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Editorials

Ethical Foundations of Health Care System Reform

Institute of Human Values in Health Care and Department of Surgery, Medical University of South Carolina, Charleston, South Carolina

^_* Address correspondence to Dr Sade, Division of Cardiothoracic Surgery, Medical University of South Carolina, PO Box 250612, 96 Jonathan Lucas St, Ste 409, Charleston, SC 29425 (Email: sader{at}musc.edu).

	Introduction

Top Introduction A Spectrum of Health... Optimizing Access and Paying... The Ethical Foundation of... The Ethical Foundation of... Conclusions and Inferences Acknowledgments References

 
Arguments for reforms of the United States (US) health care system that favor central control and financing of health care have often relied heavily on ethical reasoning related to distributive justice. Advocates of reforming the health care system by decentralizing control and financing of health care, as have been advanced by the current Bush administration [1] and by the American Medical Association [2], seldom play the "ethics" card, yet, the reforms they suggest are also ethically sound. The term "Ethical Foundations" in the title of this editorial is plural, emphasizing that many different approaches to health care system reform are morally well grounded. The debate between John Goodman and David Himmelstein with Steffie Woolhandler on health care system reform in this issue of The Annals highlights the radically different programs for reform that are now near the top of the national legislative agenda [3]. It should be no surprise that the ethical foundations of radically different programs also may differ radically.

	A Spectrum of Health Care Services Reform

Top Introduction A Spectrum of Health... Optimizing Access and Paying... The Ethical Foundation of... The Ethical Foundation of... Conclusions and Inferences Acknowledgments References

 
The health care system in this country is generally described as being in crisis because overall expenditures for health care are rising at an unsustainable rate, while tens of millions of Americans are uninsured or underinsured, suggesting that they lack access to health care. The constellation of problems associated with these observations has led to a sense of urgency in finding solutions. Himmelstein and Goodman hold nearly diametrically opposed views of the causes of the financial-access crisis, and their proposed cures are similarly opposed. Their views represent two ends of a spectrum related to degree of centralization of health care financing, one end marked by the idea that society must be responsible for providing health care to all, the other, by the notion that individuals must be responsible for seeking and paying for their own health care. Advocates of social responsibility for health care generally support reform involving some variety of single-payer system with centralized financing, exemplified by Himmelstein; advocates of individual responsibility generally support market-oriented reforms, characterized by personal payment for health services, exemplified by Goodman.

The ethical foundations of single-payer and market-oriented reform policies are very different. Most intermediate or mixed reform proposals incorporate policy strategies from both sides of the spectrum, and these strategies carry with them their ethical underpinnings. Intermediate reform proposals, therefore, are admixtures of policies with their ethical justifications; therefore, analysis of the ethics underlying Himmelstein’s and Goodman’s visions will provide a useful picture of the ethics of the entire range of reform proposals.

	Optimizing Access and Paying for It

Top Introduction A Spectrum of Health... Optimizing Access and Paying... The Ethical Foundation of... The Ethical Foundation of... Conclusions and Inferences Acknowledgments References

 
Both single-payer and free market advocates envision individuals within society as interdependent, but understand the moral functioning of interdependence differently. To single-payer advocates, interdependence means that all individuals have a positive obligation to support one another, ensuring that everyone is provided with at least the minimal goods needed to sustain life. One of those goods is health care, and this logically leads to a preference for centralized—usually governmental—solutions to problems of rising costs and lack of health insurance.

To free market advocates, all interactions with others must be voluntary; therefore, each of us is obligated to refrain from interfering with the activities of others. Under those conditions, interdependence means that achievement of our full potentials as human beings is dependent on the work of others, particularly in our society, in which production of goods and provision of services is highly specialized. The concrete expressions of the basic moral obligation of each human being to refrain from interfering with others are free markets. In health care, this leads to preferences for decentralization of financing, a small role for government, and market solutions to problems of access.

Both groups share a goal of optimizing access to health care. Optimizing access can be interpreted in many ways, however, ranging from paying for a specified range of health care services for everyone, to relying on market mechanisms to lower costs and improve quality, thus broadening the range of routes of access to health care. To single-payer advocates, the primary goal of health policy is ensuring that everyone can obtain some minimal level of health care. This can best be achieved by paying for everyone’s health care or health insurance, thus removing financial barriers to access.

To free market advocates, the primary policy goal is freedom for individuals to act for their own benefit and the benefit of those for whom they are responsible. Secondarily, market mechanisms will ultimately optimize health care access by controlling cost and quality, creating a variety of ways for patients to enter the system and facilitating a broad range of health care choices consistent with many different value systems.

