The [§9.10](<9.10 Healthcare.md>) derivation carries three kinds of implication for institutional design: structural constraints, transitions, and field-engagement.

*Structural constraints.* Non-substitutability of the sufficiency floor reaches its greatest force in healthcare, because the floor in this domain is the participants themselves, in the constitutive vulnerabilities that make them participants. The general constraint named in [§9.7](<9.7 Economy.md>) — that the floor must be provided through the political community, not through profit-extracting substitutes — is at its most acute here. Privatized-insurance architectures that occupy the floor space and extract profit margins at the point of constitutive vulnerability are precluded at the level of design, not merely subject to design pressure.

Mental health and substance-related conditions belong in healthcare, not in justice. Healthcare is upstream of agentive participation (per the [§9.10](<9.10 Healthcare.md>) root and the structural requirements in [§9.10.2](<9.10.2 What is Required.md>)) and couples upstream into the justice domain [§9.13](<9.13 Justice.md>) develops. Conditions producing failures of agentive participation are therefore healthcare-domain conditions whatever their downstream behavioral manifestations. Routing mental-health crises through criminalization rather than through crisis healthcare, routing substance dependence through prohibition rather than through treatment, and routing developmental and cognitive conditions through penal rather than therapeutic systems are each a domain misallocation precluded at the design-pressure level.

Substance policy takes a three-layer structural form: use decriminalized, distribution regulated against agency-capture, harm-to-others criminally liable. The [§9.10.2](<9.10.2 What is Required.md>) mental-health-and-substance condition derives the three-layer architecture as the operational form the framework's commitments take at the substance interface. *Use* by competent adults is decriminalized on the same bodily-autonomy logic that runs through reproductive autonomy and end-of-life access. *Distribution* is regulated by the substance's empirical dependence-gradient and aggregate-harm profile rather than by historically-contingent cultural classification: supervised therapeutic administration regimes at the clinical end (the clinical-trial record on psilocybin and MDMA in treatment-resistant depression and PTSD; the Swiss heroin-assisted-treatment program for high-dependence patients), unregulated-retail preclusion at the high-dependence-and-acute-harm end (the US fentanyl crisis stands as the canonical instance of what supply-substitution under prohibition produces when distribution-regulation is absent). *Harm to others* through impairment-driven negligence remains criminally liable on standard recklessness-and-negligence doctrine. The three layers operate together and not separately: prohibition-only collapses layers (i) and (ii) into criminalization the empirical record shows produces worse aggregate outcomes; unregulated-legalization-only collapses layer (ii) into laissez-faire retail the supply-substitution and agency-capture literatures show produces population-scale wellness damage; collapsing layer (iii) produces a harm-to-others gap the framework's harm-principle qualifier precludes.

The strict-libertarian objection to distribution-regulation operates at layer (ii). The strict-libertarian tradition (Szasz 1992; Block) rejects the three-layer architecture at the distribution layer: any restriction on what a competent adult ingests, including supervised-administration and maintenance regimes, is paternalistic intrusion on bodily autonomy. The framework grants the central concession at layer (i), user-side decriminalization on the same logic the libertarian tradition runs, and at layer (iii), harm-to-others through impairment-driven negligence on standard recklessness doctrine. Where it parts is at distribution: layer (ii) operates on the same structural logic that governs food safety, pharmaceutical quality, and licensing of professional service-providers; the strict-libertarian position would have to reject all of these to be consistent, and the strong-form Rothbardian register does, at substantial downstream cost the framework does not accept. Informed consent depends on accurate information about what is being consumed, and unregulated retail systematically undermines that condition; distribution-regulation against agency-capture and aggregate population-scale harm protects the very autonomy the libertarian position invokes rather than violating it. The residual disagreement at the layer-(ii) standing question is real and foundational (the framework holds that the political community has standing to regulate against agency-capture and aggregate population-scale harm; the strict libertarian holds it does not) and the framework's reply runs through the structural derivation rather than through a direct refutation of the libertarian axiom on its own ground.

