The post in which I pick a fight with Jake

Has anyone noticed how my sciblings are really ornery at the moment?
We’ve got PZ bringing out the angry stick over Wilkins’ criticism of Dawkins. Physioprof is getting ready to pop Greg Laden in the nose over this thread (and I tend to agree it needs a rewrite).

And then Shelley broke my heart by posting
this video mocking anesthesiologists that I posted a couple months ago. And here I thought my sciblings paid attention to me *sob*.

Mommy and Daddy fighting and my sciblings ignoring me are making me feel insecure and frightened and as a result I’m going to lash out at Jake for this libertarian nonsense. At issue is this article in the Lancet which makes the suggestion that the poaching of doctors from poor African countries should be banned by international treaty. They make a compelling argument, and I tend to agree that it’s a grossly immoral practice that results in harm to millions.

But Jake finds it unbelievable. Why?

What I am aghast at is the cavalier attitude that this article expresses towards the rights of the health care workers in question. In indicating that the health care worker “poaching” violates the rights of Africans, in what way are they construing the rights of the health care workers? Have they concluded that the nations in question are entitled to their own health care workers? Are they implying that the health care workers are a nation’s property?

True, they do include the obligatory homage to the health care workers’ rights:

However, this admission contradicts what they say about the rights of African citizens demanding care. Let me make this clear. The authors assert that the individuals in Africa have a right to health care. On the other hand, they assert that the health care workers have right to mobility and the right to pursue a career under any circumstances they find most fortuitous. Does the health care workers right to mobility not include the right to converse with and interact with any organization they choose? The authors seem to suggest that the health care workers should exist is some sort of socially beneficent darkness in which they have rights but no knowledge by which they could appropriately exercise them.

One of the critical problems here is the failure to recognize that states invest significantly in healthcare worker education. I can’t speak to the policies in each of these nations, but as a generalization, medical education does not occur without state subsidy. Here in the US, entitlement programs contribute about $100k a year for each resident’s training (they get paid about half, and the hospital takes the rest), and medical student education is heavily subsidized by state and federal governments. Your tuition, as ridiculously high as it is, is only a fraction of what it costs to educate a medical student. I also am secretly hoping that Jake is in the MSTP program. It amuses me endlessly when people are libertarians while receiving education that is 100% subsidized (and stipended) by the federal government.

My point is that yes, the government does have enough invested interest in medical education that they’re naturally going to expect a return for that investment. When rich states actively take doctors from poor states, it’s a truly disgusting and unethical behavior that is effectively stealing money from already strapped states. From the Lancet article:

In comparison, by recruiting Ghanaian doctors, the UK saved about £65 million in training costs between 1998 and 2002, while their contribution to service provision is estimated at around £39 million a year.30 The benefiting countries should make amends through supporting repatriation of professionals who have left the country, training initiatives, the building and staffing of new health schools, and support for the development of retention frameworks, including improved salaries, pensions, recruitment of retired workers, and rural-worker incentives.

We have money to pay for healthcare (ok, maybe not but more than these countries). It’s really screwed up that to save money on our healthcare training we’re letting poorer countries do it, then just snag their trained docs.

Jake however disagrees and brings up some really silly libertarian views on what our rights as Americans entail.

Defenders of this proposition might respond: it is not the rights of the health care workers we would like to curtail. We just want to limit the deleterious behavior of other individuals in the West who would steal them away. Let me give you three reasons this definitely has to do with the rights of the health care workers:

* First, the notion that they are “stolen” or “poached” or “lured” implies that their natural location is in their country of origin. This implies ownership of those individuals by the state.

* Second, each worker has the potential to have a considerably better life in the West. For every active impediment that they place in the way of achieving whatever aspirations they desire, they are in essence placing a fine on them. Worse it is placing a fine on them for an utterly arbitrary reason: where they were born.

* Third, the exchange of information between the recruiter and the recruited is a transaction. Transactions include two willing participants. You cannot penalize one without affecting the other.

This whole debate reveals why the notion of health care as a positive right is preposterous. Health care is provided by the labor of individuals. As a consequence, it is a product with a non-infinite supply. In asserting that health care is a right, you assert the right to appropriate the produce of the labor of others. You positive right contradicts their liberty.

