The ethics of health care system reform.

Every right granted to citizens carries a corresponding responsibility. The right to assembly carries the responsibility of others to endure inconvenience when marchers temporarily block a preferred route. The right to free speech implies the responsibility to tolerate disagreeable overtures from those expressing their views. The right to a trial by jury carries the obligation for citizens to serve as jurors. Rights always imply responsibilities on someone's part. Rights often also empower government to tax its citizens to pay for those rights.

What we believe to be morally correct, what we feel compelled to do or refrain from doing, what we believe is just, and what we believe to be moral imperatives are very different from what should be enacted into law for us as a right. Our beliefs affect others little. Our beliefs dictate only our own actions. In contrast, a right mandates an action on the part of others. A right in law affords us the protection of the government in securing such mandates. A right given to citizens also authorizes government to secure assets needed to provide for the rights of others.

It is therefore one thing to say, "Everyone should have access to health care," as a form of moral exhortation. It is another thing altogether to say, Everyone has a right to health care," as a matter of law and public policy. Because a strong belief is so different from a law to enforce a right, it is important to examine the different senses of a right to health care. The ethical concept of distributive justice helps us to make useful distinctions.

Distributive Justice

Justice, more specifically the justice of distribution, is the allotment of burdens and benefits in a fair and equitable manner. This principle is often rephrased as "giving to each their due." But both of these definitions beg other questions. What is fair? What is equitable? How do we know what each person is "due?" Any proposal to create a right to health care must consider the question, "How much, if any, health care is |due' to an individual?"

The principle of justice has been developed in Western philosophy for many centuries. The results of this history are the competing accounts of justice, of what is "due" an individual. Each account can be represented by maxims that adequately summarize the particular school of thought. There are three maxims relevant to the current reform debate. "To each equally" is from the egalitarian school. "To each according to contribution" (also sometimes stated "to each according to merit") is an outgrowth of the libertarian camp. And "to each according to need" is a utilitarian belief.[1]

Utilitarian: To each according to need. Followers of this account of justice typically believe that resources and obligations should be distributed in a way to maximize the overall benefit and to minimize the overall harm. This goal is intuitively logical. Star Trek's Mr. Spock said it well before his death, "The good of the many takes precedence over the good of the few, or the one." In the health care debate, the utilitarian wishes to maximize good health care for the entire population.

Unfortunately, fiscal resources for health care are finite. Therefore, in health care decisions, this greater good justifies restricting some care from those who might benefit, when others will benefit more. This belief is not unknown to physicians, as "doing the greatest good" is a basic precept of medical triage. In cost-benefit analysis language, procedures with low benefit-to-cost ratios should be forgone in favor of spending resources on treatments or preventions with large ratios. Public health programs have long used these concepts in resource allocation decisions, and managed care organizations have increasingly turned to this definition of fairness to justify benefits to their enrollees.

Utilitarians necessarily recognize planning on the part of government systems as an integral part of ensuring that each receives what it needs. Taxation and other policies aimed explicitly at redistribution of wealth to the needy are necessary for full realization of the benefits of resources. Any shortcomings of such systems are tolerated in order to accomplish the greater good of maximizing the benefit of the greatest number within society. The end goal of maximizing the utility of the resources justifies government involvement and the mechanisms created to distribute benefits (health care in this case) and burdens (taxes in this case) throughout the society.

Because it is the right of the needy individual to expect redistribution of resources, and because government is mandated by society to honor the rights of the needy, government is not only empowered but compelled to extract the resources necessary. Political systems born of this line of thought ascribe to government the duty to maximize the usefulness of the resources available in society. It is the right of each citizen to expect government to extract what is necessary from those who hold resources.

Once incorporated into law, the utilitarian view is not simply an ethical or moral imperative (i.e., not simply "what is morally correct"). It is not only the responsibility of each capable member of society to contribute. The right of the needy individual results in the authority of the government to mandate and enforce contribution on a societywide basis. Government has the responsibility to force individuals to give up resources under penalty of law. In short, a right to health care based on a utilitarian concept of distributive justice results in taxation to support and fund that right.

