Abraar Karan: Revisiting health as a human right—does everyone have the right to be healthy?

abraarIs health a human right? This question has been a point of global contention, and in particular has driven the highly partisan ideological views on health reform in the United States.

A number of health governance bodies have tried to make sense of this notion. The constitution of the World Health Organization (WHO) asserts that “the highest attainable standard of health” is a “fundamental right of every human being” and lays out the importance of the principles of non-discrimination, availability, accessibility, acceptability, quality, accountability, and universality in safeguarding this right.

Similarly, the famous International Covenant on Economic, Social, and Cultural Rights (ICESCR) states that every human has a right to the “enjoyment of the highest attainable standard of physical and mental health” and to the “creation of conditions, which would assure to all medical service and medical attention in the event of sickness.” The National Economic and Social Rights Initiative (NESRI) defines the right to health as everyone having 1) a system of health protection; 2) the healthcare they need and living conditions that enable them to be healthy, such as food, housing, and a healthy environment; and 3) health provided as a public good for all, financed publicly and equitably.

For many, particularly in my specialty of global health and primary care, health as a human right is viscerally obvious: how could we ever be comfortable with the idea that people don’t have a right to be healthy? But I want to push back on this to give credence to the concerns of those who disagree. Firstly, we must ask what “health” really means. One could easily argue that “health” is a process, and others just as easily that “health” is an outcome. Is my right to be able to attain good health through my actions, or do I have a right to be healthy regardless of what I choose to do in my personal life? This brings forward a fork in the road: is it health or access to healthcare that is a right?

What if a government provided healthcare that was affordable and accessible, but people decided not to utilize it, especially when they were not sick? We know that most people are less likely to see a doctor when they do not have physical symptoms, and as primary care physicians, we are all too familiar with the fact that many patients do not attend all of their expected check-up visits. So, for those patients who do have accessible, affordable care, is their having the highest attainable health outcomes a right? Do we have a right to be healthy if we don’t take care of our own health?

This is more of a theoretical argument than one that reflects real life, largely because of what we recognize as the social determinants of health—factors that are independent of someone’s  ability to see a doctor. This is perhaps where the definitions that highlight the right to a healthy environment become relevant. One example that people often use is that of cigarette smoking. In essentially all Western countries, it is public knowledge that smoking cigarettes is bad for your health. Those who don’t believe that health is a human right argue that people who choose to actively harm their own health do not have a right to unlimited utilization of publicly funded healthcare. “Why should they? They could have avoided harming themselves, and now other people have to pay for it,” is the response that is often given.

This argument is often extended to include those who misuse drugs and alcohol, but I would propose that this logic could really be developed much further. For instance, what is the difference between someone who smokes cigarettes and someone who eats unhealthy foods, or those who choose not to see their primary care physician for chronic conditions and instead present to the emergency department with expensive medical emergencies, and so on. Are they not just as guilty of neglecting their health or choosing less health optimizing options?

The fundamental value that is evoked is the notion of personal responsibility: even if people are provided with high quality, accessible, affordable healthcare, their “health” is dependent on how they choose to live as well. And while most physicians fall into the trap of assuming that health is the number one priority of every patient’s life, the reality is that many people don’t think of things this way. Other factors, such as choosing options that make life more enjoyable, exciting, or fulfilling, are often more important to people than making decisions that are conducive to the best possible clinical outcomes for them.

I don’t believe that assigning blame to patients is compatible with the values of what we are taught in medicine, and the line between acknowledging personal responsibility and assigning fault for people living their complex lives to the best of their abilities is a very thin one. For instance, the fact that a patient chooses to smoke may not be a choice at all, or at least not a fair one: smoking is far more common in lower income groups and in people who identify as being American Indians. It is much more difficult for someone to avoid smoking if they live in a household, neighborhood, or society in which smoking is commonplace compared to someone who does not. This could be applied to drugs, alcohol, eating unhealthy foods, and choosing when to visit a doctor too. Context matters.

With that in mind, I still think that “health as a human right” is too simplistic a notion, which doesn’t account for the fact that health is both a process and an outcome; that health is both a part of the systematic conditions that we are part of, as well as a component of how we choose to live our lives. I think that health is easier to argue as a negative right—that we have a right to live without our health being harmed—and that high quality healthcare access is a positive right. Every person deserves to have the opportunity to improve his or her own health with the guidance, care, and compassion of a physician, and to live in environments that do not inherently cause harms.

Abraar Karan is a physician at the Harvard TH Chan School of Public Health in the Department of Health Policy and Management. Twitter:@AbraarKaran.

Competing interests: None declared.

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