The word ‘need’ should be eliminated from the vocabulary of political discourse. It is inextricably bound up with a dangerous oversimplification of reality, the idea that there exist certain values infinitely more important than all others, things I need rather than merely want, and that these ‘needs’ can be determined objectively.

At first glance, this idea seems reasonable. Is not my need for food, water, and air entirely different from my desire for pleasure or comfort? These things are necessary for life; surely life is not merely more important than anything else but infinitely more important. The amount of food, water, and air required to maintain life is not a matter of taste or preference but of biological fact.

The consequence for my life expectancy of being deprived of food, water, or air may be a matter of biological fact. The value to me of living is not. Staying alive is, for most of us, highly desirable, but it is not infinitely desirable. If it were, we would be willing to sacrifice all other values to it. Every time you smoke a cigarette, every time I drive a little too fast, we are knowingly exchanging life — a little bit of life, a very small chance of dying now or a large chance of not living quite as long — for a rather minor pleasure.

The person who says, as almost everyone does say, that human life is of infinite value, not to be measured in mere material terms, is talking palpable, if popular, nonsense. If he believed that of his own life, he would never cross the street save to visit his doctor or to earn money for things necessary to physical survival. He would eat the cheapest, most nutritious food he could find and live in one small room, saving his income for frequent visits to the best possible doctors. He would take no risks, consume no luxuries, and live a long life. If you call it living. If a man really believed that other people’s lives were infinitely valuable, he would live like an ascetic, earn as much money as possible, and spend everything not absolutely necessary for survival on CARE packets, research into presently incurable diseases, and similar charities.

People who talk about the infinite value of human life do not live in either of these ways. They consume far more than they need to support life. They may well have cigarettes in their drawer and a sports car in the garage. They recognize in their actions, if not in their words, that physical survival is only one value, albeit a very important one, among many.

The idea of need is dangerous because it strikes at the heart of the practical argument for freedom. That argument depends on recognizing that each person is best qualified to choose for himself which among a multitude of possible lives is best for him. If many of those choices involve needs, things of infinite value to one person which can be best determined by someone else, what is the use of freedom? If I disagree with the expert about my needs I make not a value judgment but a mistake.

If we accept the concept of needs, we must also accept the appropriateness of having decisions concerning those needs made for us by someone else, most likely the government. It is precisely this argument that is behind government subsidies to medicine, present and prospective. Medicine, like food, water, or air, contributes to physical survival. The kind and quantity of medical attention necessary to achieve some particular end — to cure or to prevent a disease, for example — is a question not of individual taste but of expert opinion. It is consequently argued that the amount of medical attention people need should be provided free. But how much is that? Some ‘needs’ can be satisfied, and at a relatively low price; the cost of a fully nutritious minimum-cost diet (largely soy beans and powdered milk), for instance, is only a few hundred dollars a year. Additional expenditures on food merely make it taste better — which, it might be argued, is a luxury. But additional medical care continues to bring improved health up to a very high level of medical expenditure, probably up to the point where medicine would absorb the entire national income. Does that mean that we should satisfy our need for medical care by having everyone in the country become a doctor save those absolutely needed for the production of food and shelter? Obviously not. Such a society would be no more attractive than the life of the man who really regarded his life as infinitely valuable.

The error is in the idea that improved health is worth having at any price, however large, for any improvement in health, however small. There is some point at which the cost in time and money of more medical care is greater than the resulting increase in health justifies. Where that point occurs depends on the subjective value to the person concerned of good health, on the one hand, and the other things he could buy with the money or do with the time, on the other. If medical care is sold on the market, like other goods and services, individuals will consume it up to that point and spend the rest of their money on other things. Through Medicare, government makes the decision; it forces the individual to buy a certain amount of medical care whether he thinks it is worth the price or not.

A program such as Medicare may also transfer money from one person to another; such an effect is often cited by those who claim that such programs make it possible for the poor to get good medical care that they could not otherwise afford. If so, the transfer should be evaluated separately from the specifically medical part of the program. If transferring money from the rich to the poor is good, it can be done without any program of compulsory medical insurance; if compulsory medical insurance is good, it can be done without any transfer. There is no sense in using the transfer to defend the insurance.

In fact, it is very questionable whether government medical programs transfer money from rich to poor. There is evidence that socialized medicine in Britain has had the opposite effect. The upper-income classes pay higher taxes but also, for various reasons, take much greater advantage of the services. In America, Medicare has been tacked onto Social Security, an existing system of compulsory ‘insurance’ which, as I showed in an earlier chapter, probably transfers income from the poor to the not-poor.

If past experience is any guide, the poor are not likely to get much that they do not pay for and may pay for things they do not get. The principal effect of such programs, on them as on everyone else, is to force them to pay for services that they would not buy willingly because they do not think them worth the price. This is called helping the poor.

Defenders of such programs argue that the poor are so poor that they cannot afford vital medical care. What this means, presumably, is that they are so poor that in order to pay for even minimal medical care they would have to give up something even more vital — food, for instance. But since the benefits the poor receive are usually paid for by their own taxes, the situation is only made worse; instead of having to give up medical care in order to eat, the poor are commanded to give up eating in order to get medical care.

Fortunately, the situation is rarely that bad. Lurid reports to the contrary, most poor people are not on the edge of literal starvation; evidence indicates that in this country the number of calories consumed is virtually independent of income. If the poor spent more of their own money on doctors, they would not starve to death; they would merely eat worse, wear worse clothes, and live in even worse housing than they now do. If they do not spend very much money on medical care it is because that cost, which they are in an excellent position to evaluate, is too high. If people who have more money wish to donate it to providing medical care to the poor, that is admirable. If they wish to donate the money of the poor, it is not.