By Richard D. Lamm
I would suggest that a certain segment of medical ethics creates unethical public policy. Key tenets of medical ethics drive too much marginal spending for some people while ignoring other people equally in need and other needed social goods.
However well meaning, medical ethics assume that we can afford and should pay for what they demand. They focus on a particular patient to the exclusion of others, and give little insight into how health care needs are to be weighed and balanced against other civic needs. They neither guide nor allow a sense of proportion among total civic needs. Medical ethics have no lateral vision.
No nation can build a health care system one patient at a time.
The difficulty of medical ethics and culture is that it allows, indeed it makes morally obligatory, practices and behaviors that increase health care spending without regard to other social priorities that get crowded out by the incessant demands of health care. To the extent they drive resource use, they do not give adequate moral guidance to the larger distributional decision faced by government or other third-party payers.
The tragedy of medical ethics is that to the extent they drive marginal spending, they actually lower both the quality of life and the well-being of the community.
The moral life of the community includes but cannot be controlled by medical ethics. Medical ethics may be useful in making medical decisions but they cannot be allowed to trump all other public demands. Taxpayers now fund over 50 percent of U.S. health care, and public budgeting needs a broader moral vision. It cannot give the Hippocratic oath a blank check.
Karen Ann Quinlan was kept alive in a persistent vegetive state in a community where women gave birth without prenatal care, kids went without vaccinations and large numbers of uninsured had unmet medical needs. Equally important to public policy, there were a large number of other unmet public needs in that community.
Some thoughtful scholars claim our current practice and ethics actually decreases the overall health of the nation. Robert Evans warns: “A society that would spend so much on health care that it cannot or will not spend adequately on other health enhancing activities actually may be reducing the health of its population through increased health spending.”
Medical ethics directed at individuals doesn’t even allow us to have a dialogue on how to best keep a society healthy within health spending. Medical philosopher Haavi Morreim says it so well: “We cannot fairly insist that physicians owe to the patient resources they neither own nor control … we should neither expect nor permit the medical profession unilaterally to chose the values that will set the amounts and purposes for which other people must spend their money.”
From a public policy viewpoint, America has an unethical health care system because we ignore the most important ethical standard: we don’t cover all of our citizens with basic health care. Then we waste billions of dollars on marginal medicine driven by myopic ethical views of what that unethical system should cover. Public policy should build the house of health, not the house of health care.
Ethical beliefs are successful when they promote moral behavior that fosters the integrity and moral well-being of the total society. Any ethical practice that decreases the overall well-being of the community, or that doesn’t recognize its specific relationship to the total public good, disqualifies itself as a guide to social policy.
Ironically, a significant portion of our health care dollars could buy more health outside of the health care system.
We can give compassionate and comprehensive health care to all our citizens, but we cannot give them everything. This dialogue must be driven by what public policies produce the most health for citizens, not medical ethics. We shall have to decide among a myriad of things we can do in modern society, what we ought to do with our limited resources to build a just and healthy society.
The sooner we admit that we can’t do everything, the sooner we will be able to maximize limited funds. We must start a community dialogue about how we can put our health care dollars to the highest and best use. It is an inevitable dialogue and we ought to make a virtue out of necessity.
Richard D. Lamm is the former three-term Governor of Colorado. He served from 1975-1987. Lamm is co-director of the Institute for Public Policy Studies at the University of Denver. A lawyer and certified public accountant, Lamm’s research and teaching have focused on the dysfunctional nature of American institutions, with special emphasis on health care reform and allocation of health care resources.