Everything else in political life assumes the people in it are alive and well enough to take part, which makes health care not one more service a society offers but the floor the rest of the society stands on. Even the most limited view of government grants that a community must not let its people be killed or left to violence it could have prevented; untreated illness, injury, and unmanaged pain knock people out of participation by exactly the same door, so a line that stops short of medicine is drawn in the wrong place. That is also why selling basic coverage for profit reads as extraction: the insurer's margin is taken from sick and grieving people for a service the community already has the capacity to provide directly. And it is why questions about one's own body (what to take, whether to continue a pregnancy, how to meet the end of life) land here too: the body is not an object politics manages from outside but the very thing through which anyone is a participant at all.

The people whose direction a political community is meant to recognize must be alive and well enough for that recognition to mean anything. Healthcare derives from the chapter's opening (Awareness as depth-axis), [§8.2](<8.2 Feeling.md>) (Feeling), and [§8.7](<8.7 Mortality.md>) (Mortality), read at the institutional scale [§9.2](<9.2 Belonging.md>) establishes. If consciousness (recovered in [§7.8](<7.8 Life.md>) as the inside of self-producing recursion and traced through the chapter's opening as awareness at depth) is what being a participant *is* (the basal condition the whole argument presupposes), then maintaining conscious participants is not one good among many that the political community might or might not provide. It is what makes political participation possible in the first place. Feeling and the proximity of death give the point its urgency. A person in pain or danger is not merely uncomfortable; their capacity to take part in civic life is at stake. The modal field ([§8.3](<8.3 Knowledge.md>)) the person holds (the structured space of action-possibility within which any meaningful participation occurs) collapses toward crisis-management whenever the body holding it is in pain, threatened, or breaking down. Healthcare maintains the conditions under which that person can participate at all.

That places healthcare on the side of the [§9.1](<9.1 Rights.md>) aversion-asymmetry the libertarian frame already concedes. Political community has uncontested obligations on the aversive-prevention side: do not let participants be killed, do not let them be unjustly imprisoned, do not let them be subjected to violence the polity could have prevented. Healthcare is the maximum-force case of that conceded obligation: the conditions whose failure dissolves bodily participation directly, on the side of the asymmetry [§9.1](<9.1 Rights.md>) places Subsistence on through the *bios* reading. The frame's selective acceptance of negative-aversive obligation for harms enemies and criminals could cause, while denying it for harms disease, injury, and unmanaged pain produce, is internal incoherence rather than principled distinction. Both work the same way structurally: they dissolve the body's modal field below the threshold required for participation. The asymmetry does not care about the proximal cause; it cares about the outcome the polity is committed to preventing.

The argument places healthcare *upstream* of agentive participation rather than parallel to it. A political community that fails to maintain its participants' baseline health is not failing at one of its tasks; it is failing at the precondition of having tasks. Where it was derived at [§9.7](<9.7 Economy.md>) that mechanisms substituting for subsistence maintenance are structurally precluded, healthcare is the case where that derivation lands at maximum force: the floor is the participants themselves, in the constitutive vulnerabilities that make them participants in the first place. The bodily-health and bodily-integrity capabilities Nussbaum develops in *Women and Human Development* (2000) and *Frontiers of Justice* (2006) Part I are the closest analytic-philosophical engagement with healthcare-as-constitutive-capability: Part I's disability-case analysis bears directly on the section's disability-rights critique passage, and the capabilities-approach methodology of starting from concrete cases that dominant theories have marginalized converges with the [§9.1](<9.1 Rights.md>) wanting-downstream result applied here.

A working person who breaks an arm and skips the emergency room because they cannot afford the deductible is recognizing the failure the floor exists to prevent: their participation capacity has been narrowed by structural cost rather than by the injury itself. A society in which that calculation never has to be made is what the healthcare derivation calls for; whether single-payer, multi-payer-with-floor, or hybrid is the architecture that delivers it is left to design literatures and recognized direction.

A genuine participation floor covers the actual material necessities of functioning and participation, not a neutral-looking average that silently undercounts needs specific to one part of the population. A floor written as a falsely-neutral basket leaves some people to cover a body-cost others do not bear, and that is the same recognition-substitution the framework names elsewhere: the society being maintained is changed from the one everyone inhabits. The principle is generating, not enumerating — whatever conditions are necessary for a person to function and participate in the shared structure, the floor must cover. Menstrual products and diapers are not special pleading added to a general list; they are one-line illustrations of what the principle generates, and the social-reproduction point they carry — that the material cost of raising a child is collective investment, not a private household cost — is already part of the framework's architecture. Not taxing such items as luxury follows a fortiori; providing them on the floor is the stronger claim this section delivers.