And here the libertarian naivete strikes with a vengeance. To point one, yes, investment in citizens by a state can reasonably result in that state demanding a service in return. This is hard if they leave the country. As far as the second point, no one is saying they can’t leave the country. What they can’t be doing is getting a medical education on their countries dime, then run off with it to a rich country. If they want to educate themselves in the US on the States’ dime, no worries. A brain drain is still in effect, but at least it’s not additionally stealing resources from their home country. Finally, as to the third point I’m afraid Jake’s going to be in for a shock when he gets his MD. As a doctor you have all sorts of restrictions on your rights. You are a professional. You have added responsibilities and higher standards. You lose certain rights of free speech, you lose certain privacy rights, and you are subject to professional punishment and discipline for things that would never apply to most other jobs. Same with lawyers and most other professions. Ask a lawyer if, as a free citizen she could, for instance, insult a judge? Nope.

And can we please just not even go into how silly this notion is that there are rights that have no cost in the form of money or labor of others? All rights are “positive”. Your free speech rights are protected by all sorts of people, if you want to get a bunch of Nazis together, you better have cops there too. If you want to own guns, someone is going to regulate them, pay for the damage they cause and pay the trauma bills when you shoot your ignorant ass or someone else. Your right to trial costs the time of an attorney, a judge, a jury etc. All of our rights result in costs to government and in the form of labor of other individuals, this is a silly division.

Then Jake goes way off the deep end and was guaranteed to piss me off by quoting a goddamn Randian

To push this point further (and probably enrage quite a few of you), I cite this passage by Leonard Peikoff of the Ayn Rand Institute (Hat-tip: Kevin, MD):

The American concept of [rights]…is officially stated in the Declaration of Independence. It upholds man’s unalienable, individual rights. The term “rights,” note, is a moral (not just a political) term; it tells us that a certain course of behavior is right, sanctioned, proper, a prerogative to be respected by others, not interfered with–and that anyone who violates a man’s rights is: wrong, morally wrong, unsanctioned, evil.

Now our only rights, the American viewpoint continues, are the rights to life, liberty, property, and the pursuit of happiness. That’s all. According to the Founding Fathers, we are not born with a right to a trip to Disneyland, or a meal at Mcdonald’s, or a kidney dialysis (nor with the 18th-century equivalent of these things). We have certain specific rights–and only these.

Why only these? Observe that all legitimate rights have one thing in common: they are rights to action, not to rewards from other people. The American rights impose no obligations on other people, merely the negative obligation to leave you alone. The system guarantees you the chance to work for what you want–not to be given it without effort by somebody else.

Do you see how silly this is? For one thing, the Declaration of Independence is not the document that defines our rights in this country. It’s a nice little piece of writing but lacks any legal significance to our rights as citizens. That being said, his arguments are still absurd. These rights put all sorts of obligations on people. Your right to property is protected by police (and half a dozen other things). Your right to liberty costs the time of the courts and the service of your fellow citizens against their damn will. There are no rights that come with no responsibility as citizens, or costs to society and government.

Finally, you do have a right to medical care in this country already, even if it’s not explicitly guaranteed. You might not get free plastic surgery but if you have zero cash and you need medical care (say for a gun shot wound pursuant to the 2nd amendment) you get it and the state eats the cost. How we pay for the inevitable provision of medical care is the issue. We’re not going to stop treating people. As professionals, we really cant. But we have to find a way to pay for it so the damn medical system doesn’t collapse.

As far as the African docs go we could find solutions less drastic than criminalization, but that should remain an open option. For one thing states could make it a more explicit contracts with their docs to ensure they spend a significant portion of their career in-country in exchange for their training and certification by the state. Leaving the country makes such contracts very hard to enforce, but it might make it clear the obligation you have as a doctor to serve the citizens of your country. Libertarians may not like that obligation, but if they’ve got a problem with it, then they probably shouldn’t become docs.


  1. I do have to ask – why should the writers in the Lancet give a toss about the American Declaration of Independence? Other than it means you don’t pay us rent any more.

