Pure Pedantry

Unbelievable.

Unbelievable is simply the only word that can describe this article in the Lancet. Citing problems with retention of doctors in under-treated populations in Africa, Mills et al. argue that direct recruitment of doctors by groups in the West should be criminalized and the individuals perpetrating it prosecuted in the International Criminal Court.

The authors present clear and compelling data to support the assertion that there is a brain drain of health care workers from Africa. Further, they show that this brain drain is exacerbating an already severe doctor shortage in Africa. Thus, the brain drain will have inevitable consequences for Africans, not the least of which is that a lot of people are going to die.

I do not dispute any of these findings. (Kerry Howley, writing in the LA Times, does, however. He She argues that the brain drain is not the real source of health care shortages. Read the whole thing.)

What I find absurd is the solution that they propose.

To wit:

Although the active recruitment of health workers from developing countries may lack the heinous intent of other crimes covered under international law, the resulting dilapidation of health infrastructure contributes to a measurable and foreseeable public-health crisis. There is now substantial evidence of state and organisational involvement in active recruitment of health workers from developing to developed nations.

There is no doubt that this situation is a very important violation of the human rights of people in Africa. In recent years, international law has developed the notion of international crime to strengthen the accountability of individuals for serious violations. One indication of the gravity of acts and that they deserve treatment as international crimes that has been developed by the International Criminal Court is that they create social alarm.

Active recruitment of health workers from African countries is a systematic and widespread problem throughout Africa and a cause of social alarm: the practice should, therefore, be viewed as an international crime. Recruitment of health workers from Africa is an structured initiative led by recruitment organisations, but clearly sanctioned by countries that then accept these placements, such as Australia, Canada, Saudi Arabia, the UK, the United Arab Emirates, and the USA. Active recruitment is considered unethical under many national policies, leads to negative health outcomes, and undermines the right to health as asserted in the Universal Declaration of Human Rights, various International Covenants, and numerous declarations and legally binding treaties including the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination against Women. (Citations removed. Emphasis mine.)

And later:

When the international community permits for-profit companies to actively entice overworked and often underpaid workers away from the most vulnerable populations, it is contributing to the deterioration of essential health-care delivery. Improvement of the health of the world’s poor is a challenge that the international community is failing to adequately address. Current international treaties and commitments are severely compromised if we are unwilling to adhere to their principles and prevent obvious harms to poor people. Clear, enforced regulation is needed to prevent recruitment companies from enticing health workers away from their local work, and developed countries should adequately compensate less-developed countries for the human resources they have lost and continue to lose.

Let’s set aside the practical issues of whether it is even feasible to withhold information from these individuals about the benefits that can be gained from moving to the West. Let’s set aside trying to justify a standard that a crime is something that “creates social alarm.” (How the Rule of Law is to be maintained under such a standard is utterly beyond me.) Finally, let us set aside that international organizations and agreements consider it unethical to help someone improve their lot through recruitment.

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:

We, of course, recognise that while there is a right to health for everyone, there are also health-workers’ rights to consider. Health workers should have freedom of movement and choice of where they live and work, just as any workers should.

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.

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.

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.

The right to life, e.g., does not mean that your neighbors have to feed and clothe you; it means you have the right to earn your food and clothes yourself, if necessary by a hard struggle, and that no one can forcibly stop your struggle for these things or steal them from you if and when you have achieved them. In other words: you have the right to act, and to keep the results of your actions, the products you make, to keep them or to trade them with others, if you wish. But you have no right to the actions or products of others, except on terms to which they voluntarily agree.

To take one more example: the right to the pursuit of happiness is precisely that: the right to the pursuit–to a certain type of action on your part and its result–not to any guarantee that other people will make you happy or even try to do so. Otherwise, there would be no liberty in the country: if your mere desire for something, anything, imposes a duty on other people to satisfy you, then they have no choice in their lives, no say in what they do, they have no liberty, they cannot pursue their happiness. Your “right” to happiness at their expense means that they become rightless serfs, i.e., your slaves. Your right to anything at others’ expense means that they become rightless.

Caveat #1: I am not saying that health care is not highly desirable and that we should take steps to ensure the creation of more of it. Quite the contrary, I think that by treating it as a non-good that will always be there when we need it, we have diminished its supply. When a good is desirable, you need to pay more to get it. People tend to assume that because health care is important, it will just appear by spontaneous generation when they need it. This clearly is not true.

