Obama Care and Ethics

The big news, or the lack of it, last week was the Health Care Summit. The big news because it was discussed ad infinitum in every news or opinion venue. The lack of big news because it seems that, despite our tentative hopes, no miracles emerged from the summit. I began thinking about the ethical issues related to health care, why this has become such a big issue, why it is and promises to affect so many people. Here are my thoughts.

First of all, we are promised the freedom to “life, liberty, and the pursuit of happiness,” and clearly we consider these rights to be equivalent to ethical mandates. Health, and therefore, health care, is clearly related to all three of these mandates. And I don’t think any of us would argue that we have an ethical responsibility to ensure that people’s health is attended to. After all, our higher moral sentiments are clearly aroused when we see pictures of starving or ill children from less advantaged countries. We hardly want our children or parents or other family members to be writhing in pain from some treatable problem or disease merely because they have no health insurance or are unable to pay for the health care they need. We hardly want anyone we know to die of a stroke for the “lack of a $6 prescription to high blood pressure medication,” to quote a doctor speaking during the Clinton health care debates.

Second, some people are very clearly disadvantaged when it comes to access to health care, and, as a result, find their health and happiness, and even their ability to work, at risk. Some may be unemployed and not have money to pay for health insurance or health care. If they have access to a government supplemented plan (Medicaid), they may not have access to the best that health care has to offer. If they do not have a car, accessing this health care may be difficult. Other people may be self-employed; and again, insurance and/or health care may be beyond their reach financially. Still others may work for small businesses, that may have difficulty providing health coverage for their employees. And finally, anyone may be denied health care because of their inability to pay for it, or denied health insurance coverage if they have preexisting conditions that threaten the profitability of the insurance company. If we believe that health care is a moral obligation, then we have to find some answers to these problems. We don’t worry about the wealthy because they can pay for whatever they can find. We worry about the middle class and lower income folks who can’t. And our worries are called humanity. They are about caring. They are about sensitivity to need. And, of course, given that most of the country is middle or lower class, these worries may also be about our self-interest.

Third, in a free market economy – which most argue is best for our citizens – we believe that people have the right to make a living (part of those freedoms above), and this clearly includes doctors and hospitals and those who run insurance companies and medical/pharmaceutical research companies. If these medically-associated businesses can’t make a living or a profit, if they can’t pay their employees, sooner or later, they will have to stop providing care or go out of business. They suffer, and we lose out on their services or what they might produce or create.

Relatedly, emergencies or crises create a greater sense of need than ongoing health maintenance or prevention, and so, marketing and profits being what they are, it is sometimes difficult to persuade the general public to take care of their health or to pay for prevention. And so the medical culture in our country has become overly focused on problems and medication, and under-focused on self-care, prevention, and health promotion. The crises and emergencies also bring in more money for health care providers and cost more for insurers. The ethical question becomes, how much profit do they have the right to make? On the backs of whom? What is fair? How much disparity in benefits and income will we tolerate between the heads of these companies and the disadvantaged who are in need of services before a revolution breaks out? History points to revolutions that broke out in the face of vast disparity.

Fourth, much of government exists to take care of “externalities,” that is, those services that benefit us and are often times needed for society to function well, but are not profitable for businesses to invest in (ie., roads, bridges, the military). And we are taxed in order to spread the burden of these societal needs among all that benefit from them. Health care for those who are disadvantaged in some way, or whose health problems challenge the ability of the health care industry to make a profit, is clearly one of those externalities.

But therein lies the rub – most Americans are not aware of these larger pictures; instead, they hold onto only a myopic view of “what’s good for us and ours.” In addition, we have to work out our differences with regard to what we think government needs to take care of and how much tax we can afford to pay without discouraging the free enterprise that creates our country’s standard of living. This additional need requires that we have some understanding of our political system and that we take the responsibility to vote or to otherwise voice our values. Unfortunately, I think it is pretty clear that many people in our society don’t have a grasp of the larger picture, nor do they understand the need or the ways to participate in resolving society-wide problems. A certain level of consciousness, of responsibility, of awareness of our connectedness is necessary to enable the larger view and to motivate action.

We are all pretty good at knowing when the system is failing us, or when it feels unfair to us, or when too many people that we know or come into contact with are suffering. And this awareness brings moral outrage to our lips when doctors charge so much money, or when insurance companies deny our claims or deny us coverage, or when insurance or pharmaceutical companies are making such large profits. If we can lift our vision above our own or our family’s health, we also don’t want people that we know and care about to be denied essential services. We don’t think it is fair that people who are wealthy get that new heart they need, while those who are middle class or below can’t afford basic medical care.

So, what are the ethical issues? The health care debate has brought forth questions about fairness, about caring, about inequities, about responsibility. It is about how money impacts choices (for instance whether the best quality care is provided, or whether prevention is fully funded to prevent medical crises), and whether those choices take into consideration what is the best for the long run, rather than only the short run. It is about whether everyone gets a fair and equal vote on decisions to be made, rather than “money doing the talking” and the financially disadvantaged having little voice. It is about how to have respectful, responsible, even-handed dialogue about important issues, rather than disparaging other people and ideas. What will you do related to the health care debate that takes into consideration these ethical issues?