Respected, well-known scholars at both ends of the health care reform spectrum have advanced ethical justifications for their differing positions. The following sections describe the moral underpinnings of health care system reform from their respective viewpoints.

	The Ethical Foundation of Social Responsibility for Providing Health Care

Top Introduction A Spectrum of Health... Optimizing Access and Paying... The Ethical Foundation of... The Ethical Foundation of... Conclusions and Inferences Acknowledgments References

 
Health care is a fundamental human good because "it protects our opportunity to pursue life goals, reduces our pain and suffering, prevents premature loss of life, and provides information needed to plan our lives" [4]. Health care is critically important because it may prevent disease and disability, thereby helping to maintain health, and may also cure disease and repair injuries. It can help individuals to compensate for loss of function and capacities and to preserve functions they already have. Making access to health care widely available assures each of us that we are full members of society and of the moral community. Moreover, by helping to make us whole, health care ensures that each of us can exercise the freedom that our democratic, free society promises.

From this point of view, the moral ideals upon which health care access should be built are justice, equality, and community. These ideals require that the health care system be universal, comprehensive, and equitable in the distribution of benefits and burdens [5]. From this moral infrastructure, certain principles emerge to complete the foundation.

There should be universal access to health care, with no financial or other barriers to obtaining health care services. Losing a job or suffering economic difficulty should not raise the fear of losing health care. Access to needed services should not be denied "because of pre-existing conditions, age, race, genetic background, or disability. Barriers to access arising from linguistic or cultural differences, geographic distance, prejudice, residence in economically deprived or underserved areas, or excessive out-of-pocket payments must also be removed" [5].

A comprehensive package of benefits should be offered to all Americans. The package should cover primary, preventive, chronic, and long-term care, as well as acute care, home care, hospital care, and treatment for both physical and mental illnesses.

Ensuring fair burdens in health means that payment for health care should be based on ability to pay; that is, costs of providing for health care needs should be spread across the entire community. Differences in the likelihood of illness and the cost of treating it are, for the most part, beyond the control of individuals, so it is only fair to spread the cost of providing health care across the whole community. To this end, everyone must belong to the health care system and must shoulder a fair share in supporting it.

	The Ethical Foundation of Individual Responsibility for Seeking Health Care

Top Introduction A Spectrum of Health... Optimizing Access and Paying... The Ethical Foundation of... The Ethical Foundation of... Conclusions and Inferences Acknowledgments References

 
This viewpoint rejects the claim that the need for health care is categorically different from the need for other goods and services for supporting human life [6 ^pp83–90]. The need for health care is undeniable by modern standards, but it is not obviously different from the need for food, shelter, or other basic goods and services. Satisfying these needs is an important goal, but human life has many other goals as well, and a flourishing life requires that people have the freedom to weigh their need for health care against their need for food, shelter, education, exercise, and the many other goods and services that contribute to health and to a good life. Life itself has many inherent risks, illness and injury among them. The goods and services required to deal with such risks, for example, medications and complex surgery, are not found in nature but must be produced by the effort of human beings. No one can have a positive right, that is, an entitlement, to the efforts of those who provide health care services any more than they have an entitlement to the products and services of farmers and grocers to satisfy their need for food or of architects and builders to satisfy their need for shelter.

Moreover, justice and fairness cannot ground claims of a right to health care, because there are many different visions of the standards by which they can be measured: "Loose talk about justice and fairness in health care is, therefore, morally misleading, because it suggests there is a particular canonical vision of justice or fairness that all have grounds to endorse ... [T]his is not the case" [7].

"Freedom" describes a state in which an individual can act independently, that is, unrestrained from choosing among alternative actions. Life offers many opportunities and many goals that may be of value to human beings. Freedom to use their own judgments in pursuing the specific goals they have chosen also requires the freedom to choose the means to reach those goals. The range of human needs that must be satisfied includes both physical needs and spiritual, social, and psychologic needs. Those needs may be satisfied in an endless variety of ways, and because no two people are the same, only individuals are in the best position to decide which of the many available long-term projects will be most suitable for them to achieve their particular goals [6 ^p66].

Government is an instrument of coercion; that is, it is empowered to use force to compel or to restrain choices by those within its jurisdiction. As an institution of this nation’s pluralistic society, government is morally unjustified in using its power to impose on its citizens a particular vision of the proper or the good life. Instead, its role should be confined to protecting the freedom of all persons to choose their own goals and the means to pursue them. The fundamental role of government is to protect the innocent from unconsented-to force, to provide a legal framework for enforcing contracts and preventing fraud, and to establish procedures to resolve disputes when they cannot be resolved by agreement among the parties to the dispute [8]. In health care, government’s role should be to protect the right of all to seek health care without obstruction by others and to provide an environment that protects the freedom of patients, physicians, and other entities to establish relationships without outside interference.

