ETHICAL PERSPECTIVES 20, no. 1(2013): 154-162.

2013 by Centre for Ethics, KU Leuven. All rights reserved. doi: 10.2143/EP.20.1.2965131
Can Moral Integrity Warrant Opposition to Tax-Funded Healthcare?
Noam Zohar Bar Ilan Univerity, Israel
I. INTRODUCTION
Moral opposition to a tax-funded healthcare system can be based on several
reasons, including both a general libertarian repudiation of transfer pay-
ments and specific opposition to funding, through ones taxes, of activities
and practices one deems immoral. In the present contribution, I examine
and reject the latter position. I readily grant that respect for personal integ-
rity justifies the exemption of conscientious objectors from military service.
It has been argued that a similar exemption should extend to individuals
who, in order to avoid complicity in evildoing, withhold a portion of their
taxes that funds warfare or capital punishment. If this were granted, then a
cognate argument could be made regarding healthcare, a realm rightly per-
ceived as involving many sensitive and contested actions impinging on life
and death. Here too, the entitlement to conscientious objection should
supposedly be extended to exempt individuals from participating through
their taxes in healthcare practices and actions that they deem immoral.
Against this, it might be questioned whether it is right to place healthcare
on a par with warfare or capital punishment. But I will instead argue gener-
ally against extending conscientious objection to tax resistance.
In line with arguments made previously by Gutmann, Thompson
(2012) and others (including myself 2003; 2007), I conclude that a demo-
cratic polity presumes a perspective of moral pluralism, and that this
implies a commitment to cooperate despite moral disagreements (except
for instances of absolute evil, beyond the pale of even pluralist morality).
The ideal of preserving personal moral integrity by avoiding complicity
in evildoing should not be misapplied to political participation through
taxpaying. Thus there does not seem to be a valid case for moral opposi-
tion specifically to tax-funded healthcare.
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In most countries (and in virtually all developed economies) health-
care is financed like other crucial services, such as police protection and
public education, that is, through tax revenue. Forms of actual delivery
vary greatly, but the underlying premise is uniform and simple: providing
basic healthcare is among the proper functions of government, and like
all such functions it is rightly funded by taxes, which the government is
entitled (indeed, obligated) to collect.
The US has hitherto not adopted this common approach; yet the
recent Affordable Care Act
1
constitutes a significant move in that direc-
tion. Indeed, Chief Justice Roberts pivotal vote allowing the ACA to
stand was based on construing the financial penalty attached to the so-
called Individual Mandate clause as a tax and affirming that the gov-
ernment may impose such a tax, essentially in order to fund national
healthcare coverage. This construal seems plausible; but even if mistaken,
it seems clear that the government could (in theory, at least) have taken
the straightforward path of expanding Medicare and/or Medicaid and
establishing universal, tax-funded healthcare coverage.
My concern here is to address principled opposition to tax-funded
healthcare. The position I will consider is not the sweeping Libertarian
stance that denounces the welfare state in general and regards all transfer
payments as a violation of sacrosanct private property.
2
Rather, I will
focus on the claim that there is something wrong with taxation for health-
care specifically.
This claim can be comprised of two logically distinct components.
The argument can point either to some positive value inherent to the
current mode of healthcare delivery a value that will purportedly be lost
with the shift to a tax-funded system; or to some disvalue attached to
tax-funded healthcare. These two forms of the argument are not mutually
exclusive and are often advanced in combination, but each must be exam-
ined separately.
First, consider the warning that valuable aspects of medical care will
be lost by the shift to a tax-funded system. Some base this on claims
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about efficiency. More compelling, perhaps, from a moral perspective, is
the argument that state-funded delivery should be avoided, as it threatens
to erode, for instance, the doctor-patient relationship with its emphasis
on personal care and trust. This leads to an interesting moral question:
supposing the threat is valid, does this loss outweigh the moral advan-
tages of obtaining healthcare coverage for many millions who otherwise
lack it? Yet the question here is not only and perhaps, not primarily of
values, since the argument (like the one based on efficiency) hinges cru-
cially on debatable empirical claims, such as the notion that choice of
care-giver or continuity of care are more easily protected in a profit-
driven system than in a non-profit and/or tax-funded setting.
