Freedom and moral diversity: The moral failures of health care in the welfare state

Social Philosophy and Policy

Volumn 14, Issue 2, 1997, Pages 180-196

  Tristram Engelhardt Jr , H ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

AGE; ANALYTICAL APPROACH; ARTICLE; COST BENEFIT ANALYSIS; ECONOMICS; ETHICS; FEMALE; FINANCIAL MANAGEMENT; FREEDOM; HEALTH CARE AND PUBLIC HEALTH; HEALTH CARE DELIVERY; HEALTH CARE ORGANIZATION; HEALTH INSURANCE; HUMAN; HUMAN RIGHTS; INTERNATIONAL COOPERATION; LIFESTYLE; MALE; MEDICARE; MENTAL STRESS; MORALITY; MORBIDITY; MORTALITY; PERSUASIVE COMMUNICATION; PHILOSOPHY; POLICY; POLITICAL SYSTEM; POVERTY; RELIGION; RESOURCE ALLOCATION; RISK; SECULARISM; SOCIAL BEHAVIOR; SOCIAL JUSTICE; SOCIAL PSYCHOLOGY; SOCIOECONOMICS; STANDARD; UNITED STATES;

ANALYTICAL APPROACH; HEALTH CARE AND PUBLIC HEALTH;

AGE FACTORS; COERCION; COST-BENEFIT ANALYSIS; DELIVERY OF HEALTH CARE; DEMOCRACY; ECONOMICS; ETHICAL RELATIVISM; ETHICS; FEMALE; FINANCING, GOVERNMENT; FINANCING, PERSONAL; FREEDOM; HEALTH CARE RATIONING; HUMAN RIGHTS; HUMANS; INSURANCE, HEALTH; INTERNATIONAL COOPERATION; INTERNATIONALITY; LIFE STYLE; MEDICARE; MEN; MORAL OBLIGATIONS; MORALS; MORBIDITY; MORTALITY; PHILOSOPHY; POSTMODERNISM; POVERTY; PUBLIC POLICY; REFERENCE STANDARDS; RELIGION; RESOURCE ALLOCATION; RISK; SECULARISM; SOCIAL JUSTICE; SOCIAL RESPONSIBILITY; SOCIAL VALUES; SOCIOECONOMIC FACTORS; STRESS, PSYCHOLOGICAL; UNITED STATES; WOMEN;

EID: 0347203033     PISSN: 02650525     EISSN: None     Source Type: Journal    
DOI: 10.1017/s0265052500001874     Document Type: Article

References (40)

