Weekly Discussion Board Rubric
Meets
Approaches
Expectation
Expectation
Content, Research, and Analysis
5 Points
4 Points
Content
Demonstrates
Demonstrates
excellent
fair knowledge of
knowledge of
concepts, skills,
concepts, skills,
and theories.
and theories
relevant to topic.
5 Points
4 Points
Support
Statements are
Statements are
well supported;
partially
posts extend
supported; posts
discussion.
may extend
discussion.
5 Points
4 Points
Writing
Writing is well
Some significant
Quality
organized, clear, but not major
concise, and
errors or
focused; no
omissions in
errors.
writing
organization,
focus, and
clarity.
5 Points
4 Points
Timeliness Initial before
Initial post 1 day
deadline.
late (Friday).
5 Points
4 Points
Quantity
Initial post and
Initial post and
two other posts. one other post.
Points Possible: 25
Below
Expectation
Limited Evidence
No Evidence
3 Points
Demonstrates
significantly
flawed
knowledge of
concepts, skills,
and theories.
3 Points
Support is
deficient; posts
do not extend
discussion.
2 Points
Demonstrates
poor or absent
knowledge of
concepts, skills,
and theories.
0 Points
Did not
participate
2 Points
Statements are
not supported.
0 Points
Did not
participate
3 Points
Numerous
significant but
not major errors
or omissions in
writing
organization,
focus, and
clarity.
3 Points
Initial post 2 days
late (Saturday).
3 Points
Initial post only.
2 Points
Numerous errors
or omissions—at
least some
major—in
writing
organization,
focus, and
clarity.
2 Points
Initial post 3 days
late (Sunday).
2 Points
One post to
colleague.
0 Points
Did not
participate
0 Points
Did not
participate
0 Points
Did not
participate
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Medical
Responsibility
Ronald Hamowy
T
hese comments seek to take issue with the contention that society has a responsibility to provide its members with any needed health care.
In order to deal with this claim, we must first make
clear exactly what it meant by the proposition. I take
it that those who embrace this view mean considerably more than that each of us has a moral obligation
to contribute to those in need of medical attention
who are unable, for one reason or another, to afford
the necessary care. This is a moral proposition and is
traditionally dealt with under the heading of charity.
But the contention, as here used, means considerably
more since its main implications are not moral but
primarily political.
This is not to suggest that there are no moral implications to politicizing the administration of health
care. We do well to remind ourselves of a fact that is
almost always forgotten or neglected, that any recourse
to the political process is ultimately dependent on the
use of force. It is in the nature of all law that it seeks
to change our behavior from what it would otherwise
have been in the absence of the threat of coercion.
Either at least some of us would have acted in some way
or refrained from acting in some way in the absence of
the sanctions that accompany any government directive. This, of course, is as true regarding how we spend
our money as of any other command. We are, unfortunately, quick to seek solutions to our social problems
by turning to the government, only dimly aware of the
fact that these solutions — if indeed they were effective in solving the problems they address — are dependent on compulsion and that truly free societies have
recourse to compulsion as rarely as is consistent with
social order. The more we force people to act, even in
their own interests, the less we are free and the more
we compromise the autonomy of each of us. And to
place in the hands of bureaucrats decisions as to what
and how much medical aid will be extended is to rob
individuals of the power to determine the extent to
which they control what should be intimately personal
choices.
That government should ultimately be responsible
for the health care of its citizens is predicated on the
idea that medical care is a right, not dissimilar from
the right we all possess to our own religious beliefs,
and that, as is true of all rights, the state has a duty
to enforce it. This claim was put forward by President
Franklin Roosevelt as far back as 1944 and was reiterated by President Obama, in October 2008.1 But this
notion is both philosophically and practically flawed.
Ronald Hamowy is a Professor Emeritus of Intellectual
History at the University of Alberta and a Fellow in Social
Thought at the Cato Institute in Washington, D.C.
532
journal of law, medicine & ethics
Ronald Hamowy
Philosophically, the use of the term “right” to denote a
positive obligation to supply a scarce resource is predicated on a confusion between a right and a grant of
privilege.