*Accessibility and the earnings trap.* The same upstream commitment reaches the accessibility costs that let a participant with a disability move through the world and take part in it: mobility aids, personal assistance, adaptive equipment, and the supports that make a setting navigable are maintenance of the conditions of agentive participation in exactly the sense the section grounds, not a discretionary benefit a separate program extends at its discretion. Covering them is provision rather than reward: owed because the participation they restore is constitutive, not earned by any demonstration of desert. That commitment exposes the structural defect in disability programs built around an earnings cap, where the maintenance is withdrawn once outside income crosses a threshold. Such a design turns the floor into a ceiling: it forces a participant to choose between the support that makes participation possible and the exercise of whatever work capacity they have, and it penalizes the second by revoking the first. The [§9.1](<9.1 Rights.md>) result names the form exactly. The floor is neither earned by participation nor forfeited by it; the earnings cap is the forfeited-by-it case, the mirror of the earned-by-it violation [§9.1](<9.1 Rights.md>) already precludes. Partial capacity is the ordinary case and not the exception: a person constrained along one axis is typically capable along others. The political community's task is to let that capacity be exercised on top of the floor rather than forcing a person to trade support against work. A floor that competes with the participation it exists to enable contradicts maximum possibility at its root.

*Insurance as structural extraction (the maximum-force case).* The same derivation that makes insurance structurally redundant for subsistence-floor coverage in [§9.7](<9.7 Economy.md>) makes the privatized-medical-insurance industry the textbook case of structural extraction. The industry draws premiums from a collective pool of payers; denies claims as a profit-maximization strategy; extracts margins and executive compensation from sick, injured, and bereaved people; and operates only because it is embedded in legal, regulatory, banking, public-health, and educated-workforce infrastructure it neither built nor proportionately maintains. The same derivation that makes the industry redundant explains why it was extractive while it lasted, and predicts that the industry will be the most ferociously resistant entity to any collective-investment political project.

The symmetry note from [§9.7](<9.7 Economy.md>) applies in full force here: individual-scale fraud (staged accidents, false claims, gaming benefits) is a structural infraction on everyone who contributes to the pool, on the same logic. Neither party is moralized against preferentially; the framework identifies the structural form and lets the form do the work. Employer-sponsored insurance in particular operates as Private Government extension (Anderson, *Private Government* 2017): healthcare access tied to employment converts at-will employment into at-will-but-healthcare-revocable: a deeper domination structure than the wage relation alone, and the [§9.7](<9.7 Economy.md>) workplace-authority register applies directly at the healthcare interface.

*The race-stratified healthcare record presses the recognition logic at maximum force.* The [§8.12](<8.12 Morality.md>) mutual-recognition mechanism that grounds the healthcare-as-precondition derivation is the same mechanism whose historical failure has produced a documented record of race-stratified medical conditions: Black maternal-mortality rates three to four times white-women rates in current US conditions; systematic pain undertreatment for Black patients tracked to pain-belief myths in medical training (Hoffman, Trawalter, Axt, and Oliver 2016 PNAS); race-correction in clinical algorithms (eGFR until 2021 revision; spirometry race-correction still standard; Vyas, Eisenstein, and Jones 2020 NEJM 'Hidden in Plain Sight' survey); the historical record running through Tuskegee (1932–72), Henrietta Lacks, and J. Marion Sims's experimentation on enslaved women without anesthesia. Roberts's *Killing the Black Body* (1997) and *Fatal Invention* (2011) develop the canonical analytic engagement at the race-stratified-reproductive-healthcare and race-in-medicine registers. Foucault's *The Birth of the Clinic* (1963) develops the biopolitics tradition's critical-theory engagement with healthcare-as-state-power at the same register. The upstream-conditions commitment applies directly: the conditions of agentive participation have been systematically withheld from specific populations across institutional generations, and the maximum-force case the section grounds runs at maximum force at exactly this register.

