Bryan Caplan  

The Puzzling Ethics of Emergency Care

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The disdain most Americans feel for illegal immigrants appalls me, but it does not surprise me.  What does surprise me: Even though Americans will call a person a "criminal" for accepting a job from a willing employer, they still think they have a moral obligation to give these so-called "criminals" free emergency medical care.

It's hard to see the logic.  It's right to forbid a total stranger to earn an honest day's pay, but wrong to refuse the same stranger expensive charity?

If I had to argue in favor of the standard view, I'd probably invoke something like the legal doctrine of the "last clear chance":
The last clear chance is a doctrine in the law of torts that is employed in contributory negligence jurisdictions. Under this doctrine, a negligent plaintiff can nonetheless recover if he is able to show that the defendant had the last opportunity to avoid the accident.
For emergency care, analogously, you might say that you have a moral duty to help a stranger if you are the last person around able to save him. 

But this story really doesn't work.  When someone needs emergency care he can't afford, every rich country is packed with people who could help.  No one individual has a "last clear chance" to save the day.  On the other hand, if you say you're only obliged to help if no one else is likely to do so, then we'd owe strangers far more than emergency medical care.  After all, no one else is likely to help the world's starving, chronically sick, etc.  So why don't we owe food and non-emergency medical care to every desperate person on earth?

Anyone got a better story?  Before you share, please check whether your account is consistent with another popular moral intuition.  Namely: That the moral obligation to help nearby people in need of emergency care is a moral justification for keeping such people so far away that your moral obligation doesn't kick in.


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COMMENTS (20 to date)
Bob Knaus writes:

Because when I helped drag the guy out of the swamp north of Key Largo who had been driving crazy and wrecked his pickup, and then helped stop traffic on US1 so the rescue helicopter could take him to the hospital, the last thing on anyone's mind was whether he was an illegal alien, even though he probably was.

Ghost of Christmas Past writes:

Re that last paragraph, you're right: the moral obligation to help nearby people in need of (emergency) care is a moral justification for keeping at least some potential neighbors away.

Suppose I feel morally obliged, or perhaps just morally inclined, to provide not only emergency care, but care for any particularly appalling affliction of an indigent, especially a child.

If all the world's sick indigent children were to show up on my doorstep, though, I would rapidly experience "donor fatigue" (or else just run out of money). Worse, if I decided to restrict my charity to, say, children of my longtime neighbors, or my co-religionists, or members of my ethnic group, all sorts of busybodies would feel they were morally justified in berating and upbraiding me (and denouncing me to others) as a moral monster for "discriminating" against anyone I failed to bestow my charity upon. That sort of treatment might well make me angry and persuade me that the whole notion of charity as a moral obligation is wrong.

Look, recognizing a moral obligation to help others in an emergency is a form of pro-social cooperation. I help others that I may be helped in my turn; I participate in a social compact which asks me to train my children that such cooperation is a moral imperative. I know that's what's going on and I participate because I think it's a good thing.

Real emergencies have an element of surprise: I don't expect illegal aliens to get themselves hit by cars (for example) just so they can experience the joy of emergency medical care at the expense of strangers.* For this reason I don't think being the "victim" of an emergency situation is a moral failing or defection which would justify excluding someone from the social compact. Even though I don't want illegal aliens in the country at all, I consider maintaining the social compact (that even strangers must be helped in an emergency) even more important than punishing illegal aliens. (And if were walking near the border and saw a foreigner fall down ill on the other side, I would not hesitate to fetch him to a hospital on my side of the border, if it were the most convenient one.)

But consider the kind of "emergency" which isn't really a surprise: injuries due to war or criminal violence or dangerous stupidity. The kind of injuries which many thousands of Africans suffer every year. I don't want to confront a steady stream of such emergencies in my country, because they would make the morally-enforced social compact I prefer untenable!

So I don't want a zillion destitute and dangerous aliens to flood into the USA looking for subsistence jobs ("willing employers" be damned) and then incidentally, what an economist might term "just a little externality," destroying the social compact by inducing donor fatigue in all of my neighbors and everyone else in the country.