The principled opposition obtains its most purely ethical form when
it ascribes a morally negative character to tax-funded healthcare in par-
ticular. In what follows, I will delineate and critically assess an argument
of this form.
II. MORAL CHALLENGES OF HEALTHCARE: LIFE, DEATH AND COMPLICITY
It seems that the most intriguing moral argument against tax-funded
healthcare points to a potential moral problem with all taxation and claims
that this problem is manifested especially, if not uniquely, when taxes are
used to fund healthcare. Since the problem purportedly calls for conscien-
tious objection emphasizing an individualistic ethical perspective I will
formulate it in the first person.
By definition, taxation consists in compulsory taking of my money to
facilitate actions determined by others. True, in a democracy I too have
my small say in directing state actions; but unavoidably my views will often
not prevail. The state, using my money (along with much money collected
from others), will do things that I morally oppose, even some that I abhor.
If these evil deeds amount to crimes, then in facilitating them I might
conceivably be deemed an accessory; in moral terms, my problem is com-
plicity in evildoing.
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There is a venerable tradition favoring conscientious objection, first
and foremost relating to warfare. This is grounded in according supreme
value if not sanctity to the individuals conscience. A strong reluctance
toward compelling a person to violate a deeply held conviction, whether
religious or moral, yields acceptance of a pacifists refusal to take up arms,
often translated into a legal exemption from being drafted. Even if most
citizens believe that they face circumstances that justify the massive killing
and maiming of warfare, the few who disagree should not be forced to
personally take part in these deeds, which they regard as terrible transgres-
sions.
Crucially for our present discussion, some have argued that a similar
exemption should apply beyond personal enlistment in the armed forces,
extending to complicity in warfare through paying taxes. In fact there is
a history of war tax resistance of pacifists who withhold some of their
taxes, calculated to represent the portion that finances warfare (Korn-
hauser 1999). On this view, the same conscience that informs a person
that killing is absolutely forbidden even in a defensive war forbids any
participation in or contribution to the prohibited activity, since a person
is responsible not only for what he or she does but also for the deeds he
or she helps others do.
Now it seems obvious that this cannot plausibly be applied to the
realm of politics across the board, that is, to any and all activities of the
state to which I take moral exception. In saying so, I am not thinking
primarily of dishonest people, who would seek to evade paying some or
all of their taxes by falsely claiming moral grounds. Rather, I have in mind
the unsustainable scope of honest non-payment that might be legitimized;
after all, people hold moral convictions about educational practices, police
treatment of suspects, rules and procedures governing family law, and
myriad other issues. If each citizen were to withhold taxes that support
state activities in such realms, simply on the grounds that they are con-
trary to his or her convictions, too much of these activities would grind
to a halt, or at least be seriously obstructed. Thus it does not seem an
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exaggeration to say that such wholesale exemptions would take us on the
road to anarchy, as sincerely dissenting minorities would systematically
foil the crucial mechanism of democratic decision-making, namely deci-
sion by the majority.
3
Accordingly, advocates of conscientious tax resistance (and exemp-
tion) have for the most part focused narrowly on the most severe trans-
gression, namely bloodshed mainly in warfare, and also in capital pun-
ishment. Thus in general I must take it for granted that through my tax
money I will be facilitating some things that I consider immoral. But I
may and should stop short of facilitating intentional killing of human
beings.
How, then, can this be relevant to tax-funded healthcare? After all,
even opponents of such a healthcare system must surely admit that, in
stark contrast to warfare or capital punishment where killing people is
a core aim of the activity healthcare is aimed primarily at saving lives
and ameliorating suffering. It seems incredible that of all state activities,
this should be singled out for conscientious objection.
