Civil Disobedience: A Necessary Tool To Achieve
Universal Healthcare and Fulfill the Universal Declaration of
Norbert Goldfield, M.D.
Physicians for National Health newsletter, March
The Universal Declaration of Human Rights was adopted by the
United Nations General Assembly on December 10, 1948. Article
25 states: "Everyone has the right to a standard of living
adequate for the health and well-being of himself and his family,
including ... medical care..." Yet at present, there is no
commitment on the part of either political party to universal
healthcare coverage. Indeed, the number of uninsured is increasing.
The Republican-dominated 104th Congress passed, and a Democratic
President signed welfare legislation, which, among its many impacts,
cut millions off Medicaid. The executive branch under President
Clinton has a similarly dismal record on health care reform. Most
notably, in 1996, the President deleted from the Democratic Party
platform the call for national health insurance, which had been
in the party platform since 1948. Given the refusal of politicians
to meaningfully address the problem of uninsurance, and the ongoing
failure of traditional modes of political action, should we consider
I begin with a definition of civil disobedience, then describe
health care issues that have given rise to civil disobedience
in the United States and elsewhere in the past quarter century,
and finally discuss types of civil disobedience that health professionals
might undertake on behalf of the uninsured.
Definition and General Comments
As used in this article, civil disobedience consists of illegal,
non-violent, political acts committed with the express purpose
of drawing attention to the urgent need for universal coverage
and other health care reforms.
This article defines success as having two parts:
1. Increasing public awareness of increasing numbers of uninsured
due to Clinton/Congressional cuts.
2. Encouraging the public to force elected representatives
to reverse the current trend of increasing numbers of uninsured.
In particular, the American public should communicate the spirit
of Cardinal Bernardin's pronouncement: "Health care is an
essential safeguard of human life and dignity, and there is an
obligation for society to ensure that every person be able to
realize this right."
Thus, actions would not be successful if only awareness were
raised. Awareness must be translated into active support for reversing
the trend of increased numbers of uninsured, together with a renewed
commitment on the part of government and/or employers to providing
Civil disobedience consists of publicly announced defiance
of specific laws or policies which an individual or group believes
to be unjust or unconstitutional. The defiance must be publicly
announced since the purpose of civil disobedience is to bring
the perceived unjust laws/policies to the attention of the public,
with the ultimate purpose of stirring public conscience to change
policies. The defiance, moreover, must be a premeditated act,
understood by the perpetrator both to be illegal and to carry
penalties. Willingness to accept such penalties is crucial to
this form of civil disobedience. Other than polls, which only
involve an individual responding to an abstract question or statement,
the majority of Americans have never had to confront the financial
and political implications of meaningful health reform. Civil
disobedience would bring the issue of health reform into the living
room of the majority of Americans.
A Brief Summary of Civil Disobedience Devoted to Health Care
Issues in the United States and Elsewhere
While less visible in the United States, civil disobedience
occurs with regularity in a very public manner in the industrialized
world. However, civil disobedience by health care providers has
typically been undertaken to enhance professional prerogatives
such as physician pay and privilege.
In contrast, the French have had a tradition of civil disobedience
involving action for the purpose of improving care to disadvantaged
segments of society. According to a letter from the founder of
Doctors Without Borders, physicians from this French-based organization
have taken actions such as openly-declared needle exchange programs
for drug addicts in defiance of state law (similar actions have
also occurred in some locales in the U.S.). Several physicians
were incarcerated. The effort had the desired effect, i.e. the
legalization of needle exchange programs throughout the country.
In the United States, there have been large demonstrations
and even acts of civil disobedience by health care professionals.
In the 1970's large groups of New York City-based interns and
residents, including the author, went on strike to improve not
only their own pay and working conditions but also access to care
for the poor. In 1989, unionized interns and residents at Boston
City Hospital held a three day "heal-in," filling up
the hospital and resulting in the closure of the emergency department.