*Engaging the classical-liberal health-policy objection.* Three counter-traditions are developed in full at [§9.10.1](<9.10.1 What is Disputed.md>): Friedman's medical-licensure + consumer-directed-care critique (*Capitalism and Freedom* 1962, ch. IX), the Cato-tradition Singapore-medical-savings-account + catastrophic-backstop architecture, and Pauly's moral-hazard analysis (*The Economics of Moral Hazard* 1968). The framework grants the central concession in each case. Licensure-rent capture is granted in the form the licensure-economics literature has confirmed; the framework's anti-extraction architecture ([§9.7](<9.7 Economy.md>)) applies symmetrically. Singapore-style MSA + catastrophic-backstop is granted as one framework-compatible architecture alongside single-payer and multi-payer-with-floor: each delivers the floor without profit-extraction at the floor, and the choice among them is left to design literatures and recognized direction. Moral hazard is granted in its empirical form and applies above the subsistence floor (premium services, elective procedures, consumer-discretionary choices); the framework's constraint operates at the floor and does not preclude price signals above it. Where the framework parts is on whether the maintenance floor itself can be priced: at the floor, where failure-to-receive-care is failure to remain the kind of subject political life consists in, price signals are not information-transmission mechanisms but coercion of the constitutive. Convergence with the classical-liberal tradition holds on price signals above the floor, on opposition to licensure-rent capture, and on Singapore-MSA as a framework-compatible design alternative; the parting is on whether the floor is a market interface or the precondition of having markets at all. Daniels's *Just Health Care* (1985) and *Just Health* (2008) extend Rawlsian political-liberalism to healthcare through the normal-opportunity-range argument (that healthcare is constitutive of fair equality of opportunity rather than additive to it) converging with the framework's upstream-of-agentive-participation derivation on different grounds. Where the framework parts from the Daniels/Rawls grounding is on grounding: normal-opportunity-range grounds healthcare standing in fair-equality-of-opportunity (which the original-position procedure delivers), while the framework grounds it directly in [§8.12](<8.12 Morality.md>) mutual recognition and the participation conditions that recognition presupposes.

The care-ethics tradition reaches the healthcare-as-precondition conclusion on a third set of grounds. Kittay (*Love's Labor* 1999), Held (*The Ethics of Care* 2006), and Tronto (*Moral Boundaries* 1993) ground moral and political obligation in the dependency relation itself: every subject is, across the lifespan, both a recipient and a giver of care, and the caregiving relation, not the contract among independent equals, is the relation political theory has to take as basic. The central claim is granted and treated as convergent: healthcare on the framework's account is the institutional form the care-relation takes once the subjects who depend on one another number in millions, and the dependency the care-ethics tradition makes central is the same constitutive vulnerability [§8.12](<8.12 Morality.md>) grounds recognition in. Where the framework parts is on grounding (it derives healthcare standing from the participation conditions mutual recognition presupposes rather than from the dependency relation taken as primitive) but the care-ethics tradition supplies something the recognition argument under-develops: caregiving labor, paid and unpaid and disproportionately performed by women and by racialized and migrant workers, is itself collective investment in the §9 root sense: infrastructure the political community depends on and has historically declined to recognize or resource as such. The collective-investment concept brings that labor inside the account rather than leaving it as the unpriced substrate on which the priced system runs. Care is not merely a service delivered after someone has become a participant in public life. It is part of how participants are sustained and formed in the first place: pregnancy, infancy, disability, illness, and old age all make dependence a normal condition of human life rather than an exceptional failure. A political community that relies on care while treating its labor as private, invisible, or freely supplied offloads a constitutive cost onto the people who perform it. The framework therefore requires public support for care as a condition of participation, while leaving the household forms through which care is given open.

*Drugs and bodily autonomy.* The treatment of drugs and substances follows from the healthcare derivation rather than being added to it. If healthcare is upstream of agentive participation, then addictive use, untreated mental illness, and coping-mechanism dependency are conditions the political community has to address. Addiction does not carry special moral weight; it shows that a person's basic conditions of support are failing in a way public institutions must recognize and address. Purely prohibitionist drug regimes systematically underperform regimes that combine harm reduction, treatment access, and investment in upstream conditions, for reasons [§9.13](<9.13 Justice.md>) (Justice) develops further when it picks up the justice side of the same problem. The [§9.1](<9.1 Rights.md>) wanting-downstream result names the foundational structural form: the addictive use is the participant's maintenance failure showing up downstream, not autonomous expression of the participant's preferences. From these commitments follows a layered architecture for substance policy. *Use* by competent adults is decriminalized: the participant's choice to ingest is a bodily-autonomy matter the political community has no standing to criminalize, on the same 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 operate 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) and unregulated retail at the high-dependence-and-acute-harm end is precluded because it produces the supply-substitution dynamics the US fentanyl crisis exemplifies. *Harm to others* through impairment-driven negligence (impaired driving; impaired-while-responsible-for-dependents; impaired-while-operating-machinery) remains criminally liable on standard recklessness-and-negligence doctrine: user-side autonomy does not collapse into license to harm third parties. These layers operate together and not separately; the structural derivation and the dialectical engagement with prohibitionist and strict-libertarian objections are developed at [§9.10.2](<9.10.2 What is Required.md>) and [§9.10.5](<9.10.5 What is Concluded.md>).