    I’m unhappy with the suggestion that we should have a treaty to stop doctors working in the West, on the other hand it does look embarrassingly like exploitation. Perhaps the solution is to pay African countries suitable recompense for the skilled workers we are bringing over.

  2. Duae Quartunciae

    Here, here. I was very glad to you see pick up and address this matter. I was disturbed by Jake’s post, but did not take the time to comment. You’ve nailed the problem.

  3. Dan Riley

    The “right” answer seems obvious: explicit contracts (as you suggest), and an international treaty enforcing said contracts. In order to be internationally recognized, contracts should be voluntary (i.e., it should be possible to get a medical education and license without signing one, albeit at much higher cost), and there should be a (high priced) buyout provision. Libertarians shouldn’t object to enforcing a contract voluntarily entered.

  4. This is a very interesting argument. Internal to various African countries in which I’ve worked, there is yet another layer. This is not necessarily related to highly trained health care workers (M.D.s), but very much related to the more pedestrian health care workers, and relevant to all other areas of “expertise” in the professional and business worlds.

    This has to do with community based development. Let me explain with a story based on real life contrasting two situations.

    Version A:

    Hiltonomnitree (a fictitious international hotel chain) decides to open a resort in a remote area of Africa, where “semi tribal” (let’s talk about what that means some other time) people are currently living. They hire an architect, and engineer, a community relations manager, contract a builder, hire and begin to train managers and middle level management including restaurant manager, bar manager, sommelier, etc.

    A VP at Hiltonomnitree is in charge. One day, the community relations manager comes running into the VP’s office and says “Hey, I’ve to a local guy here who, it turns out, can actually tend bar. He lived int Bigobvillia (the main city) for a few years and tended bar in USKRUD Oil’s country club. It would be great to hire him.”

    “Only if he’s really as good as you say” the VP intones.

    Two weeks later, the community relations person comes in and says “Hey, there’s this woman who we should hire as a hostess for the resturant. She has no background or education but she’s really nice, smart, and really wants to do something on this project. She’s highly motivated, and it would be great to have her representing us and the community”

    “Only if she’s really as good as you say” the VP intones.

    And so on and so forth.

    After a few years, the resort is built and is very successful.

    Version B:

    The same as above but the primary agency is not Hiltonomnitree, bur rather, an NGO. And, in this case, the Community Organizer is in charge.

    The same project proceeds, but at every step of the way, the person carrying out the job (designer, building contractor, bar tender, host/hostess, day manager, night manager, restaurant manager, etc.) is a person from the local community.

    This is a community with 750 people, of which slightly more than half are: babies, really old people, individuals with some other reason that they are simply unavialble for involvement in this project. So there are about 300 people from which to chose about 35 individuals who will:

    1) Be available
    2) Be interested
    3) Be good enough

    to do these jobs that no one in this community has ever done before in all of history.

    A few years later, the project is a bunch of abandoned buildings and bitter memory, and is in fact used for only one purpose. As evidence that “these people just can’t do this sort of thing on their own.”


    Mark: The reason I came over her originally was to thank you for your intervention. I really do prefer to take criticism and use it rather than repel. But I am an adult human, not a poorly behaved child or a badly trained dog, so when someone comes out of the gait bitching at me, I’m not really even remotely interested in what they Have to say. I do not believe that criticism is valid no matter how it is delivered. I believe that how something is delivered is part of the civil nature of our discourse, and we get that straight first, then talk. This is not hard to do.

    I appreciate your reasonable approach.



  5. I think disagreement in the hive is a good thing. For one thing, it belies the recent critisms of incestuous blogging. For another, it’s just good to have healthy disagreement and debate among intelligent people.

    Just to toss this in, I couldn’t function in my clinic without doctors from the developing world. Not enough American grads want to go into internal medicine. Perhaps if we subsidized their ginormous medical debt…

  6. A contract is definitely the answer. For example, I can’t see how Jake would see the contracts that the U.S. military makes medical students sign as any infringement upon freedom. In return for a free ride at the military’s expense, newly minted physicians are obligated to serve as doctors for a fixed period of time in the branch of the military that paid for their education.