This concept is not totally unfamiliar in American society. Government is responsible for education, defense, and maintenance of the general welfare fare in our society. While we may not always agree with how the money is spent, few would argue that these are not reasonable duties of government. Government then should have the authority to extract from its citizens the resources necessary to provide what its citizens have established as their set of rights, including a right to health care.

Egalitarian: To each equally. Egalitarians believe in equality in distribution of society's benefits and burdens to the greatest extent possible. This concept is also a part of the American culture. One person-one vote and equality under the law are examples of egalitarian theories at work. So too is the right to a basic education. Most of the noteworthy egalitarians of our time qualify their belief, and do not include all societal benefits. Only some basic equalities of distribution are necessary.

The definition of equality and identification of the basic set of benefits divides egalitarians into two camps. One interpretation of this philosophy holds that, after basic benefits are distributed, distribution based on individual initiative/effort/merit is acceptable. This group would support a multitier health care system, with basic benefits distributed to all, and freedom given to consume additional resources. Cost-benefit analysis may play a part in defining the minimum set of health benefits, but it is the external concept of meeting basic needs that ultimately quantifies the resources needed to ensure justice.

The moral imperative to distribute resources to the needy is limited by this group's belief that individual initiative should play a part in acquisition of some goods. Were egalitarians successful in enacting law regarding health care, government authority would be limited to ensuring only a basic set of benefits. A national health care policy framed according to this school of thought would not provide a comprehensive package of health benefits, but would ensure only a basic health package that would be the same, or equal, for everyone.

The other branch of the egalitarian camp emphasizes fairness of opportunity as the basic benefit goal to be achieved. It argues that fairness compels us to negate biological or social accidents and give each member of society an equal opportunity. In this camp's radical form, distribution of resources should ignore any characteristic for which an individual is not responsible.

The fair opportunity rule would force society to share disproportionately its benefits with those disadvantaged by poor luck. The physically and mentally disabled should enjoy the benefits of society equally, which may require more resources to make up for their disabilities. Misfortunes of birth into depressed economic situations should be negated by societal resources. Equal distribution of economic resources is not important. The equal opportunity to enjoy society's benefits is the goal of this group. This concept justifies significantly unequal distribution of economic resources in favor of "leveling the playing field." Those severely disabled from birth defects would require exceptional medical care and training in order to receive a fair opportunity.[2] The cost-to-benefit ratio is unimportant, as long as additional resources will assist the underprivileged toward equal opportunity.

When incorporated into law, this theory gives enormous authority to government to distribute both benefits and burdens unequally for the greater good of securing equal opportunity for the disadvantaged. No longer is it a moral imperative for each of us to help those in need; it becomes a legal right for each of the underprivileged to receive that help from government. Government is therefore authorized to gather the resources needed from those more privileged, until there is no longer a privileged class with respect to opportunities for activities that humans value.

Libertarian: To each according to merit. The principle of distribution according to ability to pay is justified by the libertarian definition of justice. Libertarians, in contrast to the other schools of thought, emphasize size fair procedures in the marketplace rather than a predefined result. These concepts are the underpinnings of the concept of a free market widely accepted in this country.

But the basis for distribution of benefits should not be viewed as solely monetary. Mother Theresa, although obligated by a vow of poverty, would probably have little difficulty in mustering resources through the generosity of others to pay for a kidney transplant. It is the measure of contribution to society that justly defines the appropriate distribution of resources. Because libertarians believe that individuals should be rewarded according to the value they offer, monetary measures simply become. the easiest and most common yardstick for resource consumption decisions.

Libertarians generally do not object to giving resources to the underprivileged. They do regard as unjust the mandating of contributions by government. They do not recognize a moral obligation on society's part to provide even a basic set of health benefits to the unfortunate When successful in the legislative process, this group produces law that ensure fair processes and procedures, securing the individual's right to use his or her resources. To the libertarian, it is unfortunate, but no unjust, that some in society cannot afford health care. Benefit-to-cost ratios are not important in the libertarian decision-making process. Those with great wealth are free to consume whatever health care resources they choose.