1. The White House Domestic Policy Council, The President's Health Security Plan (New York: Times Books, 1993), presents a robustly egalitarian blueprint for health-care policy. In its "Ethical Foundations of Health Reform," the Clinton plan rejects a tiered system: "The system should avoid the creation of a tiered system providing care based only on differences of need, not individual or group characteristics" (p. 11). When the plan recommends that a new federal criminal statute be enacted prohibiting "the payment of bribes, gratuities or other inducements to administrators and employees of health plans, health alliances or state health care agencies" (p. 199), the goal is inter alia to proscribe payment to physicians for better basic care. The implications and the stated purpose of the plan are egalitarian. I have developed my critique of the Clinton plan in some detail elsewhere; see, for example, H. Tristram Engelhardt, Jr., "Health Care Reform: A Study in Moral Malfeasance," Journal of Medicine and Philosophy, vol. 19 (October 1994), pp. 501-16.
2. The White House Domestic Policy Council, The President's Health Security Plan (New York: Times Books, 1993), presents a robustly egalitarian blueprint for health-care policy. In its "Ethical Foundations of Health Reform," the Clinton plan rejects a tiered system: "The system should avoid the creation of a tiered system providing care based only on differences of need, not individual or group characteristics" (p. 11). When the plan recommends that a new federal criminal statute be enacted prohibiting "the payment of bribes, gratuities or other inducements to administrators and employees of health plans, health alliances or state health care agencies" (p. 199), the goal is inter alia to proscribe payment to physicians for better basic care. The implications and the stated purpose of the plan are egalitarian. I have developed my critique of the Clinton plan in some detail elsewhere; see, for example, H. Tristram Engelhardt, Jr., "Health Care Reform: A Study in Moral Malfeasance," Journal of Medicine and Philosophy, vol. 19 (October 1994), pp. 501-16.
3. I take it that the postmodern era is characterized by the circumstance, as a matter of sociological fact, (1) that all people do not share the same moral narrative or account, and (2) that this moral diversity is apparent and widely recognized. Moreover, as a matter of our epistemological condition, (3) there is no way to establish in purely secular terms the correct moral narrative or account without begging the question or engaging in an infinite regress, and (4) this is also widely recognized.
4. See also H. Tristram Engelhardt, Jr., Bioethics and Secular Humanism: The Search for a Common Morality (Philadelphia: Trinity Press International, 1991), esp. pp. 130-38.
5. See for example, J. K. Iglehart, "Canada's Health Care System Faces Its Problems," New England Journal of Medicine, vol. 322 (February 22, 1990), pp. 562-68; M. G. Marmot, George D. Smith Stephen Stansfeld, et al., "Health Inequalities among British Civil Servants: The Whitehall II Study," Lancet, vol. 337 (June 8, 1991), pp. 1387-93; G. J. Schieber, J. P. Poullier, and L. M. Greenwald, "Health Spending, Delivery, and Outcomes in OECD Countries," Health Affairs, vol. 12 (Summer 1993), pp. 120-29; and Schieber, Poullier and Greenwald "Health System Performance in OECD Countries, 1980-1992," Health Affairs, vol. 13 (Fall 1994), pp. 101-12.
6. See for example, J. K. Iglehart, "Canada's Health Care System Faces Its Problems," New England Journal of Medicine, vol. 322 (February 22, 1990), pp. 562-68; M. G. Marmot, George D. Smith Stephen Stansfeld, et al., "Health Inequalities among British Civil Servants: The Whitehall II Study," Lancet, vol. 337 (June 8, 1991), pp. 1387-93; G. J. Schieber, J. P. Poullier, and L. M. Greenwald, "Health Spending, Delivery, and Outcomes in OECD Countries," Health Affairs, vol. 12 (Summer 1993), pp. 120-29; and Schieber, Poullier and Greenwald "Health System Performance in OECD Countries, 1980-1992," Health Affairs, vol. 13 (Fall 1994), pp. 101-12.
7. See for example, J. K. Iglehart, "Canada's Health Care System Faces Its Problems," New England Journal of Medicine, vol. 322 (February 22, 1990), pp. 562-68; M. G. Marmot, George D. Smith Stephen Stansfeld, et al., "Health Inequalities among British Civil Servants: The Whitehall II Study," Lancet, vol. 337 (June 8, 1991), pp. 1387-93; G. J. Schieber, J. P. Poullier, and L. M. Greenwald, "Health Spending, Delivery, and Outcomes in OECD Countries," Health Affairs, vol. 12 (Summer 1993), pp. 120-29; and Schieber, Poullier and Greenwald "Health System Performance in OECD Countries, 1980-1992," Health Affairs, vol. 13 (Fall 1994), pp. 101-12.