There is probably nothing more pernicious to the
language of political philosophy than the vulgarization of the term “rights.” While the point has often
ence progresses and we find more ways to diagnose
disease and extend life, the cost of the resources that
can be applied to any particular patient increases. The
effect is that the “rights” of some will of necessity conflict with the rights of others as scarce resources are
parceled out. The incapacity to meet total demand
logically implies that one’s “rights,” at some point, will
The more we force people to act, even in their own interests, the less we
are free and the more we compromise the autonomy of each of us. And to
place in the hands of bureaucrats decisions as to what and how much medical
aid will be extended is to rob individuals of the power to determine the
extent to which they control what should be intimately personal choices.
been made, it bears repeating, that the rights to which
serious political discourse refer are negatively conceived. They have reference to the limitations placed
on governments and on others regarding attempts to
restrain how we may act. This conception of rights is
the one put forward in, among other documents, the
Declaration of Independence and the American Bill of
Rights. Rights so conceived do not require that others be forced to act in specific ways if I am to exercise
my rights but only that they refrain from intervening
in certain areas without my consent. Thus, my right
to life does not entail that others are obligated to do
everything within their power to keep me alive but
only that they cannot kill me.
Unfortunately, advocates of socialized health care
commonly employ the term not in this negative manner
but in its imprecise sense to refer to some privilege
that entails that others not refrain from acting, but
positively act in certain ways. They are, of course, not
alone in this. The last hundred years have witnessed
a serious erosion in political discourse as politicians
have increasingly invoked such terms as “liberty” and
“rights” solely to elicit certain emotional responses in
their hearers. And discussions of health care, far from
being immune to such imprecision, have embraced
it, especially by those employed as government
functionaries of one kind or another. Those who
support socialized health care are particularly prone
to use the term to refer to privileges which entail an
obligation on others to provide certain services, either
directly or through the intermediation of taxes.
In addition, there are serious practical consequences to conceiving of health care as a right. The
demand for medical services at zero price to the consumer far exceeds supply. On the other hand, our
resources are, of course, limited and as medical sci-
conflict with those of others. And this, in turn, means
that some organization will have to be empowered to
determine whose rights will be met and whose will be
denied. Thus, the ultimate decision for what and how
much medical care we will, of necessity, be entitled to
rests in the hands of some bureaucracy.
The economics here are simple. Whenever the
demand for a good or service outstrips the supply,
there must be some method of rationing. And there
are ultimately only two methods of rationing. The
price system reflects our individual demands and the
extent to which we want a particular good or service as
compared with all the other goods and services available to us. This demand is distinct for each of us and
varies from time to time demanding on all the other
factors that impinge on our lives. The other method of
rationing is by fiat, in which some bureaucracy determines how much medical care will be forthcoming
and by imposing costs in forms other than price-waiting lists, overcrowded facilities, etc. A governmentadministered system is thus predicated on the creation of a bureaucracy empowered to make rationing
decisions which intimately effect how, when, and how
much health care each of us will receive.
Nor should we ignore the enormous cost of administering a government health care system. An examination of the administrative costs associated with Medicare underscores the inefficiencies associated with
management of the program. While the Center for
Medicare and Medicaid Services claims to spend less
than 3.1% of total expenditures on administration,2
this figure does not include the spectacularly high
costs imposed on physicians and hospitals in complying with the almost 150,000 Medicare regulations.
In an often-quoted paper published in 2003, Drs.
Steffie Woodhandler and David Himmelstein3 con-
health care reform: controversies in ethics and policy • fall 2012
533
S Y MPO SIUM
cluded that the administrative costs associated with
doctors, hospitals, nursing homes, insurers, and
employers accounted for 31% of health care costs in
the United States, almost twice the amount as that in
Canada. Their recommendation was that the United
States switch to a single-payer system similar to the
Canadian model. The facts, however, in no way comport with these findings. That portion of Canadian
administrative costs associated with their national
health insurance system is substantially higher than
Woodhandler and Himmelstein report — for a system
offering considerably less than does American health
care.4 In addition, the portion of the private sector of
Canada’s health system is saddled with fewer regulations and is thus spared the substantial costs imposed
on American providers. More important, a singlepayer system tends to veil waste, fraud, and gross inefficiencies far more effectively than does one where
competition prevails. More suspect are the overall figures put forward for administrative costs in the United
States. The National Health Expenditure Accounts5
for 2005 show administrative costs at 7.2% of total
health care spending — 14.1% for private insurers
and 5.2% for public programs (3.1% for Medicare and
7.0% for Medicaid).6
In sum, a careful examination of the actual costs
of administrating a government health system reveal
substantially higher numbers than generally supposed. Careful cost accounting serves no real purpose
when dealing with bureaucratic entities since, unlike
with profit-making organizations, it is unlikely that
uneconomic units will be consolidated or shut down.
