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Cost Issues In Medical Ethics

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Understanding the Price: Cost Issues in Medical Ethics

By: S. Michael Robinson

PHL 310


Understanding the Price: Cost Issues in Medical Ethics

Medical ethicists contend with scores of contentious and controversial issues, yet no issue affects such a broad sector of the population as issues of medical cost and cost responsibility. Beyond mere policy debate, an ethical analysis of medical costs must consider all aspects of health, from research, practice methodology, and public health policy, but also legal, social and economic factors that impact health. This document will revue these issues and focus on three core questions: Does society or the individual bear the ethical burden of cost issues, is there an ethical argument to limit liberties or privileges in the interest of reducing health costs and to what extent should cost efficiency be a factor applied when determining care?

As we enter the 21st century, experts foresee a looming crisis in providing healthcare within the United States. Government entitlements, such as Medicare and Medicaid, face impending insolvency, private employers seek to remove medical expenses to reduce costs and insurers raise premiums and co-pays, preventing many citizens from obtaining adequate healthcare. Establishing an effective and ethical response to the issues of health care remains a top priority of planners, policymakers and politicians in the coming years.


Health care carries the burden of cost. Who carries the burden of this cost faces constant debate in the fields of philosophy, economics and medicine. On one hand, the individual, who is the primary beneficiary of health care benefits, holds a responsibility to repay the costs incurred by the benefits in question. The opposite perspective views the individual as a societal component, insured to good health as a benefit of membership to the larger whole. As the individual benefits society, so society holds an obligation to provide health services to insure his or her continued productivity. Examining both extremes in detail clarifies the issues involved in health care costs.

The perspective of total individual responsibility reflects a strong belief in the autonomy of the individual from society. As a result, the individual alone must bear the burdens of his actions and choices. From a strictly individualist viewpoint, all decisions carry consequences, and to some degree the individual is liable for any outcomes experienced as a result of these choice. From this perspective, while the individual has the right to seek medical care, there is no obligation to provide care if the practitioner is unwilling. Individualism carries strong connections to natural law theory, and views society and government as artificial creations with limited rights, powers and obligations. Needless to say, from an individualist perspective, providing, managing or limiting healthcare is not among government powers or responsibilities .

A strictly individualistic generally encourages personal responsibility and places costs based on who directly receives the benefit, rather than speculating on who instigated the problem. However, this perspective carries with it implications that cause substantial problems. Because cost responsibility defaults to the primary beneficiary, it becomes difficult to transfer obligation to an injurious party in circumstances where evidence warrants redress. The individualist perspective requires a tort system to handle such disputes. This creates additional costs both for the individual (i.e. legal fees) and the medical provider. These additional costs do not provide additional health benefit, and largely inflate the cost of care. Secondly, the individualist perspective strongly emphasizes personal wealth as the determiner for access to health care. This leads to a problem in instances where misfortunes, rather than poor choices, result in health problems. In such a circumstance, there is no guarantee that the economically underprivileged will receive adequate care, despite the fact that their economic status does not reflect any ethical implication on their person. Also, the individualistic perspective fails to recognize a societal interest in the health of its citizens. Quality of health directly affects the economic, military and political aspects of a country, and thus government does posses at least some interest in public health.

Advocates of social obligation often cite historical evidence to support their claim of government and social interest in healthcare. The majority of public works created under the Roman Empire were not temples or arenas, but aqueducts, hospitals and public baths. Health impacts all layers of society and government, vested with the task of managing society, posses a clear interest in improving the health of its citizens. From the perspective of social responsibility, a government provides healthcare to individual citizens to benefit everyone. The logic for this argument may seem weak, yet it carries some very real validity. Each individual benefits society through economic activity, civic involvement and family growth. Regardless of the cause, a citizen impaired by illness cannot contribute, thus government provides health to insure the continued productivity of its constituents .

Critics of the social obligation perspective point to three very practical problems: coverage, cost management and personal consequence. The coverage under a social system may be universal, but will not cover all medical procedures. Determining the extent of that coverage can be crucial, as it can greatly limit access to needed procedures. The greatest problem is economic. Effective cost management under a social system, while not impossible, presents serious challenges. Providing universal access also includes the problem of overuse and misuse. While systematic remedies exist, many are troubled by the effect such a system would have of awareness of personal consequence. A system that provides no questions asked healthcare could encourage destructive behaviors as well as reducing personal initiative in the realms of health and economics. Likewise, it is difficult to engineer a system that fairly benefits health care providers economically.

The majority of positions within the health care debate fall between these two extremes. Through understanding what is ethically appealing about both positions, a clear idea of what would be optimum emerges. An ethical medical system must make medical care accessible to all who need it, while retaining an element of personal accountability to discourage frivolous use. While



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