MORAL ARGUMENTS for UNIVERSAL HEALTH CARE

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Contents

Dedication........................................................................................ixForeword..........................................................................................xiAcknowledgements..................................................................................xvPreface...........................................................................................xixPart One: INTRODUCTION............................................................................1Chapter One: Universal Health Care from a Moral Point of View.....................................3Part Two: GOAL-ORIENTED (TELEOLOGICAL) ETHICS.....................................................73Introduction to Part Two..........................................................................75Chapter Two: The Principle of Utility.............................................................85Chapter Three: The Principle of Beneficence and Medically Necessary Care..........................125Chapter Four: The Principle of Nonmaleficence.....................................................150Summary And Evaluation Of Part Two................................................................169Part Three: DEONTOLOGICAL ETHICS..................................................................179Introduction to Part Three........................................................................181Chapter Five: Deontological Ethics: Monistic, Pluralistic, and Mixed Theories.....................184Summary And Evaluation Of Part Three..............................................................215Part Four: JUSTICE IN HEALTH CARE.................................................................221Introduction to Part Four.........................................................................223Chapter Six: Justice, Utility, and the Common Good................................................225Chapter Seven: The Principle of Fairness-Based Justice............................................259Chapter Eight: Rights-Based Justice and Responsibility............................................284Summary And Evaluation Of Part Four...............................................................320Part Five: CONCLUSIONS............................................................................333Care Act of 2010..................................................................................335A Postscript......................................................................................385Afterword.........................................................................................387References........................................................................................393

Chapter One

In this chapter I will introduce the subjects of ethics and universal health care which are the focus of this book. After noting the challenge of placing these two subjects in dialogue, I will provide a brief definition of universal health care and contrast it with the present health care system in the United States. Thereafter, I will define a moral point of view, address objections to applying it to the health care debate, followed by reasons for adopting it.

The Challenge of Evaluating Health Care Policies and Reforms

This is a book about ethics and health care reform. Both subjects are complex and characterized by several diverse approaches presented by persuasive advocates. The complexity and diversity of approaches to health care reform are illustrated by the numerous topics of workshops held in Washington D.C., September 22-24, 2008 at the National Congress on Health Reform, which was scheduled in conjunction with the Second National Congress on the Uninsured and Underinsured. Workshops were featured to provide discussion on "reform building blocks." Topics included comparative effectiveness; tax policy; primary care, medical homes, and retail clinics; payment reform, incentives, and transparency; health information technology; consumer driven health care; regulating hospital-physician relations; disease management and chronic care. Additional workshops addressed health system governance strategies for community benefit; provider and health plan obligations to serve the uninsured; local and state initiatives to cover the uninsured; initiatives to address the problem of the under-insured. The array of topics indicates both how complicated this issue has become technically, politically, and economically, as well as the wide range and variety of competing proposals for reform.

Another illustration of the complexity of health care reform is the Congressional debate of 2009-2010. After numerous hearings in multiple committees, the largely Democratic Senate and House of Representatives produced separate bills for comprehensive reform. Each bill was more than 2,000 pages in length. A contentious debate lasted more than a year over both specific provisions and general philosophical differences between Republicans who favored market solutions and Democrats who favored greater regulation and intervention by the federal government. Of course, much of the delay was due to the inefficient procedural rules of both bodies, and the power politics applied by competing, self-interested groups. But a third factor was (and is) the enormous complexity of both the present fragmented health care system and the issues that need to be addressed simultaneously, such as access, cost, and quality, all in the context of the severe economic recession beginning late 2007, a nine percent rate of unemployment, the rising budget deficit and growing national debt. Given the complexities of health care reform, it is not surprising that more than a hundred amendments were offered throughout the Congressional debate.

How do we decide among so many proposed reforms which ones merit our support? Given limited resources, both human and financial, how do we prioritize these proposals for reform to maximize positive impact? Are all of these policies and strategies equally necessary and equally good? Or are some better than others, and if so, in what sense? What criteria should we apply to evaluate them? Is health care reform solely an economic issue or a matter of political strategy? Or is it primarily a technical matter of information transfer or system design?

My general answer to these questions is that while several perspectives and strategies are both relevant and necessary to guide health care reform, none alone is sufficient. Neither is a moral perspective sufficient, but it is also necessary. Unfortunately, throughout the national health care debate of 2009-2010 there was a relative absence of thorough discussion about the values upon which all proposed reforms depend for their ultimate justification. Those values need to be made explicit and defended to inform both the ends of reform and the means selected to achieve the ends (Roberts, Hsiao, Berman,& Reich, 2008). Moreover, values provide the criteria by which we evaluate the relative merits of proposed reforms. Additionally, people advocating different strategies might find common ground in discussion of shared values that inspire us to make needed reforms.

