A saúde é um direito?
O direito a saúde é algo garantido pela Constituição Brasileira de 1988. Mas o que isso significa em si?
Primeiramente, necessitamos entender que existem dois tipos de direito que se entendem sob um aparato legal: direitos negativos e direitos positivos.
Os direitos negativos são bem abordados pelo princípio simples que toda criança aprende: o seu direito termina onde o direito do seu coleguinha começa. São aqueles direitos que você tem independente do outro e que a sua garantia se dá apenas pelo impedimento de alguém ir e proibir o seu exercício deles. Eles envolvem aspectos da vida que são inalienáveis da pessoa — como definido por Thomas Jefferson na declaração de independência americana –, sendo descritos como direitos naturais das pessoas. Os exemplos mais prementes desse tipo de direito são vida, liberdade e propriedade privada como definidos por John Locke. Todos os outros direitos negativos emanariam desses três, como a liberdade religiosa, a liberdade de expressão, o direito de ir e vir, direito ao porte de armas, etc, sendo que a própria base dos Direitos Humanos tão apregoados por diversos grupos está nesse princípio de ninguém poder violar os seus direitos negativos.
Por outro lado, os direitos positivos surgiram da concepção de que o Estado é a fonte dos direitos e que ele deve prover coisas para as pessoas. Ao invés de impedir que alguém lhe tome alguma coisa ou viole a sua integridade física, esses direitos impõe a obrigação de ação a alguém. Por exemplo o direito a moradia — abordado por Anthony Ling nesse post — obriga alguém a lhe oferecer um teto para morar, seja através da desapropriação de terras de alguma pessoa, da violação da propriedade a partir de tributos, do trabalho forçado para o Estado, ou qualquer outra forma de coerção que se faça necessária para que um sem-teto ganhe um abrigo. Desse modo, os direitos positivos são em quase sua totalidade contrários aos direitos negativos e violam estes para seu cumprimento.
No caso da saúde, entramos então no debate: seria ela um direito positivo ou negativo?
A saúde pode ser considerada como direito negativo se entendida como a proibição que algo ou alguém dotado de razão social — no caso uma pessoa jurídica — viole a integridade física de outrem. Ou seja, se ninguém voluntariamente deixa o outro doente — visto que há possibilidades de contaminação involuntárias como no caso de alguém que está gripado e não tem sintomas –, o direito a saúde está sendo plenamente exercido.
2. Philosophical and moral choices on healthcare systems
With this economic viewpoint in mind, we can also discuss about other areas that are usually so called moral choices in healthcare. Usually people defend the idea of the universal coverage because it aims to protect those who cannot originally access health treatments. However, they choose to ignore that defending this kind of system they are proposing a solution that is temporary and not sustainable in the long run. They are also ignoring principles related to what is coverable by an insurance or what is individuals’ responsibility, and how the economics of the system will affect its outcomes in the long run.
In addition, a healthcare system funded solely by the government has a limited budget that is not proportional to the number of individuals who use it, coming from taxation of a previous year or estimated taxation of the current one. Hence, with lower costs for the users, the demand will increase but the economic gains will be constant implying in less money to spend per user, aggravating the results of wrong governmental choices.
We saw that the loss of the price as a feedback mechanism and the lack of incentives in a controlled market would result in shortages. They imply in the implementation of some rationing mechanism – because it is easier to change demand than supply for a regulated market. This usually will happened in two ways: long lines and discrimination of whom will receive care or not. I consider these topics as another set of philosophical/moral choices along with the existence of universal healthcare.
Older patients wait in a line (source: http://goo.gl/YclQpk)
The simplest rationing mechanism is generating lines: no matter what is the condition of your illness, you will have to wait for the treatment based on when you discovered it. These lines can be as short as waiting to see a specialist the next day or waiting two years for a consultation, depending on how big is the shortage of the system. Someone can argue that the good point is the rich and poor wait the same time in the line. However, usually the ones who wait are the poor, because those with money can travel to abroad in order to do what is called health tourism. Hence, a system that is designed to be egalitarian still lacks of egalitarianism and imposes two-tier healthcare.