I propose that the reason this nevertheless seems to have some plau-
sibility lies in the prominent place in healthcare of decisions that are
directly about life and death. The qualifier directly is crucial here, as a
great many state activities have a large indirect impact on human lives and
deaths, from road construction and environmental policy to social ser-
vices and education. Note that I am not speaking here of unforeseen or
unintended consequences: building a safer road is meant to save lives, and
deferring the project will foreseeably cause deaths. But those deciding
about such matters (and even the actual construction teams) do not bring
about life or death in the same direct way as a doctor, for example, main-
taining or removing life-support.
I thus surmise that many people perceive healthcare as the realm
of life and death par excellence (at least in peacetime), and therefore
regard the moral stakes in healthcare policy and practice as higher
than in most other social practices and activities. In the absence of
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empirical support, this remains a speculation. But philosophically, it
seems to me that only such a perception can putatively justify a claim
for conscientious objection regarding tax-funded healthcare. It is per-
haps important to emphasize that this perception is by no means lim-
ited to the issue of abortion; rather, it can apply to numerous aspects
of healthcare practice.
Suppose, then, I realize that healthcare delivery, with its great variety
of settings and multitude of caregivers, involves several practices affect-
ing life and death that I regard as immoral. As long as all interactions are
undertaken by agents contracting and consenting either individually or
through voluntary affiliations, I am only responsible for my own actions,
or for those of others with whom I have agreed to associate. A shift to
society-wide, tax-funded healthcare will make me responsible for every-
thing in the system including all kinds of problematic decisions and
actions, from beginning of life to end-of-life, as well as quandaries of
allocation, where life-giving resources are denied to some who need
them.
If it were granted that, in order to avoid complicity in evildoing, a
pacifist or a death-penalty opponent may withhold tax money that goes
to funding war or capital punishment (respectively), then a similar con-
scientious objection could conceivably apply to a portion of the taxes
levied to fund healthcare. Those who regard abortion as the killing of
unborn children will resist paying for abortions
4
; those who (like some
Orthodox Jews) reject the notion of brain-death will resist funding trans-
plantation of vital organs; those who believe in sanctity of life without
regard to its quality will resist funding for end-of-life planning; and so
on.
One response to this might be sharpening the distinction regarding
freedom of conscience between warfare and healthcare. There may well
be some merit in that approach; but I will instead argue here for a more
sweeping response, denying the moral force of all reservations about
complicity through taxpaying.
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III. RESPECT FOR OTHERS AGENCY: A CASE FOR MORAL COEXISTENCE
The argument presented above rests upon a premise about complicity: if
action X is evil, then I must refrain not only from doing X, but also from
facilitating the doing of X by other persons. Note that this is perforce a
deontological claim, focused on X being a prohibited action not on the
bad consequences that it yields. It is true that a consequentialist approach
requires me to give equal weight to averting a bad outcome, whether it will
be produced directly by my action or through a more complex chain of
events. But such an approach also requires considering the results of non-
action, including failure to fight in self-defense
5
in diametric opposition to
the pacifist stance. That is why the argument is couched in terms of complic-
ity: if I contribute to X being done by another agent, then my own contrib-
uting action is tainted by the evil of X and is therefore also forbidden.
It seems to me, however, that living up to such a sweeping concep-
tion of complicity is impossible. If avoiding complicity in evil is to be a
practicable principle, it must be construed far more narrowly. Note that
in the paradigm case of war tax resistance, the actual mode of contribu-
tion is rather indirect nothing like handing a gun to a murderer. The
causal chain from tax-payment to shooting on the battlefield is long and
intricate, if not obscure. If such causal contribution amounts to complic-
ity, then similar responsibility rests upon people who produce or sell
many things, from fuel and metals to clothing and foodstuffs all of
which can and do serve questionable (sometimes, outright evil) purposes
in the hands of some clients. Or consider the large support staff of every
government people who facilitate whatever is done by government
agencies, probably more directly than taxpayers. Is everyone complicit?
It is of course possible to reply that indeed the scope of complicity is
very broad, but we must learn to live with the attendant moral burden, since
we simply cannot refrain from our everyday activities. But I believe another
kind of response makes more sense: restricting the notion of indirect
complicity to instances of absolute evil. By absolute I mean evil that lies
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beyond the pale of pluralistic disagreement.