8. See for example, J. K. Iglehart, "Canada's Health Care System Faces Its Problems," New England Journal of Medicine, vol. 322 (February 22, 1990), pp. 562-68; M. G. Marmot, George D. Smith Stephen Stansfeld, et al., "Health Inequalities among British Civil Servants: The Whitehall II Study," Lancet, vol. 337 (June 8, 1991), pp. 1387-93; G. J. Schieber, J. P. Poullier, and L. M. Greenwald, "Health Spending, Delivery, and Outcomes in OECD Countries," Health Affairs, vol. 12 (Summer 1993), pp. 120-29; and Schieber, Poullier and Greenwald "Health System Performance in OECD Countries, 1980-1992," Health Affairs, vol. 13 (Fall 1994), pp. 101-12.
9. Schieber, Poullier, and Greenwald, "Health System Performance." It is clear that much more would need to be said about differences among countries with regard to achieving morbidity relief. See, for example, Henry J. Aaron and William B. Schwartz, The Painful Prescription (Washington, DC: Brookings Institution, 1984).
10. Schieber, Poullier, and Greenwald, "Health System Performance." It is clear that much more would need to be said about differences among countries with regard to achieving morbidity relief. See, for example, Henry J. Aaron and William B. Schwartz, The Painful Prescription (Washington, DC: Brookings Institution, 1984).
11. John Rawls invokes a hypothetical contracting position as an expository device to lay out what he takes to be the defining features of a just and voluntary society. The success of this account in producing the conclusions he wants depends on his prior characterization of the contractors' thin theory of the good, their level of aversion to risk, their absence of envy, etc. See John Rawls, A Theory of Justice (Cambridge, MA: Harvard University Press, 1971).
12. If one of the worst possible outcomes is to die young, and if establishing just health-care policy on the basis of Rawls's original position leads one to adopt the maximin rule-which "tells us to rank alternatives by their worst possible outcomes: we are to adopt the alternative the worst outcome of which is superior to the worst outcomes of the others" (p. 152f.) -then it would seem that contractors in the original position would want first and foremost to protect themselves against pediatric deaths. They would want this because children who die young would count as the worst-off class, and because such deaths would most undermine fair equality of opportunity.
13. The claim here is not that disruptive disputes divide polities with regard to health-care allocations and/or delivery. Rather, the claim is that there are real and substantive moral disagreements, even when they may not preclude the imposition of a particular health-care policy. The debates regarding abortion, physician-assisted suicide, and egalitarian health-care policy present these differences even when they do not rule out the possibility of governance.
14. For a study of the meaning of equality, see Larry S. Temkin, Inequality (New York: Oxford University Press, 1993), esp. pp. 157-90, 292-307.
15. One might interpret the so-called Oregon proposal as driven by an egalitarianism of altruism. Oregon proposed limiting the range of health-care resources available to Medicaid recipients so that all the poor could be covered. The proposal was that all the poor should be insured, although (1) Medicaid recipients would not receive the same level of health care as previously, and (2) the affluent would be able to purchase better basic care, as well as luxury care (i.e., there would be a tiered provision of health care with a limited package for the poor and with the affluent left free to purchase whatever they wished and could afford). For discussions regarding the plan, see Martin A. Strosberg, Joshua M. Wiener, and Robert Baker, eds., Rationing America's Medical Care: The Oregon Plan and Beyond (Washington, DC: Brookings Institution, 1992).
16. Schieber, Poullier, and Greenwald, "Health System Performance."
