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What philosophical issues and perspectives relate to how healthcare is provided in a nation?

Lets suppose someone says: "Health care is a service that has a cost, so only the people that pay directly at time of need for the full cost of their treatment, should be allowed to have it, morally."

Is this ok or wrong? People pay for cars in installments or by signing up to a fleet supplier that meets business transport needs as a service, and then we have public transport, but these don't seem to be judged as moral issues like healthcare is.

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    There are plenty of services that are taxpayer-funded and therefore don't have an individual cost to the people using them (public schoolteachers, for example), and the argument doesn't give any reasons why health care should be a service that people pay for individually instead of being taxpayer funded. It just starts from the position that it is payed for individually (which isn't true in many countries), and then concludes that therefore only those who can pay individually "deserve" it; this seems to assume that who deserves something is just determined by whatever the current law is.
    – Hypnosifl
    Commented Sep 9, 2022 at 2:01
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    Ethics and politics are a very wide field of philosophical study. It is very difficult to answer your question comprehensively as so many estimed philosophers have proposed so many different approaches to the problem of who deserves what in society. Yet from the get go, one noticeable weak point in the argument you present is the equivocation of the need for an individual car and the need for health. People can live correctly without car, but unhealthy people die. That would be my first rebuttal when confronted to the argument.
    – armand
    Commented Sep 9, 2022 at 3:12
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    "Everything people need should be free."
    – Scott Rowe
    Commented Sep 9, 2022 at 3:13
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    No philosophical issue here... it is a social and political issue. Modern Welfare state was a great improvement, but it must be implemented according to current social ideologies and consistently with resources allocation. Commented Sep 9, 2022 at 7:12
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    Healthcare is not like buying a thing or even most services, because being healthy is not optional. You can't be crippled or dead and still derive value from anything else, or contribute. It is Game Over. So healthcare is not something that should ever have to be purchased, or be withheld, any more than you would make people pay for air, or not give them water. We simply live in a demented world, with a hangover from millennia of terrifying scarcity. We need to wake up, the nightmare is long over!
    – Scott Rowe
    Commented Sep 10, 2022 at 0:40

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What do you mean by philosophical justification? There are a number of ethical frameworks that would like that more or less.

But it's certainly useful to have it. First of all even "free health care" is not actually without cost and no sane person would claim that. The idea of an insurance is just that you spread the damage on a large group of people, rather than letting the individual receive the full impact of an illness that is likely more accidental than within their personal responsibility. The idea being that when spread on a larger group of people the impact per person stays manageably small, while for a single individual it could be devastating. So it's the calculation of a planable inconvenience vs an erratic event that, in the worst case, can destroy the individual in question and leave the group 1 short.

What the "free" refers to is that you have no or very little costs at the time of using the service. Which is actually a very good idea for several reasons. First of all in the event of a sudden injury you're not at your best, so you might be physically and psychologically impaired (shock aso), so the less you have to worry in that situation the better. Also usually the sooner and more professional an injury is treated the better, as illnesses and injuries often tend to get worse if untreated, while treated or even prevented medical problems might only cause a small inconvenience or be reversed completely.

From it's general idea, it's as far as I can see, not in an obvious conflict with most ethical frameworks and it can be a net positive for both the individual in need of it and for society who profits from what that individual is able to contribute because of the treatment. And that's not just physical labor, but also experience, compassion and whatnot. Not to mention that usually human rights would also demand that you help each other if that's possible. Or rather it asserts the value of their rights to an equal and dignified existence which makes that more important than a slight inconvenience on your end.

In the end it depends on what morals and what ethical framework you subscribe to and how it's implemented. Like the assertion that you'd need to coerce medical personal to perform their service is usually completely unfounded. Helping people is usually a job that is highly demanded, highly valued and lots of people volunteer for that. That being said these people have to be cared for as well so it's not without cost and that cost is to be taken care of either by those who provide it (unlikely), by those who use the service (possible for smaller stuff, impossible for larger operations) or by society as a whole (meaning people have regular expenses even if they are not sick themselves).

And there's a spectrum on what you would like to and are able to cover as "preventable medical problems" and how vast the expenses for the individual ought to be and how they should be distributed. And there are probably people who claim to be an isolated self and thus see this as an intrusion upon themselves. Now for most people that is simply not practical because you are not an isolated self but on a daily basis make use of the inventions and the work of other people and even the purely transactional perspective doesn't really work as you're likely also making use of what people gave you "for free" under the assumption of it being a society. So most people neither are nor what to isolate themselves to that extend or are even able to do so.