Another form of rationing is making the discrimination of who receives care and who does not. Usually this decision is based on some criteria like who are more likely to recover from disease, who will be paying taxes for longer period of time, who is more socially valuable, etc. These decisions are also questionable, especially because they create multiple tiers for the healthcare receivers – and it also affects the quality of care. In addition, a system like this without complementary private agents will end up selecting who lives and who dies in a manner worse than the current American standard, where the biggest problem is not the lack of care, but the ultimate cost that result from it.
Furthermore, the cost control due to socialization usually affects innovation by reducing its incentives. It happens because in order to fund the current established system there will be lack or delay in the adoption of new technologies, little or no money is dedicated for research, controlled profits for medical or technological companies, loss of intellectual property rights. Without the innovation, the scarce resources will almost always be the same and we could not see something like the green revolution that enabled the production of food and generated enough amount of goods to feed more than the current world’s population. Therefore, forbidding people to benefit indirectly from the system like those who are young now and will have better technologies in the future, or those who are poor and are protected because people are taking vaccines and avoiding that hazardous diseases spread.
With this in mind, one realizes that when a Newsweek article claims that universal healthcare is a moral choice, the authors choose to ignore these economics principles behind this choice. Even though I tend to agree with them that is morally important to have some kind of universal coverage – the choice on which and who will provide healthcare being more political than anything else -, it is impossible to maintain a universal system in the long run without significant problems. Canada, the Scandinavian countries, and the United Kingdom are in most advanced stage of these problems and one see various discussions on what to do to fix their systems.
One the other hand, it is clear that keeping this kind of socialized system will be good for some time – before shortages start happening -, even though we can go around this without mandatory universal coverage. Moreover, this model is good especially for those who do not have money right now or who are not willing to cut spending in other areas to pay for their healthcare. However, we are putting the burden of paying the bill on somebody else’s shoulders.
Faceplam (Source: http://goo.gl/K3XQIu)
This is the third moral choice that I consider: selecting who pays the bill, which is usually higher in universal systems when evaluating for the quality of care. I also think that the answer to this question is as important as who we are covering. The choice is not necessarily related to imposing the riches high taxes to “redistribute” the wealth, but making the healthier pay for the sicker (even though these might have had preventable diseases and opted to not take care of themselves). Another possibility is making the next generations suffer because of years with non-sustainable spending, similar to what is happening with other social security and welfare measures that are asking for their prices in Europe.
In this sense, the reminder by the physician and former member of the US House of Representatives from Texas, Dr. Ron Paul, that healthcare is not a right, but a good is important. He presents and interesting perspective and goes against the view of Senator Bernie Sanders from Vermont or Dr. Ezekiel Emanuel, who consistently choose to ignore the problems of socialized medicine. According to Dr. Paul, we can have the right of accessing to healthcare (hospital availability, physicians, nurses, and other care professionals in the market), as we have to food, electricity, water, housing. However, if we admit that healthcare itself is a right, someone becomes obliged to offer it regardless of the price and our condition – reducing individual’s liberties.
Senator Rand Paul, a physician from Kentucky, goes further on the topic of making and defends that it might ultimately result in a kind of slavery for the professionals, because law enforcement agents can be used to make physicians provide the services whenever someone wants it. Even though Senator Paul is talking about an extreme case in the current American reality, it is not an impossible situation as the Cuban example shows us. In the island, physicians are obliged by the government to live in their primary care facilities and to treat everyone even without good conditions to perform their duty. In addition to the Cuban situation, Senator Paul’s concern can be justified with the Swedish example that shows how laws can modify moral principles of a society in just two generations even in a developed country.
Again, the use of law enforcement agents to provide the care would too create multiple tiers of the systems quality. Physicians would not work as motivated under the use of force, and those with access to better lawyers could get more expensive and faster treatments than the others. The egalitarian principle would reside only in the paper that it was written.