In the absence of such constraints, it is simple, when
calculating how much the government is spending on a program, to slough off a portion of its costs
onto other programs and miscellaneous expenditures.
Thus, none of the following are included in the operating expenses of Medicare: (1) the cost of collecting
the taxes to fund the program; (2) program marketing
and outreach; (3) the cost of auditing the program;
(4) the costs associated with negotiating contracts; (5)
building costs; (6) staff salaries of those employees not
directly employed by the Medicare system but whose
duties center on Medicare affairs; and, (7) the costs of
congressional resources used in setting Medicare fee
schedules.7
The Office of the Inspector General of the Department of Health and Human Services has conceded that
the amount of waste and fraud in the Medicare and
Medicaid system amounts to many billions of dollars.
To give some idea of the magnitude of the problem,
it is worth noting that the Chief Counsel of the OIG,
in testifying before the Subcommittee on Oversight of
the House Committee on Ways and Means, said that
534
“in fiscal year (FY) 2009, the Centers for Medicare &
Medicaid Services (CMS) estimated that overall, 7.8
percent of the Medicare fee-for-service claims it paid
($24.1 billion) did not meet program requirements.”8
The larger the program, of course, the more incentive to waste resources and to abuse the regulations
governing payment. In September 2009 President
Obama conceded that “there are hundreds of billions
of dollars of waste and fraud” in the health care system.9 There is simply no possibility that such massive fraud and misuse of resources could occur in the
private sector because of the dispersion of buyers and
sellers and the existence of price signals that immediately call attention to these anomalies. It is much
easier to spend other people’s money than one’s own
and not be too concerned with waste and inefficiencies
when the costs fall on some faceless anonymous entity.
There lies behind most criticisms of a health care
system operating according to the principles of a free
market: a deep distrust of private enterprise and a
suspicion that the profit motive should play no role in
this crucial aspect of our lives. This follows conventional Marxist analysis that the relationship between
health care provider and patient should not be a commodity relationship comparable to selling refrigerators or providing piano lessons, where the participants
are in some sense adversaries, but one in which they
are cooperative and benevolent.10 This view, however,
completely misconstrues the nature of free markets
and their alternatives. Markets are predicated on the
harmony of interests between buyers and sellers who
seek to satisfy their own welfare by satisfying that of
the people with whom they deal. Far from being an
antagonistic relationship, the relation between buyer
and seller is a cooperative one.
The nature of unhindered markets is that both parties freely enter into an agreement to trade a good or
service because the trade is beneficial to both. Compulsion plays no role in the exchange. It is not predicated
on the notion that one party owes the other something
that impels him to act. The competition that is central
to a system of free markets is the competition we have
to satisfy the demands of others, thereby benefitting
ourselves. This distinction is often lost when people
refer to “competitive” markets. More important, the
nature of exchange is such that each of us remains
autonomous, making our own decisions and acting on
them as we freely choose. Whether we like it or not, we
are all born, live, and die as independent beings, and
the nature of our association with each other is either
voluntary or coerced, that is, originating in decisions
we make for ourselves or in those made for us. There
is no third alternative.
