Health of nations: government participation in medical care management.

  Man has almost constant occasion for the help of his brethren, and it
is in vain for him to expect it from their benevolence only.
--Wealth of Nations (1)
Adam Smith. 1776.

Benjamin Franklin, a virtue ethicist among other things, believed that, "Early to bed and early to rise makes a man healthy, wealthy, and wise."

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His advice is arguable, but few disagree with his list of greater goods--health, wealth and wisdom. Should a government be concerned with citizens' health, or only with their economic security and education?

What ethical principles are available to help us answer that question? Which ethical principles are reflected in existing U.S. health care policy and its implementation?

The three features of an ethical dilemma are:

1. Decisions made and actions taken affect many stakeholders

2. This impact persists over a long time

3. Because stakeholders have conflicting interests, no available and feasible choices are either absolutely right (correct, and virtuous) or absolutely wrong (incorrect, and vicious).

In university classrooms, one ethical dilemma discussed by students is: How much health care should be provided by government, if any, and for whom? Should all citizens get government-funded medical care, or only groups selected to receive this entitlement?

If selective, what should be the basis for including and excluding citizens from health care coverage? Are some mechanisms of funding health care fairer than others? We claim to be a "moral nation." Does existing U.S. health care policy support that claim?

Let's look at the aspect of health care most worrisome to a nation's citizens--the ability to get needed medical care when illness or injury strikes.

The first question is, why doesn't government simply abandon attempts to participate in paying for and providing health care? We know the political answer to that question; such a suggestion is certain political suicide. But what is the ethical answer?

Stakeholders in medical care include patients, payers, providers, health care professionals and politicians. Problems satisfying conflicting interests of these groups exist in all third-party payer programs. So do dilemmas about eligibility, benefits, cost, accessibility, payment practices and dependability of services.

If government-funded health care is abandoned, then consistency requires that we abandon the health insurance industry also. This road, leading to old-fashioned out-of-pocket payment for new-fangled expensive medical technology, seems the surest way to guarantee that no one's interests are well served.

Ethicists Jeremy Bentham and John Stuart Mill developed and championed utilitarian ethics. An action is right and good, they believed, if the action satisfies the utilitarian equation:

Pleasure - pain = a positive value

The pleasure of restored health without personal economic devastation seems well worth the effort to make government involvement in health care as painless as possible. Excusing government from concern about the health of the nation is not only politically impossible; it also would be ethically immature.

Utilitarian ethics is a useful starting point in considering ethical aspects of national health care policymaking. However, utilitarianism alone cannot bear the weight of ethical discourse on this subject. Indeed, the days when ethicists defended one school of thought as a stand-alone absolute are gone forever.

Today's ethicists are pragmatic thinkers who use an eclectic synthesis of principles from ethics and other disciplines to help us with a whole host of difficult 21st century situations. Other ethical principles useful in this context are virtue ethics, and the concept of distributive/social justice.

In the context of diagnosing and treating an individual patient, the virtues of caring and integrity are critically important. So far, we have not replaced the term, patient care. Let's hope that we never do.

What's fair?

However, the role of government is not to care for individual patients. Rather, the role of government is to consider the medical care needs of all citizens, and also to safeguard citizens' interests as taxpayers. Thus, in the context of government policy, the predominant ethical principle is distributive/social justice.

Distributive/social justice is "a fair, equitable, and appropriate distribution according to justified norms that structure the terms of social cooperation." (2)

At first glance, we think this is a simple and familiar idea. "Everybody should get their fair share. Every American knows that." However, this idea is not simple at all. (One reason that ethicists are a pain in the neck is they will not allow us to be satisfied with less than a full view of possibilities, priorities and potential problems when dealing with important issues).

Social justice is one of the most difficult ethical concepts to define and use, because there are so many ways that the "justified norms" could be established. An equal share for everyone (egalitarianism) is certainly one choice.

However, an equally ethical choice is distribution of resources and services based on need. Inequalities in the system would not be unfair, because people's needs are different. What is wrong with allowing government not to provide/pay for services to people who do not need them?

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Still another choice would be basing distribution on individual effort. Perhaps gainfully employed individuals would receive benefits to which unemployed people are not entitled. What is unfair about providing the hardest workers with the most rewards?

The method chosen as a basis for distributing government services and social goods depends on the political and ethical underpinnings of various types of government.

