No need to pick a fight, but I will respond

MarkH, SciBling at denialism blog and fellow MD-PhD student, takes issue with my post about a move to ban "poaching" of doctors from African countries. I can't say I am entirely surprised, since I knew that post would be controversial. I want to respond to his -- in my opinion very substantive -- criticisms.

(You might notice that people on ScienceBlogs don't always agree. No worries. I have no expectation that a group of smart and diverse people will agree on everything, particularly in science. I respect the opinion of everyone who blogs here including Mark, so I don't lose sleep in they think I am wrong.)

I'm sorry if this is a bit discombobulated, but the criticisms of the post were very diverse. I want to deal with each in turn.

Issue #1: Does the government paying for doctors' education imply that they have to stay? Does this imply that the government owns them in some way? You're a libertarian, Jake. Don't you feel guilty taking so much of the government's money?

Mark argues that states do in a sense own doctors. This is because states invest a great deal in medical education:

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.

Yes, I would imagine the US government would be quite (justifiably) miffed if all of us MSTPs decided to emigrate en masse to another country. However, if the US government wanted to avoid this eventuality, they should have had us sign a contract in advance agreeing not to do so. (Orac asked in a comment, to Mark's post whether we are expected to sign such a contract for the MSTP. No, we are not -- or at least not at Mount Sinai.)

If we were required to sign a contract -- such as people attending medical school on the government's tab in return for entering the military for a certain tenure -- that is perfectly fine with me provided that each party is aware of the terms of the contract in advance. I actually considered doing that military gig before I settled on the MSTP. I don't see any abridgment of rights in someone voluntarily deciding to receive a benefit for a certain cost, even if that cost is labor in a particular setting for a particular period. Adults make decisions like that all the time, and it is totally fair for governments to make these sorts of deals to encourage people to go into socially desirable occupations. (If I ran the government, I would strongly circumscribe the "socially desirable occupations," but justifying why it doesn't bother me that the government spends on science is a post for another day.)

With respect to the MSTP, if the government said "you have to be an academic/doctor for X years," I imagine people would still participate in large numbers. (I am not certain whether I would have. I would have to think about it.) However, the government didn't do that. Presumably they didn't do that because they view having people with MDs and PhDs as being so desirable that they are willing to omit that clause in the contract to make it worth prospective students while. A similar logic presumably is being employed in the government subsidizing residency programs: having doctors is so desirable and doctors are in such short supply that they are willing to pay to get more of them. With respect to these cost-benefit analyses, the government is allowed to make whatever call it sees fit.

For those of you reading in, if you do not think they have made the appropriate cost-benefit comparison in this case, call you Congressmen and convince them to change the law. Before you call you Congressmen though, I would mention that MD-PhDs spend a long, long time in graduate education working hard and getting paid squat. If they get to be professors (maybe) they get paid reasonably well, but that job is still hard, hard work. No one I know is doing the MD-PhD for the money. Most are doing it because they love science. However, I guarantee that if it wasn't government subsidized very few people would do it. There are just too many sacrifices you are already making to have to also pay 400K. (Whether or not you think MD-PhDs perform a useful function, I will leave it to you to decide.)

Also, I would observe that a great many MD-PhDs do not end up being clinical scientists or scientists of any type. They have a huge problem already because a great many end up being straight doctors. In some cases, people are doing the MD-PhD to get into a better residency. So in the sense of "contract fulfillment" the MD-PhD program is already failing to receive 100% compliance. If NIH wants to improve that then they need to change the terms by which someone can receive MD-PhD education.

What I disagree with is the notion that because they are spending money on me, I am morally beholden to them. If that was what they wanted, they should have told me in advance and let me make the judgment whether it was in my best interest. For them to come back now and "change the rules" is just plain lying. It is lying in the same way that recruiters have been cheating people entering the military for the Iraq war. Further, as a practical matter it nearly guarantees that everyone in this program is not going to be as productive as they could be. They are going to be pissed off and feel cheated. People in my experience are willing mercenaries but not willing slaves.

