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National health care policy: The moral issuesby H. Tristram Engelhardt, Jr., MD, PhD, Houston, TX To be human is to frame projects in the face of ineradicable limitations. The beginning of sound health care policy is the recognition that one must accept some risks of death, suffering, and disability, and that one should forgo attempting to prevent death, suffering, and disability when the costs are high and the likelihood of success low. Sound health care policy requires recognizing the extreme burdens that would be incurred if one truly attempted to save lives at all costs. Framing realistic health care policy also requires taking account of the circumstance that being rich is positively correlated with living longer, and that the secular moral authority of the state to remedy this circumstance is limited. After 15 years of an all-encompassing health care system, Canada still had striking differences between the life expectancies of highest-earning and lowest-earning citizens.1 The second challenge for secular health care policy is: To what extent may the state forbid individuals, after they have paid their taxes, from using their private resources to buy better health care so they can live longer than the poor who lack such resources? Or should one focus instead on determining which interventions are most cost effective in narrowing the gap in life expectancy and morbidity statistics between the rich and the poor? The first strategy leads to an all-encompassing, one-tier health care system in which moral energies are expended on trying to prevent the rich from buying more. The second strategy leads to a focus on cost-effectiveness analysis, on the output of health care systems rather than the input, in order to determine howbest and most cheaply to advantage the poor. To embark on what might be termed an egalitarianism of envy (jealously-driven concepts of fairness) in contrast to an egalitarianism of altruism (beneficence-driven concepts of fairness) is to ask who is getting more than the rest, rather than to ask who is suffering and how they can be helped. An egalitarianism of envy contrasts with an altruism by focusing on how to prevent those who would from purchasing yet better health care. Accepting the finitude of life should be a point of departure for directing energies to helping those in need, rather than attempting to achieve equality or save lives at any cost. The four cardinal finitudes Humans are finite in life, in resources, in their moral vision, and in their secular moral authority. To recast the first of Hippocrates' aphorisms, life is short, money is scarce, moral vision diverse, and secular moral authority limited. The first of these finitudes intertwines with the second to present one of the core challenges of health care policy: How much money should be invested in postponing the inevitable and in diminishing, while recognizing that one will not eliminate, the prospects of suffering and disability? The first of the finitudes, that of human mortality, is the most difficult to face. Humans have all the aspirations of gods and goddesses, but only the life expectancy of finite men and women. This tension between expectation and reality makes it difficult for politicians and health care policy theoreticians to remind the public frankly that they will not live forever, and that they are well advised to consider how much money they wish to spend trying to postpone the inevitable. But such choices are integral to framing both individual budgets and national policy. Money invested in the arts, formal gardens, or protecting endangered species is money that could have been invested in saving lives, preventing suffering, and ameliorating disability. If one attempted to respond to all people in need, one would not have resources left to support the humanities or to engage in the transient but expensive pleasures of this life. The finitude of human resources in the face of unavoidable death, suffering, and disability confronts us with framing policy that accepts the circumstance that some will die, suffer, and be disabled because resources are not invested in health care but instead in the pursuit of other important goods or engaging in frivolities. Such policy choices are best approached through the insurance metaphor, in which one can ask individuals how much they will pay to insure themselves for treatment that may diminish the risk of illness, disease, and disability. Insurance allows individuals, communities, and political entities to decide in advance and budget for how much they wish to invest to protect themselves against particular losses. The concept of health insurance discharges its full service when it does not simply invite us to protect ourselves against a risk, but also to decide against which risks to purchase what amount of protection and at what cost. The insurance metaphor should be a vehicle to introduce individuals and society to the rational management of risks. Rational risk management also involves accepting the consequences of losing a gamble and being confronted with disease, disability, and the threat of death in the absence of funds to secure protection. Here the special character of health losses must be noted. When one insures against crop loss or fire damage, one can in fact make whole the persons whose property is damaged. But health care often cannot restore health. There is frequently no means to prevent pain, suffering, disability, and disease. One cannot adequately insure against many of the losses occasioned by our finitude in the sense of making the losers whole. Specifically, all of the unfortunate circumstances of the human health condition cannot be considered as unfair in the sense of engendering a realizable claim to be made whole. If all that is unfortunate in health circumstances is unfair, and if all health care needs generate rights, one would be awash with claims that could never be satisfied.2 The difficulty with claims about welfare rights is even more fundamental. It is not just that death and suffering are inevitable and resources limited, it does not appear possible to discover in general secular terms how one should respond to the claims of people in need. Secular accounts ofjustice and of rights to health care conflict because each account of justice or basic rights depends on a particular ranking of goods or understanding of how to compare preferences, of how to discount time, of how to frame an appropriate theory of the good or of justice, or accounts of moral rationality. Though many persons in bioethics or applied ethics act as if it were