*End-of-life access and the subsistence floor.* End-of-life policy is the [§9.1](<9.1 Rights.md>) result's healthcare-design instance. The same derivation that places healthcare upstream of agentive participation determines the shape of end-of-life policy. Where a person wants to end their life because of intractable suffering or terminal illness (conditions the subsistence obligation did not require the political community to have prevented), the wanting is genuinely autonomous. The political community's obligation to maintain the conditions of agentive participation includes maintaining the conditions under which that autonomous choice can be made well and acted on without coercion or shame. Where a person wants to end their life because they cannot get housing, food, work, or care, the wanting is the unmet subsistence obligation showing up downstream of failure ([§9.1](<9.1 Rights.md>)). The political community's obligation is to meet the obligation, not to provide an exit from the conditions it failed to meet. The two cases call for the same commitment from opposite ends: end-of-life access is real, and the subsistence floor must hold underneath it so that the access is exercised by the population whose wanting is genuinely autonomous rather than by the population whose wanting is structurally produced. The diagnostic the [§9.1](<9.1 Rights.md>) result provides is binding here. Where the rate at which people seek to end their lives rises within a population, the first investigation the political community is obligated to perform is of the subsistence conditions producing that rise. The response here is the same as to the disability-rights critique below: address the social conditions that drive the slide through the [§9.10](<9.10 Healthcare.md>) upstream commitments. End-of-life access for the autonomous-wanting population is preserved; substitution of access for the subsistence floor is structurally precluded. The deeper structural move [§9.10.5](<9.10.5 What is Concluded.md>) develops is that the categorical-against position, applied under the framework's upstream commitments, names forced continuation against the subject's wellness-failed substrate as the structurally controversial move rather than the resourced exit.

*What remains open.* Single-payer, multi-payer-with-floor, and hybrid implementations remain design questions. The fixed claims are that the subsistence floor is constitutive, that mechanisms substituting for the floor are precluded, and that the floor must cover conditions producing failures of agentive participation, including mental health and substance-related conditions. Where multiple institutional designs satisfy those constraints, the choice remains open.

Reproductive autonomy is political because pregnancy joins two structural facts Chapter 8 separated for clarity. The developmental-gradient consciousness result is given at [§7.8](<7.8 Life.md>): the developing configuration acquires a first-person perspective along a gradient as the neural architecture capable of integrated registration comes online, with thalamocortical integration developing substantially between the twenty-third and twenty-eighth weeks of gestation (Lagercrantz and Changeux 2009; Koch 2019). The sexuality result is given at [§8.6](<8.6 Sexuality.md>): reproduction-choice becomes agency once a subject can take the production of another subject as an object of self-modeling. The political register is where those results become consequential, because institutions must decide how to protect participation conditions when one already-existing subject's body is the site through which another subject may come into being.

The structural standing question follows from the awareness threshold. This application inherits the Chapter 8 register: it is conditional on the fit-defended identification of consciousness with the inside aspect of a sufficiently integrated self-modeling recursion, rather than a fresh strict deduction from Chapters 1–2. Given that identification, the conditions of maximum possibility, the vulnerability argument, and the intersubjective recognition that grounds morality all require a subject with a first-person perspective. Before the structural threshold the account has identified, there is biological process (metabolism, reflex, cellular development) but not yet the integrated subject whose standing the account grounds moral and political obligation in. The pregnant person's participation conditions are never in question: those are established throughout, and any arrangement that degrades them fails the maximum-possibility account in the same way any other degradation of participation conditions does. As the developmental threshold is reached, the developing person's conditions acquire standing alongside the pregnant person's, whose bodily autonomy remains a participation condition the present account protects throughout.

The standing the threshold confers is structural, not a matter of degree. What grounds it is the presence of an integrated subject, not the richness, complexity, or quality of that subject's experience. Before the threshold, what is absent is the subject, not a faint or partial version of one: the account does not rank early-developmental stages by how much experience they sustain, and the conclusion that early termination does not destroy a subject follows from the subject's absence rather than from any judgment that its experience is too slight to matter. After the threshold, standing holds invariant to the richness of the experience a subject sustains. That invariance is what forecloses the slide that would withdraw standing from the disabled, the cognitively impaired, the unconscious, or the newborn on the ground that their experience is diminished: the same failure of recognition the account precludes when a community declines to recognize beings who structurally meet the threshold. A criterion that tracked richness of experience rather than the presence of a subject would license exactly those devaluations; locating standing at the threshold is what keeps it capacity-independent once it is held.