journal of law, medicine & ethics
Ronald Hamowy
That we are part of some organic body and that
we are interconnected so that we “belong” to and are
responsible for each other is basically antithetical to
our notion of the sovereignty of the individual. Nothing is more elemental to the nature of man than that
he be in control over the decisions that affect him. And
no decisions are more central to his existence than the
medical care he receives. This extends to being able to
determine the type and degree of medical care he opts
for and to choose among those who might provide
is to increase the premiums for non-smokers. And the
only groups that benefit from the legal mandate that
health insurance must cover the costs of alternative
medical practice such as acupucture or naturopathic
medicine are their practitioners. These requirements
add unnecessary costs to health insurance policies and
doubtless contribute to why a portion of the population has foregone medical coverage.11
I am unsure why free markets remain so distrusted
after they have proven themselves time and again as
such a spectacular engine of progress
and as the underlying cause of modern wealth creation. Anyone familiar
Self-responsibility is not a burden — or at least
with the history of the last 50 years
not just a burden — but a method of insuring that must be impressed by the immense
success in producing and distributthe each of us has plenary control over our lives.
ing goods and services and the develAnd the only economic system compatible with
opment of the technological means
individual autonomy is one of free markets, which for securing its production. One
need only look at the material progalso serves as the most efficient system for the
ress of Japan and South Korea since
production and distribution of goods and services. the end of World War II and of China
since the economic reforms of Deng
Xiaoping in 1978 to see how effective
free markets are in transforming poverty into wealth.12
these services. Self-responsibility is not a burden — or
at least not just a burden — but a method of insurYet despite the overwhelming evidence, huge numbers
ing that the each of us has plenary control over our
of otherwise intelligent people continue to insist that
lives. And the only economic system compatible with
capitalism only benefits the rich.
individual autonomy is one of free markets, which also
What is particularly exasperating is the charge
serves as the most efficient system for the production
made by many of those who support wholesale government intervention in the health care system that
and distribution of goods and services.
the claims of economists who point to the inefficienPrivatizing government health care will do much to
cies and opportunities for fraud inherent in such a syseliminate the billions of dollars lost to the waste and
tem are thoroughly unrealistic and that the real world
inefficiencies endemic to central planning. At the same
simply does not reflect the idealized conclusions of
time, it will unleash the forces that drive capitalism to
classical economics. At the same time, the advocates
reduce the costs of medical care and health insurance.
of a governmental-administered medical system offer
This is not the place to outline all that could be done
up the image of a kind and beneficent bureaucracy
to reduce the substantial medical costs we all confront
selflessly dedicated to the public weal and refuse to
in the face of government regulation, but certainly the
judge how in reality such systems have always worked.
limitations placed on the sale of private health insurHow much proof must be offered before it is finally
ance could be eliminated so that it would be available
admitted that progress in any area, including health
to more people.
care, is a function of the freedom permitted individuNo sensible reason exists for most of the regulaals to compete with each other in reducing costs and
tions imposed by the federal government and the variincreasing quality?
ous states that prohibit the sale of insurance limited
Yet even allowing for all of this, what are we, as a
to catastrophic expenses or that place limits on lifecompassionate society, to do about those people who
time or annual payments. And why prohibit the sale
are in need of medical care and who simply cannot
of policies that exclude preexisting conditions or that
afford it, even after we have repealed the restrictive
mandate mental health coverage or coverage for the
legislation that now hobbles the market? It is at this
expenses incurred in childbirth. Nor does it make
point that self-responsibility merges with our fellow
sense to require that all applicants, regardless of the
feeling for those less fortunate than ourselves and
risks they assume to their health, be charged the same
issues in charity. We are charitable because we have a
premium for the same coverage. The only effect of
sense of responsibility for ourselves and know what it
including smokers in the same pool as non-smokers
health care reform: controversies in ethics and policy • fall 2012
535
S Y MPO SIUM
means to fall short of some goal. To shift responsibility
to some entity whose resources are dependent on the
use of force is not compatible with a basic respect for
individuals, which is the underpinning of charitable
society, nor is it in any way efficient. For those who
claim that private charity will fall short of being able to
care for those in need of medical help is to badly underestimate how charitable our society is. Americans currently surrender 28% of their wealth to federal, state,
and local governments in the form of taxes.13 Yet in the
face of such a sizable tax burden, charitable contributions from American individuals, corporations, and
foundations totaled $303 billion in 2009 and public
charities had total revenues of 1.37 trillion dollars.14
Surely a nation so philanthropic would insure that no
one who lacked the means to afford it went wanting
for needed medical care.
