Gary Weiss, among other critics of Ayn Rand, portrays her ideal world as a grim place. Among other things, they say, public hospitals would not exist. But would government hospitals cease to exist? Why might some of them still stand? And if they did not stand, would indigent patients have no place to go? Not so. Private charities would take up the slack. (And to answer one other canard: Ayn Rand did not despise charity; she despised taking wealth by force for “charitable” goals.)

Ayn Rand on charity

In 1964, Ayn Rand famously gave an interview to, of all publications, Playboy. In that interview, Ayn Rand had a message about charity that sounds bracing. She said, specifically:

1. Charity for charity’s sake is not a moral duty. It is a choice that a free person can make.
2. A free person can choose to be charitable or not, and choose the objects of his or her charity.

The problem that Ayn Rand had, is that government charity is not free. The government, at some level, has forced its citizens to be charitable.

Ayn Rand said nothing specific about public hospitals. She did decry socialized medicine. To her that meant that the government directly employs the doctor (or else presumes to pay for all medical care) and tells the doctor how to practice and what reward he will get. But she never looked closely at public hospitals. That was simply one more function that government had taken on, improperly in her view, because health care is a service, not a right.

Why public hospitals?

The Star of Life, featuring the Rod of Asclepius, the true symbol of medicine. Photo: US Department of Transportation

Public hospitals exist because governments decided to build them. Different levels of government build them for different reasons. The federal government runs two groups of hospitals, one for active-duty military, and one for honorably discharged veterans. The federal government has judged that building such hospitals is the price of “rais[ing] and support[ing] armies” and “provid[ing] for and maintain[ing] a navy.” (Congress seems to have decided that a hospital for treating veterans is a “needful building” under the Constitution. No one has challenged Congress on that point.)

Counties and cities build hospitals for two different reasons:

1. Many of their patients have suffered a violent criminal attack. (This essayist was once a clerk in surgery at Ben Taub General Hospital in Houston, Texas. Half the patients on those wards were there for gunshot, stab, or even shotgun wounds.)
2. The rest of their patients simply cannot pay.

These hospitals often give value beyond treating the patients who go to them. Regrettably, some parts of Houston, Texas were combat zones when this essayist lived and studied there. The Emergency Center at Ben Taub General would see wounds from almost every kind of bullet that anyone invented. The Uniformed Services University of the Health Sciences trains Army and Navy doctors and flight surgeons. Many of its trainees “externed” at Ben Taub General precisely to see such wounds and learn how to treat them.

Beyond that, charity hospitals are the “farm system” for doctors and nurses in the United States today. Medical school teaches basic knowledge of how the body works and how different medical specialists work. But a doctor really learns his trade only by doing. Charity hospitals, whoever runs them, are where they can learn the most. That is why they will accept low stipends and, at some institutions, dormitory living while they get an education.

Why government hospitals?

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Ayn Rand did not ask this question, but free people must. How does building and running a hospital serve the purpose of protecting people’s rights?

In fact, the Objectivist system does not stop the government from striking any bargain with a free citizen to induce him to lay his life on the line for his country. Part of raising an army, or keeping a navy, is recruiting people to join them. Certainly the government must take care of its military officers and enlistees while they serve. One can argue for taking care of such a person after his or her service ends, especially if that person suffered permanent wounds on duty. If taking care of all a veteran’s needs, “service connected” or not, is part of the bargain that the government must strike, so be it. (Not all veterans seek treatment at veterans’ hospitals. If they can afford to go elsewhere, most do. And after what this essayist has seen in at least two VA medical centers, he can scarcely blame them.)

City hospitals are on shakier ground. Ayn Rand did say that emergencies, which are life-threatening events, deserve everyone’s help. She never worked out how to give that help in every case. More to the point: treating the innocent victim of a criminal attack is one thing. (So is treating the police officer who takes a wound on duty.) Treating the perpetrator of the attack, or one who forces another to shoot or stab him in self-defense, is another.

The important question, of course, is not whether to treat or not, but how to pay for it, and who should pay. This is especially true of emergency care at a hospital other than the local city hospital. Is any emergency center, at any hospital, an extension of the city-hospital system? The legal answer that most governments have arrived at does not satisfy. Advocates of “single-payer medicine” or outright socialized medicine say,

But you’re paying for it anyway, when these patients go to the emergency room.

That’s because, by law, an ambulance brings an accident or violent-attack victim to the nearest emergency room. The staff must then treat him completely, whether he (or his insurer) can pay or not. The same politicians who wrote those laws, now use them to advocate for the next step toward the goal that they now see within their reach: a total “command economy” in medicine.

Where do they go instead?

That question is part of a broader question: what would the Ayn Rand world look like, outside the hospital? First, though “we always have the poor with us,” the Ayn Rand world would have fewer of them. A free-market society will prosper more than the present “mixed economy.” So many patients, who today “can’t afford to pay,” will be able to afford to pay.

They might also benefit from other insights on health and wellness that many doctors will find that the government will not let them give their patients. Former Representative Alan Grayson (D-FL) sarcastically said,

The Republican plan is: Don’t get sick!

A lot of “alternative medical” practitioners and researchers would love to tell him that, more often than he supposes, people don’t have to “get sick.”

Second, people carrying a lesser tax burden could afford to give more to charity. In fact, almost no hospitals exist without private charity. The usual price that a high-volume donor demands is his name on a wing (or the whole building) and his oil portrait in the hallway. As long as people will buy such fame, charity, and charity medical care, will stand. (And so will medical education.)

Third and foremost: today the government distorts the market for health care. It does so with its myriads of rules and regulations, including whether anyone can sell insurance across State lines. In the Ayn Rand world, many of the worst market-distorting rules, and the agencies that make them, would disappear. Doctors, hospital administrators, and insurers would then be free to offer health care that is more efficient, and better for the patient, than one can get today.

Military and police hospitals would still have their place. So, too, would charity hospitals, though universities and large charitable foundations, not city or county governments, would run them. The Byzantine system by which some teaching hospitals pay their “house officers” would be far simpler. And most important, all patients would still get good care.

This is part of the Ayn Rand World series.

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