Moral Arguments for Universal Health Care: A Vision for Health Care Reform

By R. Paul Olson

Health care reform is always about more than morality and values, but
if it lacks a moral foundation, it will not stand the test of time. Dr.
Olson provides a moral foundation expressed in eight standards derived
from his study of ethics, systems theory, and health policy research. From
these normative standards he derives a vision of universal health care as
both a public policy of protecting and promoting the health of an entire
population, and a system for organizing, fi nancing, and delivering high
quality care, which is affordable and accessible to everyone based on
their need. Universal health care is fi nanced fairly to ensure sustainability
through shared responsibility with personal choice of health care providers
and/or health care plans. This unifying vision for health care reform is
pluralistic with respect to the design of systems to implement it.
The author provides several moral arguments from divergent ethical
theories, which converge to support his vision of universal health care
and its specifi c elements. In the process, he illustrates how to reason to
moral conclusions based on clear thinking about both values and relevant
facts. He also shows why and how ethical discourse is both relevant and
necessary to the formulation, implementation, and evaluation of health
care policy. Discussion of the controversy over medically necessary care
and an ethical analysis of the Affordable Care Act are unique features of
this book.

• Language: English
• Publisher: AuthorHouse
• Release date: Feb 6, 2012
• ISBN: 9781467856263

R. Paul Olson

R. Paul Olson earned his B.A. degree from Carleton College, an MDIV. degree from Yale Divinity School, and his Ph.D. in clinical psychology from the University of Illinois-Urbana. His perspective on health care reform derives from several years of clinical experience, teaching on professional ethics, and research on health care systems.

Book preview

Contents

Dedication

Foreword

Acknowledgements

Preface

Part One:

INTRODUCTION

Chapter One:

Part Two:

GOAL-ORIENTED (TELEOLOGICAL) ETHICS

Chapter Two:

Chapter Three:

Chapter Four:

Part Three:

DEONTOLOGICAL ETHICS

Chapter Five:

Part Four:

JUSTICE IN HEALTH CARE

Chapter Six:

Chapter Seven:

Chapter Eight:

Part Five:

CONCLUSIONS

Chapter Nine:

A Postscript

References

Dedication

To the millions of Americans who continue to suffer

from inequitable access to high quality health care.

Foreword

In his essay On the Liberty of the Press, David Hume expressed his hope that men, being every day more accustomed to the free discussion of public affairs, will improve in the judgment of them, and be with greater difficulty seduced by every idle rumour and popular clamour.¹ Dr. Olson expresses the same hope when he says at the end of his volume, What we fail to realize is that through practiced moral reasoning and public, ethical discourse we can learn more about what we ought to do to straighten out our health care system for the benefit of everyone, and even how we can do it.

As David Hume knew all too well, and as we are reminded daily, bad ideas and idle rumors still seduce far too many of the public and exhaust the air better spent discussing the good ideas that, perhaps too infrequently, make their way into public affairs. Dr. Olson has argued extensively, and well, for a good idea: universal health care is a moral imperative.

Many have argued for universal health care, on a variety of grounds, but Dr. Olson has upped the ante. The grounds on which he argues for universal health care have altered the landscape of the discussion as dramatically as an earthquake. To understand how, we need to remind ourselves how arguments work and especially how we up the ante when we argue.

The move is one we all made as children. A friend says of one of our toys, I want that. We reply, It’s mine. We just upped the ante, pushing the argument to a new level where the only possible response meets the new kind of claim. But I really want it! is now irrelevant. Our friend must move up to a new level of argument, one that is responsive to the claim of ownership. Our friend must either deny that we own the toy—That’s not yours!—or claim that ownership is itself irrelevant: Ownership is a bourgeois concept that has no place in a playground where what matters is sharing and communitarian justice.

We find the same sort of moves in legal arguments. The best legal defense is to up the ante, leaving an opponent’s arguments irrelevant to the point at issue. A lawyer may be arguing that a particular law should not be interpreted as, say, a prosecutor is interpreting it, and the prosecutor may up the ante by arguing that to question that interpretation is to question a Constitutional provision. Suddenly the decisive issue is no longer about how to interpret a law, but how to understand a clause in the Constitution. The only possible responses are to provide an alternative understanding of the relevant clause or to up the ante once again, arguing that the very conditions of having our Constitution support the relevant reading of the clause.

