The Trilemma of State Healthcare, Freedom, and Democracy

Within my consideration of political issues, I keep coming across an internal contradiction of liberal democracy, which seems to maintain a relatively similar state across a multitude of issues. And I believe I have been able to abstract it out into the following trilemma:

1. The state shouldn’t interfere with the personal lifestyle of individuals

2. The state should provide free healthcare for everyone

3. The democratic state is a representative of the people

The conflict that constantly re-emerges is this: state-funded healthcare transforms a variety of personal issues into national concern, because they have direct economic implications. As the central concern of the state is taxation and its expenditure, a healthcare system dependent on state funding therefore necessitates a level of scrutiny which is expected on government finances. The only way in which this can be circumvented is if the government is separated from the people, but that has clearly anti-democratic implications.

I first noticed this issue when it comes to trans healthcare. Quite understandably, transgender people wish to get affirmative surgery without having to defend the validity of their identity; and point out the lengthy waiting lists for transgender healthcare under the NHS as an issue. The problem arises however is that since such surgery is funded by the taxpayer’s dime, they have the democratic right to question if they wish to fund such surgery. Not only to debate the validity of transgender surgery, but also its prioritisation with the various other ways UK healthcare is struggling. In the US it would be hard to make a case for preventing an adult from surgically transitioning because it only affects themselves; whereas in the UK it quite literally affects the whole nation. And yet public healthcare undermines the existence of viable and affordable private alternatives, making it harder for transitions out of one’s own volitions. A liberal welfare economy therefore conflicts with a liberal laissez-faire attitude to one living their own way of life.

The same applies with the physical health of the nation - because sedentary lifestyles and unhealthy eating exacerbates the pressure on the NHS, it is taken as invaluable economically to encourage healthy living. Whilst relatively unobtrusive so far, it is becoming a wider domain for the NHS to expand its services past the physical treatment of ailments. The theoretical justification for the expansion of this into intruding on people’s lives is clear: “The harm principle doesn’t apply because your life decisions have economic ramifications, therefore the state has the right to regulate your personal behaviour to reduce the strain on its services”. The intertwining of health and economics permits the curtailment of the former through the justification of the latter. And since such a wide range of things have an impact on health, this would allow a pretty far-reaching restrictions on the individual under economic justification. 

Doesn’t non-public healthcare just mean that scrutiny and regulation enters the hands of businesses rather than the state, of which care little for your wellbeing? Yes, but this creates the opposite problem - a business will give you even harmful things for money. Businesses are quasi-democratic: if there is a profitable demand, it will be provided. This itself has damaging implications: conversion therapy and fast-food advertisement function because people are convinced or coerced into desiring things which will ultimately damage them. But this is no infringement on personal liberties; businesses unimpeded will give people everything that they are asking for.