A New Moral Vision for Healthcare

Richard D. Lamm

Two major transforming realities have overtaken the health care system that requires us to redraw the health care map:

I. Taxpayers now fund approximately 50% of U.S. health care.

II. It is now inescapably clear that resources are limited relative to needs.

When limited funds meet unlimited demands, they must be budgeted and prioritized. The "rationing" of health care goes from outrage to obligation, from intolerable to inescapable. Those who distribute pooled or taxpayer funds become not mere payment agents but allocators of limited resources who must maximize the health of the group they cover.

There is a largely unexplored ethical analysis applicable to the macro-allocation of health resources. Those who allocate limited resources should not mechanically pay for everything within the doctor/patient relationship. As one perceptive author suggests:

" ... the distinction between macro-allocation and micro-allocation of resources is crucial. More traditional bio-ethical analysis may well clarify the micro-allocation issues, but it is inappropriate at the macro-allocation level and therefore misses the point. ... The allocation of health care resources is best understood as a political rather than an ethical issue." (emphasis added)

American health policy has missed a crucial point. Medical ethics may control the behavior of health providers, but it should not control the macro-allocation process. Public policy has its own independent ethical duties. As Rudolf Klein has said:

"For if maximizing collective welfare trumps maximizing individual benefits, then it is information about the impact of specific resource allocation policies rather than information about the characteristics of individual would-be beneficiaries that becomes crucial."

If this correctly describes the new world of health care, it would seem to follow that:

1. A nation's health goal can never be, nor should it be, to fund the sum total of all its citizens' individual needs. Thus, the legislature should not be limited to or controlled by the ethics of the physician-patient relationship. That relationship is important but not exclusive. Not only is it not it in the public interest to fund everything" beneficial" to the patient, but, correctly analyzed, it is not in the patients' interest.

2. Public policy should concern itself more with extending the health care floor than raising the research ceiling. Public policy makers must care about the health of the total society as passionately as health providers care about an individual's health.

3. Group funds, public or private, should maximize the health of the group. It is the duty of those distributing pooled money to optimize the health of all those in the pool. The doctor-patient relationship may be the most important relationship in health care, but it is not the only relationship. Doctors are patient advocates, but they are imperfect agents to maximize the health of a group of patients.

4. When people pool funds, they cannot maximize the amount of beneficial treatment to each member of that pool, and cost has to be a consideration when distributing those funds. As Haavi Morreim says: "we cannot fairly insist that physicians owe to a patient resources they neither own nor control... we should neither expect nor permit the medical profession unilaterally to choose the values that will set the amounts and purposes for which other people must spend their money."

5. Not only is the Oregon health plan ethical, it is unethical for a state not to have a system of priorities. Likewise, those in health plans who distribute pooled resources have an independent ethical duty to prioritize and budget those funds to maximize the total health of the group. Governor Kitzhaber demands that we give our attention to the "hydraulic relationship" between coverage, benefits and cost. All are important; all are interrelated. Public policy must find a way to prioritize what benefits are covered instead of which citizen is covered.

6. We must recognize that the problems of the uninsured and the problems of cost containment are not separate problems, but inextricably intertwined and must be solved together.

7. What may have been unethical under assumptions of infinite resources, becomes ethical in the tradeoff world of finite resources. Many concepts must be reconsidered and redebated. Does not a society owe a greater moral duty to a 10-year old than a 90-year old? Should not a patient' s smoking and drinking habits be laid on the scale for high cost rescue procedures?

8. Life is precious but cannot be priceless. Death is always a loss, but now it is often a publicly subsidized event. There will always be "ten leading causes of death" no matter how brilliant our medicine. The threat to biologic life cannot highjack a disproportionate share of finite resources needed elsewhere for the quality of life. People have a "right to die" but it is a negative right against interference not a positive right to a state subsidized death regardless of cost. The postponement of death is an important value but must take its place among other health values.

9. We do not necessarily maximize health by maximizing health care. Society must better analyze and study the determinants of health for a state and nation. How do we keep a nation healthy? What factors produce health? In this we have the benefit of a number of other countries having considered the subject.

10. Goethe warned, "If you are going to live in your father's house, you must rebuild it." We have not adequately structured the house of health ethics. We have overbuilt and overfurnished the first floor, but most of the rest of the structure remains not only unfinished but unframed. There is more than one level of ethical analysis in health policy; there are multiple. A legislator, a health plan and a family member have a different moral duty than a doctor. We need different levels of ethical analysis corresponding to the various levels of moral obligation.

11. The first level is the ethics of the doctor/patient relationship; the second is the ethics of the health insurance plan whose financial obligation is to the total group whose premiums made up the money under their control; and the third level of ethical analysis is to determine the role of the government and their fiduciary duty in the funding of health care. All three levels of analysis are necessarily related but not coterminous.

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