Population-scale public-health infrastructure is constitutive infrastructure. Cooperative infrastructure includes the conditions for participants to remain participants. Public-health infrastructure (vaccination programs, communicable-disease control, sanitation, environmental-health monitoring) is therefore not a discretionary subsidy but constitutive infrastructure on the same logic as the legal system or the public-education system. Privatizing or dismantling such infrastructure violates the constraint at the structural level.

*Transition.* The derivation fixes where the transition must arrive, but not how it gets there. A political community currently configured around privatized insurance does not reach a sufficiency-floor-non-substitutable architecture by decree. The transition is its own engineering problem: existing employment relationships, financial structures, patient-provider relationships, and institutional capacities all have to be brought to a new equilibrium without producing transitional collapse. The destination of insurance-occupies-the-floor is precluded; the path from the present to a non-substitutable-floor arrangement is left open. That work belongs to the implementation literatures and to the political processes [§9.3](<9.3 Representation.md>) (Representation) and [§9.2](<9.2 Belonging.md>) (Belonging) constitute.

Industry pushback is structurally predicted. Industry resistance to floor-substitution alternatives will be the most ferocious in any economic transition, because the industry's structural redundancy is more thoroughly derived than for any other private-sector lobby. The transition design has to anticipate it and route around it — not because such resistance is illegitimate to face, but because it is structurally maximal and predictable.

*Field-engagement.* The class-warfare deflection applies here as in [§9.7](<9.7 Economy.md>). The argument against privatized insurance occupying the floor is not an argument against any particular insurance executive, employee, or shareholder personally. It is an argument that the structural position the industry occupies is one that the political community is structurally obliged to occupy directly, and that the resulting redundancy means the industry's continued occupation of that position is a form of structural extraction whatever the personal qualities of the people involved. The same symmetry that holds in [§9.7](<9.7 Economy.md>) holds here: institutional and individual extraction at the floor (denying claims for profit; filing false claims for payouts) are one structural pattern at different scales.

Illness is not pathologized. The healthcare-as-constitutive-infrastructure derivation explicitly precludes any reading in which sick people are burdens on the political community. Sick people are participants in the constitutive vulnerabilities that make them participants, and the political community maintains them because doing so is part of what being a political community consists in. Any rhetoric that frames healthcare provision as charity-from-the-healthy-to-the-sick mistakes the structural relation, which is constitutive, not charitable.

*Genetic medicine.* Therapeutic genetic medicine sits on an already-established continuum of preventative biological modification (sanitation, iodine fortification, folic-acid fortification with neural-tube-defect reductions of 30 to 40 percent since 1998, Rh immunoglobulin, in-utero surgery, newborn metabolic screening, pediatric surgical correction, somatic gene therapy via Casgevy for sickle-cell, Luxturna for hereditary blindness, and Zolgensma for SMA). Five structural questions (welfare benefit to the being, proportionality, parental autonomy, reversibility, universality of access) apply uniformly along that continuum; therapeutic genetic medicine to address severe suffering is one gradation, not a categorical break. The moral weight attaches to the subject of experience, not to the genetic configuration as such: where modification at the genetic level reduces suffering for the person who comes to exist with personhood and accommodation fully intact, the framework's suffering-minimization commitments license the intervention; where it does not, they do not. Sandel's openness-to-the-given (2007), Habermas's autonomy-of-the-second-person (2003), Kass's wisdom-of-repugnance, and the natural-law teleological tradition each articulate a stance the framework respects without deriving as a structural constraint on others. Here the disagreement routes through parental autonomy: parents holding any of those orientations have full standing to act on them in their own reproductive choices, and the framework's commitments protect rather than override that exercise. What the framework does not derive is that those positions function as structural constraints on what therapeutic genetic medicine may be made available to others. The disagreement runs at the level of personal moral commitment expressed through autonomous choice, not at the level of architectural design pressure.

Targeting a condition is not denying the personhood of those who have it. The standard logic of therapeutic medicine holds: treating cancer does not deny the personhood of cancer patients; treating sickle-cell disease does not deny the personhood of people with sickle-cell; addressing a genetic source of suffering does not deny the personhood of those who develop from unmodified versions of the same genetic configuration. The framework's mutual-recognition commitments hold equally for all subjects of experience without regard to genetic configuration, and the framework's healthcare and education commitments ([§9.10](<9.10 Healthcare.md>), [§9.9](<9.9 Education.md>)) require full structural accommodation and support for all conditions whatever their genetic origin. The condition-targeting register is structurally distinct from any register that would treat persons as defective or less worth supporting.