Caveat #2: Nor am I saying that health care delivery in Africa — particularly with respect to HIV/AIDS — is not a very serious issue that deserves immediate international attention. I probably differ from the hardcore libertarians and Objectivists with respect to this issue. Most would argue that since it is not our moral bad, we have no horse in that race. We have no moral imperative to act. While I don’t feel ethically obligated to save everyone suffering in the world, I think it is bad policy to let millions die without doing something. It would very likely lead to instability and unfortunate consequences for all of us down the road. Call it enlightened self-interest.

What I am saying is that this policy would necessarily curtail the rights of the health care workers in Africa. Further, the only policy that I know that would help solve this problem without violating someone’s rights is to organize the incentives so that health care workers find it desirable to stay in Africa. That’s right. In order to fix this problem, we are going to have to pay for it. The frustrating part is that the authors mention this very strategy:

To encourage the retention of health workers, governments and policy makers need to use incentives and to address the reasons for migration: low salaries, inadequate resources, long hours and heavy workloads, a threat of infections and violence, and lack of career development.

Why they couldn’t have written a piece suggesting this solution and only this solution is genuinely perplexing to me.

Organizing incentives such that is better for health workers to stay is not only the only reliable way to solve this problem, it is the only ethical way to solve this problem.

Hat-tip: LA Times

Comments

  1. #1 oljb
    March 7, 2008

    You had me until you quoted the Ayn Rand Institute. Libertarianism always seems more appealing until you realize it’s “all for me, none for thee” self-serving claptrap.

    I guess it’s easier to perceive medical care as something other than a positive right when you already have access to it by means apart from a government-secured entitlement.

  2. #2 Jake Young
    March 7, 2008

    I understand your frustration with the all or nothing approach of many libertarians and Objectivists, oljb. I would note, though, I am not an Objectivist. I posted that article because I think that Peikoff makes the clearest argument for why positive rights to goods contradict the notion of negative rights, not necessarily because I agree with everything he says.

    OK, so I posted it to be a bit provocative too. :)

  3. #3 oljb
    March 7, 2008

    Fair enough. And I generally agree with you- I’m in favor of people having a great freedom of movement and professional choice, and find the notion of the state controlling the lives of medical personnel to be unpalatable.

    But it’s certainly easier to hold those opinions when I won’t be the one that suffers the consequences of brain drain. In my experience it’s often the case that the most ardent libertarians are people who already have access to some degree of wealth or privilege and for whom a Randian paradise would be a deck stacked in their favor to begin with (i.e. not your average patient in Africa).

    In any event, thanks for the interesting post. I’m sure this will only become a larger issue in the coming years.

  4. #4 Mike P
    March 7, 2008

    But I’m not sure how the proper solution is to therefore stack the deck against your average doctor in Africa.

  5. #5 El Christador
    March 7, 2008

    Good one! That is, some of your comments overlap with some of my thoughts on the subject, and I had a lengthy rant going on about the item.

    The authors think an African doctor moving to the first world is bad. One wonders if a first world doctor moving to Africa constitutes an equal amount of goodness. And if so, why don’t the authors move there to practice there? Presumably because they’re not African doctors so they don’t “belong” in Africa and they’re not “owned” by any African country, or at least so I conjecture. That is, you’re exactly right that the underlying assumptions are that the country that produced the doctors owns the doctors.

    In essence, they think that if there’s a given new doctor, then it’s evil and heinous to assign that doctor to the first world rather than Africa, if the doctor is an African doctor. But if we produce a new doctor in the first world, then there’s nothing wrong with placing that new doctor in the first world rather than in Africa.

  6. #6 Caledonian
    March 7, 2008

    Neosocialists believe that everything is group property, even people. No individual can determine what can and cannot be done with resources and lives, only the group, and the group can make and enforce any decision it pleases.

    African doctors are leaving? That deprives the African peoples of their right to the labor and services provided by those doctors. What they personally prefer is irrelevant. They have no right to live their lives as they wish, because society is entitled to their skills.

    Society owns the people within it, they think. That is why making doctors in the First World and not sending them to the Third is bad, because that doesn’t deprive the Third World of its resource. A Third World doctor is a resource to their minds. Not a person.

  7. #7 razib
    March 8, 2008

    Kerry Howley, writing in the LA Times, does, however. He argues that the brain drain is not the real source of health care shortages. Read the whole thing.

    hm. should i tell will wilkinson that his life-partner is a man? ;-)

  8. #8 karlg
    March 8, 2008

    “Now our only rights, the American viewpoint continues, are the rights to life, liberty, property, and the pursuit of happiness. That’s all.”