The consent framing that recurs in the public debate misfires on the same structural fact. To object that termination proceeds without the developing being's consent is to presuppose a bearer of the will whose authorization could have been sought or refused. Before the threshold there is no such bearer: a subject emerges through the developmental process rather than preceding it and awaiting its permission, so there is no party whose consent is withheld or overridden. The objection locates a consenting party where the account finds none, while the one consent-bearer present throughout, the pregnant person, is the party whose authorization the arrangement actually turns on.

This precludes both binary simplifications that dominate the public debate. A conception-as-full-standing view treats biological life as already equivalent to a subject with a first-person perspective, collapsing the [§7.8](<7.8 Life.md>) developmental-consciousness gradient. A birth-as-full-beginning view treats the developing configuration as politically irrelevant until separation, collapsing the same gradient from the other side. Three intermediate positions deserve direct engagement. *Potentiality* arguments (Marquis 1989; Stone 2014) hold that what matters is what the developing being is becoming rather than what it is at any moment, and that the structural standing of the eventual person extends backward to the inception of the developmental sequence. The argument grants what potentiality tracks (the developing organism is becoming a subject of experience) and locates standing at the developmental point where that becoming reaches integrated consciousness rather than at the inception of the process. Extending standing backward across the entire developmental range would collapse the [§7.8](<7.8 Life.md>) developmental-consciousness gradient. *Viability* arguments, central to the Roe v. Wade (1973) and Planned Parenthood v. Casey (1992) frameworks, locate standing at the point where survival outside the pregnant person's body becomes possible. The work the viability criterion does is respected, but the structural threshold is located at consciousness directly, with viability recognized as one empirical correlate rather than as the criterion itself. *Personhood-as-conferred-by-community-recognition* arguments (Warren 1973; English 1975) locate standing in the recognition the community extends rather than in any developmental fact. That mutual recognition is constitutive of moral standing ([§8.12](<8.12 Morality.md>)) is granted, and the threshold sits at the developmental point where mutual recognition becomes structurally available. Communities can decline to recognize beings who structurally meet the threshold, as the historical pattern across slavery, gendered exclusion, and disability erasure demonstrates. That decline is precluded as a failure of recognition rather than as a definitional question about who counts.

The *disability-rights* critique of selectionist regimes (Saxton 2000; Kafer 2013; Garland-Thomson 2012) tracks the same concern [§9.10.5](<9.10.5 What is Concluded.md>) develops at the genetic-medicine and end-of-life thresholds: that the slide from threshold-permission to existence-selection is real and partly socially produced. The same response applies: address the social conditions that drive the slide through the [§9.10](<9.10 Healthcare.md>) upstream commitments. Hold the critique as ongoing pressure on policy design rather than as resolved by structural reform alone.

The *religious and natural-law* traditions articulate stances toward existence and contingency the framework respects as stances: Aquinas on delayed animation (*Summa Theologiae* I.118), Catholic magisterial teaching from *Humanae Vitae* (1968) onward, Orthodox Jewish threshold positions in the rabbinic tradition (Mishnah *Ohalot* 7:6), and Sandel's (2007) openness-to-the-given orientation. Where parents hold these orientations, the framework's autonomy commitments protect the exercise of those commitments. What the framework does not derive is that those positions function as structural constraints on what reproductive healthcare 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.

The argument does not make these debates disappear. It locates standing at the threshold its own account of consciousness identifies. It does not name a moment at which a switch flips: thalamocortical integration develops gradually, and the relevant threshold is not a sharp line but a range over which standing comes into being. Before it, one set of conditions is at stake. After it, two are. This is not a political position chosen in advance. It is what follows when the account of consciousness and the account of reproduction-choice are applied together.


- [9.10.1 What is Disputed](<9.10.1 What is Disputed.md>)
- [9.10.2 What is Required](<9.10.2 What is Required.md>)
- [9.10.3 What is Predicted](<9.10.3 What is Predicted.md>)
- [9.10.4 What is Confirmed](<9.10.4 What is Confirmed.md>)
- [9.10.5 What is Concluded](<9.10.5 What is Concluded.md>)


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← [9.9.5 What is Concluded](<9.9.5 What is Concluded.md>) | [9.10.1 What is Disputed](<9.10.1 What is Disputed.md>) →