The playing-God concern is engaged at its secular core, not dismissed via theism. The objection that genetic intervention amounts to playing God carries a secular core independent of any particular theological commitment: humility about the unintended consequences of irreversible interventions, suspicion of hyperagency, regard for the value of openness to the unbidden. That secular core is engaged directly through reversibility-graded epistemic standards rather than through categorical preclusion. Somatic interventions on existing or developing beings, where reversibility is high and population effects absent, face the same standards as other therapeutic medicine. Germline interventions, where heritability and irreversibility are at issue, face tighter standards; the He Jiankui 2018 case stands as the canonical instance of how clandestine, premature, and ethically-unreviewed germline work fails those standards. Enhancement interventions targeting capacities beyond therapeutic baselines face categorical preclusion on grounds developed below. The response to the playing-God concern is a structure of standards, not a categorical line at the genetic threshold.

The eugenic concern is engaged precisely and precluded structurally. State-directed selection of which kinds of people exist is precluded structurally by the framework's mutual-recognition commitments and the [§9.13](<9.13 Justice.md>) Justice constraints. The lineage running through Buck v. Bell (1927), Nazi-era racial-hygiene programs, Indian Emergency-era forced sterilizations (1976), and the Peruvian forced sterilizations of Indigenous women in the 1990s is what those constraints preclude. Disability-as-defect framing is precluded: people with disabilities are fully-recognized subjects of experience, and the framework's response to disability is full structural accommodation under [§9.10](<9.10 Healthcare.md>) and [§9.9](<9.9 Education.md>), not selection-against. Enhancement-as-class-marker is precluded: genetic interventions that operate as positional class advantages would reintroduce sanctioned disproportion at the biological level, on the same structural grounds that preclude economic sanctioned disproportion in [§9.7](<9.7 Economy.md>). Hierarchies of valued-versus-non-valued existences are precluded throughout.

The broader commitments substantially address what drives the disability-rights critique without claiming to resolve it. The disability-rights critique of selectionist genetic-medicine regimes (sharpest where prenatal screening followed by selective termination operates as de facto selection-against-existence at population scale) tracks a genuine concern: that the slide from therapeutic intervention to existence-selection is real, well-documented, and partially driven by social conditions outside the parental decision itself. The response is not to override parental autonomy and not to deny that the option exists; it is to address the social conditions that drive the slide. Within the framework's commitments (floor income, secure employment, universal healthcare access, full educational accommodation, structural inclusion, and mutual-recognition of all subjects) the cost-on-experience calculation a parent faces when receiving a prenatal diagnosis is genuinely different from the calculation in current society. Much of the suffering that current selectionist patterns implicitly track is socially produced, and the framework was already going to address it upstream. Whether the upstream-condition repair fully neutralizes the disability-rights critique is empirically uncertain, however, and the framework holds the critique as ongoing pressure on policy design rather than as resolved by structural reform alone. Parental choice operates inside conditions that have been substantially repaired, with the disability-rights challenge held open as a continuing constraint on how that choice is informed and supported.

Genetic medicine is option, not mandate, with universal access through the political community. Availability of therapeutic genetic medicine at the floor is supported under the [§9.10](<9.10 Healthcare.md>) non-substitutability constraint, though its use is not required. Parents who decline genetic intervention for religious, philosophical, or personal reasons retain full autonomy and full access to the framework's accommodation and support commitments. The framework's commitment is that the option exist, that access not be class-marked, and that the conditions of choice be substantially repaired upstream. It is not that any particular parental choice be enforced.

*End-of-life autonomy.* Where reproductive autonomy locates a healthcare-domain commitment at the early-life threshold and genetic medicine locates an intermediate commitment at the developmental register, end-of-life autonomy locates the symmetric commitment at the late-life threshold. The framework's commitment to wellness rather than bare life as the variable healthcare maintains, combined with the chapter's opening (Awareness as depth-axis), [§8.2](<8.2 Feeling.md>) (Feeling), and [§8.7](<8.7 Mortality.md>) (Mortality), derives that resourced, dignified end-of-life options belong inside the healthcare floor in cases where wellness has become irretrievable by any intervention the framework's commitments can mobilize.