References
1. Franklin D. Roosevelt, in his State of the Union Address of
January 11, 1944, declared that all Americans “have the right
to adequate medical care and the opportunity to achieve
and enjoy good health.” During the presidential debate held
in Nashville, Tennessee, on October 7, 2008, Obama maintained that “I think [health care] should be a right for every
American.”
2. However, this figure does not include Medicare’s share, which
is substantially greater than 3.1%, of general governmental
administrative expenses. See M. Matthews, Medicare’s Hidden Administrative Costs: A Comparison of Medicare and the
Private Sector (Alexdandria, VA: The Council for Affordable
Insurance, 2006) and B. Zycher, Private Health Insurance:
Would a Single Payer System Save Enough to Cover the Costs
of the Uninsured?, Medical Progress Report No. 5 (New York:
Center for Medical Progress of the Manhattan Institute, 2007).
3. S. Woodhandler, T. Campbell, and D. Himmelstein, “Costs of
Health Care Administration in the United States and Canada,”
New England Journal of Medicine 349 (August 21, 2003):
768-775.
4. For a comprehensive survey of the Canadian health care system and its limitations, see B. J. Skinner, Canadian Health
Policy Failures: What’s Wrong? Who Gets Hurt? Why Nothing
Changes (Vancouver: Fraser Institute, 2009).
5. See United States Census, Statistical Abstract of the United
States: 2011 (Washington, D.C.: Government Printing Office,
2010): 100 (Table 132).
6. McKinsey & Company estimated that in 2006 health administration and insurance costs accounted for $145 billion
while total health care spending came to $2,053 billion. This
536
amounts to 7.06%. McKinsey & Company, Accounting for the
Cost of US Health Care: A New Look at Why Americans Spend
More: Executive Summary, December 2008, at 14.
7. American Medical Association, “Administrative Costs of Health
Care Coverage,” available at (last visited August 17, 2012).
8. Testimony of Lewis Morris, Chief Counsel, Office of Inspector General, U.S. Department of Health and Human Services, on Reducing Fraud, Waste, and Abuse in Medicare,
before the Committee on Ways and Means, Subcommittee on
Health, Subcommittee on Oversight, House of Representatives, April 19, 2011, available at (last visited August 17, 2012).
9. President Barack Obama in a statement to the Joint Session of Congress on September 9, 2009, quoted by Vincent
L. Frakes, Policy Director for the Center for Health Transformation, testifying before the Committee on House Oversight and Government Reform, February 11, 2011, available
at (last visited June 22, 2011).
10. See J. Ehrenreich, “Toward a Healing Society,” in E. F. Paul
and P. A. Russo, Jr., Public Policy: Issues, Analysis, and Ideology (Chatham, NJ: Chatham House Publishers, Inc., 1982): at
186-197.
11. The Wall Street Journal on August 23, 2009, reported that
the executive vice president of the American Association of
Retired Persons, Mr. John Rother, noted that the annual cost
for an individual plan for a 25-year old man in New Jersey in
2006 was $5.880, while a similar plan in Kentucky would have
cost $1,000. See “The Compeition Cure,” Wall Street Journal,
available at (last visited August
17, 2012).
12. A. Maddison, The World Economy: Historical Statistics (Development Center Studies: Paris: Organization of Economic Cooperation and Development, 2003), and Historical Statistics for
the World Economy, 1:2003 A.D. show the following GDP for
the three nations: (1) Japan: 1946: 1,444; 2003: 21,218; (2)
South Korea: 1946: 686; 2003: 15,732; and (3) China: 1950:
448; 1972: 802; 1978: 978; 2003: 4,803. See (last
visited June 24, 2011).
13. See the Tax Foundation’s Special Report (no. 190) on Tax Freedom Day, dated March 2011, which calculates that in 2011
Americans will have paid all their taxes by April 12.
14. Giving USA Foundation, Center for Philanthropy at Indiana
University, June 9, 2010. The National Center for Charitable
Statistics at the Urban Institute reports that public charities in
2009 had revenues of 1.373 trillion dollars, and of this number, 54%, or $741 billion, were devoted to health.
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PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
PRINTED BY: Matthew Langner . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without
publisher's prior permission. Violators will be prosecuted.
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