6
If my government engages in
genocide, then I must do all I can to stop it, and certainly should avoid any
kind of contribution to the atrocities, however indirect. But if it wages a
defensive war, or administers capital punishment, or implements a debat-
able policy in healthcare then, even if I consider these actions immoral,
I should remember that my co-citizens, who support the actions, reason-
ably regard them as morally permissible or even required.
I should refrain from doing myself what I regard as evil, and a strong
case can be made that I should not be compelled to act against my con-
science, whether in warfare or in healthcare. But this relates only to my
own actions. Once my focus shifts to the actions of others, I ought to
bear in mind before worrying excessively about the indirect responsibil-
ity I incur through facilitating them that they are in fact the actions of
other people, autonomous moral agents with their own values and views
of right and wrong.
Respect for others status as moral agents should yield a pluralistic
approach, wherein each persons actions are assessed first of all from his
or her own moral perspective. The evil of complicity is derivative: if you
are wrong to do X, then I am wrong to help you do it. But if on your
view X is a fine deed, it is haughty paternalism for me to withhold some
contributive action that is otherwise expected or even required of me, just
because in my view X is immoral.
7
The very existence of a shared polity depends on a mutually respect-
ful willingness to cooperate despite moral disagreements. The moral and
legal right to conscientious objection is meant to protect individual integ-
rity, and should not be extended into a tool for enforcing ones values
upon others. Conscientious tax resistance cannot then plausibly be based
on the idea of protecting personal integrity. It can, of course, be seen as
a form of civil disobedience but that is another ballgame altogether.
Thus there seems to be no valid argument for a moral resistance to
tax-funded healthcare in particular. Moral opposition to such a healthcare
system can of course still be based on general libertarian arguments,
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sharing whatever merit they may have. But even if healthcare is truly a
realm of uniquely weighty moral issues, directly affecting life and death,
opposition to funding it through ones taxes cannot convincingly be pre-
sented as a matter of conscience.
WORKS CITED
Epstein, Richard A. 1985. Takings: Private Property and the Power of Eminent Domain. Cam-
bridge, MA: Harvard University Press.
Boyle, Joseph. 1999. Collaboration and Integrity: How to Think Clearly About Moral
Problems of Cooperation. In Issues for a Catholic Bioethic. Edited by Luke Gormally,
187-199. London: Linacre Centre.
Gutmann, Amy and Dennis Thompson. 2012. The Spirit of Compromise: Why Governing
Demands It and Campaigning Undermines It. Princeton: Princeton University Press.
Kornhauser, Marjorie E. 1999. For God and Country: Taxing Conscience. Wisconsin
Law Review 5/XI: 939-1016
Wolff, Susan. 1992. Two Levels of Pluralism. Ethics 102/4: 785-798.
Zohar, Noam. 2003. Cooperation Despite Disagreement: From Politics to Healthcare.
Bioethics 17/2: 121-141.
Zohar, Noam. 2007. Moral Disagreement and Providing Emergency Contraception:
A Pluralistic Alternative. American Journal of Bioethics 7/6: 35-36.
NOTES
1. See http://www.healthcare.gov/law/full/.
2. In the American constitutional context, this opposition is based on the so-called Takings
clause, which is construed as precluding all transfer payments. On this view, the entire New Deal
ought to be reversed. See Epstein (1985).
3. For a moral justification of paying taxes despite the evil use of some portion thereof,
offered in terms of necessity. See Boyle (1999).
4. Or even imperialistically demand that no ones tax money be employed to pay for abor-
tions, or for any part of the budget of an organization that provides abortions. That goes, of
course, far beyond conscientious objection
5. Or to take an example from the healthcare context: the consequences of restricting access
to abortion.
6. A doctrine of moral pluralism as distinct from moral relativism will normally hold
fast to some core values and norms, while allowing a broad range for their interpretation and
application, and a variety of additional values. See Wolff (1992) and Zohar (2003).
7. I have endeavoured to explore this issue in Zohar (2003) and also in Zohar (2007). See
also the discussion on Mutual Respect in Gutmann and Thompson (2012).
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