The argument concedes the point and relocates the dispute: end-of-life suffering is tragic, the political community is obligated to mobilize every continuation its commitments can deliver, and the rigorous-process gauntlet operates as the auditable form of that obligation. The categorical-against tradition's moral-seriousness register (life under suffering carries weight; the political community is committed to accompaniment, palliation, and care; the physician's role is healer) is conceded in full. The disagreement is not over whether the weight is real but over what the political community is obligated to do once that weight has been honored by every upstream commitment the framework can mobilize and wellness remains structurally irretrievable. Under those conditions, what enforced continuation against the subject's registered will preserves is not life under the framework's *bios* reading but *zoē* under suffering the framework's wellness commitments are structured against. The structurally controversial move is the forced continuation, not the resourced exit.

No one reading this book wants a governing body forcing them to remain alive in suffering after every available support has been mobilized and wellness has not returned. The categorical-against position, applied under the framework's upstream commitments, names forced continuation against the wellness-failed substrate as the structurally controversial move rather than the resourced exit. What the position calls protection of life, the framework calls forced unwell-being on a subject whose wellness is structurally irretrievable.

The dialectical-inversion runs uniformly across the [§9.10](<9.10 Healthcare.md>) categorical-prohibition family. The same inversion-move that runs the end-of-life burden-flip runs across the three categorical-prohibition opposition traditions [§9.10](<9.10 Healthcare.md>) engages, on the framework's signature dialectical apparatus.

*Categorical-against on euthanasia* names forced unwell-being on the wellness-irretrievable subject: what the position calls protection of life under suffering, the framework calls coercion of *zoē* against the wellness commitments the political community has already mobilized.

*Prohibitionist on substance policy* names forced unwell-being through prohibition's own structural effects: what the position calls protection from substance harm, the framework calls structurally-produced harm through supply substitution toward more concentrated and more dangerous products (the US fentanyl crisis as canonical instance), untreated dependence under criminalization, and criminal-cycle blockage of reintegration into the framework's broader wellness-floor commitments. *Slippery-slope on rigorous-process regimes* names a regraded slope, paved away from the residual case by construction: the wellness-floor commitments [§9.10.2](<9.10.2 What is Required.md>) derives are not a response to the slope but are the slope, regraded; the Canada Track 2 expansion is not refutation of the framework's residual-case derivation but confirmation of what happens when the wellness-floor is not installed alongside legalization, and the framework's own derivation precludes the Track 2 cases as substitution of access for the subsistence floor.

The three inversions are one signature applied uniformly across the categorical-prohibition family. What the framework does not refute in any of the three cases is the position's foundational axiom on its own ground; what the framework does is name the cost of holding the axiom in the framework's own vocabulary and let that naming do the dialectical work.

The eudaemonist commitment is biologically grounded, not merely normative. Conscious organisms are structured around homeostatic and allostatic regulation toward conditions that support continued function (Cannon 1932; Sterling 2012; Damasio 2018); pain avoidance and reward seeking are universally conserved across nervous systems; and the conatus the framework's account of mutual recognition tracks from the inside is wellness-directed rather than bare-life-directed (Spinoza [1677] 1994, III, P6–P9). When the biological substrate can no longer support its own structural function (when the drive cannot be fulfilled by any continuation of the body), enforcing continuation against bodily failure is vitalism: treating the body as the good rather than what the body is structured for. The framework's wellness-not-bare-life commitment, applied at the late-life boundary, precludes that move.

Wellness-irretrievability is the residual criterion after the framework's upstream commitments operate. Most current end-of-life requests track conditions the framework's broader architecture substantially repairs: untreated pain, isolation, fear of bankrupting the family, untreated depression, fear of becoming a burden in a society that does not accommodate dignity. Within the framework (universal floor, healthcare access without financial barrier, structural inclusion, robust palliative care, mental-health access without barrier or stigma) the share of cases driven by remediable upstream conditions falls substantially. What remains as residual is the case where wellness is not retrievable by any intervention the framework's commitments can mobilize. The response there is the resourced exit, not enforced continuation.