We have at this level of argument reached almost the most powerful form of argument we can provide in Constitutional adjudication. If the very conditions for having our Constitution require a particular interpretation of the law in question, the argument has now moved to a very different level from where it began, making arguments about how to read the particular law irrelevant except insofar as they embody features that necessarily follow from the conditions for having our Constitution. The only way to raise the ante is to argue that the conditions for having any constitution require interpreting our Constitution in a different way.

Each move in the level of argument trumps the preceding move and forces the argument to a new level—from how to interpret a particular law to how to interpret a particular Constitutional clause to how to understand what our Constitution or any constitution requires. To continue to argue about how to interpret the particular law with which the ascent began is as irrelevant as saying, But I want it!, in response to But it’s mine. The geography of the discussion has changed.

When we look at the various reasons that have been offered for universal health care, we find that they cover the field. It might seem that an appeal to self-interest would suffice. After all, each of us with health care is at risk of losing it (by being laid off, for instance, or finding the premiums suddenly significantly higher than we can afford), and those without health care are at risk at any time of illness or of harm (in a traffic accident, say). Unfortunately, an argument from self-interest is an argument for prudence, and individuals make radically different evaluations of what is prudent and what is not. Some are risk-averse; others are high fliers. Otherwise, we would not see people texting while driving or tailgating so closely that they must hit the vehicle in front should it have to stop suddenly. In addition, those without health care know they will be treated even if they lack health care insurance. So arguments from self-interest fail because, it may be claimed, it is not in everyone’s self-interest to have health-care.

This response is about self-interest and so on the same level as the claim that self-interest justifies universal health care. But what Dr. Olson has done is so change the ground of discourse that we need not consider the problems with the various reasons offered for universal health care. He is arguing that we have a moral obligation to provide universal health care. It is more than a little difficult to argue that we ought not to do what we ought to do. In fact, Dr. Olson’s move leaves opponents with only three possible responses:

• They can deny Dr. Olson’s thesis, arguing that morality does not require what he argues it requires. But he argues that every moral theory justifies universal health care. Those who disagree must argue at Dr. Olson’s level, showing that he has somehow gotten the moral theories, or their implication, wrong.

• They can argue that we cannot do what we are morally required to do. but that would be a sad commentary on our capacities, political or otherwise, to do what morality says we ought to do.

• They can try to trump Dr. Olson’s argument in turn, claiming that something superior to morality makes moral arguments irrelevant to the health care discussion. It is difficult to imagine what that could be.

In short, Dr. Olson has so altered the discourse on universal health care as to leave all the standard arguments stranded. He has raised the level of discourse so that the only way forward is to argue on moral grounds. We can only hope, with Hume and Dr. Olson, that his work will be widely read and that the free discussion of public affairs will thus benefit from what he has so done so well, leading to better decisions about what we ought to do regarding health care.

Wade L. Robison

Ezra A. Hale Professor in Applied Ethics

Rochester Institute of Technology

Rochester New York

Acknowledgements

I wish to thank the following colleagues for very helpful pre-publication reviews.

Gunnar Almgren, Ph.D., LCSW. Associate Professor of Social Work and Social Welfare, University of Washington

Joel Ario, JD, MDiv. Former Director of the Office of Health Insurance Exchanges in the U. S. Department of Health and Human Services, and former Insurance Commissioner in Oregon and Pennsylvania

Pamela Behan, Ph.D. Associate Professor of Sociology, Dept, of Liberal Arts & Social Sciences, Our Lady of the Lake College, Baton Rouge, LA.

James F. Hart, MD, MBA, PHC. Retired general physician and medical and public health educator, University of Minnesota School of Public Health and Regions Hospital, Twin Cities, MN.

Bob Power, MBA, CEBS. Health Economist (retired), Minneapolis.

Wade Robison, Ph.D. Ezra A. Hale Professor in Applied Ethics, Rochester Institute of Technology, Rochester NY.

I am grateful for permissions from the following publishers to quote selections from their books:

Alan C. Hood & Co., Inc. for quotations from Dr. Henry LeBow’s Health care meltdown, 2004.

Augsburg Publishing House for Karen Lebacqz’s Six theories of justice: Perspectives from philosophical and theological ethics,1986.

Cengage Learning/Nelson Education (www.cengagee.com/permissions) for Theodore Denise, Nicholas White, and Sheldon Peterfreund’s Great traditions in ethics (with Info Trac), 11E, Copyright 2005, Wadsworth, a part of Cengage Learning, Inc.

Charles C. Thomas, Springfield, Illinois, for R. Paul Olson (Ed.) Mental health systems compared: Great Britain, Norway, Canada, and the United States, 1st ed., 2006.