clear which ethics ought to be applied or which moral theory or theory of justice should be rendered practical, any candid examination of contemporary moral theory or contemporary moral disputes shows the implausibility of this assumption. Bioethics and ethics in general have not been able to provide a secular substitute for the uniformity of moral vision once sought from religious conviction. There are as many foundationally different accounts of moral theory and ofjustice, and indeed of the moral point of view, as there are major theologies. A pluralism of belief has been exchanged for a plurality of ideologies. This failure or limitation of secular moral vision has major implications for the moral authority of any secular state to impose a particular account of justice. In the absence of an appeal to divine authority, and given the failure of ethics to provide a canonical understanding of proper moral action, moral authority can only be derived from individual agreement. In short, even if one cannot discover a canonical secular account of justice or human flourishing, one can fashion a procedural morality based on individual authorization—a limited morality without a priori content. It is this limited procedural morality that provides the secular moral foundation of such broadly engaged social practices as free and informed consent, the free market, and limited democracies.* *My arguments in these matters are elaborated in greater detail elsewhere: The foundations of bioethics, New York: Oxford, 1986, and Bioethics and secular humanism, Philadelphia: Trinity Press International, 1991. My goal is not to deny what may be understood by faith. I am a believer. Rather, the goal is to 12 show the limits of the secular moral philosophical project. This morality does not require that one value liberty or individuals. Rather, this grammatical moral possibility recognizes that in the face of divergent religious and ideological moral convictions, moral authority is best derived in general secular terms not from God or from some concrete moral vision, but from individual consent. There is, in summary, no general secular way to discover how much money should be invested in the alleviation of morbidity versus mortality, just as there is no way to discover how much money should be invested in the arts versus health care. Such answers in general secular terms are appropriately the creations of public choice regarding public resources through open discussion in free, limited democracies. Since there are no final answers regarding the correct composition of an appropriate basic adequate health care package, there should be ample room for divergent additional purchases of health care, as well as the purchase of better basic care. The diversities of moral visions and the limited charter of secular public moral authority place the burden of proof on those who would forbid the existence of a second luxury tier of health care. We generally accept this notion in other areas. We take it for granted that a basic education should be provided to all citizens, yet we do not forbid private schools from providing basic education and perhaps a more excellent basic education for those individuals who can pay. We take it for granted that basic nutritional needs should be met, yet we do not forbid those who can from purchasing three or four meals a day at the best of restaurants and at the most exalted of prices. We provide basic police protection for all, but do not forbid those who wish to hire private guards from doing so in order to enjoy luxury security. We fashion limited solutions to the most basic of human problems, while allowing alternative approaches because the human condition is marked by a diversity of moral vision and by finite secular moral authority. Living honestly with mortality and inequality If life is short, money scarce, secular moral vision diverse, and secular moral authority limited, then the best one can hope is to frame a health care policy that creates a basic package of health care services available to all through open public debate and by democratic decision. The contours of such a package should be recognized as a democratic creation, not a philosophical moral discovery. Though experts can help determine the most cost effective ways to treat dental problems, inguinal hernias, and adult leukemia, only a democratic choice can rank these problems or determine whether the basic health care package should include the surgical treatment of inguinal hernias or the provision of a truss. The best example of an attempt to democratically come to terms with the problem of providing adequate health care in the face of finitude is the Oregon plan, framed by the Oregon legislature in 1989 to provide health care to all Oregonians.3 The Health Services Commission of Oregon used the results of an opinion poll, 47 town meetings, as well as commission hearings to ascertain community and individual values as a basis to use technical data in prioritizing treatment. The goal was to use Medicaid funds to pay for as many items on the list of treatments, while covering 100 percent of Oregonians under the poverty line regardless of age or family structure.3 Low-ranking items on the list would not be provided, and there would be no civil or criminal liability for not providing such treatment in the absence of the ability to pay. The goal was also to mandate by 1995 that all employers provide their workers with a health insurance package at least equivalent to that available under the Oregon Medicaid program. Despite its rejection, the plan remains as an articulate commitment to create a basic health care package democratically, recognizing the limitations of resources and the unavoidable inequalities of persons.