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.