HarperCollins Publishers for Ian Barbour’s When science meets religion, 2000.

Harvard Business Publishing for Michael Porter & Elizabeth Teisberg’s Redefining health care: Creating value-based competition on results, Harvard Business Press, 2006.

Health Affairs Permissions Department to cite quotations from Health Affairs, 2011.

John Wiley & Sons. for John Hare’s God and morality: A philosophical history, 2007.

McGraw-Hill Companies, New York for Robert Solomon & Clancy Martin’s Morality and the good life: An introduction to ethics through classical sources, 4th ed., 2004; and for Thomas Bodenheimer & Kevin Grumbach’s Understanding health policy: A clinical approach, 5th ed., 2009.

Oxford University Press, Inc. for Charles J. Dougherty’s American health care: Realities, rights, and reforms,1988; and for Tom L. Beauchamp & James F. Childress’ Principles of biomedical ethics, 5th ed., 2001.

Pearson Education Inc., Upper Saddle River, New Jersey, for citations from William K. Frankena’s Ethics, 2nd ed., 1989.

Perseus Books Group for The Staff of the Washington Post’s Landmark: The inside story of America’s new health-care law and what it means for us all, 2010.

Random House for Donald Barlett & James Steele’s Critical condition: How health care in America became big business—and bad medicine, 2006.

Scribner, a Division of Simon and Schuster, Inc. for permission to reprint from Mortimer J. Adler’s Six great ideas, 1981. Copyright 1981 by Mortimer J. Adler. All rights reserved.

Springer Publishing Company, New York for Gunnar Almgren’s Health care politics, policy, and services: A social justice analysis, 2007.

St. Martin’s Press, New York, for quotations from Tom Daschle’s Critical: What we can do about the health-care crisis, 2008.

State University of New York Press for Pamela Behan’s Solving the health care problem: How other nations succeeded and why the United States has not, 2006. State University of New York. All rights reserved.

The Cato Institute for Arnold Kling’s Crisis of abundance: Rethinking how we pay for health care, 2006.

The Century Foundation for Nancy Harris (Ed.). Does the United States need a national health insurance policy? 2006; and for Arnold Relman’s Second opinion: Rescuing America’s health care, 2007.

The National Academies Press for the Committee on Quality of Health Care in America, Institute of Medicine’s Crossing the quality chasm: A new health system for the 21st century, 2001.

University of Rochester Press, Rochester, New York for quotations from Tom Engstrom and Wade Robison (Eds.). Health care reform: ethics and politics, 2006.

World Health Organization, Regional Office for Europe for Sarah Thomson, Thomas Foubister, & Elias Mossialos’ Financing health care in the European Union, 2009:xiii, xiv, xx, 15. (http://www.euro.who.int/en/what-we-publish/abstracts/financing-health-care-in-the-european-union).

World Health Press for The world health report 2000—Health systems: Improving performance, 2000.

Preface

This book is about ethics and health care reform. More precisely, my aim is to provide several arguments derived from a variety of ethical theories to support a unifying vision for reform of the American health care system. My vision is a health care system that achieves eight goals: Ensure equitable access and effective care; provide cost-efficient care and finance health care fairly; generate and sustain the resources required; protect participants’ rights and ensure representation of everyone in the system; and finally, provide health care services responsive to the population’s expectations and health care needs. These elements and norms constitute my definition of universal health care.

A basic premise of my argument is that our health care debate is not solely about economic, political, medical, or legal issues; it is fundamentally a moral issue and reflects a persistent conflict of values. In other words, to achieve and sustain universal health care in America requires wider agreement about the kind of society we should be and ought to become. Health care reform is ultimately a matter of social ethics. A second premise of this book is that an ethical analysis should be an essential element in all phases of a policy cycle—problem identification, policy formulation, implementation, and evaluation. Policy proposals should cite their guiding values and moral justifications.