*I have real experience with emergency care for illegal aliens, having worked in several Southern California hospitals. I remember one poor soul, a Mexican Indian, who we cared for in the U.C. Irvine Medical Center (formerly Orange County Hospital) after his pelvis was shattered in a car accident. He didn't even speak Spanish and we had a hard time finding an interpreter. He had never seen city traffic before wandering into it nearly killed him. Of course he had no money. California taxpayers gave him months and hundreds of thousands of (1980's) dollars of free care out of the goodness of their hearts, and I'm glad we did,** but I wish we had averted that expense by excluding the man from the country in the first place. The value of his work as a farmhand was far less than the cost of treating injuries he would never have suffered if he had just stayed home. (Perfectly fair analyses show that low-skilled immigrant workers and their families cost California taxpayers vast sums of money. If you believe their wages are anything close to the marginal product of their labor, then you have to admit that they are literally a drag on the country and should not be admitted.)

**I wasn't an illegal alien (I was a tourist with a visa) but I received unstinting emergency care in Mexico when I was injured in a bad auto accident there. I could and did pay afterwards but no one asked for money before helping. As far as I'm concerned, that's the social compact in action, on both sides of the border. I think the Mexicans have every right to decide whether they will allow me to enter their country (and they agree-- Mexico has tougher immigration laws and enforcement than the US). I think we have every right to decide whether we will allow them (or anyone) to enter ours.

John writes:

@Bob Knaus, that doesn't really answer the question. Yes, we don't care about citizenship when providing emergency care. But the point is that we do care--very much--about citizenship in other circumstances, which aren't obviously less morally significant. Why the disconnect?

For example, most people pity the American poor and think it's wrong not to forcibly transfer resources to them. But even if a Haitian is literally eating dirt to survive, most Americans believe that it's right to use force to prevent him from working or living here.

So:
First, we forcibly demand charity for poor (and middle-class) Americans.
Second, we forcibly prohibit beneficial exchange that would help much, much poorer Haitians.
Third, we forcibly demand a particular type of (very expensive) charity for certain Haitians, as long as they come here and get injured first.

Individually, those policies might make intuitive sense. But collectively, they seem pretty bizarre.

Jody writes:

Why is enforcement/preservation of club goods so hard for some economists to understand? Similarly, 1) why is an affinity-distance social utility function hard for those economists to understand and 2) why is the fact that people, and apparently most people, have a different utility function than the economist so hard for the economist to understand?

steve writes:

My opinion runs along these lines. No you can not under any circumstances be required to be somebodys slave. However, keep in mind. People have every right to think of your actions what they will. Do you really want to be known as that guy that watched him die for no reason?

Dave writes:

It is a matter of priorities. First, we don't let anyone die if we can help it. That covers emergency care.

Second, if you commit a crime by coming here illegally then we send you back and you need to get in line if you want in. Just like everyone else.

The job isn't the point. It's not that we don't want you employed. That would be silly. It would be like a man getting stopped in the grocery store parking lot by a cop who caught him on radar speeding on the way there and the man yells "Why don't you want me to buy milk!"

If you make the hiring of an illegal alien itself illegal then you are simply trying to remove the incentive to come here ahead of the lawful immigrants.

Fralupo writes:

Jody siad what I've been thinking everytime I read one of Bryan's immigration posts. Most people aren't economists and are under no obligation to pre-clear their policy preferences with college professors.

Pandaemoni writes:

I generally agree with Bryan on immigration matters, but this one seems to be an easy call.

There's a difference between providing free medical care and free emergency medical care. The latter is intended to prevent death or the escalation of serious suffering in the extreme short term. There is no closely analogous "emergency" with respect to jobs in a typical case. (An illegal immigrant might need the cash that comes from the job for an emergency, but he's not likely to be paid up front, in any event.

Plus, I imagine many of these people don't like to imagine others being in pain or dying. Denying emergency medical care brings that image to mind...whereas denying a job does not. That's not where the mind's eye takes you when you hear that someone didn't get a job.

Joe Cushing writes:

Dave:

Any talk about getting in line is ridiculous. People would gladly come here legally if they were allowed to. The fact is there is no legal way for these people to get here. They have been denied access to America. Our grandparents were allowed in, then we shut the door to keep everyone else out. Talks about immigration are talks about whether we should be keeping these people out or whether we should let them in. Sure, they have broken a law but the debate is about whether the law should exist in the first place. Is the law just or not.

The breaking of laws in itself is not a bad thing. There was a time when slaves would break free from their captors. That was illegal and so was helping them, which many people did. Today, we have laws that prevent us from hiring people who live in conditions little better than those slaves. Those laws are unjust and I have no problem with people who break them.