    I also agree that, if Jake is an MSTP student (that’s Medical Scientist Training Program for those not familiar with it, a program that pays for a student to get an M.D. and a Ph.D.), it would be particularly amusing to see his Libertarian (big-L) complaints. For one thing, even the MSTP (and various government training grants) often have a clause that requires the student, in exchange for a free medical and scientific education), to commit to an equal number of years working in an academic setting, so that the beneficiary of the funding doesn’t go off right away and get a high-paying private practice position. I signed such a contract when I received training funds to do my Ph.D.; I assume the MSTP program has a similar requirement. Of course, if one’s going into the MSTP program, one plans on being an academic physician anyway, which means that the payback requirement isn’t in the least bit onerous.

  7. This sentence:

    “For one thing, even the MSTP (and various government training grants) often have a clause that requires the student, in exchange for a free medical and scientific education), to commit to an equal number of years working in an academic setting, so that the beneficiary of the funding doesn’t go off right away and get a high-paying private practice position.”

    should read:

    “For one thing, even the MSTP (and various government training grants) often have a clause that requires the student, in exchange for a free medical and scientific education, to commit to an equal number of years working in an academic setting, so that the beneficiary of the funding doesn’t go off right away and get a high-paying private practice position.”

    It’s known as the “extra parentheses” disease…

  8. Another Anonymous Poster


    We did not have to sign any such contract at any point during our tenure in the MSTP here at Virginia. However, in my experience there tends to be a tendency to ‘shun’ those who decide not to go into academic medicine, though of course there’s not much legally enforced way to make someone pay you back via a system of shame.

    That being said, I’m not sure how great of a deal it would be to use an MSTP to fund a private practice. While I realize that the average med student comes out with ginormous debt, my PhD took me six years. That’s six years of salary that I missed out on. And, specifically, that’s six years of end-career private practice salary, since the crappy residency and early career salary will end up being the same. I’m not sure if that trade off would put me financially ahead.

    In addition, my experience is that graduate school can be miserable for someone who isn’t truly motivated, and that those individuals end up dropping out midway through the PhD years.

  9. Graculus

    Hey Greg, in your scenario does the NGO have a big twirly mustache and an English accent? The playground fantasies of Libertarians are so much more honest when done as the “Perils of Pauline”, with pure-hearted capitalists rejecting the blandishments of greedy statist villans.

    The problem, of course, is that Libertarians see everything as a fairytale, where there are only two ways to do things. The narrow way where money has the rights and people have the responsibilities (to money, but not to other people) and the broad road of co-operation that leads only to failure.

    Of course, reality isn’t a fairy tale, so I’ll stop the Thomas Rhymer references now.

    The problem with Libertarianism, as is obvious from Greg’s post, is that it is a philosophy of parasites that denies that the host is entitled to exist, and then accuses the host of being the parasite.

  10. I am not a Libertarian, but coming from a developing country, and knowing what developing country doctors must cope with throughout their working lives, I think it is a bit rich to compare the resources spent on training doctors in the US with that in developing countries.

    While a shortage of doctors may be a problem in developing countries, it is not the main issue that “results in harm to millions”. All the doctors in the world will do nothing if you don’t have the resources to buy hospital supplies, drugs, etc. “Poaching” doctors is not a major source of concern. The dismal health budgets are, and they incidentally may lead to doctors choosing to leave.

    Plus, the statement that poaching doctors “results in harms to millions” means that each individual doctor is responsible for harm to tens of thousands. Because, of course, it’s not all the responsibility of evil organizations recruiting doctors. If anyone is aware of the consequences of their departure, it is the doctors themselves. So why do they leave? Again, I would say that it is out of frustration with their current circumstances, which are mostly beyond their power.

    One last thing. What follows is my gut reaction to this post, and it is not rational at all.