Mayes (2004) discussed six federal initiatives to achieve universal health care in America: 1934-35, 1949-50, 1964-65, 1974-75, 1979-80, and 1993-94. All of them failed. The federal Patient Protection and Affordable Care Act of March 23, 2010 and the Health Care and Education Reconciliation Act of March 30, 2010 constitute significant progress toward universal health care but fell short because about 23 million Americans are expected to remain uninsured. (The number who are voluntarily uninsured despite an ability to afford health insurance is unknown.) Moreover, the coverage extended to the additional 32 million Americans will not be implemented fully until 2014, and prior to that time, opponents will continue to try to repeal it or deny the funding necessary to sustain this landmark reform. As a consequence, at the time of this writing the value and vision of universal health care remains unrealized for millions of Americans who have restricted access. Between 2000 and 2004, the number of uninsured Americans increased at an annual rate of about one million to an estimated 47 million (Holahan & Cook, 2005). As the result of a severe recession beginning in late 2007, more than six million Americans lost their jobs by June, 2009, and for most, that meant loss of their employment-based health insurance. The number of under-insured Americans has been increasing at an even higher rate to an estimated 25 million (Schoen, Collins, Kris, & Doty, 2008). America remains the only Western industrialized democracy with high income that fails to ensure access to even basic health care for everyone in our country.

Access to health care insurance is a major concern because it is related to disparities in both health care and health status. There is also a growing awareness among some health policy analysts that

. . . one of the major barriers to controlling health care costs is exactly this lack of universal coverage. This is not only because it is difficult for poor and sick people to seek preventive care, but also because it fragments the financing system, requiring the existence of an expensive safety net as well as aggravating the problem of cost-shifting. (Anderson, Rice, & Kominski, 2007, p. xxxiii)

As an observer of the recent health care debate in the United States, I have been struck by the number of references to ethical principles and moral values, which have appeared in various books and articles by advocates of reform. These references are usually implicit rather than explicit, and frequently cited without justification, as if everyone knows what the values are and mean, their relative rankings, or the merits of the implied moral arguments. The most common values have been expressed in three goals of proposed reforms: to contain costs, improve quality, and expand access. While some proposals are comprehensive and include all three values as goals, many piecemeal proposals advocate incremental reforms focused on one of these three or on a more specific objective such as improved information technology (e.g., electronic medical records).

What has been lacking in several proposals and in the debate leading to the federal Patient Protection and Affordable Care Act of 2010 is an informative, public discussion of the ethical foundations and moral arguments that support the various reforms proposed. More often than not, health policy literature and discussions seem to be expressed in the language of the social sciences (notably health economics and politics), business (especially managerial principles), medical science or health care law. Many of the concepts and terms used by health policy experts are theoretical and technical, and allow an easy inference that this whole topic of health care reform is either a theoretical or empirical issue, hence value-neutral or value-free.

In this book I am presenting a different perspective. My moral point of view affirms that formulating, implementing, and evaluating health care policy are value-laden activities. Value judgments are implicit in stated ends and means expressed in the goals and strategies that distinguish various proposals for reform. For example, implicit in the goal of expanding access to health care are the ethical principles of beneficence and justice, respect for human dignity and the common good. The concept of quality of health care is itself a value judgment about best practices, which are contrasted with interventions lacking empirical evidence. That medical interventions should be evidence-based is also a value judgment. The goals of cost containment and cost-effectiveness are not only practical necessities in light of economic realities; they reflect moral judgments about how health care services should be financed, allocated, and delivered.

My aim for this book is to illustrate applications of ethical reasoning to health care policy by demonstrating how diverse ethical theories converge to provide a moral foundation for universal health care as I have envisioned it. My intent is to contribute to the development of a moral consensus that will provide justification for a more compassionate and just health care system for all Americans. I am articulating a value-based vision of a good health care system with the hopes that the recent gains will be maintained despite continued opposition, and that further progress will be achieved based on a broader moral consensus about what a good health care system is, and why we must strive to attain a system that ensures universal health care as a unifying vision.

At various points in this book I will support particular policies, goals and strategies related to achieving this vision of universal health care. I offer these not as dogmatic prescriptions, but to stimulate readers to consider a range of options from a moral point of view. What are the ethical principles and rules that seem operative in the present health care system in the United States, and what do you think they should be? What are the values explicit or implicit in the competing proposals for health care reform? I want to encourage clear thinking about the ethical dimensions and moral consequences of the ends and means advocated in the particular policy and system of universal health care as I define it. The arguments are not being offered as definitive proofs, but as justifying reasons. I invite my readers to evaluate the validity of these reasons, and to decide whether they are both reasonable and relevant to our recurring public debate about health care reform.

I will not be discussing the evolution of the American health care system because that historical perspective has been provided by others (e.g., Almgren, 2007; Blendon & Benson, 2001; Mayes, 2004; Starr, 1982). Rather, I will address health care policy from a moral point of view. The arguments presented to support universal health care illustrate the variety of approaches that might be taken to frame the debate ethically. In order to apply several ethical theories, I must limit discussion of each one to an introductory level. I will cite references for readers to pursue greater depth in a particular theory.

