Vision of health care gets lost in special interest debates
Vision of health care gets lost in special interest debates
The ethical debate is subdued
Rationing. Responsibility for immigrant health care. Socialism. Death panels. Individual responsibility. Single-payer option. Malpractice reform.
Those are just a few of the hot-button topics that have emerged in what has been the health care reform debate thus far, although no clear resolution has developed as to how to fix what ails the U.S. health care system.
Although there has been a lot of noise, there hasn't really been a national debate, according to some. Instead, there has been enormous effort to get the messages out from particular advocacy groups, says Nancy Berlinger, PhD, MDiv, research scholar and deputy director of The Hastings Center in Garrison, NY.
Writing in the April 8, 2009, issue of the Journal of the American Medical Association, Darrell G. Kirch, MD, president and CEO of the Association of American Medical Colleges in Washington, DC, claims the ethical debate regarding health care reform simply has not risen to the surface.
"While many have described the dysfunctional aspects of the US health care system, the focus has prioritized issues of payment systems and delivery models over a fundamental underlying ethical conflict," Kirch writes.1
"Within an ethical context, it is important to discuss how the commercialization of medicine has fostered a distortion of emphasis among the basic tenets of medical ethics, and how this unbalanced emphasis has created serious barriers to improving the health care system," he writes.1
Robert J. Barnet, MD, MA, a cardiologist and senior scholar at the Center for Clinical Bioethics at Georgetown University Medical Center in Washington, DC, bemoans the advent of "medicalization" in the health care system. Medicalization refers to the heavy sway market forces and commercial groups have in determining what is appropriate for health care. Barnet cites the pharmaceutical industry, medical device industry, and insurance groups, which, to a large extent, have shaped how health care currently is delivered in this country.
Berlinger notes that while most people, from legislators to physicians to the public, agree on what is wrong with the health care system, there is no one solution to correcting the problems it faces. In part, that is because no one system serves everyone in this country, she says.
"We're a pluralistic country — very, very diverse and very large. We're 50 states plus the District of Columbia and Puerto Rico. We have people who get their health care in a variety of different ways," Berlinger tells Medical Ethics Advisor. "It is much easier to talk about a health care system when there is one system that everybody recognizes as being their system."
"The short answer to this is this is a big country," she says, so just in the diversity alone there are problems in building consensus.
Business or service or profession?
"Physicians have certain privileges that others do not have, because it is assumed that unless physicians hold these rights and responsibilities, the health of society will be compromised," writes Kirch. "This social contract is at the heart of the medical profession. Physicians must use their best informed judgment when caring for individuals who need assistance and in return, physicians must be given appropriate freedom to do so."1
Kirch notes in the JAMA article that "the teaching of medical ethics has long focused on a 4-pillar foundation of the profession: beneficence (provide good care), nonmalieficence (do no harm), respect for autonomy and justice."
"It would appear that in the United States, however, attention to these 4 principles has become unbalanced. Currently, far less emphasis is given to considerations of justice (especially for society as a whole) relative to the other ethical principles," Kirch writes.
Berlinger notes that some argue that health care is a right; others argue that it is a responsibility; and still others argue that it is both a right and a responsibility.
"I don't even want to say that these are arguments — these are ways of looking at health care," Berlinger says. "But because we're talking about doctors in particular, doctors recognize that a core part of their vocation, no matter what specialty they're in — the reality of illness and suffering and pain [coincides] with the fact that there are some people we entrust to be trained to be professionals to help us cure disease, to help us manage diseases that cannot be cured, and to address pain and suffering, and, we hope, to prevent all of these things."
Physicians, she says, are "already inside of an ethical relationship; they've already taken a stand with the idea that health care is a social good. I don't know any doctors for whom that is up for debate."
What physicians may disagree with is how to pay for health care, she says.
However, Kirch suggests in the JAMA article that perhaps physicians have become too self-interested from a financial perspective. "In the current system, however, and in the face of the powerful commercial forces at work in health care, the expression of physician autonomy at times appears to have become more aligned with independence of practice, especially fiscal independence and the right to enhance physician revenue…."1
Berlinger says, however, that health care is a business, even though it's not "just a business."
And so, there is this question, she says: "What do you do when there seems to be common agreement that there are a lot of things wrong, but nobody can do without a health care system. You can't just close it all down for a day and then reopen it like you do with a store. It's not a consumer good in the same way as almost any other kind of business is."
The need for a vision
Just as we have entrusted certain public safety issues to others, such as police and fire departments, we as a society in the United States have entrusted physicians to take care of us when we are sick.
But beyond that, there seems to be a world of disagreement, much as there has been in previous iterations of the health care reform debate, such as with the Clinton initiative in the early 90s.
One "enormous difference" in the current debate vs. the debate surrounding the Clinton initiative is the presence of the Internet and the fact of the 24-hour news cycle, Berlinger says. The media have the task of constantly reporting and are fed by the fact that "there are so many sources that have taken a position on a particular issue [and] are really investing themselves in talking."
Mostly, it seems, the Internet allows both individuals and groups to find other individuals and groups who agree with their position, she says.
"So, it's not really a discussion or a debate in the cases that we've been seeing," Berlinger notes. "We've been seeing lots of parallel conversations, but it hasn't been one big national debate."
The discussion, she says, really needs to center around the "values that can sustain health care reform — not just health insurance reform, or this vs. that, but what values sustain them."
For example, she notes, there is currently a great deal of literature on the social determinants of health, and one of the surprising findings is that the quality of an individual's health may have more to do with such things as whether a person smokes, maintains proper weight, or genetics vs. how much access he or she has to health care.
Resolution will come — for the time being — because legislators will vote, and bills may be signed into law.
"It seems like what will happen is that more people will have health insurance. It is debatable whether that constitutes health care reform," Berlinger says.
"If it's health insurance reform, but we haven't really determined how we will change how health care is delivered in this country — that is going to be a continuing conversation," Berlinger notes.
Georgetown's Barnet agrees, suggesting that it may be 10 years or more before this current debate is resolved in any real way, because in a way, it is only the beginning of the discussion.
What is clear to Barnet is that health care resources are finite and must be delivered in line with other social goods, such has food, housing, and jobs. In fact, his thesis in the 70s looked ahead to the possibility of rationing in its title: "Allocation, Scarce Resources, and the Philosophy of Limits."
"The fact that [health care] resources are finite, I agree [with] completely, and we need to look at that and see how we allocate what we have," Barnet tells MEA. "One of the positions I've taken is that there are other social needs, and there's a maximum that we as a society can meet to contribute to health care."
Reference
- Darrell G. Kirch, David J. Vernon, The Ethical Foundation of American Medicine: In Search of Social Justice. JAMA. 2009;301(14):1482-1484.
Sources
- Nancy Berlinger, PhD, MDiv, Research Scholar and Deputy Director, The Hastings Center, Garrison, NY.
- Robert J. Barnet, MD, MA, FACP, FACC, Senior Scholar, Center for Clinical Bioethics, Georgetown University, Washington, DC.
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