The fork is explicit. Once the political community has supplied the resources that could make continued life livable (care, treatment, accompaniment, material security, pain relief, and time), denying a competent subject access to a resourced exit does not simply preserve life. It forces continuation as suffering while overriding the subject's registered will about the body in which that suffering is borne. That is a twofold structural infraction: prolonging the suffering the healthcare system exists to relieve, and converting bodily autonomy into institutional possession at the point where autonomy matters most. The political community's job is to collectively preserve the conditions of a person's needs; what the person needs is not up to the arrangement to decide from outside. Every possible support can be required before the exit. Forced endurance cannot be called care.

The locus of decision sits with the subject whose wellness-drive is at issue. Empathy-registration is structurally asymmetric across substrate conditions: observers register the situation through their own intact wellness-drive, which honestly reports preserve-life, while the subject whose drive is failing has phenomenological access observers structurally lack (Scarry 1985; Nagel 1974). Under the framework's mutual-recognition commitments, what subjects register about their own conditions is the data institutions must protect, especially where substrate divergence makes outside-registration unreliable. Observer veto-power over a subject's wellness-irretrievability assessment is precluded structurally. The bereavement of family and community is real, full-strength, and warrants the framework's palliative-care, bereavement-support, and accompaniment commitments; it is not, however, a structural reason to deny the suffering subject access. Disentangling are-we-ready-to-lose-them from is-this-subject's-wellness-irretrievable is part of what the framework's healthcare system does at the late-life boundary.

The rigorous gauntlet is integral, not optional. Capacity assessment, mental-health screening, confirmation that suffering is irretrievable rather than treatable, waiting periods, multiple-physician sign-off, and confirmation of non-coercion are not paternalistic encumbrances on autonomy; they are what makes the structural-asymmetry argument honest. The argument depends on the failing-drive subject being competent to register their own condition without distortion by treatable depression, transient crisis, or external pressure. What the derivation yields is a tightly-scoped, rigorously-operationalized exit, not a generalized license; the gauntlet is part of the structure, not a concession to opponents of it.

Existing rigorous-process jurisdictions confirm the framework's empirical predictions. Oregon's Death with Dignity Act (1997) operates at under one percent of all deaths, with eligibility requiring terminal prognosis under six months, capacity confirmed by two independent physicians, witnessed written request, and a fifteen-day waiting period; thirty to thirty-five percent of patients who receive prescriptions never use them, with research suggesting the option itself reduces suffering by providing a sense of control (Ganzini et al. 2008). Comparable rigorous-process regimes in the Netherlands (since 2002), Belgium (since 2002), Switzerland, and Canada (MAID, since 2016) operate at approximately one to five percent of deaths with rigorous capacity-assessment processes throughout. The slope-to-mass-euthanasia worry has not materialized in any jurisdiction with reasonable oversight; where slope concerns exist (the Canada Track 2 expansion, Dutch psychiatric-euthanasia cases), they concentrate at specific contested edges rather than at the general regime. The expectation that residual cases under upstream-repair conditions are rarer still is structurally derived, not asserted.

The harm-reduction logic deployed for drug policy generalizes here. A subject determined to end intractable suffering will do so whether or not the political community provides resourced options, and the alternative to resourced options is not preserve-the-subject; it is unresourced suicide by violent means, with attendant trauma to family and discoverers, frequent failure with severe-injury survival, isolation from the possibility of family presence and goodbyes, and forfeiture of advance planning. The structural form is the same as the drug-policy case: prohibition does not prevent the behavior, makes it more dangerous, and forfeits the political community's capacity to mitigate harm. Relocating the question from permission to healthcare-access-for-capacity-confirmed-wellness-irretrievable-cases follows the same structural pattern as the mental-health-belongs-in-healthcare commitment derived above.