17. Although a judgment may be made to provide only a certain amount of resources to avoid particular risks of disability and death, when confronted with a particular person actually facing that disability or risk of death, groups will often provide much higher levels of resources. Even if a particular treatment is not considered to be obligatory (given its high cost and low yield), when a particular patient could possibly benefit from the treatment, there may be the inclination to rescue the patient, thus distorting policy developed for the prudent use of communal resources. For a treatment of the difficulties faced in health-care policy when confronted by particular individuals in need of medical rescue, see E. Haavi Morreim, "Of Rescue and Responsibility: Learning to Live with Limits," Journal of Medicine and Philosophy, vol. 19 (1994), pp. 455-70.
18. Norman Daniels provides a justification of an egalitarian approach to health care that, in the service of equality of opportunity, advances arguments for proscribing the purchase of better basic diagnostic and therapeutic interventions. See Norman Daniels, Just Health Care (New York: Cambridge University Press, 1985). Daniels was among the advisory members of the White House Task Force on National Health Reform, which developed President Clinton's 1993 health-care reform proposal. See also Dan Brock and Norman Daniels, "Ethical Foundations of the Clinton Administration's Proposed Health Care System," Journal of the American Medical Association, vol. 271 (April 20, 1994), pp. 1189-96.
19. Norman Daniels provides a justification of an egalitarian approach to health care that, in the service of equality of opportunity, advances arguments for proscribing the purchase of better basic diagnostic and therapeutic interventions. See Norman Daniels, Just Health Care (New York: Cambridge University Press, 1985). Daniels was among the advisory members of the White House Task Force on National Health Reform, which developed President Clinton's 1993 health-care reform proposal. See also Dan Brock and Norman Daniels, "Ethical Foundations of the Clinton Administration's Proposed Health Care System," Journal of the American Medical Association, vol. 271 (April 20, 1994), pp. 1189-96.
20. For a discussion of different approaches to how health-care needs may generate rights, see Thomas J. Bole III and William B. Bondeson, eds., Rights to Health Care (Dordrecht: Kluwer Academic Publishers, 1991). See also E. Haavi Morreim, Balancing Act (Washington, DC: Georgetown University Press, 1995); and H. Tristram Engelhardt, Jr., and Michael A. Rie, "Intensive Care Units, Scarce Resources, and Conflicting Principles of Justice," Journal of the American Medical Association, vol. 255, no. 9 (March 7, 1986), pp. 1159-64.
21. For a discussion of different approaches to how health-care needs may generate rights, see Thomas J. Bole III and William B. Bondeson, eds., Rights to Health Care (Dordrecht: Kluwer Academic Publishers, 1991). See also E. Haavi Morreim, Balancing Act (Washington, DC: Georgetown University Press, 1995); and H. Tristram Engelhardt, Jr., and Michael A. Rie, "Intensive Care Units, Scarce Resources, and Conflicting Principles of Justice," Journal of the American Medical Association, vol. 255, no. 9 (March 7, 1986), pp. 1159-64.
22. For a discussion of different approaches to how health-care needs may generate rights, see Thomas J. Bole III and William B. Bondeson, eds., Rights to Health Care (Dordrecht: Kluwer Academic Publishers, 1991). See also E. Haavi Morreim, Balancing Act (Washington, DC: Georgetown University Press, 1995); and H. Tristram Engelhardt, Jr., and Michael A. Rie, "Intensive Care Units, Scarce Resources, and Conflicting Principles of Justice," Journal of the American Medical Association, vol. 255, no. 9 (March 7, 1986), pp. 1159-64.
23. H. Tristram Engelhardt, Jr., "Sittlichkeit and Post-Modernity: An Hegelian Reconsideration of the State," in Hegel Reconsidered: Beyond Metaphysics and the Authoritarian State, ed. H. Tristram Engelhardt, Jr., and Terry Pinkard (Dordrecht: Kluwer Academic Publishers, 1994), pp. 211-24.
24. The term "natural and social lotteries" identifies the natural and social forces that advantage and disadvantage individuals irrespective of their deserts: some live long and healthy lives, while others contract serious diseases and die young (examples of the natural lottery); some inherit fortunes, while others are born destitute (examples of the social lottery).
25. See, for example, David T. Beito, " 'This Enormous Army': The Mutual Aid Tradition of American Fraternal Societies before the Twentieth Century," elsewhere in this volume.
26. Virginia Baxter Wright, "Will Quitting Smoking Help Medicare Solve Its Financial Problems?" Inquiry, vol. 23 (Spring 1986), pp. 76-82.
27. Because of disagreements regarding the proper moral response to inequality, people in good conscience buy into private health-care provision or go to other countries to secure treatment, as occurs with Canadians, egalitarians to the contrary notwithstanding.