By way of summary, in this book I will introduce several ethical theories and compare them by applying their principles to a single, common topic of health care policy. Secondly, I will evaluate them according to the criteria of a good ethical theory. Thirdly, I will discuss a number of the health care topics addressed by ethical theories, with special reference to the norm of universal access to health care services. Fourthly, I will illustrate how divergent ethical theories converge to provide moral justification for universal health care as a public health policy and health care system.

Organization of This Book

In Part I, chapter one I establish the need for an ethical perspective on health care reform by addressing some of the moral issues implicit or explicit in the variety of reforms proposed. Arguments are presented to support the thesis that health care reform is fundamentally a moral issue, not exclusively an economic, political, medical or legal matter. Thereafter I define Universal Health Care as a value-based vision of a good health care policy to guide reform of the health care system in the United States. I adopt William Frankena’s (1973) moral point of view, and respond to five objections to applying it in public debate: (a) a moral perspective cannot yield a consensus in a pluralistic society; (b) it is unnecessary and (c) irrelevant to the health care debate; (d) it is polarizing, and (e) moral judgments are merely subjective expressions of personal preferences. In support of a moral point of view, I make four arguments: (a) health care reform is a moral activity informed by implicit or explicit values and obligations as both the ends and means of change; (b) the serious moral deficiencies of the U.S. health care system warrant an ethical response; (c) human beings are moral agents, and (d) a moral perspective is both reasonable and practical.

Following the introduction in chapter one, chapters two through four of Part II illustrate support for universal health care based on principles of utility, beneficence, and nonmaleficence derived from goal-oriented (teleological) ethics. The principle of utility is illustrated in concepts of medical and social utility, quality of life, cost-containment, and cost-effectiveness as goals of health care reform. From the principle of beneficence I deduce the goal of medically necessary care, while recognizing its controversial misuses. The principle of nonmaleficence leads to discussion of topics such as (a) safety and the quality of care, (b) due care versus negligence, (c) withholding and withdrawing treatment, (d) maltreatment, (e) protecting the vulnerable, and (f) the rule of double effect.

Chapter five of Part III presents rule-oriented (deontological) ethics illustrated by monistic, pluralistic, and mixed theories. Two versions of monistic deontologies are discussed: (a) Kant’s categorical imperative, including his important ethical corollary, and (b) theological voluntarism. Pluralistic theories articulated by other ethicists are also presented, with special reference to the four principle framework of Beauchamp and Childress (2001). As examples of mixed ethical theories, I present my own normative-systems framework and the principled approach articulated by the Institute of Medicine.

Justice-based theories of ethics are particularly germane to the public debate about health care reform. They are addressed in Part IV. I discuss various concepts, types, and theories of justice in chapter six. Special attention is given in that chapter to the utilitarian theory of justice. Fairness-based theories are applied in chapter seven to questions of access, allocations of resources, and financing of health care. In chapter eight rights-based notions focus on access to health care as a civil right, natural right, and moral right. The chapter ends with a basic question: Why should we be just?

Chapter nine of Part V includes a recapitulation of my thesis, goals, and method. After reiterating my definition and requirements of a policy and system of universal health care, I summarize several moral arguments from philosophical ethics supporting this policy. I conclude there is a broad consensus about the moral imperative of universal health care despite diverse reasons given to support it, and even in the face of arguments against it. Thereafter I cite multiple strategies for financing and delivering universal health care. The chapter ends with a critique of the Affordable Care Act, and some final thoughts about ends and means.

For each of the major ethical theories, I provide ethical syllogisms to illustrate how to reason correctly from an ethical principle to a valid conclusion. To simplify my presentation and to facilitate comparisons, I have applied one form of deductive syllogism outlined in the standard text on logic by Copi and Cohen (2009). Logic specifies the rules of correct reasoning and helps us to identify fallacious reasoning due to incorrect construction of arguments. A common example of the latter (called the naturalistic fallacy) is the attempt to derive a normative proposition from a factual proposition, an obligation from an observation, an ought from an is, or a value from a fact. Properly constructed syllogisms avoid such logical errors.

In Summary and Evaluation sections to Parts II, III, and IV, I cite strengths and limitations of each ethical theory according to a standard set of criteria: A good ethical theory is clear and coherent, logical and verifiable, comprehensive and parsimonious, important, relevant, and practical. Though the criteria developed are most germane to evaluating specific theories, I will cite the potential strengths and risks of the general types of theory (e.g., teleological and deontological theories) as they apply to health care policy and reform. I will also discuss the relevance of each ethical theory to the general argument supporting universal health care in addition to illustrating particular normative arguments related to more specific issues.