Proposals for health care reform are recommendations for change in the actions we take to organize, finance, and deliver health care services to our population. We should ask of any proposed change why it is needed and whether the proposal will meet the need in a reasonable manner. Was the Affordable Care Act of 2010 both necessary and reasonable? More specifically, what deficiencies or harms in the current health care system did the legislation address? What good was intended or expected, and for whom? Will the reforms cause more or different harms, or will they yield an improved health care system? At what cost? These are all questions about the goals and consequences of reforms, which is to say, their good or ill effects.

To ask about goals and consequences is to raise the question of what we value as outcomes or ends. Thus, ultimately we must address moral questions, evaluate proposed reforms ethically, and justify them on moral grounds. Lacking a solid moral foundation, all other "reform building blocks" will rest upon shifting sands blown about by political and economic forces and fads. Stated another way, health care reform is fundamentally a moral issue—a matter of selecting and justifying morally acceptable ends and the means that achieve desired ends without unintended harmful consequences.

We must not confuse ends with means, treat means as ends, nor limit policy discussions to instrumental strategies. We need to be especially clear about the valued ends expressed in our purposes and goals, and determine whether they are justified and related coherently or if they are in conflict. It is important and helpful to clarify and rank our values. A recent contribution is Daniels, Salome, and Gilpin (2009), who rank expanding opportunity, sharing burdens equally, and respect for persons as primary standards which limit the means that can be applied to achieve the end of social justice in our health care system.

Clarifying and ranking values is one of the functions of ethical theories, though achieving such clarity is a challenge due to the range of diverse ethical theories. A contemporary anthology by Denise, White, and Peterfreund (2005a), entitled Great Traditions in Ethics, includes thirty different theories, both classic and modern. The collection illustrates the broad scope of competing foundations of moral judgments and different norms that have been advocated: Happiness, pleasure, utility, knowledge, reason,virtue,moralsentiment,naturalorcivillaw,socialcontract,justice, the common good, faith or conscience. Ethical theories vary in both their normative ethics (prescribed obligations and commended virtues) and in their metaethics (definitions and justifications).

These two general topics—ethics and health care reform—are obviously too broad and too complex to address both comprehensively in a single book. To make this task manageable, I have selected elements from each area. From moral philosophy I have selected a few of the major ethical theories to illustrate general types. From the area of health care reform I have selected the topic of universal health care. While I will define the latter broadly to include several elements such as quality and cost-effectiveness, my focus will be upon the policy (and value) of universal access. One of the major differences between Democrat and Republican proposals for health care reform in the 2009-2010 debate was on this issue of who should be covered by health insurance. The Democrats' bill signed into law March, 2010 is expected to insure about 32 million more Americans versus 3 million that would have been added in the Republicans' proposal. Neither proposal would achieve universal access prior to full implementation of the law beginning 2014, and even then, an estimated 23 million more residents (of whom about eleven million are undocumented immigrants) will not be covered, except as federal law requires hospitals to provide emergency medical care and federally funded health centers to provide them outpatient services.

Universal Health Care is a Moral Imperative

I will be applying a variety of ethical theories to support the general argument that universal, equitable access is a fundamental moral imperative for any and all health care systems. By "moral imperative" I mean to assert that universal, equitable access is a necessary condition and minimal criterion for the acceptable performance of a good health care system. Absent this condition the health care system cannot be considered as either humane or fair, nor can we judge the society in which it functions as either civilized or just. More specifically, I will argue that the harm being done to millions of Americans due to the absence of equitable access to medically necessary care is so egregious that it is not enough to say we should reform the system; rather, we must reform it or replace it.

To state this more generally, I am asserting that ensuring universal, equitable access is not merely an aim, it is an obligation; it is not merely a goal, it is also a duty; it is more than merely a noble ideal we might like to realize if only we could afford it; rather, it is a reality we must bring into being for the entire population our health care system is designed to serve. It is morally unacceptable to say that universal health care is desirable, but optional; rather, it is a goal we must achieve because it is grounded in a universal human need, not merely in what people want. Universal access must be ensured as a priority and prerequisite for a health care system to qualify as a morally justified system. Other factors being equal, a health care system that provides universal access is morally superior to a discriminatory system that limits, delays, or denies equitable access to portions of the population. Stated positively, the ethical arguments in favor of universal health care are so compelling as to make implementing it a moral mandate. It is also a practical necessity because to someone denied access, it simply does not matter that the system provides high quality and cost-effective care. Inaccessible care is ineffective care; indeed, inaccessible care is no care at all.

