In order to make legislative choices about health care that are both humane and rational, we need to ask and discuss whether health care is a right or a commodity. If some sort or degree of health care is a right, we owe that care to each other regardless of individual ability to pay. If some sort and degree of health care is just a commodity, then you are owed merely what you can pay for, and nothing more.

Of course the question is not easy to answer–or even to frame. The possible answers depend on how ‘health care’, ‘right’, and ‘commodity’ are defined and delineated.

But that’s the point. Unless we at least try to be clear with each other about those concepts, we’re not going to agree on how to finance health care. And so the legislation now pending in Congress will satisfy few, if it passes at all. We’ll still be stuck with a system that the majority are unhappy with, but that we can’t agree on how to change.

Nobody wants that result either. But that’s the result we’re going to get without the necessary discussion. How to conduct such a discussion?

Intellectual Takeout contributor Martin Cothran had something to contribute to that discussion a few months ago. He distinguished, rightly, between rights that are inherent to being human and rights that we acquire merely as a result of civil legislation. That’s the old distinction between natural and positive rights, which is entailed by the classical distinction between natural and positive law. And it’s definitely worth asking, in effect, what kind and amount of “health care” is a natural or positive right.

For instance, we can all agree that fixing a broken leg is health care, and that it is necessary for the patient’s well-being. Most people would agree that “boob jobs” for vanity’s sake are not health care, even if the patient believes they are necessary for her attractiveness or self-esteem. So the consensus, I take it, would be that if a given patient with a broken leg lacks the financial means to get it fixed, they should have at least the positive right to help from the public coffers, and maybe even the natural right. Whereas the woman who wants cosmetic surgery has no right to it in any sense beyond her own ability to pay for it.

But where to draw the line in the gray areas? How much “preventive” care is “necessary,” or at least so important that it should be treated as at least a positive right? Just how much care for the elderly and demented, and/or the terminally ill, is “necessary” for their well-being? Whether they admit it or not, a good many people believe that such patients are probably better off dead once their “quality of life” falls below a certain threshold. If that belief is true, it makes no sense to finance the patients’ health care from the public coffers. If that belief is false, it might well make sense.

I’m not giving any deep or controversial answer to the key questions here, or even asking all the necessary questions. I’m just saying that these are the kinds of questions that we and our elected leaders need to be raising and discussing if we’re going to make good decisions about health-care financing.

But that kind of discussion, while it does still take place in classrooms and policy-wonk circles, doesn’t seem to survive politics. Number-crunching, horse-trading, and rhetorical posturing drown it out. And that’s going to have an outcome nobody will be happy with.