    I have tried not to be overly sensitive, but seeing Americans (and Europeans) discuss how these people should stay in their home country is really upsetting. It makes me angry. You were extremely lucky to be born in one of the richest societies of the planet. Billions of people live every day in conditions you cannot even imagine. If some of these people manage to study medicine and graduate, who are you to say that they are morally wrong to leave? You are not migrating to Africa any time soon, to try and sort things out. Why would you say that someone who was *much* less lucky than you in the birth lottery, actually had to grow up in the developing world, and is trying to get out is morally questionable? I’m not saying that everyone there wants to leave their country (it is a *very* tough decision to make), but it someone does, I don’t think you have moral grounds to object to their decision. And since they are intelligent beings, shifting the blame to the organizations that provide them with the opportunities to leave is not different from blaming them.

    Ok, rant over. Sorry about that.


  11. But Maria I didn’t suggest at all that people have to stay in their country. I’m just saying that if states subsidize medical education, which they must do, then they have a right to expect recompense from citizens that are trained in their state.

  12. Anonymous

    From most countries when you come to the US on a working/study visa there is a requirement that you return to your home country for a number of years following visa expiry (or get onto a citizenship track). This was specifically designed so that following training in the US you took those skills back to your home nation. It might seem sensible that a similar system should operate in Europe and other states.
    Of course the points made by Maria are extremely salient, and I feel deeply uncomfortable about tying people to their “home” nation, but the reality is that we accept such people into our health services because they save us money and effort over training our own citizens. By mandating some payment back to originating nations, or some other method, this would at least level the economic playing field for employers. Of course this should be just one of many things we should do to try and encourage all countries to build capacity in areas such as healthcare – including the US and Europe which have used the developing world as a source of doctors to avoid their own chronic lack of personnel.

  13. Mark,

    I agree that is a good point, states do subsidize medical education. But I would argue that in most developing countries the subsidy stops when classroom instruction ends. At that point, doctors for the most part enter extremely low paying jobs as interns and residents. These jobs may pay better than others, but for the most part the subsidy runs from trainee doctors to the state. I believe the doctors who leave are experienced, and I don’t think it’s obvious that at that point they owe their state anything for their education.

    This is of course subject to data, but it is my impression.

  14. grasshopper

    … As professionals, we really cant. …

    cant: noun 1 insincere talk, especially with a false display of moral or religious principles. 2 the special slang or jargon of a particular group of people, eg thieves, lawyers, etc. verb (canted, canting) intrans to talk using cant. canting adj. cantingly adverb.

    For want of an apostrophe, an argument was lost.

    (sorry, I couldn’t help myself.)

  15. Graculus:

    I’m not sure I grok the libertarian connection here. Anyway, the NGO in this case (and this may be typical) is acceding to political pressures that arise from a history of paternalistic outsiders running everything in rural areas. There is something to be said for considering that, however, I think there are other, better solutions.

    As an Africanist working in various countries for the last 25 years, here is what I’ve seen again and again:

    You meet the people running the government in a country somewhere, and you see a lot of talent, but also a lot of lack of talent. Makes one wonder if there even is talent there. Then, you go to a major International Studies program somewhere (like in the US, but could be in Europe) and you meet dozens of people from the same country who are so capable and well trained that any half dozen of them could form a very effective core cabinet for any country in the world, especially the country they are from.

    Why are they in Gainesville Florida or Boston, Mass instead of Wherever, Africa? Usually it is not because of the pay or the opportunities. Usually it is because they are exiles.

    Now, it would be a gross generalization to apply this across the board, and medical professionals may represent a very different issue. But for some reason it seemed appropriate to throw this in.

  16. MarkH says

    But Maria I didn’t suggest at all that people have to stay in their country. I’m just saying that if states subsidize medical education, which they must do, then they have a right to expect recompense from citizens that are trained in their state.

    So Hoofnagle, how much do you think you should have to re-pay to the commonwealth of Virginia before you are allowed to take your subsidized education out of state?

    Oh and I’ll be sure to let me brother in law, studying medicine in Addis Ababa, know that a privileged class white boy has pontificated that he and his family should have to live in poverty to satisfy said leftist punk’s arrogant worldview.

  17. Graculus

    I’m not sure I grok the libertarian connection here. Anyway, the NGO in this case (and this may be typical) is acceding to political pressures that arise from a history of paternalistic outsiders running everything in rural areas. There is something to be said for considering that, however, I think there are other, better solutions.