For example, two contrasting styles of government are libertarian and socialistic. Ironically, one father of U.S. government was not a colonist. John Locke was an English philosopher whose most productive years pre-dated the American Revolution. Locke greatly influenced the basic framework of American government.

When Thomas Jefferson wrote in the Declaration of Independence that people are entitled to "life, liberty, and the pursuit of happiness," he was influenced by Locke's claim that inalienable human rights include "life, liberty, and ownership of property." Often overlooked, however, is Locke's admonition that "liberty is not license," and that government is necessary to curb encroachment on one person's freedoms by another's failure to respect the rights of others.

Libertarian forms of government base distributive justice on entitlement. Citizens receive that to which they are entitled by law, personal effort or custom. Government has no obligation to provide for citizens beyond this assurance of freedom from interference.

No one is obliged to share the fruits of their labor to provide redress to those dealt a bum hand by nature.

Socialistic health care

The contrasting model of government is socialism. In a socialist government, citizenship alone entitles a nation's people to some basic level of essential services such as education, income and medical care.

Modern liberalism is an attempt to blend libertarian and socialist approaches. (3) Capitalist entrepreneurship is encouraged within a context of social justice based on fair dealing and social concern.

Perhaps things do always come full circle. This sounds like Adam Smith's original idea of capitalism, born of his combined experience as a moral philosopher and economist. Smith's intent was that reasonable self-interest motivates economic success so that "a general plenty suffuses itself throughout all ranks of society." Modern liberalism also sounds like Abraham Lincoln's idea of what capitalist-based Republicanism should be like.

Which basis for distributive/social justice prevails in existing U.S. health care policy? The answer is, none of the above. For people over 65 and younger people with certain medical conditions, health care is a right of citizenship, which is a socialist model.

However, there is unrest among younger working-class Americans because for them health care is a right of employment or of having private insurance or both, because they are governed by a libertarian capitalist health care policy called managed care. In addition, middle-class Americans in their best years find themselves forced to pay for the care of the elderly as well as for their own care and care for their children.

Indeed, managed care health policy as currently implemented reflects an ethical/social concept that goes a few steps beyond libertarianism. That is social Darwinism as described by Henry Spencer, a 19th century English philosopher/sociologist. (4)

At about the same time Charles Darwin was postulating that biological evolution made creation a continuous event, Spencer applied the same "survival of the fittest" thinking to sociology and economics. His views can be summarized as an ego-ethics based belief that society is favored by those actions that encourage predominance of elite members of society, meaning those most able to make the most money and therefore most able to advance society's common good.

Social Darwinist thinking has enjoyed a recent revival as rationalization for government and business decisions that favor the wealthy, just as misinterpretations of Adam Smith's theories and statements have been used to support the notion that greed is good.

Certainly, health care policy makers do not intend that such an egoist ethic replace the traditional caring ethic practiced by physicians, nurses, and other health care professionals. And surely, satisfaction with this health care policy model and its implementation cannot be widespread.

Finally, we must ask ourselves, who cares about such an analysis anyway? Aren't discussions of ethical aspects of any issue just academic parlor games? No, they are not.

In the United States, we have only 40 years experience with government involvement in medical care. During that time, political and economic aspects of health care policy have been debated ad nauseum, but ethical aspects of government involvement have seldom been addressed.

A fresh look at the past, present and future of U.S. health care policy in the bright light of ethical impact could be one overlooked key to unlocking a treasure box of innovative and feasible solutions to actual and perceived problems in U.S. health care policy.

Richard E. Thompson, MD, can be reached at [e-mail] or 417-848-9435.

References

1. Smith, A. Wealth of Nations. Originally published in 1776. Prometheus Books Great Minds Series. Amherst, NY, 1991.

2. Beauchamp, TL and Childress, JF. Principles of Biomedical Ethics. Fifth Edition. Oxford University Press. New York, 2001.

3. MacKinnon, B. Ethics: Theory and Contemporary Issues, 4th Edition. Wadsworth, a division of Thomson Learning. Belmont, California. 2004.

4. Spencer, H. "Progress: Its Law and Causes." The Westminster Review, Vol. 67, April, 1857. http://www.fordham.edu/halsall/mod/spencer-darwin.html

By Richard E. Thompson, MD