* *The Bush administration refused to provide the needed Medicaid waiver on the ground that the plan was discriminatory under the Americans with Disabilities Act of 1990 because it neither covered liver transplants for nonabstinent alcoholics nor provided neonatal intensive care for newborns with birthweights under 500 grams. (Firshein J: Anatomy of a waiver: Oregon plan stumbles. Med & Health Perspect, Aug 24:1-4, 1992.) The virtues of the Oregon plan as generally understood are five. First, it emphasizes the democratic creation of the content of the basic health care package. The content of what will count as a basic adequate package of health care does not depend on particular religious or ideological viewpoints, but instead on the democratic creation of a publicly supported basic insurance package against losses in the natural and social lotteries. The package translates a portion of the unfortunate events of life into the realm of the unfair by creating entitlements for health care. Second, the Oregon approach emphasizes democratic authorization. The decision regarding the contents of the package is made openly, rather than closeted from public view, as was the case in Great Britain.4 This point has both theoretical and practical significance. First, public authorization acknowledges that the moral authority for the package does not depend on the rational authority of a particular theory of rights or justice .in health care, but on the only generally available source of secular authority in a secular pluralist society: common authorization. In addition, there is a protection through publicity against choices being. made contrary to the wishes of those who pay—the citizens. Third, consideration is taken of costs, benefits, quality of well-being, effectiveness, and life span secured through a dialogue that invites the participation of citizens, medical experts, politicians, and health care policymakers. Oregon has faced some difficulty in explicitly incorporating considerations of cost effectiveness.5 The Oregon plan contributes to the education of a culture regarding what it means to make choices about the technologies it creates and sustains. The plan does not presuppose that there are no value experts who can tell the public how they ought to compare the various risks of morbidity and mortality, though experts can help to disclose the consequences, costs, and implications of different decisions. This aspect of the Oregon plan is perhaps as challenging as any, for it undermines the sacerdotal role of bioethicists and health care policymakers as those who purport to know the proper ranking of values regarding morbidity and mortality. Fourth, the Oregon plan acknowledges its limited scope of authority by clearly permitting and protecting the existence of a second, luxury tier of health care. Those persons who would want more than the basic package provides can demand it only if they have the money to pay for it, somewhat on the model that those who wish additional police protection can hire their own guards. A line is clearly drawn between that basic package of welfare protection created out of common goods and the luxury package of health care available through private insurance or direct private purchase. It must be emphasized that the plan leaves individuals free to purchase luxury access to services provided under the private package, not just to services that are excluded from the basic package.6 Finally, as an endeavor of the citizens of Oregon rather than the United States as a whole, the Oregon plan emphasizes the experimental character of all of our attempts to come to terms with providing health care in an era of high technology and high costs. Since there are no final content-full moral guidelines to direct democratic choices, because democratic societies have limited secular moral authority, and because different states may in their approaches reflect different choices in values, there is the possibility of learning from diverse views of what should count as a basic adequate package of health care for all citizens.* All of this is possible, however, only if the federal government will allow state-based policymaking and experimentation. *In order to allow the states individually to proceed in fashioning basic health care packages for their citizens, there would need to be a number of points of coordination among the states to avoid the emigration of businesses in flight from the costs of providing basic health care to employees. In the end, such incentives to flee may be replaced, under plans such as Oregon's, by incentives to stay because of cheaper, more cost-effective health insurance packages for all employers. (Moon M, Holahan J: Can states take the lead in health care reform? J Am Med Assoc, 268(12):1588-1594, 1992.) Conclusion The framing of a two-tier system should not be regarded simply as an accommodation to finitude, a kind of failure to achieve the divine and a making-do with the merely human. Instead, it should be understood as a positive achievement, as a moral accomplishment. It is no mean thing to acknowledge one's finitude and make plans in the face of the limitations it imposes. Further, it is a scientific accomplishment to begin seriously to study what interventions are cost effective in large-scale health care planning. It is a special cultural accomplishment to bring citizens to public dialogue with experts regarding which of the protections against morbidity and mortality risks ought to be purchased and at what price as part of a basic health care package. The Oregon plan, despite any shortcomings, is a major success in frankly facing finitude and in achieving an open, democratic discussion that is focused on creating a basic adequate health care package for all citizens, while recognizing the moral inevitability of a second health care tier. The task of humans is to realize their visions of the good while recognizing the diversity of moral visions and the limitations of the human condition. Wisdom and honesty are found in acknowledging not only our limitations of resources, but of life, secular moral vision, and secular moral authority. Ancestral versions of this paper were presented as the Ethics and Philosophy Lecture at the American College of Surgeons Clinical Congress, New Orleans, LA, October 14, 1992, and as the Alexander Ming Fisher Lecture, College of Physicians and Surgeons, Columbia University, New York, November 5,1992. References 1. Iglehart JK: Canada!s health care system faces its lems. New Eng J Med, 322(8):562-568, 1990. 2. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: An ethical framework for access to health care. In: Securing access to health care. Washington, DC: US Government Printing Office, 1983. 3. Strosberg MA, Wiener JM, Baker R (eds): Rationing America's medical care: The Oregon plan and beyond. Washington, DC: Brookings Institution, 1992. 4. Aaron HJ, Schwartz WB: The painful prescription: Rationing hospital care. Washington, DC: Brookings Institution, 1984. 5. Hadorn DC: Setting health care priorities in Oregon. J Am Med Assoc, 265(17):2218-2225, 1991. 6. Welch HG: Health care tickets for the uninsured. New Eng J Med, 321(18):1261-1264, 1989. Dr. Engelhardt is professor, department of medicine, and member, Center for Ethics, Medicine and Public Issues, Baylor College of Medicine, and professor, Rice University, Houston, TX. Bulletin of the American College of Surgeons
Ethics and Philosophy Lectures
by the American College of Surgeons, Chicago, IL 60611-3211 |