Most recently, nursing associations, particularly the California
Nurses Association, staged demonstrations on behalf of professionals'
prerogatives, improved patient care and a single payer health
plan. Health professionals have also participated in acts of civil
disobedience to highlight problems in the delivery of care and
inadequate government funding for AIDS patients. No acts of civil
disobedience have highlighted the dangers that managed care poses
to patients, though nurses' actions have probably grown, in part,
from worries about the changed and diminished role of nurses in
a managed care-dominated health care system.
Actions taken to protect professional prerogatives represent
a problem. Acts of civil disobedience for the purpose of enhancing
professional prerogatives may attract neither additional supporters
nor a sympathetic audience. The recently organized Ad Hoc Committee
to Defend Health Care is unfortunately perceived by some as focusing
on issues pertaining to physician prerogatives. Such action will
not result in universal coverage. Tactics and strategies need
to be carefully thought out if an act of civil disobedience is
to be successful, and its goal not misinterpreted.
A Typology of Civil Disobedience Actions
Two types of general actions fall under the rubric of civil
1. Actions which explicitly violate a state or federal law
2. Actions which violate administrative procedures of an organization
(i.e. monkey-wrenching or gumming up the system). These actions
must be publicly announced to be considered civil disobedience.
A key issue facing health professionals considering civil
disobedience is deciding whether or not the individual is willing
to countenance violating the rights of others. Three types of
violations should be distinguished:
1. Sitting and blocking the offices of a health care organization
violates the rights of individuals trying to enter the building.
2. Sitting in at a managed care organization or government
agency can be structured to avoid violating the rights of individuals
trying to enter or work. In a review of successful acts of civil
disobedience Per Hengren, in the The Activist Handbook - A Primer
for the 1 990s, stated that actions that allowed employees to
continue their work garnered the greatest amount of support. The
word sit-in is a catch-all phrase for any non-violent illegal
action undertaken by a group of individuals.
3. Refusing to complete billing forms does not explicitly
violate anyone's rights. However, this tactic needs to be carefully
analyzed and discussed, as some individuals may believe that it
will lead to problems with patient care.
A list of administrative "actions" which health
care professionals might undertake in an attempt to impact these
negative health care delivery trends include:
* Refusal to fill out or accurately complete insurance forms
required for payment to an institution.
* Refusal to abide by gatekeeping functions (such as barriers
to specialist referral) when working as part of a managed care
Acts of civil disobedience which non-violently violate the
rights of others may be necessary if the public is to be sufficiently
aroused to consider legislation and public policy leading to universal
coverage. This paper suggests three actions which could be undertaken
in Massachusetts (where the author resides).
1. In response to decreases in hospital length of stay, the
number of home health care workers has dramatically risen in the
past fifteen years. It is estimated that more than one-quarter
of home health care workers are uninsured. Many of these individuals
are single mothers supporting families. The large number of uninsured
in this group is particularly ironic since many home care workers
serve patients covered by Medicaid. Two types of sit-ins should
be considered: sit-ins at Medicaid offices and at the corporate
headquarters of home health care agencies, with the demand that
adequate health care coverage be provided to this vulnerable group
of middle-aged adults.
2. Managed care organizations in Massachusetts are required
to provide annual reports to the Massachusetts attorney general
specifying what, if any, charity care, termed "community
benefit," has been provided in the past year. HMOs, in general,
and not for-profit HMOs, in particular, should be required to
put in a fair share of their profits to increase access to care
for the uninsured. A specific not-for-profit HMO, which has provided
minimal community benefit might be identified. Sit-ins at its
corporate headquarters could then be organized until the HMO devoted
an adequate percentage of profits to charity care. An issue which
needs addressing is whether efforts should be made to enlist the
active support of the managed care organization's employees prior
to the implementation of a sit-in strategy.
3. Legislators and executives of health care organizations
enjoy generous health care benefits. Another type of civil disobedience
would be sit-ins of health care professionals in state legislative
offices and/or managed care organizations demanding health insurance
coverage for all citizens.
Diverse groups of individuals should participate in civil
disobedience if the issue of universal coverage is to enter the
living rooms of America. A sizable number of Americans watching
the evening news who currently have health insurance coverage
are probably concerned that they could lose their insurance. They
can identify with the fate of those without health insurance.
