For healthcare to obtain at the scale of a political community whose participation conditions presuppose maintained, capacitated participants (articulating the institutional conditions under which the maintenance floor lands at the constitutive vulnerabilities that make participants participants in the first place), the framework draws up a structural-necessity inventory specific to healthcare as constitutive infrastructure. Each is necessary and the necessity is joint; what healthcare architecture has to deliver to count as healthcare architecture rather than as profit-extraction at the point of constitutive vulnerability is the whole set, not any part of it.

*Sufficiency-floor non-substitutability at constitutive vulnerability.* The political community is structurally obliged to maintain its participants in the bodily, mental, and developmental conditions that constitute their participation. Profit-extraction at the floor (margins drawn from sick, injured, and bereaved people) is precluded at the level of design, not merely subject to design pressure. Various coverage architectures satisfy the alternative (single-payer; multi-payer-with-strong-floor; Singapore-style medical-savings-accounts with catastrophic backstop; Beveridge-style direct provision; Bismarck-style social-insurance); the framework precludes profit-extraction-at-the-floor and does not pick among framework-compatible designs that hold the floor without it.

*Insurance-occupies-the-floor architectures are structurally precluded.* The same derivation that makes insurance structurally redundant for subsistence-floor coverage in [§9.7](<9.7 Economy.md>) is at its most forceful here. Where the floor is the participants themselves in their constitutive vulnerabilities, an industry occupying the floor space and drawing profit margins from claim-denial, gatekeeping, and administrative bloat is structural extraction at the point where extraction is least defensible. The preclusion operates at the floor; price signals above the floor (premium services, elective procedures, consumer-discretionary choices) remain available as design instruments, and the framework's symmetry note (institutional-scale claim-denial-for-profit and individual-scale fraud are one structural pattern at different magnitudes) applies in full.

*Mental-health and substance-related conditions are routed through healthcare rather than through justice; substance policy takes a three-layer structural form.* Healthcare is upstream of agentive participation. Conditions producing failures of agentive participation are 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 domain misallocations precluded at the design-pressure level. The harm-reduction logic the empirical record confirms (Portugal decriminalization: Hughes and Stevens 2010; Greenwald 2009; the Swiss heroin-assisted-treatment program; the CAHOOTS Eugene, Oregon operational record; Housing First: Tsemberis 2010) generalizes as the operational form the condition takes. For substances specifically, a three-layer architecture follows. *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) and 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 work jointly rather than separately: prohibition-only collapses layers (i) and (ii) into criminalization the empirical record shows produces worse aggregate outcomes than regulated-distribution alternatives; 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.

*Population-scale public-health infrastructure is constitutive infrastructure.* Vaccination programs, communicable-disease control, sanitation, environmental-health monitoring, and pandemic preparedness are not discretionary subsidies but constitutive infrastructure on the same logic as the legal system or the public-education system. Privatizing or dismantling such infrastructure violates the condition at the structural level. Specific institutional housing (national public-health agency; sub-national public-health departments; multilateral coordination through WHO and successors) is underdetermined within the constraint.

*Reproductive healthcare is a participation condition; bodily autonomy holds throughout.* 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. Withholding any of them through profit-extraction or legal-restriction institutions violates the floor's structural form. Bodily autonomy of the pregnant person is a participation condition throughout the gestational arc; as the [§7.8](<7.8 Life.md>) consciousness threshold is reached the developing person's standing acquires structural recognition alongside (not against) that autonomy. Binary collapses of the gradient at either end are precluded: conception-as-full-standing and birth-as-full-beginning are both ruled out as collapsing the developmental sequence the consciousness account derives.

*Therapeutic genetic medicine: option-not-mandate, universal access, reversibility-graded epistemic standards.* Therapeutic genetic interventions sit on an already-established continuum of preventative biological modification (vaccination, prenatal nutrition, neonatal screening, pediatric surgical correction, somatic gene therapy). Universal access at the floor follows from the non-substitutability constraint; option-not-mandate follows from the framework's autonomy commitments protecting parents who decline. Somatic interventions on existing or developing beings face the same epistemic standards as other therapeutic medicine. Germline interventions face tighter standards (the He Jiankui 2018 case stands as the canonical instance of failed standards; Cyranoski and Ledford 2018). Enhancement interventions targeting capacities beyond therapeutic baselines face categorical preclusion on the same grounds that preclude economic sanctioned disproportion in [§9.7](<9.7 Economy.md>). State-directed selection of which kinds of people exist is precluded structurally; disability-as-defect framing is precluded; enhancement-as-class-marker is precluded.

*End-of-life autonomy for capacity-confirmed wellness-irretrievable cases under rigorous-process safeguards.* The wellness-not-bare-life commitment, applied at the late-life boundary, 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 rigorous-process gauntlet (capacity assessment; mental-health screening; confirmation that suffering is irretrievable rather than treatable; waiting periods; multiple-physician sign-off; confirmation of non-coercion) is integral to the structural form, not paternalistic encumbrance on autonomy: the structural-asymmetry argument depends on the failing-drive subject being competent to register their own condition without distortion. The floor's symmetric form holds at this end of the gradient too: the political community is obligated to substantially repair the upstream conditions that make wellness retrievable (palliative care without barrier; mental-health access without stigma; secure income; structural inclusion of disabled subjects as fully-recognized participants), and the residual case where wellness is irretrievable after upstream repair is where the resourced exit lands. The condition's structural form already concedes what the categorical-against tradition reaches for at the moral-seriousness register: end-of-life suffering is tragic, the political community is obligated to mobilize every continuation its commitments can deliver, and the rigorous-process gauntlet is the auditable form of that obligation. Once the upstream commitments have operated and wellness remains structurally irretrievable, the question of what enforced continuation against the subject's registered will preserves becomes the structurally controversial question: the dialectical-inversion that compresses this engagement is developed at [§9.10.5](<9.10.5 What is Concluded.md>).

Together, these seven conditions are what healthcare as constitutive infrastructure structurally requires: each indispensable, substantive healthcare architecture standing up only when all of them are met. [§9.10.3](<9.10.3 What is Predicted.md>) runs its predictions against that set.


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← [9.10.1 What is Disputed](<9.10.1 What is Disputed.md>) | [9.10.3 What is Predicted](<9.10.3 What is Predicted.md>) →
