Civil Disobedience: A Necessary Tool To Achieve Universal Healthcare and Fulfill the Universal Declaration of Human Rights?

Norbert Goldfield, M.D.

Physicians for National Health newsletter, March 2000



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 civil disobedience?

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 universal coverage.

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 disobedience:

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 organization.

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 reasons:

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.

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