Hopefully, Americans will be influenced by the social standing
of health professionals committing acts of civil disobedience,
and come to believe that universal coverage is meritorious. Participants
in civil disobedience must make the point that the best protection
against the potential loss of health insurance for Middle America
is the provision of coverage for everyone.
Most importantly, physicians need to convince a minimum number
of health care professionals of the importance and relevance of
the civil disobedience program. A minimum of 200 health care professionals
must be willing to commit acts of civil disobedience if the effort
is to succeed. I suggest this number because a successful action
will require civil disobedience in at least fifteen to twenty
cities throughout the country, with at least 10 people participating
at each site.
The second ingredient for success consists of using the act
of civil disobedience to encourage healthcare leaders (hospital
administrators, community leaders at a local and state level)
to facilitate such protests. There are direct and indirect participants
in any act of civil disobedience. While one can easily define
the make-up of direct participants in civil disobedience, indirect
participants are as important for the success of any action. Again
several hundred people in positions of authority will be necessary.
Lastly, health professionals must use their position of respect
within society to galvanize elements of both low and middle-income
individuals into passive and active support of increased access
to care for all Americans. In the final analysis, only mass participation
will signal success. It should be emphasized that from a tactical
perspective, individuals can participate in civil disobedience
in a variety of ways.
Why not Rely on Political Action? Will Civil Disobedience
Result in Less Support for Increased Access to Care?
Analysts might argue that civil disobedience is unnecessary
and potentially counterproductive. Pundits may, understandably,
point out that federal and state legislation is beginning to address
specific barriers to access. Thus, they may refer to the recently
passed federal legislation to increase coverage for children.
But CHIP is a stopgap measure for only a few years. Any gains
due to CHIP have been more than offset by losses due to welfare
cuts. Another recent federal initiative to extend coverage, the
Kennedy-Kassebaum legislation, has been sabotaged by insurance
companies. While such initiatives should be pursued, they are
inadequate to address declining healthcare coverage due to welfare
reform and employer benefit cutbacks.
We should be concerned about alienating low and middle income
individuals since they are the key constituency needed for the
success of civil disobedience. Appropriate planning, leadership,
and timing of civil disobedience can assure that actions are not
misunderstood. The reason to recommend civil disobedience at this
time is that access to care has been diminishing. No major national
political leader has made any proposal which would ameliorate
the draconian effects of welfare cutbacks on access to care, let
alone address employer cutbacks in health insurance coverage.
The title of a recent New England Journal article summarizes
why traditional political action will not significantly improve
in health care access. In "The Limits of Incremental Reform"
Robert Kuttner clearly demonstrates how the traditional American
approach to health reform simply will not work in an era of increased
part time workers and decreased employer commitment to the provision
of health insurance benefits.
At this juncture of American political history, civil disobedience
may constitute a legitimate and necessary tool to improve access
to care for all Americans, particularly poor families who will
lose their access to health care as a result of federal welfare
cutbacks. Civil disobedience should be considered for the following
The rate of uninsured continues to rise in the face of a booming
economy. Almost 100,000 individuals are added to the uninsured
rolls every month.
Recently passed Congressional welfare legislation will diminish
access to healthcare and the quality of life of many poor families.
Employers, many of whom believe that they are paying too great
a portion of employee health care premiums, will likely continue
to reduce health benefits.
In his last monograph, Martin Luther King, outlined a three-step
process prior to committing acts of civil disobedience:
* collecting information
* formalizing goals
* negotiating for social reconstruction
Civil disobedience in health care is now at the stage of collecting
information. Debate on the suggestions provided herein are part
of that information gathering.
Health care professionals need to seek all available means,
such as traditional legislative remedies, to address increased
barriers to health care access. Yet, it is unlikely that traditional
political activities will suffice to reverse the deteriorating
access to care of America's poor. This paper has attempted to
lay out a set of actions within the framework of civil disobedience
which should be taken now before the full negative impact of welfare
reform is realized.
According to Martin Luther King, "the beauty of nonviolence
is that in its own way and in its own time it seeks to break the
chain reaction of evil.