What is Universal Health Care?

I have said that universal health care involves universal access and more. Since I am applying ethical theories as moral arguments to support universal health care, I want to state what more I mean by this concept. I will discuss universal health care as both a policy and as a health care system.

Universal Health Care is a Public Health Care Policy

First, as a public policy, universal health care does not mean simply ensuring access to health care for everyone. Providing access for everyone to unsafe and ineffective health care at a cost that causes patients financial impoverishment is hardly a worthy goal or public policy that warrants moral support. Considerations of quality and cost must be included and addressed to maximize value for the patient and the population served. Nevertheless, universal health care does mean positively that everyone receives high quality, affordable health care based on their medical need. Everyone who needs it, gets it—everyone. Universal, equitable access to effective, affordable health care is the foundation and essential element of a policy of universal health care.

Accessible health care means it is available. A distinction was drawn between access and availability in Section 12 of the Canada Health Act 1984, which set standards for Canada's national health insurance program, a publicly financed system of universal social insurance. In order for Canada's provinces and territories to receive federal funding for the health insurance programs which provincial governments administer (and partly fund), they must conform to several national standards. Among them is the standard of "reasonable accessibility." I will quote a Canadian's summary of this standard to illustrate the distinction between accessibility and availability.

The intention expressed here is that insured residents of a province or territory have reasonable access to insured hospital, medical, and surgical-dental services on uniform terms and conditions, unimpeded, either directly or indirectly, by user fees or extra billing by facilities or health care providers or other means. It also stipulates that physicians and dentists must be reasonably compensated and that payments to hospitals cover the costs of providing the services. Reasonable access follows the `where and as available' rule, which means that residents are entitled to access on uniform terms and conditions to insured services at a setting `where' the services are provided and `as' the services are available in that setting. It does not preclude lengthy waiting lists, although there is an expectation that they will be managed equitably for all residents. In addition, not all services are necessarily provided in close proximity to where a person lives. Nor does it guarantee that all services that a person may need will be available—only that a person has equitable access to the services that are actually provided. (Ahern, 2006, p. 152)

This standard reflects a realistic appraisal that all health care services included in a comprehensive benefit set for everyone may not be available due to costs, limited human or material resources, population dispersal, or maldistribution of providers and facilities. But if services are not available, the right of access to health care services becomes a hollow entitlement. Perhaps it is in recognition of this fact that another standard required by the Canada Health Act 1984 is portability of benefits in the national health insurance plan. Health care services unavailable in one city or province might be available in another. And for a similar reason, in Chaoulli v. Quebec, the federal Supreme Court of Canada ruled in 2005 that the Province of Quebec could not prohibit coverage by private insurance for services in the private sector when either poor quality or delays in the delivery through the public health care system are unreasonable (Gratzer, 2006, p. 3). Like justice, service delayed is service denied.

Canada is not the only country that faces the problems of delays in services or maldistribution of providers, though by virtue of its size and uneven population densities across the country, the challenge is greater in Canada than it is for a geographically smaller country like Great Britain. It is well known that the United States has both an inadequate supply and maldistribution of primary care physicians and nurses (Bodenheimer & Grumbach, 2009, pp. 78-82; Rother & Lavizzo-Mourey, 2009). Bodenheimer and Pham (2010) reported that "... sixty-five million Americans or about one in five, live in what are officially deemed primary care shortage areas, and adults throughout the United States face difficulty obtaining prompt access to primary care" (p. 799). Another recent estimate is a shortfall of 260,000 full-time equivalent registered nurses by 2025 (Buerhaus, Auerbach, & Staiger, 2009).

What this discussion suggests is that health insurance alone is not sufficienttoensureuniversalandequitableaccesstohealthcareservicesin the United States, nor would a policy of "free" care at the point of service guarantee that the service will be available. The health care system must also make adequate capital investments and train a sufficient number of qualified health care providers, with incentives for them to locate in underserved areas. Satisfactory service delivery and equitable access depend upon the development of a sufficient workforce with needed skills, qualified faculty in sufficient numbers to teach them, accessible hospitals and clinics, and the availability of necessary medical supplies. These essential functions of service delivery and resource generation are in turn influenced by the system's performance of two other essential functions—financing and oversight (stewardship). According to the World Health Organization (WHO, 2000), satisfactory performance of all four functions is prerequisite to achieving the universal goals (values) of all health systems: Population health, responsiveness to the population's expectations, and fair financing.

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Excerpted from MORAL ARGUMENTS for UNIVERSAL HEALTH CAREby R. PAUL OLSON Copyright © 2012 by R. Paul Olson. Excerpted by permission of AuthorHouse. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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