The bios/zoē distinction applies at the late-life boundary. It was derived at [§9.1](<9.1 Rights.md>) that the right to life, properly articulated, is a right to agency: what matters for the right is *bios*, life-as-agency, the substrate-with-its-pursuit-capacity-intact, rather than *zoē*, bare biological substrate (*Politics* I.2, 1252b30; Agamben 1998). When the biological substrate has failed irretrievably (when the drive-to-wellness can no longer be fulfilled by any continuation of the body that hosts it), the *bios* the right was structured to protect has already departed; what continuation preserves is *zoē* alone. Forcing continuation under those conditions does not preserve the right to life; it preserves the legal form of the right while denying its substantive content. The choice to refuse continuation when wellness is irretrievable is not a waiver of the right to life but the right exercised at the depth where it grounds: the subject's agency over the agency-bearing substrate that is its own. Right-to-life objections that invoke the right against the rights-bearer's own substantive autonomy deploy the legal form of the right against the *bios* it was structured to protect; Agamben's diagnosis of the structural injustice that occurs when sovereign power reduces subjects to *zoē* applies in the converse direction.

The revocability condition clears the resourced exit rather than barring it. A consent-based account owes an answer to an objection its own structure raises: valid authorization holds only while it remains revocable ([§9.1.2](<9.1.2 What is Required.md>)), death is the most irreversible act a subject can authorize, and the resourced exit can therefore look like the one waiver the framework's inalienability commitment should refuse.

The objection mistakes what revocability protects. Revocability does not require that an authorized act be undoable, since many authorizations the framework licenses are irreversible in their effects; it requires that the authorizing agent never be permanently bound by a past authorization its present self can no longer reach. A waiver that leaves a living agent in place while stripping that agent of all standing to revoke is void at the structural level, because it preserves the very thing (an agent with a present will) whose authority it claims to have cancelled and overrides that will at every later moment.

The irreversible exit has the opposite structure: rather than holding a surviving agent to a past decision against present judgment, it ends the agent, so no later moment arrives at which a revocation is owed and refused. Revocability is vacuously satisfied at the late-life boundary rather than violated, and the authorization stays fully open until the act itself, which is the structural work the capacity-confirmation, waiting-period, and non-coercion requirements ([§9.10.2](<9.10.2 What is Required.md>)) perform. The same condition that forbids a lifelong, irrevocable waiver of one's own agency clears the end-of-life exit, because the first leaves behind a subject permanently subjected to the waiver and the second leaves no subject at all.

The pet-euthanasia case shows the underlying logic is already exercised at intermediate mutual-recognition depth. When a beloved animal is suffering without recovery, the cross-cultural human response is to refuse continued suffering as an act of love rather than to enforce continuation as an act of devotion. The structural logic (wellness-irretrievability warrants resourced exit, not enforced continuation) is one humans already exercise where mutual-recognition depth is intermediate. The human case runs the same logic at greater attachment depth, where mutual-recognition of one human by another is fullest. The greater attachment makes the bereavement weight greater and harder; it does not change the structural logic. What greater attachment changes is who bears the grief and how heavily. That is a domain the framework's bereavement-support, palliative-care, and community-accompaniment commitments address; it is not a domain that converts bereavement-difficulty into structural denial of the suffering subject's access.

Individualism amplifies the bereavement-burden, and the framework's broader commitments reduce that amplification. Bereavement under conditions of dense cooperative infrastructure differs structurally from bereavement under atomized individualism. In a configuration where each household privately self-insures against caregiving, financial cooperation, emotional infrastructure, and labor-sharing, losing a family member compounds grief into real escalation in survival vulnerability: the surviving partner carries the mortgage alone, the aging parent has no caregiver, the social network that ran through the lost person is severed without redundancy. Resistance to a loved one's resourced exit under those conditions is not only attachment-grief; it is partly a rational response to the survival-stakes amplification individualism imposes. The bidirectional distortion individualism produces (observers resisting more because losing the person threatens their own survival, subjects feeling the weight of leaving family to higher-stakes survival as their own cost-on-experience calculation worsens) is corrected at both ends as the framework's broader architecture operates. The framework's commitments to floor income, healthcare access without financial barrier, structural caregiving infrastructure, and community-accompaniment ensure surviving family members are not simultaneously losing emotional connection and material safety. What looks like a bereavement-objection to end-of-life autonomy is partly an individualism-objection in disguise; addressing the upstream individualism reduces the resistance the late-life-autonomy commitment actually has to navigate.