    But not scenario A.

    I don’t recall anyone who has actually worked over there (and I have friends involved with different NGOs and with CUSO) who have had any problems whatsoever with training “semi-tribal” folks to do “entry-level” jobs. The idea that you can’t train the locals to be wait/kitchen/bar staff is on its face, ridiculous. Perhaps you aren’t going to stumble over a Cordon Bleu chef in the village, but you will probably have no problem finding someone who has the talent and enthusiasm to eventually become one… but you have to start somewhere, and that person may start as your soup wrangler.

    In the 1950’s Kemoya Kimeu was a barely literate “graduate” of a local Christian school in his hometown. Do you recognize the name? He is the one that found Turkana Boy, when he was the head of Kenya National Museum’s “Hominid Gang”. He’s currently in charge of all prehistoric sites in Kenya. When he first got a job “digging for bones”, he thought they meant moving graves. In scenario A the resort wouldn’t hire him… no experience. He started as a labourer for the Leakey team, and discovered his enthusiam and talent.. which was then recognized and promoted.

    The KNM (under Richard Leakey) offered access to the fossils on one condition… the Western researchers who came to Kenya (because the fossils weren’t leaving) had to teach a Kenyan student while they were there. That is what you call a “win-win”.

    BTW, my mother, now retired, taught vocational school to Western children with far less native brain-power and talent than you’ll find in most “semi-tribal” places (that’s why they were in the vocational stream). Scenario A is ridiculous.

  18. Ah, my favorite troll is back. He’s almost as fun as scam sham sam was.

    Lance, I’m funded almost 100% by the federal government through MSTP and the subsidization of medical education is largely federal. Some states may be different, but VA does not contribute significantly to medical education unless it’s re-directing federal entitlement money through medicaid or CHIP. The state gives very little money to UVA, and the hospital is run as a separate corporate entity. And yes, I plan a lifetime of performing the job I was trained to do – academic medicine in the United States. While they do not require us to sign contracts to that effect they easily could and for quite a few training programs they do so. In particular, training programs that subsidize MD education in order to increase coverage in underserved rural areas do make the students serve a certain amount of time serving rural populations in the state in exchange for funding their medical education. It’s a contract. Pea-brained libertarians like you understand contracts right?

    Further, it should be clear to the non-retarded that in this instance I was referring to “state” as in “country”. Not “states” as in the places defined by little lines dividing up our happy little federalist enterprise.

    As usual you’re flying off your reactionary little handle, not even reading the material in the post or comments before spouting off about what you are totally ignorant of.

  19. Oh I read your post Mark. How fortunate that you happen to live in a prosperous modern country where you want to spend the rest of your career. See how nice it is to make your own personal choices. You of course want to make that choice for others, like my brother in law.

    How silly of him to think that he should be free to practice medicine where he, not you, would choose to.

    The state gives very little money to UVA.


    The commonwealth of Virginia provided $846 million for higher education, including $68 million for the University of Virginia.(Most recent University of Virginia financial statement.)

    Small change to a big shot socialist like you I guess but quite a bit more than the entire modest budget of Addis Ababa University.

    They do not require that medical school students indenture themselves to the state as you would like. The government of Ethiopia realizes that most graduates will stay in the country because, well it’s their country. The ones that don’t will send back hard currency that will help fuel the economic development of the country and further enable the education of its people.

    Ethiopia was devastated in the 1970’s and 1980’s by the socialist Derg. They have no wish to return to the socialist policies that you wish to foist upon us.

  20. The state gives very little money to UVA.

    Wow Lance you little troll. How dare I say something so untrue!

    Oh wait. I didn’t say that. I said that VA doesn’t significantly subsidize medical education, it is largely federal. Nice job cherry-picking what I say when it’s clear to anyone I’m talking about my education at the medical school, not the University as a whole. Keep bending over backwards to read things I’m not saying though. It just makes me look good.

  21. good weblog…hope be successful always.

Leave a Reply

Your email address will not be published. Required fields are marked *