A drug treating seizures in small children formerly sold for $40 per vial. Mallinckrodt, the manufacturer, has raised the price to $39,000 per vial, causing one city in Georgia to expend over $2 million for just one employee’s child.  Yes, the manufacturer has “reasons” and the story is more complicated than the headline. Regardless of this complexity, does this pricing bother you? And how would your perception change if this were your child receiving the medication?
Classical ethics and religious duty meet science and economics in the current healthcare debate. The “Big Question” that dogs both the defense of the current ACA system and the several proposed expansions is “Why should I pay for your healthcare?” Let’s try on a few answers to that question and see how they fit.
We could start with Genesis…
The well-known reference in the title of this post is one of the first questions asked in the Bible’s Old Testament. First son Cain kills second son Abel, and then denies it, with this rhetorical question to God, “Am I my brother’s keeper?”
Regardless of whether this account is historical or mythical, the question is a very old one in human culture, and familiar to Christians, Muslims and Jews worldwide. Yet, while much of the rest of the Bible teaches that the answer to the question is “Yes, you are,” humankind has frequently denied this responsibility from the time that this story appeared.
We each have our own “wiggle room” answer here (perhaps,“That guy in the emergency room is not really related to me”). And I am not personally handing out cash for other people’s medical care either, so don’t get in line. So let’s look beyond our society’s religious tradition. 
Throwing in a little Kant…
From the perspective of classical philosophical ethics, Immanuel Kant (1724–1804) is credited with citing the ethical dilemma of “ought implies can.” This means that, if I tell you how you ought to behave, I am also assuming that you indeed have the ability to achieve that which I am requesting you to do.
This conditional ethical duty runs into the classic economic argument that healthcare is a service which has natural scarcity, and thus an unavoidable cost that someone needs to bear. The free market economist thus says, “We simply cannot direct unlimited health resources to every person.”
But that is not what is happening in the world’s democracies who come closer to universal healthcare coverage for their residents at equal or better results compared with the United States. We are talking more simply here of (1) providing some basic “floor” standard of healthcare, usually with shared cost from taxpayers and employers, and (2) putting an economic stopgap on “the worst cases” of illness and corporate overcharging in order to protect sick people from financial ruin (i.e., “real” insurance, not the current fake-y kind).
The first goal is certainly feasible, with lots of good examples worldwide outside of the U.S (which we routinely ignore). The second raises some interesting ethical questions like “How much is my loved one’s life worth?” in an economic sector where technology and profit options abound. And yet, these same countries have found a variety of ways to minimize healthcare bankruptcy with less emphasis on price as the primary filter.
A persistent myth about American healthcare is that poor people can always go the nearest emergency room when they need to. The reality is that hospitals have very limited obligations when it comes to the uninsured people who show up, mostly to make sure they are not dying. Emergency rooms are usually lousy places to get “healthcare.” In addition, poor and uninsured people will still get financially hounded for that visit at the facility’s “rack rate,” which is usually far above what an in-network insured person will pay for the same services. When the hospital gives up trying to collect from you, there is an entire industry of bill collection bottom-feeders who will hound your relatives forever. 
Thus, there is an economic argument here as to the best way to optimize the cost and services of healthcare, but “We just can’t afford it” is a crappy, lazy answer.  With the spiraling deficits caused by the 2017 tax rate reductions and simultaneous “no limits” military spending, economic conservatives in the U.S. have forever forfeited any moral voice as to any “We can’t afford it” objection.
John Rawls and the “veil of ignorance”
I get it. You don’t want to pay for the healthcare of some “undeserving” person. The best “brother’s keeper” argument is the one that turns this question around. When you are faced with expensive medical treatment that exceeds your healthcare plan’s limits, or when you lose your job-related healthcare coverage, or when an ambulance takes you to the “wrong” emergency room not in your network/cartel, what is my obligation to you?
Ethicist John Rawls (1921–2002) set out his famous “veil of ignorance” thought experiment, which has perfect applicability to the healthcare debate. Rawls asked us to imagine what kind of world we would want to have if we had no idea where and under what circumstances we might be birthed. If we did not know whether we would be coming out of the chute as rich or poor, male or female, or having some sort of disability, or perhaps being born into a socially-repressed racial or ethnic group, how would we want society to treat us? 
If you can imagine wearing this “veil” and cannot see what kind of healthcare you or your family would require, nor know what level of private insurance would be available to you, what kind of system would you hope to see in place when that veil is removed? If you answer, “The current U.S. system,” then I suspect you have not been getting around much. You likely know little about how other countries have addressed this problem. And you likely have not spent much time around families who have faced serious health challenges, only to find that their plans were inadequate. Or those who have lost their jobs because of their illness. Or those who made bad Medicare plan bets after being sucked in by misleading commercials on the television.
In short, if you are “betting the farm” for your family’s security on the current system in the United States, you need to do some more research into the reality faced by millions of Americans who enter the “dark side” of the healthcare system annually. The dice are rolling on your family right now.
John Rawls defined justice as that set of actions which are of “the greatest benefit to the least-advantaged members of society.” When it comes to healthcare, it turns out that this criterion would actually work pretty well for the vast majority of us. I am not “better off” by keeping you sick and poor.
- Contrary to popular opinion, the “insurers” servicing many cities and companies are not really insurers, rather they act primarily as administrators of self-funded, shared coverage pools. See this earlier post. Also, ever the ethical corporate citizen, Mallinckrodt has just reached a $1.6 billion settlement of claims against its opioid business.
- American Christianity, including/especially its leaders at the top of many denominations, has not fared well in recent years in living up to its traditional ethical creeds. See more on this subject here.
- See my earlier post on “Grease, friction and Amway markups in healthcare” for more about the “stupid stuff” in the U.S. system. And if you have not really looked at how countries comparable to the U.S. resolve this problem, read “Three options between the ACA and Medicare-for-all.”
- The irony here is that much of this “bottom-feeder” debt can be purchased for pennies on the dollar. Churches and other organizations have done this in order to free people from this never-ending troll industry, but any billionaire could free thousands of people from perpetual medical debt with the change that falls from their pockets. See John Oliver’s $15,000,000 medical debt giveaway (which cost only $60,000).
- For more on John Rawls, read “John Rawls and justice ethics.”