My point is that the libertarian in me doesn't lose sleep in taking the government's money because my relationship with them is voluntary and contractual. In no way does the nature of my contract with them imply that they own me. The government pays a great deal of money training soldiers. Does the government own the soldiers? If they want to change that contract, so be it. I might do something different. The fact that I can do something different implies that I am their employee, not their slave. Further, I do not feel entitled to their money. I deeply appreciate the privilege of the public's money which allows me to do a job that I deeply enjoy. On the other hand, I do recognize that the public is giving this "gift" because they want something from me. We are involved in a transaction in which neither of us is being entirely altruistic.

(Just because I know people will ask, I fully intend to try to be a faculty member at a teaching hospital if I can find a job that allows me to do so. I fully intend to do research, see patients, etc. I have no intention of leaving this country. In this way, I am complying with what I think is the government's intention of our program, even if that intention is not explicitly contractual.)

Issue #2: Does being a doctor include submitting to a higher ethical standard that involves the surrender of one's liberties?

Mark also invoked a higher professional standard to show that the policy suggested is ethically acceptable:

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.

Mark is correct in noting that becoming a doctor implies additional ethical responsibilities. For example, I am not ethically (or legally) allowed to talk about my patients because that would violate my patient's privacy. However, while I agree with Mark that there is a higher ethical standard involved in being a doctor, I don't think that standard includes allowing others to define when and where you practice medicine. Saying that a doctor is ethically required to work for their patient's maximum benefit while on the job is different from defining the terms when they work for them.

Saying that doctors are because of professional ethics no longer at liberty to decide when they should work is tantamount to saying that they should be entirely altruistic with respect to their labor. I want to address this view particularly because I think it reveals a widespread misconception in the public about doctors and medicine. (I am not saying that this what Mark is arguing, but bear with me.)

Doctors are as a group pretty altruistic people. Say what you want about doctors, but most of them do genuinely care whether their patients get better. (This future doctor included.) Most of them are willing to go through a lot for the privilege of helping people. I have every reason to believe that this is true of doctors working in Africa -- probably to an even greater degree. However, this altruism has limits. Doctors are people. Most are not willing to completely surrender their personal lives and live in a state of ascetic poverty. Thus, I understand why a doctor working in Africa who is poorly remunerated, poorly appreciated, and possibly in physical danger thinks that is a bum deal, good feelings or no. We're doctors, not martyrs.

For people who find these limits to doctor's altruism offensive, I want to argue that you don't really want them to be entirely altruistic either. Which is the better guarantor of good behavior, self-interest or altruism?

Not everyone has the moral stamina for altruism. Not all of us are like Mother Theresa. This means that in any large group of people in a profession only a subset will be consistently altruistic. If that profession relies on that altruism for good behavior, then the results are going to be unreliable. In contrast, if incentives are aligned such that it is in an individuals self-interest to behave well, there is no problem. Some people will be altruistic and some will not, but all will be motivated to indulge in good behavior. (They may fail to be good, they may make mistakes, but it won't be because they are insufficiently humane.) Self-interest aligns private ethics with the public benefit.

This argument is hardly new. It is an argument that Adam Smith makes in The Wealth of Nations:

It is not from the benevolence of the butcher, the brewer, or the baker, that we expect our dinner, but from their regard to their own interest. We address ourselves, not to their humanity but to their self-love, and never talk to them of our own necessities but of their advantages. Nobody but a beggar chooses to depend chiefly upon the benevolence of his fellow-citizens.(Emphasis mine.)

This argument about self-interest being a better guarantor than altruism applies to doctors -- especially doctors in Africa. I think that it is awesome that doctors are altruistic, but the only reliable way to keep them working is for it to be in their best interest to do so. I think that Mark and I fundamentally agree that this is the best way to solve the problem of African doctors, but more on that later.

Issue #3 Positive vs. Negative Rights

Many people, Mark included, took issue with my argument that positive rights for goods contradicts the notion of negative rights:

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.

...

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.

Particularly, people seemed to object to my quoting Leonard Peikoff. Peikoff argues that positive rights to goods involve the appropriation of someone's labor to provide them, contradicting their negative rights.

Let me clarify for a moment. I want to distinguish between the philosophical notion of natural rights and the legal application of rights in this country.