Temporal locus of autonomy unifies advance directive and contemporaneous capacity. The locus-of-decision derivation yields a symmetric implication for advance directives: a subject who specifies, while contemporaneously competent, the conditions under which continuation should not be enforced (irreversible loss of the conditions of integrated experience, irreversible suffering without retrievability) authorizes the exit through the same structural channel that authorizes contemporaneous decision. The framework derives no principled distinction between the family executing an advance directive and the subject taking the resourced exit under contemporaneous capacity; both honor the locus-of-decision the framework's mutual-recognition commitments protect. The institutional differences (who executes, what documentation confirms the directive applies to the actual condition, what safeguards confirm capacity at the time of authoring) are implementation matters; the structural commitment is unified.

The disability-rights critique applies here on the same terms it applies to genetic medicine. The disability-rights critique that end-of-life regimes can slide toward selection-against-disability (sharpest where access is offered to people whose suffering is socially produced rather than biologically irretrievable) tracks a genuine concern, well-documented in the Canada Track 2 expansion debate. The framework's response is the same as in the genetic-medicine subsection above: address the social conditions that drive the slide, not override the autonomy of capacity-confirmed subjects whose suffering is irretrievable after upstream conditions have been substantially repaired. Within the framework's commitments (secure income, universal healthcare access, full structural accommodation, and mutual-recognition of disabled persons as fully-recognized subjects of experience), the cost-on-experience calculation a person faces in late-stage suffering is genuinely different from the calculation in current society. Whether the upstream-condition repair fully neutralizes the disability-rights critique is empirically uncertain, and the framework holds the critique as ongoing pressure on policy design rather than as resolved by structural reform alone. The convergence with the disability-rights critique at the Canada Track 2 case is structural, not contingent: Track 2 cases involve subjects whose wellness is structurally retrievable but for whom the framework's upstream commitments have not been delivered, and the framework's own derivation precludes those cases as substitution of access for the subsistence floor ([§9.10](<9.10 Healthcare.md>) root). The framework and the disability-rights critique converge on the empirical critique of Track 2 and diverge only on whether procedural safeguards can detect structural soft-coercion *in principle* under operating wellness-floor conditions: the framework holds that the rigorous-process gauntlet is structurally responsive to soft-coercion when the wellness-floor commitments are operating; the strong-form disability-rights critique holds that no procedural form can detect structural soft-coercion. This is a real empirical disagreement the framework does not pretend to dissolve.

End-of-life autonomy is option, not mandate, with universal access through the political community. The resourced exit is available at the floor under the [§9.10](<9.10 Healthcare.md>) non-substitutability constraint; no one is required to take it. Subjects whose religious, philosophical, or personal commitments lead them to refuse the option retain full autonomy and full access to the framework's palliative-care, hospice-care, and community-accompaniment commitments. The framework's commitment is that the option exist for capacity-confirmed wellness-irretrievable cases, that access not be class-marked, and that the conditions of choice be substantially repaired upstream. It is not that any particular subject's choice be enforced.

The implications stated in this subsection are derived under engagement with the contested classical-liberal-health-policy traditions [§9.10.1](<9.10.1 What is Disputed.md>) names at premise: Milton Friedman's medical-licensure and consumer-directed-care critique (*Capitalism and Freedom* 1962, chapter IX), the contemporary Cato-tradition health-policy position and Singapore medical-savings-account architecture, and the Pauly moral-hazard analysis (*The Economics of Moral Hazard* 1968). Those traditions are engaged at section length in [§9.10.1](<9.10.1 What is Disputed.md>), and the implications stated here apply under that engagement.

The threshold dissolves a stratum of derivative health-related anxieties. A great deal of what currently shows up as personal-financial anxiety in healthcare is downstream symptom of the threshold's absence: each person is forced to privately self-insure against everything universal coverage would otherwise carry (Case and Deaton 2020). The medical-bankruptcy problem dissolves: healthcare without bankrupting is in the threshold by definition. The job-loss-as-existential-threat problem dissolves: the threshold cushions the transition, so losing a job never means losing housing, food, or healthcare. The caregiving-as-financial-ruin problem dissolves: caring for an elderly parent or a disabled child does not bankrupt the caregiver, because the care is funded by the shared pool the family is part of. The retirement problem dissolves: a person whose old age is structurally part of the population the threshold covers does not need to accumulate enough to privately survive non-work-years. Each of these is a distinct anxiety stratum in the present US configuration, and each dissolves under a non-substitutable-floor architecture without further intervention. The framework derives, rather than asserts, why this is the case: the anxieties are downstream of the structural mismatch between the floor's structural function and the floor's substitution by profit-extracting apparatus.

