By Richard D. Lamm
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 public priorities that get crowded out by the incessant demands of health care.
To the extent medical ethics drive resource use, they do not give adequate moral guidance to the larger distributional decisions faced by government and other third party payers. Ironically to the extent that medical ethics drive marginal spending, they actually lower both the quality of life and well-being of the community.
Key tenants of medical ethics drive too much marginal spending for some people while ignoring other needed social goods and other people equally in need. However well meaning, medical ethics assume that we can afford and should pay 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 national civic needs. They neither guide nor allow a sense of proportion among total community needs.
The moral life of the community includes but cannot be controlled by medical ethics. Medical ethics may be useful in dealing with individual patients, but not for the broader allocation issues all nations face.
Karen Ann Quinlan was kept alive in a persistent vegetative state in a community where women gave birth without prenatal care, kids went without vaccinations and large numbers of people had unmet medical needs. Her doctor might have been able to focus solely on her needs, but public policymakers must look at the total community needs and recognize that they do one thing at the expense of not doing another. Haavi Morreim says it so well:
“We cannot fairly insist that physicians owe to patient resources they neither own nor control … we should neither expect nor permit the medical profession unilaterally to choose the values that will set the amounts and purposes for which other people must spend their money.”
A doctor may not have to “ration” medicine, but public policy always rations for it must decide among the total needs of their jurisdiction. Governors “ration” taxpayers’ money in a process called budgeting. Public policy deals with broad goals that maximize the broad public interest. Public policy can never maximize individual goals in a system for there is too often a conflict between the individual good and the good of the group.
Some thoughtful scholars claim our current practice and ethics actually decrease 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 may be actually reducing the health of its population through increased health spending.”
We cannot hope to solve the problems facing health care until we first get our ethical theories straight. This will require us to rethink the nature and assumptions of important parts of health ethics. Setting ethical standards and practices in a world of common resources must be thought of as an empiric process. Ethical beliefs are theories or suggestions about how human beings can live in a just society. They are human constructs not written in stone nor can they be morally obligatory. They must be tested by trial and error, tempered with reality, evaluated by what they cause to happen in the total social world when we follow those ethics.
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 for public policy. If it decreases the moral life of the community, it repudiates what ethics is all about.
Good public policy is not the domain of abstract thought developed unrelated to resources available. It is not purely hypothetical or theoretical like physics, geometry or mathematics. Ethical principles of the public budget cannot be independent of fiscal realities. They cannot assume that a priori criteria (such as reason, conscience, and the great moral traditions) justifies unconditional moral behavior. It is not theological, but a painful process of practical trade-offs with winners and losers.
Public policy has no obligation to fund social policy that conforms to medical ethics or maximizes every service that is or may be beneficial to every patient. On the contrary, pubic policy must look at the total battlefield of social need and justice. There should be no unexamined demands on the public purse, no mega-priorities, no blank checks.
Present ethical principles both reward and require behavior that maximize medical care spending at the expense of all other social goods. They look at the moral health and well-being of the community with one eye. They too often ignore the law of diminishing returns. If every American would get all the “beneficial” health care demanded by current medical ethics and practice, it would create an unethical society where medical care trumps too many other important social goods.
Medical ethics provide no mechanism to weigh and balance health needs with other social needs. However elegantly reasoned, they cannot control the practical allocation of pooled funds.
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.
Opinions communicated in Solutions represent the view of individual authors, and may not reflect the position of the University of Colorado Denver or the University of Colorado system.