Peikoff and I are making a philosophical argument from the concept of natural rights -- the rights that you have by virtue of being alive. While the concept of natural rights was incorporated into the Declaration of Independence and U.S. Constitution, what people argue is included or not included in natural rights differs. I am arguing that in terms of natural rights the concept of a natural right to a good is inconsistent with the negative right of liberty.

On this ground, I acknowledge that there are considerable grounds for debate. However, I do think that I make a valid argument. Further, I dispute Mark's counterargument that the enforcement of negative rights requires "positive actions" by the government. Yes, it does. In order to preserve my right of demonstration or my life the government must hire police officers. However, each individual officer is not compelled to be a police officer. I cannot go to a person and demand that they bear arms for my safety. They agree to do so. (Caledonian makes an argument similar to this.)

My point is that negative rights exist separate from the means of protecting them. A society recognizes that individuals have negative rights. It contracts with individuals to facilitate keeping them. But individuals do not have the right to any particular means of protection. Perhaps I feel that my life deserves special protection. Do I have the right to go to the police and demand a police car tail me all the time? No, I don't. Furthermore, in some cases -- such as during riots -- the government may fail to protect my negative rights. However, if I were to get shot in a riot, I can prosecute the person who shot me. Could I prosecute the cop who wasn't there to protect me? I don't think so. (I could probably sue the city if they were negligent, but that is a different basis for argument.)

With respect to the issue of the legal application of the right to health care, I agree with Mark's examples, but I think the matter is rather mixed. The question is: to what degree is a right to health care enshrined in US law now? (I don't know enough about other countries to say.)

There are several good arguments that a certain right to health care is present in US law. Mark points out that people when people go to the ER in the US, we are legally required to treat them regardless of the ability to pay. This is absolutely true. I would also add the example of mental health parity laws for insurance. Mental health parity laws demand that insurance companies provide equal health coverage for mental health complaints. They imply that the law views some level of care as necessary, as a right.

If you think about it, though, the law is somewhat vague. For example, if you go to the ER, you are entitled to care, but what kind of care? Are you entitled to be treated quickly? How quick is quickly? Should you get the full-court press or just the standard of care? What is the standard of care? Saying that you have a right to health care doesn't specify what kind. Further, a right to health care in that case is unevenly applied. Some people who come into the ER are getting care by right, but some are getting it by money or by insurance. A similar observation could be made about the insurance example. You have health care as a right, but only if you are buying insurance. Some of us are more equal than others.

If you want to construe a right to health care in the Constitution, I would ask which Amendment(s) you attribute it to? I am not qualified to speak to this issue, but I could see how someone could argue for either the 9th Amendment or the 14th Amendment.

On the other hand, if you are saying that a right to health care is in the 9th Amendment, you are saying that it is an unenumerated right. Can you argue for an unenumerated right that right that so clearly contradicts the enumerated rights of life and property? If you are saying that a right to health care is included in the right to life, I argue that this reflects a contradiction in the Framer's understanding of what a "right to life" means. As I argued before, a right to life does not imply the right to the produce of other people's labor.

All of this is quite subject to a reasonable debate. With respect to court cases, I don't know whether it has even be examined whether the Constitution includes a right to health care. (Given the current Supreme Courts attitude to unenumerated rights, I can guess what they would say though.)

What I said in the earlier post was an ethical argument based on natural rights, not on their actual application in law.

Issue #4 What to do about the brain drain of African doctors?

With a couple differences, I think that Mark and I largely agree on the best way to solve the problems of doctors leaving Africa. Here is what Mark said at the end of his post:

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.

Mark, you have no argument for me there. As I said above, I have no problems whatsoever with African doctors entering voluntary contracts to stay for a certain period. (I actually don't think that most libertarians do either.) I think that in order to entice them to do so, you are going to have to make it worth their while. Money will be needed to protect them and pay them, money that may not be available in their country of origin. If the West would like to stop the outflow of doctors, it will need to pony up the bucks.

I think the core of our disagreement is that I don't think that criminalization should be on the table. This is largely because -- for the reasons I wrote -- I consider the rights of the doctors and the rights of the recruiters as non-separable. Because I consider the rights of the doctors at stake in this policy, I don't consider criminalization an ethical solution. However, we may have to agree to disagree with that issue.