Or the more likely people complain that in the implementation of it, they'd pay more than they take out or more than other people and would be better off handling their healthcare alone. Well if you pay more than you take out, you're rather lucky cause that means you're healthy and don't have to struggle with medical problems, but that's not true for all people and it might also just be a fluke for you. And that rich people are supposed to pay more is more or less a consequence of the distribution of wealth in society. Like if everybody had roughly the same then the burden for health care would be roughly the same but if you demand a contribution to healthcare that is above your wage or above what you need to survive than healthcare would simply not be that high on your priority list. But that's not a general problem but rather a consequence of a different socio-economic problem that just spills over.

Edit: An obviously with infectious diseases and especially within a pandemic protecting others by provided access to medical treatment and vaccines is also doing yourself a favor because otherwise the virus is keep coming back and has most likely way more negative consequences (lockdowns, isolation, death, aso.)

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    Good points, to which you might add that it's a matter of public safety to make sure that people with infectious diseases get treatment regardless of their ability to pay for it.
    – D. Halsey
    Commented Sep 9, 2022 at 19:46
  • Another great answer. Keep going.
    – Scott Rowe
    Commented Sep 10, 2022 at 0:45
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It's a question of a value system and how high place human life has in this system.

If human life is the highest value, then obviously, universal healthcare is not a subject for discussion, it's a fundamental human right, and it's a minimum criteria for qualifying a country as socially developed.

However, it's only one of possible value systems.

For religious fundamentalists, salvation is the highest value, and dying is only a door to the afterlife, so it makes more sense to build temples instead of hospitals and educating priests instead of doctors. If you get hit by the car, you should, in first line, get spiritual guidance. As long as your soul is safe, there's no point in saving your life.

For ancient Romans, human life had no more value than the money that person can bring you. Slaves that weren't able to work were left to die. This is the moral view that's the most similar to the one you presented.

Another example is the bandit codex. For bandit, life of the other is worthless. If you scratch big boss' car, he wouldn't hesitate to kill you to make an example. However, if you manage to kill him despite heavily armed bodyguards, no bandit would hold it against you. You kill to be killed some day. It's hard life, but if you believe in that system, it's something that you accept and adapt to it.

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Here are three types of arguments that lead to the recommendation of mutualized health care payment (i assume that is what you mean by "free").

Pragmatism: it just works in everybody's favour. Wealthy or healthy people who would end up contributing more than they use, either because they pay what the poor can't or because they seldom require healthcare are better off when other people can properly take care of their health. It is in their best interest to promote it.

There is the obvious problem of infectious diseases: it's much harder to stay healthy when everyone around you has cholera. Sure, it could be argued that it is their own responsibility to not catch the disease in the first place, but anyway their personal behaviour has an impact on the probability that careful people catch it too, wether they like it or not.

Also bosses are better off when their workers are in good shape, rich customers are better off when their service providers are healthy, etc. Economic studies have demonstrated that healthcare cost mutualisation actually reduces the part of GDP allocated to health care because people who can't afford a visit to the doctor postpone until their condition is too severe to ignore, and much more costly to treat. There is a solid argument to be made that "health care should be a commodity reserved to people who can afford it" is a short sighted opinion out of touch with economic realities.

Utilitarianism: the grand number of people who benefit from the fulfilling of fundamental needs like healthcare generates a cumulated utility much more important than the loss of utility suffered by the biggest contributors, who usually buy luxury products or services with their excess money (provided the contribution system is well balanced). Since the net utility gain is positive, mutualisation of health care cost is a moral thing.

This argument has a few caveats, the biggest one being how one measures utility. "Everybody gets healthy in exchange for some people having to give up on luxury items" seems like a no brainer, but depending on the formula used it can lead to strange edge cases like "would it be moral to reduce a few people in slavery in order to cover everyone else's health cost ?".

Social contract theory: the idea that it is legitimate for the state to govern the individuals in so far as it represents the general will. Rousseau in the Social Contract give the following argument: People want privileges, but the vast majority of people don't have the power to get those, but by forming a consensus together they can get the next best thing, that is universal rights. By setting as a rule a consensus that everybody as the same rights, it is possible to gather enough momentum to actually enforce those rights. In the present case:

  • "i want health care, but i am not wealthy enough to get it, or powerful enough to force people to provide it to me"
  • "many feel the same about the situation, but none of them individually can solve the problem"
  • "let's make health care a universal right by having fortunate people pay for the unfortunate. Since it is universal, we can gather enough unfortunates to constrain the fortunate and have them pay more than they receive." (it's a form of collective "might is right" approach: the unfortunate together are more powerful than the fortunate)
  • "Since each of us by defending this universal right is defending their own rights, it is a desirable agreement (social contract) for the majority."
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  • It's a lot of detail to think about, but fortunately Game Theory has proven that cooperation is better than trying to go it alone.
    – Scott Rowe
    Commented Sep 14, 2022 at 20:56

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