Markkula Center of Applied Ethics

System Overload: Pondering the Ethics of America's Health Care System

By Claire Andre and Manuel Velasquez

For those who have access to it, the American health care system undoubtedly delivers some of the finest care in the world. But despite the high level of technical achievement, this "system" is afflicted with mounting problems. Indeed, many health professionals and public policy makers wonder aloud if we have a "system" at all.

Unique among the industrialized democracies, the United States still retains a health care system in which the free market prevails, and physicians function primarily as free agents, selling their services to patient-consumers, most of whom attempt to cushion themselves from the potentially devastating costs of serious illness through private insurance coverage that they purchase or that they receive from employers. Intertwined with this free market system is a government funded "safety net" intended to provide basic health care services to those who cannot afford to pay on their own. Some 37 million Americans, mostly working people and members of their families, carry no health insurance, but earn just enough to be disqualified from receiving publicly funded medical care. As budgetary pressures mount at all levels of government, the "safety net" of public health programs is rapidly unravelling, and millions of poor people are falling through the giant holes that have developed in the system. Such problems invite a basic question about this tangle that we call the health care system—is it ethical?

Is it just to maintain a system that distributes health care unevenly, that cuts out the under-class, and that, some say, is excessively expensive? Is it right that we maintain a system in which an illness or injury can wipe out the savings of a family? Does it make sense to operate a health care system that forces many people to put off preventive medical care and regular health checkups because they can't afford them, only to arrive at the door of the emergency room in need of extraordinary and expensive treatments to address serious health problems. Or is this the price we must pay for the overall quality of medical care in the United States? Would a change in the system to provide greater protection to the poorest Americans endanger the health of the great majority of Americans?

"I don't think it's an ethical system," says Anne Moses, an associate director at a publicly funded hospital in a major metropolitan area. "I think the evidence for that is real simple that not everybody gets the care they need. People suffer needlessly." Moses bristles at suggestions that the flaws in the system are the result of inefficiency or high fees paid to doctors. "The context of our health care system includes a budget with enormous allocations for defense, bailouts for the savings and loan industry, and other kinds of payments which dwarf the allocations for health care."

"The fundamental question here is distributive justice," says Martin Cook, a Santa Clara University professor of religious studies and a specialist in medical ethics. "One way to phrase the question is to ask if there is such a thing as a right to health care." But Cook notes that if such a right exists, it differs fundamentally from traditionally acknowledged rights of free speech or religion. Such rights, known as "liberty" or "negative" rights, protect individuals from interference in the exercise of personal activities, but a right to health care is a "positive" or an "entitlement" right. Entitlement rights are necessarily limited by a society's willingness and ability to provide the entitlement. In other words, they depend on a society's resources and the choices it makes about how those resources are used.

Even if the right to health is accepted, says Cook, "the next problem is that it would be literally impossible to provide the highest level of medical care and range of procedures to every citizen. So if you advocate providing medical services of some sort to everybody, you necessarily have to face a fairly severe allocation question. What level of care are you going to provide? This has to do with what many people call a 'decent minimum.' It's very hard to define what that would be."

But Anne Moses insists that, at least in this country, the issue of limits on resources is not relevant. "I think that there is so much available in this country that we can make what's necessary available and have quality for everybody." Moses concedes that "in the end," society may have to confront choices about the allocation of scarce health care resources. But, she maintains, "I don't think we are 'in the end.' We ought to wake up to the fact that what's wrong with this situation is that people are not getting care at basic levels," because we are allocating public dollars to other programs.

Both Cook and Moses agree that the current lack of access in the system exacts an enormous toll. In fact, apart from rights and justice arguments in favor of making basic health care available to more people, Cook observes that utilitarian arguments in support of greater access to health care are quite compelling. "For example, governmentally provided prenatal care has been eliminated in the Reagan years, but it is easily demonstrable that for every dollar you spend on prenatal care, you save three dollars on prematurity and its attendant expenses. You really save money, not to mention producing healthier babies, if you spend your money on prenatal care" for the poor who cannot get it under the present system.

In the past, defenders of the medical system opposed any radical restructuring of the system, such as the introduction of a national health care system or greater government involvement in insurance programs, claiming that the high quality of medical care in the U.S. far outweighed the negatives such as price or unequal distribution, or asserting a libertarian view that the government should allow the market to function freely. Since many did not accept the notion of a right to health care, they also saw no need to rectify the uneven allocation of health care resources. But as the health care crisis in the U.S. worsens, it is becoming increasingly difficult to find staunch defenders of the current system. For example, the American Medical Association, which has long argued against excessive interference from the state in the health care system, now advocates a plan that maintains the "freedom of choice" that has traditionally characterized the American health care system, but which requires employers to provide health insurance to all workers and calls on the states to provide insurance for those not covered because they are in poor health or out of work. For the AMA, this is a radical departure from its earlier opposition to any government imposed health plan.

Even more ardent advocates of a laissez faire economy have, in recent years, come to express dissatisfaction with the current system. Shortly before his retirement in 1989, C. Everett Koop, the outgoing surgeon general wrote, "We have to acknowledge that there is something terribly wrong with a system that spends more and more money but seems to serve fewer and fewer people." The conservative Koop reiterated his belief in free market solutions in most cases, but in the case of a health care system where demands for service are often unrelated to price, Koop wrote, the system "is not freely competitive and has virtually no moderating controls working on behalf of the patient. We seem to have a system that is distinguished by a virtual absence of self-regulation on the part of those who provide [health care]...but distinguished as well by the absence of such natural marketplace controls as competition in regard to price, quality or service." Koop concluded that "a change needs to be made in the structure of the system," and recommended a presidential commission to determine how to proceed.

So far, no commission has been established, but if it ever is, the tasks before it will be formidable, for the issues that must be considered arc both complex and numerous. Is there a right to health care (or as Anne Moses says, a right "to health")? What constitutes a fair system of distribution? And if that system is administered by the government, what medical procedures should it provide to all citizens, and which procedures should it refuse to fund? The challenge, whether it is accepted by a presidential commission, the medical profession, or individual health care providers, is to find reasonable answers to these questions, and to one further question that Martin Cook asks: "Never mind rights language. What should a decent society do for its people?"

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