	Conclusions and Inferences

Top Introduction A Spectrum of Health... Optimizing Access and Paying... The Ethical Foundation of... The Ethical Foundation of... Conclusions and Inferences Acknowledgments References

 
Those who support centralization of health care financing have often argued their case from ethical principles, such as those described above. Supporters of a decentralized system—that is, free market reform—have usually argued on the pragmatic grounds of the efficiencies and successes of free markets, paying less attention to moral considerations. Yet, both approaches to health care system reform have well-established ethical foundations: an ethic of social responsibility for health care justifies centralization of health care financing, whereas an ethic of individual freedom and responsibility justifies the use of decentralized market mechanisms in health care services. Most reform schemes combine features found at both ends of the health system reform spectrum, so the ethical foundation for each proposal along the entire range of reform schemes borrows from the two differing sets of moral reasoning described above, in proportion to their adoption of either central control methods or free market mechanisms.

No authoritatively established standard of medical ethics obligates physicians to support one or another of the many proposals for reform of the national health care system. Therefore, medical associations, specialty societies, and other medical groups, as well as individual physicians, should advocate for policies they believe are most solidly grounded ethically and will most effectively advance the creation of a health care system that respects and responds to the goals, needs, and choices of the people it serves.

	Acknowledgments

Top Introduction A Spectrum of Health... Optimizing Access and Paying... The Ethical Foundation of... The Ethical Foundation of... Conclusions and Inferences Acknowledgments References

 
The author gratefully acknowledges the helpful criticisms and suggestions of George Khushf, PhD, Howard Radest, PhD, Stuart Sprague, PhD, Priscilla Ray, MD, Monique Spillman, MD, Mark Levine, MD, Regina Benjamin, MD, Dudley Stewart, MD, John McMahon, MD, Sharon Douglas, MD, William Martinez, MS, Audiey Kao, MD, PhD, Karine Morin, LLM, and Andy Bostick, MA.

	References

Top Introduction A Spectrum of Health... Optimizing Access and Paying... The Ethical Foundation of... The Ethical Foundation of... Conclusions and Inferences Acknowledgments References

 

1. Palmisano DJ, Emmons DW, Wozniak GD. Expanding insurance coverage through tax credits, consumer choice, and market enhancements: the American Medical Association proposal for health insurance reform JAMA 2004;291:2237-2242.[Abstract/Free Full Text]
2. Council of Economic Advisors Economic Report of the PresidentWashington, DC: U.S. Government Printing Office; 2004. pp. 189-201.
3. Himmelstein DU, Woolhandler S, Goodman JC, Sade RM. Our health care system at the crossroads: single payer or market reform Ann Thorac Surg 2007;84:1435-1446.[Free Full Text]
4. Brock DW, Daniels N. Ethical foundations of the Clinton administration’s proposed health care system JAMA 1994;271:1189-1196.[Abstract/Free Full Text]
5. Foege WH, May WF. The ethical foundations of health care reform. Christian Century 1994; Jun 1–8:572–76. Available at http://www.highbeam.com/library/docfree.asp?DOCID=1G1:15449866&ctrlInfo=Round18%3AMode18c%3ADocG%3AResult&ao=. Accessed Mar 26, 2007.
6. Kelley D. A life of one’s own: individual rights and the welfare stateWashington, DC: Cato Institute; 1998.
7. Engelhardt HT. Rights to health care, social justice, and fairness in health care allocations: frustrations in the face of finitudeIn: Engelhardt HT, editor. The foundations of bioethics. 2nd ed.. New York, NY: Oxford University Press; 1996. pp. 375-410.
9. Engelhardt HT. States and their authorityIn: Engelhardt HT, editor. The foundations of bioethics. 2nd ed.. New York, NY: Oxford University Press; 1996166–17.

This article has been cited by other articles:

				D. U. Himmelstein, S. Woolhandler, J. C. Goodman, and R. M. Sade Our Health Care System at the Crossroads: Single Payer or Market Reform? Ann. Thorac. Surg., November 1, 2007; 84(5): 1435 - 1446. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert M. Sade Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sade, R. M. Search for Related Content PubMed PubMed Citation Articles by Sade, R. M. Related Collections Professional affairs Related Articles