28. For a study of the ambiguities involved in appeals to societal consensus for the authorization of health-care policy, see H. Tristram Engelhardt, Jr., "Consensus: How Much Can We Hope For?" in Kurt Bayertz, ed., The Concept of Moral Consensus (Dordrecht: Kluwer Academic Publishers, 1994), pp. 19-40.
29. Though there is no canonical content-full secular moral standard, it does not follow that such a standard is not available through revelation; see H. Tristram Engelhardt, Jr., "Moral Content, Tradition, and Grace: Rethinking the Possibility of a Christian Bioethics," Christian Bioethics: Non-Ecumenical Studies in Medical Morality, vol. 1 (1995), pp. 29-47.
30. Alasdair MacIntyre, Whose Justice? Which Rationality? (Notre Dame, IN: University of Notre Dame Press, 1988).
31. I have explored these issues at length in The Foundations of Bioethics, 2d ed (New York: Oxford University Press, 1996), esp. pp. 67-72.
32. Moral constraints do exist within secular morality; they are derived from the right-making character of appeals to permission as the only source of authority in secular public policy. Even if all do not listen to God, and if reason cannot disclose a canonical content-full moral vision, one can still derive authority from common agreement, that is, from permission. See Engelhardt, The Foundations of Bioethics, pp. 135-88.
33. Though the appeal to permission has content-full implications, it does not presuppose any particular content-full account of the good or the right. It does not involve a choice among different rankings of goods, preferences, or right-making conditions. In this sense, the appeal to permission does not involve even a thin account of the good or of the rigth (of the sort which Rawls, for example, offers in his thin theory of the good, which does involve a lexical ordering of goods; see Rawls, A Theory of Justice, pp. 39ff.).
34. Robert Nozick, Anarchy, State, and Utopia (New York: Basic Books, 1974), pp. 26-30.
35. I do not here explore the considerable difficulties faced in providing a general secular moral justification for taxation. Instead, attention is directed to how one ought to proceed in using common resources, presuming that they can be acquired legitimately. For my treatment of issues bearing on the legitimacy of taxation, see The Foundations of Bioethics, pp. 154-80.
36. Here focus is given only to the proposal of providing the indigent with a sum of money that can be expended only for health care. At stake is the freedom from the need to establish any particular medical morality in order to provide a voucher or a health-care purchase account (the provision of funds to the indigent for the purchase of health care). Either option - a voucher system or a purchase-account system - would allow recipients to choose among a number of competing morally and medically diverse health-care systems. A health-care purchase account has the further secular moral advantage of providing the indigent with cash, so that they may more freely choose among the different health-care service options available. In this essay no attempt is made to explore the various proposals that have been advanced regarding medical savings accounts. For a recent review of the debates in this matter, see Emmett Keeler, Jesse Malkin, Dana Goldman, and Joan Buchanan, "Can Medical Savings Accounts for the Nonelderly Reduce Health Care Costs?" Journal of the American Medical Association, vol. 275, no. 21 (June 5, 1996), pp. 1666-71.
37. The Roman Catholic account of the line between obligatory and non-obligatory care, between ordinary and extraordinary care, includes an acknowledgment of the appropriateness of inequalities in levels of care due to social status, usually correlated with wealth. See, for example Daniel A. Cronin, "The Moral Law in Regard to the Ordinary and Extraordinary Means of Conserving Life," in Conserving Human Life, ed. Russell E. Smith (Braintree, MA: Pope John XXIII Center, 1989), pp. 1-145.
38. H. Tristram Engelhardt, Jr., "Vecchiaia, eutanasia, e diversità morale: La creazione di opzioni morali nell' assistenza sanitaria," Bioetica, 1995, pp. 74-84.
39. These considerations require the repeal of statutory constraints on the purchase of better basic care of the sort that currently exist with respect to Medicare.
40. Significant mortality protection appears achievable at a rather minimal level of investment in health care; see Schieber, Poullier, and Greenwald, "Health System Performance."