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...