Readers of the entire book will find some repetition in the summary and evaluation sections for Parts II, III, and IV. I have included common strengths and limitations so that readers interested in one type of theory do not have to refer to other chapters.

In his short story entitled, The Elephant’s Child, Kipling (1987) suggested some of the basic questions we need to ask to achieve a comprehensive and practical understanding of any subject matter: I keep six honest serving men (they taught me all I knew); their names are What and Why and When, and How and Where and Who (p. 63). The same questions need to be addressed to understand something as complex as the American health care system. However, my primary goal is to show the relevance of ethics to the current and continuing debate on health care reform, and specifically, moral arguments in support of universal health care as a unifying vision of a morally acceptable health care system.

A Word About Terms

Throughout this book I have used a variety of terms interchangeably: universal health care, good health care, effective health care, medically necessary care, or simply health care. I use these terms as equivalent to connote the provision of equitable and universal access, appropriate to individuals’ medical need, delivered and financed effectively, efficiently and fairly. Similarly, the term access means access to medically necessary, effective, appropriate care, not to any or all health care available or provided. I do not endorse all types of health care as equally effective or appropriate without considerations of both its medical and social utility. In particular, my definition of universal health care includes interventions to prevent disease and promote health and wellness. I encourage my readers to refer to my comprehensive definition of universal health care in chapters one and nine, which includes eight necessary elements derived from my normative-systems framework.

Throughout this book I refer to the most recent federal reform in health care policy as the Affordable Care Act (ACA). This is the final version of the Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care Education and Reconciliation Act (HCERA), signed by the President respectively on March 23 and March 30, 2010. The ACA includes the changes in PPACA made by the HCERA.

My Intended Audience

I am writing this book for people who are interested in health care policy and reform, and who have wondered whether and how ethics might make a contribution to the public debate about universal health care in particular. I write from a conviction that this is fundamentally an ethical debate about what kind of society we should be and become, what we ought to do about our current health care system, and why we think so. In other words, this is an exercise in moral reasoning applied to inform the current and future debates about health care policy in the United States. My hope is that readers will conclude that further reform of our current health care system continues to be an urgent moral imperative, and that a broader moral consensus can be achieved as a foundation for universal health care despite the diversity of ethical perspectives and competing political ideologies. One of the functions of ethics is to help resolve what appear at first to be incommensurable moral disagreements, which result in dead end discussions and protracted political conflict.

Although I have written neither a reference nor a textbook, this work will complement the education of health care professionals and apply to the practical worlds of health policy and health care reform. Students and practitioners in the health professions are becoming more aware of the need for fundamental reform of the U.S. health care system due to persistent health care inflation, the significant number of uninsured and underinsured, disparities in both the quality of health services and the financial burdens of disease affecting women, children, and minorities, and the commercialization of health insurance as a commodity sold for-profit. Health practitioners will find the systems and social ethics perspectives more inclusive than their customary focus on professional ethics related to clinical interventions with individual patients. Health plan managers and insurers will see some ways that social ethics impact their business ethics, their statements of mission and purposes, and their management practices. Persons preparing for careers in government and public health will see how a moral perspective informs all phases of the policy cycle—problem identification, and policy formulation, implementation, and evaluation.

Readers interested in the social sciences will find the application of an ethical framework to public health policy complementary to social-psychological, economic, and political perspectives. Those who are interested in philosophy will find in this book an application of two branches of philosophy—ethics and logic—particularly as the latter relates to the former. Students of ethics will appreciate both the critiques of several ethical theories as well as their practical application to demonstrate how divergent theories can lead to convergent conclusions.

Citizen advocates for health care reform, particularly for a universal entitlement to health care, will find several moral arguments summarized in my concluding chapter to support their community organizing activity and political action. Finally, an educated public interested in health care will gain an introduction to some of the issues associated with health care policy and reform. And for those who are confused and overwhelmed by so many diverse proposals for health care reform, my selective focus upon universal health care will be a manageable introduction to one of the major civil rights issues of our time—social justice in health care for all Americans in the 21st Century.

Part One:

INTRODUCTION

Chapter One:

Universal Health Care

from a Moral Point of View

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.² 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, moral sentiment, natural or civil law, social contract, 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