The Bioethics Behind Health Care Reform
by Christina M. H. Powell
I remember an exercise from elementary school called the lifeboat game. The teacher informed the class there were 10 people in a lifeboat that could only hold seven. She asked us to choose which seven should remain in the boat. She told us the gender, age, and profession of each person and whether or not they had any handicaps or terminal illnesses. Invariably, one of the 10 was a doctor. She included a handicapped child. An elderly person was on the boat as well as a younger person with a terminal illness. A young child was usually present on the boat as well. The teacher told us there were no right answers; the exercise was meant for discussion.
The lifeboat game is an exercise in values clarification and situational ethics. Students must choose how to allocate resources when there are not enough resources for everyone. While some might consider the lifeboat game as simply a classroom exercise for students, deciding how to allocate monetary resources to provide medical care for the population of a country is real. The question of how to best reform health care in the United States is open for discussion as the nation seeks the right answers. Behind the current political debates and the heated rhetoric you will find timeless ethical issues. Let us look at the principles and ethical choices that comprise the bioethical issues behind health care reform.
Compassion for Those Less Fortunate
In Matthew 25:31–46, Jesus told the parable of the sheep and goats. One of the characteristics of the sheep is their compassion for those who are suffering; “I was sick and you looked after me” (verse 25:36). Jesus cared for the poor, the outcast, and those in need of mercy. As followers of Jesus, we, too, must have compassion for those less fortunate.
The U.S. Census Bureau estimates that 46 million Americans lack health insurance. Even if this number turns out to be lower when you take into account foreign nationals1 and those who have Medicaid but mistakenly tell the Census taker they are uninsured,2 the number is still substantial. Lack of health insurance can draw an individual into a death spiral created by the link between employment and health insurance. For example, a job disruption caused by losing a job, starting one’s own business, or choosing to leave the workforce to care for small children or elderly parents can result in the loss of health insurance. The lack of health insurance can lead to medical problems going untreated, which then can make it even harder for a person to get a job that provides medical benefits. A medical problem can also initiate the death spiral that leads to employment problems. Either way, the individual becomes trapped in the downward spiral, unable to generate the physical strength or the monetary resources needed to break free.3
While Christians will differ on the best way to implement a solution that makes medical care accessible to those less fortunate, Christlike compassion must guide our decisions.
Stewardship of Health Care Resources
The unpleasant reality of the lifeboat game was that the boat was not big enough to hold everyone, necessitating the need for painful choices. Health care rationing comes into play as we distribute limited financial resources to accomplish the greatest good for the greatest number of people. Even with private insurance, rationing may happen when the insurer weighs the cost of a treatment against its benefit to a patient.
The health system can accomplish rationing by time as well as money. In countries with nationalized health care systems, many patients wait for hospitalization and access to treatments. Yet, we must not strip healthcare of its humanitarian nature and reduce it to the level of another commodity.
Good stewardship of health care resources means more people can receive quality health care. Emphasis on disease prevention, choosing the most effective treatments, and cutting waste and inefficiency are three ways to improve stewardship of health care resources.
We can prevent many illnesses. Clinical preventive services include educating and counseling patients to change certain health-related behaviors such as lack of exercise, poor diet, and smoking. Immunizations are another form of preventive medicine. Two other forms of preventive medicine involve screening for early detection of disease and preventing disease through medicine (such as drugs that lower cholesterol levels to prevent heart attacks and strokes). Screening for early detection of disease does not always result in lower medical costs, since false positives can lead to additional medical testing and treatments that do not improve health.
Comparative effectiveness research can help doctors and those responsible for paying medical bills make decisions regarding which treatment or drug works best when more than one approach to treatment is available. The research can focus only on the relative medical benefits and risks of each treatment choice or also include the cost effectiveness of the competing treatments. While such information can be useful in improving medical care while reducing costs, the use of this research raises ethical concerns.
Historically, the doctor-patient relationship has been a covenant relationship, not a consumer relationship. Doctors follow the ethical principles of nonmaleficence (do no harm), beneficence (do good), autonomy (patient gives consent), and justice. Some policymakers might want to use comparative effectiveness research to standardize care, replacing the individualized care that is the hallmark of a good doctor-patient relationship. When choosing a medical treatment, the doctor takes into careful consideration any other medical conditions the patient has that might affect the treatment choice. Comparative effectiveness research, if not done carefully, could lead to inequities on the basis of gender, age, and genetic differences. However, if researchers properly design comparative effectiveness studies to address the factors that affect how different patients react to different treatments, we can avoid this ethical problem.
A final concern raised by comparative effectiveness research is that the research is best equipped to compare available competing treatments, not developing technologies. The strength of the American health care system is innovation. Today’s tried and true method might be cost effective today but tomorrow will suffer if we do not develop and test new treatments, and make them available to interested patients.
We can also improve financial stewardship of health care resources by cutting waste and inefficiency. Electronic medical record keeping is one way to cut down on inefficiency. Of course, we must protect the privacy concerns of patients so medical professionals do not share records inappropriately. Ultimately, we must uphold human dignity in the quest for improving financial stewardship of medical resources. Cutting medical costs is important, but not at the price of compromising long-standing ethical principles in medicine.
Authority for Medical Decision Making
Health care providers in close proximity to the patient make the best medical decisions because they are best able to discern the patient’s unique medical needs. Of course, doctors must make medical decisions with a patient’s informed consent. Many times patients feel their doctor did not adequately inform them of the disadvantages as well as the benefits of a certain treatment. Studies show that patients who feel fully informed usually choose the most conservative choice, and thus often a lower cost choice. Efforts to educate patients about treatment choices could reduce medical costs while improving patient satisfaction. Shared decisionmaking between patient and doctor respects the patient’s preferences and values.