Conclusions

The debate about health care in the United States is really a debate over which definition of distributive justice in health care should become the basis of laws and public policy. Our current system is multitier, with government-sponsored care assisting those who are disadvantaged an some approximation of the free market used to distribute resources to those not qualifying for government programs. Our current system is therefore a blend of concepts of distributive justice.

We recognize certain classes of people, because of birth right (e.g., Native Americans), social situation (e.g., prisoners and the economically destitute), health status (e.g., pregnancy, chronic renal failure), or age (e.g., Medicare) to have rights to certain health care benefits. This distribution of resources is decidedly egalitarian in its origin. It suggests a belief in equality of opportunities received as a basis for defining justice. It emphasizes results rather than fairness of process.

Members of our society who do not fit into one of these classes of special benefit are subject to a distribution system based on the ability to pay. This suggests a libertarian viewpoint and the belief that justice lies in fair systems of distribution that emphasize the individual's decision-making rights. Within at least a subsequent of the group able to pay, there is an increasing movement by the health care industry toward a utilitarian definition of justice e.g., the benefit-to-cost decision process), which, as a fundamental mental element of triage, has a long history in medical decision making.

The basis of the present health care policy in the United States is therefore a blend of three contradictory concepts of distributive justice. This situation is perceived by many as not working (at best) or as in a crisis (at worst). The advantage of the present confusion is the accommodation it affords to the competing concepts of distributive justice considered above.

Any movement to a government-defined basic set of benefits as a right of all Americans would violate the libertarian definitions of justice. Such increased government authority to gather resources would impinge on the personal liberty of other individuals in society to choose how they use their resources. Likewise, movement toward a purely free market (libertarian) or benefit maximization (utilitarian) distribution system would likely be unacceptable because of our egalitarian view that the underprivileged justly deserve some assistance from government.

The core of the national debate about health care can now be identified. Should we create a right to health care, and in effect enshrine egalitarian justice as the basis for law and public policy? Any affirmative answer must acknowledge and address the competing concepts of justice. These competing concepts will not simply go away, nor will their proponents waive their intellectual authority. Thus, an affirmative answer must explicitly address utilitarian and libertarian concepts of justice and show convincingly why these competing concepts are defective as the basis for the future of health care in the United States.

ACPE Seeks Scholarship Applications

December 31 is the deadline for applications for three ACPE scholarships worth more than $4,500 each. Each scholarship includes tuition and expenses to attend the Perspectives in Medical Management conference in Chicago, Ill., May 3-6, 1995, and the College's Physician in Management Seminars I and II during 1995.

The scholarships are awarded annually to physicians employed by government agencies or organizations with Section 501(c)(3) status that are not private foundations.

To apply for a scholarship, send the College a letter containing:

* An explanation of how the management training will benefit you and your organization.

* An explanation of why funding for management training is unavailable in your organization.

* A breakdown, by percentage, of your organization's revenue sources (federal or state funds, patient revenue, other).

* Documentation proving that your organization is tax-exempt (copy of 501(c)(3) certificate).

Richard M. Lauve, MD, MBA, is Medical Director, Professional Practices Association, and Assistant Professor, Department of Health Systems Research and Development and Department of Medicine, Louisiana State University Medical School, New Orleans. He is Chair of the College's Forum on Health Policy and a member of its Forum on Bioethics and its Societies on Academic Medical Centers and on Hospitals. Laurence B. McCullough, PhD, is Professor of Medicine, Center for Ethics, Medicine, and Public Issues, Baylor College of Medicine, Houston, Tex.

References

[1.] Jonsen, A., and others. Clinical Ethics, Third Edition. New York, N.Y.: McGraw-Hill, 1992.

[2.] Beauchamp, T., and Childress, J. Principles of Biomedical Ethics. New York, N.Y.: Oxford University Press, 1989.