Bioethics @ TIU

Ethical Health Care Reform

Posted July 21st, 2017 by Joe Gibes

Recently I heard a Christian TV personality refer to Obamacare as “iniquitous.” This started me thinking, What would make a health care funding reform scheme “iniquitous”? Or, although the words aren’t synonymous, what would make such a scheme unethical? What should go into ethical health care reform?

The answers to these questions are legion and conflicting. There are some who see government intervention as inherently wrong; for them, the free market is the key to ethical health care reform. There are others who distrust the free market, and consider some degree of governmental control to be the only ethical option. Some see personal mandates to buy insurance as unethical; others understand the mandates as ethical solidarity with our neighbor. Some ardently believe justice means everyone gets exactly the coverage or treatment they pay for; others just as ardently believe justice means everyone gets the same coverage and treatment.

What is ethical health care reform? There are many possible answers. I am not sure that Obamacare is any more or less ethical than the versions of Trumpcare that have been put forward. I am not sophisticated or smart enough to pontificate about the free market or theories of justice.

One thing I am certain of, however: Whether the system relies on markets or government regulations, whether there are more or fewer mandates or taxes, whether everyone gets the same coverage or not, one final measure of whether or not a health care system is ethical is how it treats those who are the poorest and most disadvantaged among us. If those who are least able to provide for themselves are not provided for and granted access to the system, then it is an unethical system.

4 Responses

  1. Mark McQuain says:

    I agree that labeling Obamacare or Trumpcare “iniquitous” is, to be generous, unhelpful.

    Getting to your final point, I think we sometimes view “the poorest and most disadvantaged among us” as a uniform group when they are not. Some of those I care for are their own worst enemies. They simply will not do reasonable preventative health care and are therefore costing others/society even more to provide them basic care. Should we/society have the right to force/coerce them to comply as a condition of access to the system?

    In other words, we often talk a lot about the obligations of the system (doctors, hospitals, big pharma) to the individual but what about the obligations of the individual to the system? Since any future mandate/law can (and likely will) go both directions, we need to include that side in our ethical discussions.

    • Joe Gibes says:

      Thanks for the clarification that”the poor and disadvantaged” is a very heterogeneous category. A large part of my practice is made up of people who legitimately fall into that category; I also have affluent corporate bosses in my practice. Among both of those groups are those who don’t practice basic preventative care! When their own behaviors lead to their receiving care for conditions that could have been prevented, the more affluent patients often cost “the system” virtually as much as the poorer patients (because after all, the insurance premiums they have paid cover only a minuscule fraction of the costs that they incur, the rest being paid by other people’s insurance premiums, or a government program, or a charity, or the other patients to whom costs are shifted, or . . .). One difference between them, however, is that the more affluent have access to that system by virtue of the fact that they (we) can pay the entrance fee into the system (or they have a good job that will pay the fee for them) in the form of insurance premiums. And yes, the obligations or responsibilities of the individual — whether affluent or not — is a really important ethical question mark, and has not been addressed adequately as part of any discussion of health care reform that I have seen.

  2. Jon Holmlund says:

    I also agree that we should not globally label these complex laws or proposed laws “iniquitous.” That promotes the demonization that is so common and injurious in our current discourse. Still, it is true that our broad healthcare policies can support iniquitous acts (e.g., performing abortions).

    I have always thought that the issues are more prudential–what is wise, especially in the long term? I think we can all agree that society has a duty to provide true access to medical care (i.e., not just access in name only) to our most vulnerable members. Does that create a “right?” I’m not sure: a right implies a corresponding duty, on someone’s part, but that does not seem to entail the converse.

    One criticism of the ACA’s Medicaid expansion is that it created financial incentive for states to prefer new enrollees to the neediest enrollees for whom the program was initially intended. I do not have detailed on the ground knowledge to assess this, but the criticism seems plausible. We now see it created a sort of golden handcuff problem for states that accepted the terms.

    Any meaningful reform of Medicaid is being denounced as cruel. I have concluded we have rejected such reforms, and in practice settled on a course that will continue to expand entitlements at an unsustainable rate, and block most if not all alternatives, with the risk of collapse in the not-too-distant future. I don’t see this course changing much if at all. I believe that by this happening in my lifetime I have failed in a duty to the next generations to try to prevent it. And that is also unethical. Mea culpa.

    • Joe Gibes says:

      I too am uncomfortable with the language of “rights” with regard to health care. I think William F. May characterizes health care more helpfully as a “good.” He enumerates the moral foundations of health care reform as three: health care is a fundamental good, it is not the only fundamental good, and it is a public good. Sondra Ely Wheeler has written that the theological foundations of justice rest on the realization that God is the owner of all we have and think we own, including our health care resources; we are merely the stewards. They also rest on the recognition of the basic equality and dignity of every human; thus, each person has a claim to “an equitable share of the resources which God provides for the well-being of all.” I think those are more helpful places to evaluate ethical health care reform than talking about “rights.” With regards to the Medicaid expansion — one would have to have a broader perspective than my own experience of my patients to evaluate your statement, but I can say that with Medicaid expansion in Illinois, several of my own patients went from having no insurance and paying out-of-pocket to having some form of health insurance. With regards to your last paragraph — I think there are many options for reforming health care, but the two political parties seem each to have staked out very tiny bits of healthcare reform territory, beyond which they are not willing to explore or compromise.
      (The Wheeler quote comes from her chapter, “Broadening Our View of Justice in Health Care,” in The Changing Face of Health Care,ed. John Kilner, Robert Orr, Judith Allen Shelly [Grand Rapids, MI: Eerdmans, 1998] 68-9.)

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