Dealing with health care bureaucracy on behalf of their patients takes up increasing amounts of a doctor’s time. Streamlining and standardizing processing insurance claims would help cut administrative costs for doctors. Approaches to health care reform that leave the authority for making health care decisions in the hands of patients and doctors and not insurance companies or the government result in the least ethical problems. Information generated by cost effectiveness research could be helpful to patients and doctors as long as doctors have the freedom to decide between treatments based on the unique needs of their patients. If we used such research to limit what treatments are covered by healthcare insurance, the restrictions would interfere with the medical decision-making process. In effect, authority for medical decisionmaking would partially shift to government policymakers.
Ethical concerns about who retains the authority to make medical decisions become acute when approaching end-of-life care issues. We must strike a balance between tempering heroic measures that prolong the death process and withholding needed treatment solely for cost cutting reasons. Encouraging doctors to provide end-of-life counseling for patients can benefit patients, so long as the government does not dictate the details of that counseling. Recommended treatment guidelines can provide useful information while mandated treatments can damage the process of shared decisionmaking. Physicians could face a conflict of interest between the financial motivation to pressure patients into accepting a mandated treatment and the ethical desire to consider the values and preferences of the patient.
Respect for Freedom of Conscience
Just as we minimize ethical problems when the authority for medical decisionmaking rests with the patient and doctor, we also avoid ethical dilemmas when society respects a doctor’s freedom of conscience. Regulations should never force a doctor to participate in physician-assisted suicide or abortion in violation of his or her conscience. Yet if healthcare reform moves forward without the appropriate clauses that protect a physician’s right of conscience, it could force physicians who adhere to the Hippocratic Oath out of medicine.
The government should not penalize doctors for following their conscience and not participating in procedures to which they are morally opposed. In the same way, the government should not force citizens funding healthcare to pay for procedures ethically objectionable to a significant segment of the population. Additionally, people should be able to choose a health insurance plan consistent with their moral values. Health care reform that makes room for people to make choices consistent with their moral values creates the least ethical conflicts.
A good approach to health care reform takes into consideration our need to show compassion to those less fortunate, to improve stewardship of health care resources, to safeguard the doctor-patient relationship, and to respect freedom of conscience. As with most problems in medicine, there will be many possible solutions. As I look back on the lifeboat game, I realize there may have been a more creative way to address the ethical dilemma of the overcrowded boat. Perhaps the strongest passengers could have taken turns treading water while holding onto the side of the boat. Perhaps they could have used material from the sinking ship to reengineer the boat for improved flotation. Solving the problems of the health care system will require innovative solutions.
Without entering into the political debate, pastors can teach their parishioners about the bioethical issues behind health care reform. Compassion for those less fortunate and the importance of being good stewards in the area of finances are biblical values. Understanding the intrinsic worth of human life alongside the reality that there is “a time to be born and a time to die” (Ecclesiastes 3:2) forms the basis for sound end-of-life decisions.
Encouraging people to live wisely and take care of their bodies through good nutrition, exercise, and attention to safety in their jobs and recreational choices flows naturally from teaching that the human body is the temple of the Holy Spirit (1 Corinthians 6:19,20). Care for those adversely affected by the current state of the health care system can come from within the local Christian community. James 2:15,16 challenges us to action in caring for those in need within our own churches: “Suppose a brother or sister is without clothes and daily food. If one of you says to him, ‘Go, I wish you well; keep warm and well fed,’ but does nothing about his physical needs, what good is it?”
Finally, pastors can help instill in parishioners an appreciation for the complexities of the issue of health care reform. A fact of all human choices is how one choice can have far reaching consequences. In the details of any approach to health care reform are seeds we are sowing for future generations.
We must make wise choices now to be fiscally responsible to the generations that follow. We must be careful to protect the right of doctors to practice medicine in accordance with personal beliefs and convictions or risk a future without those caring, compassionate physicians working within the medical community. No one component of health care reform should cause us to lose sight of the other components.
With such an appreciation for the complexities of the ethical issues behind health care reform comes the realization that fellow believers may differ on how to best implement solutions. Pastors can help believers find unity in Christ above any differences they may have over an issue such as health care reform. Pastors can teach believers the importance of humility in the face of complex problems. This humility can help believers approach differences in opinion with love for a brother or sister in Christ who sees things from an alternate perspective. We can apply Paul’s admonition in Philippians 2:3,4 to how we approach differences in opinions within the body. “Do nothing out of selfish ambition or vain conceit, but in humility consider others better than yourselves. Each of you should look not only to your own interests, but also to the interests of others.” Debates and discussions over issues can be a means by which “iron sharpens iron” (Proverbs 27:17), as Christians help to sharpen each other’s thinking about difficult issues that impact our society.
1. C. Bialik, “The Unhealthy Accounting of Uninsured Americans,” The Wall Street Journal, 2009, June 24:A12. Found at http://online.wsj.com/article/SB124579852347944191.html. Accessed 1 October 2009.
2. Joanne Pascale, “Measuring Health Insurance in the U.S.” Research Report Series, Survey Methodology #2007–11. Statistical Research Division, U.S. Census Bureau, Washington D.C.: 2007. Found at http://www.census.gov/srd/papers/pdf/rsm2007-11.pdf. Accessed 1 October 2009.
3. S.S. Sered and R. Fernandopulle, Uninsured in America: Life and Death in the Land of Opportunity (Berkeley and Los Angeles, California: University of California Press, 2005), 1–20.