    How can you reprint such ignorance? The Declaration states
    that we are endowed with “certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”
    Note the “among these” — they need not be all, as your Ayn Rand Instituter writes.

    Likewise the Constitution has a little provision called the Ninth Amendment which states, “The enumeration in the Constitution, of certain rights shall not be construed to deny or disparage others retained by the people.”

    Where do these people get off?

    As to the subject at hand, I’m sympathetic to the notion that medical care can be a human right; but criminalizing voluntary migration, under any circumstances, violates the United Nation’s Declaration of Human Rights (to which the U.S. is a signatory):

    Article 13.
    (2) Everyone has the right to leave any country, including his own, and to return to his country.

    Article 15.
    (2) No one shall be arbitrarily deprived of his nationality nor denied the right to change his nationality.

  9. #9 MarkH
    March 8, 2008

    I think you’ve gone off the deep end here Jake. The doctors aren’t having their rights violated. This is about criminalizing the poacher. And to some degree, doctors are the property of the state. It is impossible to have medical education without significant state subsidization, and although I don’t know the specifics of every single country in Africa, that’s a safe generalization to make.

    For instance, here in the US, your medical education is heavily subsidized by the state. Probably on the order of 100k/student. Resident training programs also receive about 100k/resident from government entitlement programs.

    You as an MD/PhD student if you’re in the MSTP program are entirely subsidized by the government I assume? So imagine if another country routinely poached us from the US after the government has spent somewhere around 400k educating us? Don’t you think they’d be a little pissed about the failure of a return in their investment? Don’t you think they’d start making us sign contracts that we won’t run off to another nation after getting a free ride?

    So basically, you have governments no doubt making investments in their bright citizens that is being undermined by an anti-social tendency of capitalism and a world market in doctors. While it would be wrong to tell those doctors that they can’t leave the country, I’m not sure it is at all wrong to say that richer countries should nose out of their business and stealing away the citizens they invest money in.

    I also am disappointed, once again, with the tendency of libertarianism to result in another principles over people position. This is a real problem, a drastic solution may be required. One thing might be to make African-trained doctors sign a contract saying they must practice in country for a set number of years after their training (we have that here in the US to try to drive docs into underserved areas). Another thing might be making headhunting practices illegal, and I wouldn’t be upset at all by such a measure.

  10. #10 MarkH
    March 8, 2008

    Also this positive rights stuff is total rubbish and prima facie absurd.

    Your right of free speech comes with a cost and the appropriation of the work of others. For instance, if you are a Neo-Nazi, you have a right to assemble, and the state has to appropriate the work of others to protect your ass.

    Your right to an attorney comes with the appropriation of the labor of an lawyer – and it is appropriation with pretty piss-poor compensation in most states.

    All sorts of rights have costs. Name a right in the constitution and money and labor is being appropriated to protect it.

    Remember too as a doctor you are a professional with duties above and beyond other citizens. You don’t get to be a doctor and maintain all your other rights. You technically surrender a good bit of your free speech and privacy rights as an MD. Don’t like that? Don’t be a professional. Being a professional comes with obligations that are different from that of other citizens. If you see an injured person you are obligated as an MD to help them, you don’t have a choice about it, and if you fail to you might just end up in front of the BPQA to explain yourself.

    There is a right to health care already in this country even if its not written down on paper. If you’re sick, you get care. The state eats the cost if you can’t pay for it. If you think there isn’t already appropriation of medical workers labor in this country that is in violation of this silly doctrine of positive rights of yours, then you’re in for a shock in 3rd year.

  11. #11 Caledonian
    March 9, 2008

    Some quick corrections:

    I also am disappointed, once again, with the tendency of libertarianism to result in another principles over people position.

    The idea that people are more important than principles is itself a principle. Your complaint is absurd.

    Your right of free speech comes with a cost and the appropriation of the work of others. For instance, if you are a Neo-Nazi, you have a right to assemble, and the state has to appropriate the work of others to protect your ass.

    It’s not the free speech that costs others, but the protection. The government isn’t appropriating anything – it employs people who chose to work for it, doing the job that they would then be doing.

    Remember too as a doctor you are a professional with duties above and beyond other citizens. You don’t get to be a doctor and maintain all your other rights. You technically surrender a good bit of your free speech and privacy rights as an MD.

