Dr Domhnall McGlacken-Byrne

IRISH PEOPLE ARE polite. We thank the bus driver. We thank the waiter. And we definitely thank the doctor.

A few months ago, I was invited to speak in a panel discussion at a health promotion event in the Midlands, aimed at over-65s. The theme of the day was health literacy, and ways older people could take control over their health. I was there, as a doctor, to share some practical tips on how people could get the most out of their interactions with the health services.

I had prepared some notes. Always bring an up-to-date list of your medications, for example. Never be afraid to ask questions. But, on the day, I ended up asking if sometimes we say thank you too much – or in the wrong way.

Put it this way. Whose health service is it? Who owns the local hospital? If I’m a doctor or a nurse, who’s my boss? The answer is you. You’re my boss, actually, and it’s your hospital. My manager might be the consultant, and they answer to the hospital chief executive – but who do they work for? They ultimately work for you – for all of us. All of us interact with the health system, sooner or later. We fund that system through our taxes as well as through private health insurance and out-of-pocket charges.

However, I believe that we as Irish people relate to our health system in a way that is too deferential, too apologetic, and yes, sometimes too grateful. Our health services should instead be regarded as something collective, a source of collective stewardship and responsibility – something we see as ours.

What’s more, it’s not just because we’re paying for it. If you are a customer in a hotel or a restaurant, yes, you hold some power in that interaction. However, that power is of a purely transactional nature. You’re only entitled to sit in that hotel lobby because you’re paying to be there. Our entitlement to healthcare comes from somewhere far deeper.

That day in the midlands, I clarified to my audience that we should of course say thank you when we are grateful for care we have received. But, when you are sick, remember that medical care is not somebody granting you a favour. You are not a guest in somebody else’s home.

You are entitled to healthcare because you are you, and you matter. Healthcare is a human right, and that’s how we should think of it. ‘Our’ health system should be considered something we collectively feel both entitled to access and a responsibility to protect.

You are entitled

When somebody is described as ‘entitled’, this often carries negative connotations. A sense of entitlement usually suggests a belief that someone deserves special treatment of some kind. I don’t use the word in this way. A human right is something profound, to which everybody is entitled, because we are all people with inherent value. That is a sense of entitlement we should be proud to have.

In Ireland, a rights-based welfare state never truly took hold. This is a great shame. For a long time, health services as well as other public goods like education and social care were outsourced to the Catholic Church, and thus to the realm of charity. 

Ireland is a wealthy, diverse and largely secular country, having once been grindingly poor, culturally stagnant and stiflingly religious. Times changed. Our values changed. The trouble is that we never said this part out loud.

For a long time, the Irish State consciously adhered to what is called the residual model of welfare. We inherited the dual legacies of colonialism and Catholicism, according to which public assistance was often stigmatised. Duties of care were avoided by the state and left to the market or the voluntary sector. The Catholic version of this idea was called subsidiarity.

So, systems developed which embedded a logic of conditional eligibility. To this day, when it comes to healthcare, we classify and categorise: medical card holders and fee-paying patients; public and private; eligible and ineligible; supplicants and citizens. Deserving and not.

I believe we should embed healthcare as a right, in law. In the bones of the system, and in the minds of all those who rely upon it. The original Sláintecare Report called for a statutory right to health, in legislation. However, this particular commitment was quietly shelved.

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Healthcare as a right

In around 70% of the world’s countries, some form of right to medical care is enshrined in the constitution – places like Costa Rica, Uruguay and Finland. Other countries provide for an entitlement to healthcare on a legislative basis. In 2019, then-TD Dr Michael Harty introduced a Dáil resolution to call a referendum on changing Bunreacht na hÉireann to introduce a right to healthcare.

The Right To Health Bill was soundly defeated, however. Then-minister for health, Simon Harris, instead recommended continued work expanding ‘entitlement and eligibility’ to health services. For all the progress of recent decades, the political frame of reference had scarcely changed.

Some argue against this type of constitutional or legislative activism, saying that it places undue responsibility on the state – for example, Senator Michael McDowell. However, others argue that, while obviously no state can guarantee good health to all its people, a right to the highest attainable standard of health can absolutely serve as a powerful, practical tool to guide policy decisions and to strengthen political accountability for health. Scholars such as Harvard University professor Alicia Yamin have written extensively on this.

I didn’t manage to convey all of this to my audience that day, but I wish I had been able to. We are well able for this conversation, even if we are arriving late to it. In health, we continue to rely on categories, thresholds and eligibility criteria. And sometimes we say thank you like we are receiving a favour and not claiming a basic, fundamental right.

Those who attend our national children’s hospital, when it opens, should feel entitled to excellent care. I hope that the next generation, including many not yet born, will see that facility not as a gift, but something that is theirs by right.

Waiting lists, cost over-runs, political controversies – health is complex, and it can be hard to know where to start. But sometimes we need to simplify what is complicated. For example, I believe that most Irish people today would agree that healthcare is something everybody should have, no matter who they are. We need to clarify what we stand for, in simple terms. Values are there to guide us; the policy will follow.

Healthcare is a right. We should legislate for that right. We should embrace the idea, both radical and long overdue, that shared, universal rights are the values on which to base our health services into the future. That’s something we could all be grateful for.