MikeP writes:

The actual desire of people at play here is not alleviating poverty: It is alleviating poverty near them. Thus if there's someone poor near them, they will tax others to offer him aid. If there's someone poor somewhere else, they will prevent his getting near them.

Such apparently inconsistent values are a result of favoring personal aesthetics over considered morality.

If your ethics really led to taking from the rich to give to the poor, then you would be taking every dollar of welfare away from the poor in the US and sending it to the much poorer elsewhere. Instead, people advocate taking from the rich near them and giving to the poor near them so they don't have to see the poor near them. Poorly considered morality. Improved aesthetics.

Matt Zwolinski writes:
this story really doesn't work. When someone needs emergency care he can't afford, every rich country is packed with people who could help. No one individual has a "last clear chance" to save the day.

A child is drowning in a shallow pond off the side of the road. You and four strangers stand watching. The four strangers aren't making any move to help, and are unresponsive when you urge them to do so.

Do you have a moral obligation to save the child?

Jeff writes:
ven though Americans will call a person a "criminal" for accepting a job from a willing employer, they still think they have a moral obligation to give these so-called "criminals" free emergency medical care.

No, they don't. They've just never considered the contradiction between anti-immigrant sentiments and sentiments that there ought to be publicly funded hospitals providing free medical care to the uninsured.

Jeff writes:

Not to be snotty about it, but Caplan, you wrote a book, as I recall, that you titled "The Myth of the Rational Voter," and now you're "surprised" that people commonly hold what you view as contradictory policy preferences? How about explaining your own contradictions instead?

Monty writes:

It's the disdain many libertarians feel for the rights of citizenship that appalls me, Bryan. "Citizenship" has meaning. It's not simply dependent on where you happen to be standing at any given moment.

Monty writes:

Put differently: when I render emergency aid to another human being, it is an act of charity. This scales up to the societal level -- it is a moral act, not an economic one. But when that person's medical care becomes a financial burden on me, it seems justified to ask that my tax dollars be delivered preferentially to American citizens first.

"Emergency care" is not a synonym for generalized health-care, though you seem to be using it that way. (Is dialysis "emergency care"? How about treatment for diabetic shock?)

ThomasL writes:

Care is also given to prisoners and enemy soldiers; to people that have wronged us and to people that we hate.

The fact that illegal immigrants would be cared for too is hardly surprising. It would be surprising if they weren't.

Bryan Willman writes:

How about these more consequentialist explanations (please note I say explanation, not justification):

a. We deny admission to aliens because if everybody who reasonably wanted to come, came, there would in effect be standing room only.
It doesn't matter what the moral rules are, it is not physically sensible for everybody on Earth live in the United States.

b. We require (by law) hospitals to provide emergency care first and get legality, insurance, etc. later, because otherwise the mistakes and denials of care would cost too many lives of productive citizens. It's better to care for the occasional illegal alien than to lose a productive member of the tribe by error of judgement.
(A similar line of thought is part of why there are rules, both religious and legal, against suicide.)

asdf writes:

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Timothy writes:

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JKB writes:

First let's define emergency care, which care necessary to stop the immediate threat of death or serious preventable bodily injury. What some speak about is not emergency care but charity, in that helping someone in an emergency does not obligate you to help them/treat them to the point of no more cure. Once they are not at risk of death without assistance it is no longer an emergency and any further treatment is charity. Everyone has a stake in assistance being given in an emergency since anyone can end up in a life threatening situation. That most in the Western world now live under the umbrella of official emergency assistance doesn't alter the benefits of making it risky from a societal acceptance standpoint for someone to refuse emergency assistance.

I expect the charity treatment to the point of no more cure to abate as religiosity declines in society as there is little secular argument for assisting someone in which you have no interest except for state imposed force and we see that in the acceptance in more socialist societies when the state chooses not to render anymore treatment to some patients when they don't meet some arbitrary criteria.

As an example of emergency assistance, take for instance the traditional, though now codified in Admiralty law, requirement to render assistance to those at sea. The "moral" code is self reinforcing as the tradition means that should misfortune befall you, you will be given assistance. But that only works if all are under the same requirement to render assistance when needed.

On the other hand, the only obligation is to assist to the point of no longer at risk of being lost at sea. If you recover someone, say from a raft, you are only obligated to carry them your next port, even if that is completely out of the way of where they want/need to go. You are under no obligation to divert to some place more convenient for them. And upon arrival in port, you are no longer obligated to assist them, once they are permitted ashore by the local officials.

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