    1) The idea that ‘professionals’ are distinct from other citizens is nonsense. A professional is simply someone who practices within a field to support themselves.

    2) Professionals do not surrender any of their rights. You do not seem to understand what the concept of ‘free speech’ does and does not imply, and how individuals may or may not choose to place restrictions on their own rights.

  12. #12 Antoni Jaume
    March 9, 2008

    Well, what if the local states set that to access higher education you have to enter a contract by which you have to supply the service that this education makes you able to do? Or pay someone else to do it.

    DSW

  13. #13 Caledonian
    March 9, 2008

    There are already lots of programs that will pay for a student’s education in exchange for years of service, often in places where physicians are scarce.

    No one is entitled to health care. No one is entitled to provide health care. And no one can be denied fundamental and rudimentary human rights merely because they possess valuable skills.

  14. #14 MarkH
    March 11, 2008

    Professionals do not surrender any of their rights. You do not seem to understand what the concept of ‘free speech’ does and does not imply, and how individuals may or may not choose to place restrictions on their own rights.

    Caledonian, are you a professional? A lawyer or a doctor? I somehow doubt it, because then you’d know how silly this statement is.

    Try being one sometime and being subject to discipline by the Bar or board of medical review. Yes, any time we want we can stop being doctors and be treated like anyone else, so ultimately we do have the all the freedoms of everyone else. But if you want to stay a doctor you sacrifice certain freedoms over your actions, your politics, your speech etc. Doctors, for example, can’t unionize in this country. Did you know that? We can’t collectively bargain. Our free speech is limited in several other ways and this is a good thing. There are specific proscriptions against speech as part of being a professional. Not just to protect privacy of your patients but as part of maintaining your professional demeanor and not promoting quackery. If you were to say, publicly comment on the medical treatment of a public figure – not even your patient – you could get in a heap of trouble. If you were walk down the street making suggestive comments to women and being a prick, you might just end up in front of the BPQA. If you were to simply call up a doctor practicing down the street from you and ask how much they charge for a service, you might just lose your license. Our freedom to move about is somewhat limited too. Believe it or not, if you were to just pick up and leave town you might lose your license for abandonment. There goes freedom of movement.

    Ask a lawyer sometime about the kinds of speech that can result in disbarment. I’m less familiar with all of their restrictions, but they do exist and they impinge on the types of speech that would be available to a non-professional.

    You simply have no idea what you’re talking about.

    Being a professional comes with specific responsibilities and restrictions on behavior that reflects that professional organizations have standards above and beyond that of ordinary folks. That’s the reality of it. If you want to still do these things, guess what, you can’t be a doc or a lawyer. You do not understand what being a professional is, probably because the word has been dumbed down to include any trained monkey worker.

    So yes, you choose these restrictions. And the people in Cameroon or wherever are also choosing to become doctors. And with that choice you sacrifice freedoms. All I’m saying is if they’re making that choice, their country and the professional association within it may have the right to say they might have to make a sacrifice of their freedom to move as a result or else deny them entry into their profession.

    The idea that people are more important than principles is itself a principle. Your complaint is absurd.

    Semantic nonsense. You know exactly what I mean by this statement, quit being a prick and over-reading it.

    It’s not the free speech that costs others, but the protection. The government isn’t appropriating anything – it employs people who chose to work for it, doing the job that they would then be doing.

    How does this not also then apply then to medicine and medical care? Take the British NHS for example. Doctors can choose to work for it or not. They can receive all private patients, or take NHS patients. You make it sounds like socialized medicine is the government sending doctors to a gulag and strapping them to millstones. Stop being so dramatic.

  15. #15 Caledonian
    March 11, 2008

    I’m sure this will come as a great shock to you, but non-professionals – that is, the common people – can also enter into contractual obligations that limit what they can say and do without legal ramifications.

    It will probably also come as a shock to you to realize that there is a difference between gaining the skills and knowledges necessary to be a doctor, and possessing a medical license to practice, and it’s possessing the license that entails restrictions on your actions.

  16. #16 simonb
    January 5, 2010

    Let’s face reality, This is clearly a matter in which Africans are suffering the effects of serious diseases and dying for lack of medical help, all so that people in the West can have their blood pressure checked more easily, closer to their homes, etc. Students in UK are queuing up to join medical training. Why do we need to recruit from Africa?
    A moral government would regulate this through immigration policy, in the name of common humanity.

The site is currently under maintenance and will be back shortly. New comments have been disabled during this time, please check back soon.