*Reproductive autonomy.* The [§7.8](<7.8 Life.md>) consciousness gradient, applied to pregnancy, derives that standing comes into being across a developmental range rather than at a sharp moment, and that the pregnant person's bodily autonomy is a participation condition the present account protects throughout. Pre-threshold pregnancy is a healthcare matter, not a political-permission matter: decisions about pregnancy before the structural standing of the developing configuration is reached belong to the pregnant person and their healthcare providers, and the framework precludes carceral-or-legal-mandate regimes that route the question through the criminal-justice system. Across-the-threshold pregnancy involves two sets of participation conditions, and the framework does not derive a specific institutional response to this fact, because the resolution depends on circumstances the framework does not pre-pick (the pregnant person's medical condition, the developing person's developmental status, the resources available, the capacities of the institutional actors involved); what the framework derives is that reductive binary frames (*full standing from conception* or *no standing until birth*) are precluded as collapsing the developmental gradient. The pregnant person's bodily autonomy is a participation condition throughout: threats to bodily autonomy are threats to the participation conditions the framework holds for every subject, and the framework derives that protection of bodily autonomy is not weighed against the developing person's standing but is itself a structural commitment the conditions of participation require. And the framework's participation-conditions derivation extends to reproductive healthcare: contraceptive access, prenatal care, postpartum care, fertility care, and care for pregnancy loss are participation conditions the framework derives as part of the healthcare floor, and withholding any of them through profit-extraction or legal-restriction institutions violates the framework's structural constraint.

What the framework leaves underdetermined falls to the design literatures: it does not pick among single-payer, multi-payer-with-strong-floor, or hybrid implementations, the specific architecture of mental-health crisis response (crisis lines, mobile crisis teams, residential crisis facilities, hospital-based response, or some combination), the specific drug-policy architecture beyond the constraint that prohibition-only fails and combined approaches outperform it (the calibration of harm reduction, treatment access, and decriminalization-versus-legalization left to the implementation literatures and the recognized direction of the population), pharmaceutical-pricing mechanisms beyond the structural-extraction constraint on profit-extraction-from-vulnerability, public-health-emergency-response architecture beyond the constitutive-infrastructure constraint, the specific transition path from current US-style architectures to non-substitutable-floor architectures, and the specific eligibility criteria for end-of-life options (terminal-prognosis-only, intractable-suffering-without-prognosis-limit, or some combination), the waiting-period architecture, the capacity-assessment and mental-health-screening procedure, and the channel of administration (physician-prescription, physician-administration, or alternative healthcare-professional channels). Where multiple designs satisfy the constraints, the framework leaves the choice to the design literatures, the empirical record, and the recognized direction of the population through [§9.3](<9.3 Representation.md>) (Representation).

At bottom, the [§9.10](<9.10 Healthcare.md>) argument across its five subsections is a single thesis: the sufficiency floor binds hardest in healthcare because the floor in this domain is the participants themselves (their bodies, minds, and the continuity of the agency that makes participation possible) and the structural commitment to non-substitutability therefore runs from the beginning of life (reproductive autonomy, therapeutic genetic medicine) through life's course (mental health, substance conditions, constitutive vulnerability) to its close (end-of-life autonomy for capacity-confirmed wellness-irretrievable cases). The confirmation record shows that insurance-occupies-the-floor configurations produce the extraction-and-under-delivery patterns the framework predicts at every interface, while the framework-compatible alternatives have operating records in multiple OECD jurisdictions. The institutional-design implications are comprehensive in scope but unified in logic: what the framework precludes at every interface is profit-extraction at the point of constitutive vulnerability, and what it licenses at every interface is resourced, dignified access to what participants need to remain participants.


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← [9.10.4 What is Confirmed](<9.10.4 What is Confirmed.md>) | [9.11 Defense](<9.11 Defense.md>) →
