Economic Thinkers of the Middle Ages (Boston, MA: Baker Library, 1967): At 14. Cited by Walsh, supra note 4, at 344.

See, for example, Titmuss R. , The Gift Relationship: From Human Blood to Social Policy (London: George Allen & Unwin, 1970)

Williams B. “The Idea of Equality,” in Williams B. , ed., Problems of the Self (Cambridge: Cambridge University Press, 1973).

For a defense of commercial medicine, see Walsh , supra note 4.

For a defense of markets in general, see Meadowcroft J. , The Ethics of the Market (Palgrave Macmillan, 2006).

For an excellent account of how voluntary fraternal organizations provided health care to their members in the late 19th and early 20th centuries, see Beito D. T. , From Mutual Aid to the Welfare State: Fraternal Societies and Social Services 1890–1967 (Chapel Hill: The University of North Carolina Press, 2000).

Another alternative to a voluntary, commercially based system of health care provision would be for health care to be provided voluntarily and altruistically. However, I leave this possibility aside owing not to its impracticality – although such a purely voluntary system of health care provision would suffer from serious practical difficulties akin to those faced by any system which attempted to provide goods or services without the benefit of genuine (rather than proxy) price signals – but because it is not a serious practical alternative.

Presumably, even who enters the health care profession could be under State control in such a system, with the State conscripting as health care workers those whom it believed to be especially suited to the task. Plato might well have approved of this!.

See, for example, von Mises L. , Socialism, vol. 2, trans. Kahane J. (Indianapolis, IN: Liberty Fund).

Hayek F. A. , Individualism and Economic Order (Chicago: University of Chicago Press, 1948).

This account of how States provide health care is only held to be a typical approach that they take for it is possible that a State could secure the resources to provide health care in other ways – perhaps, for example, by exploiting oil reserves that it owns. (I thank an anonymous reviewer for suggesting this to me.) Even with this caveat in place, this account is still crude, for many if not all States will also subject non-citizens to taxation, as well, through, for example, the imposition of income taxes on aliens, or through charging them sales taxes on things that they buy. This should be of obvious concern to persons who genuinely believe that there should be no taxation without representation.

These figures are cited by Sade R. M. , “Foundational Ethics of the Health Care System: The Moral and Practical Superiority of Free Market Reforms,” Journal of Medicine and Philosophy 33, no. 5 (2008): 461–497, at 485.

Litow M. , Rhetoric vs. Reality: Comparing Public and Private Administrative Costs (Washington, D.C.: Council for Affordable Health Insurance, 1994);

cited by Sade, “Foundational Ethics,” 485.

Cited by Sade, supra note 14, at 485.

See Beito , supra note 9, at 150.

Olson M. Jr. The Logic of Collective Action: Public Goods and the Theory of Groups (Cambridge, MA: Harvard University Press, 1965).

Meadowcroft J. , “Patients, Politics, and Power: Government Failure and the Politicization of U.K. Health Care,” Journal of Medicine and Philosophy 33, no. 5 (2008): 427–444, at 435–436. These increases in both pay and staffing have not, however, had a proportional effect on productivity. In fact, as Meadowcroft notes, a 29% increase in funding between 2001 and 2005 only produced a 19% increase in outputs. (See specifically page 436.).

Danzon P. M. , “Hidden Overhead Costs: Is Canada's System Really Less Expensive?” Health Affairs 11, no. 1 (1992): 21–43, at 37. I thank an anonymous referee for bringing this article to my attention.

For a discussion of this, see Taylor J. S. , “Autonomy, Duress, and Coercion,” Social Philosophy & Policy 20, no. 2 (2003): 127–155.

The Principle of Respect for Autonomy is outlined in Beauchamp T. L. Childress J. F. , Principles of Biomedical Ethics, 5th ed. (New York: Oxford University Press, 2001): At Chapter 3.

This understanding of autonomy entails that it is an essentially political concept. For a defense of this view of autonomy, see Taylor J. S. , Practical Autonomy and Bioethics (New York: Routledge, 2009): At Chapter 3.

For a discussion of this, see Taylor , id., at Chapters 6 and 7. It should be noted that even though a person's autonomy per se (i.e., simpliciter) will not be compromised in the latter type of situation, its instrumental value to her is likely to be diminished.

For a discussion of this point, see Taylor J. S. , “Autonomy, Inducements, and Organ Sales,” in Athanassoulis N. , ed., Philosophical Reflections on Medical Ethics (Basingstoke: Palgrave McMillan, 2006): At 135–159.

“Private property” can describe various bundles of rights; this exegesis glosses over the various permutations that are possible as they are not directly germane to the discussion at hand.

Two points are worth noting here. First, to say that private property rights exist against a general background of coercion is not to claim that they can only exist “in the shadow of the State.” It is possible that private enforcement agencies could be used to protect property rights, and hence such rights are possible even in an anarchist society. Second, note that it has not been claimed that “systems of private property must exist against a general background of coercion…” – only that they (contingently) do. It is possible that a society with private property could exist none of whose members are ever motivated to transgress the property rights of others. In such a case private property could exist without the threat of coercion in the background. As such, Debra Satz is simply wrong to claim that “true laissez-faire is not even logically possible” (for it clearly is), although it might not be practically possible given the conditions of the real world. Satz D. , Why Some Things Should Not Be For Sale (New York: Oxford University Press, 2010): At 27.

Hobbes T. , Leviathan: With Selected Variants from the Latin Edition of 1668, Curley E. , ed. (Indianapolis: Hackett Publishing Co., 1994): Chapter 13, at para. 9.

Although from Section I it is clear that a purely State-based approach to providing health care would be less effective than either a market-based system or a mixed system with both State and market involvement, it is not clear where the chips would fall in this discussion when the latter two approaches are compared. It might be, for example, that a mixed system in which the persons who would not otherwise have access to health care receive this from the State with this being funded by minimally intrusive system of taxation would be better from the point of view of one who values autonomy than a purely market-based system. Or, again, it might not. This decision could only be made after both empirical research has been done on the effects of each approach on persons' health, and serious conceptual work has been done on the how these effects translate into effects on person's autonomy. Moreover, one would also have to decide whether or not it would be legitimate to trade of some persons' autonomy to secure an enhancement in that of others – and even whether this question is conceptually coherent.

For an argument that the value of autonomy might only be as a proxy for another value, see Taylor , supra note 22, at chapter 10.

See Williams , supra note 7, at 240.

Indeed, since the commercial provision of health care is more practical than its State-based alternative, as was argued in Section I, if one is truly concerned with achieving the ends of medicine, then one should support a market-based system for providing health care, not oppose this.

“Motive” is here being used in its Millian sense.

Kant I. , Groundwork of the Metaphysics of Morals, trans. Patton H. J. (New York: Harper Torchbooks): At 397.

See also Taylor J. S. , “Market Incentives and Health Care Reform,” Journal of Medicine and Philosophy 33, no. 5 (2008): 498–514, at 507–508.