Medical Ethics & the Rationing of Health Care: Introduction
For those who work in the healing professions, ethical values play a special role. The specific content of medical ethics was first formulated centuries ago, based on the sayings of Hippocrates and others. The refinement of medical ethics has continued up to the present by practicing health caregivers, health professional and religious organizations, and individual ethicists. As medical technology, health care financing, and the organization of health care transform themselves, so must the content of medical ethics change in order to acknowledge and guide new circumstances.
Four Principles of Medical Ethics
Over the years, participants in and observers of medical care have distilled widely shared human beliefs about healing the sick into four major ethical principles: beneficence, nonmaleficence, autonomy, and justice (Beauchamp and Childress, 2001) (Table 13–1).
Table 13–1. the Four Principles of Medical Ethics.
The obligation of health care providers to help people in need
The duty of health care providers to do no harm
The right of patients to make choices regarding their health care
The concept of treating everyone in a fair manner
Beneficence is the obligation of health care providers to help people in need.
Dr. Rolando Bueno is a hard-working family physician practicing in a low-income neighborhood of a large city. He shows concern for his patients, and his knowledge and judgment are respected by his medical and nursing colleagues. On one occasion, he was called before the hospital quality assurance committee when one of his patients unexpectedly died; he agreed that he had made mistakes in her care and incorporated the lessons of the case into his future practice.
Dr. Bueno tries to live up to the ideal of beneficence. He does not always succeed; like all physicians, he sometimes makes clinical errors. Overall, he treats his patients to the best of his ability. The principle of beneficence in the healing professions is the obligation to help people in poor health.
Nonmaleficence is the duty of health care providers to do no harm.
Mrs. Lucy Knight suffers from insomnia and Parkinson's disease. The insomnia does not bother her, because she likes to read at night, but it irritates her husband. Mr. Knight requests his wife's physician to order strong sleeping pills for her, but the doctor declines, saying that the combination of sleeping pills and Parkinson's disease places Mrs. Knight at high risk for a serious fall.
The modern array of medical interventions has the capacity to do good or harm or both, thereby enmeshing the principle of nonmaleficence with the principle of beneficence. In the case of Mrs. Knight, the prescribing of sedatives has far more potential for harm than for good, particularly because Ms. Knight does not see her insomnia as a problem.
Autonomy is the right of a person to choose and follow his or her own plan of life and action.
Mr. Winter is a frail 88-year-old found by Dr. James Washington, his family physician, to have colon cancer which has spread to the liver. The cancer is causing no symptoms. An oncologist gives Mr. Winter the option of transfusions, parenteral nutrition, and surgery, followed by chemotherapy; or watchful waiting with palliative and hospice care when symptoms appear. Mr. Winter is terrified of hospitals and prefers to remain at home. He feels that he might live a comfortable couple of years before the cancer claims his life. After talking it over with Dr. Washington, he chooses the second option.
The principle of autonomy adds another consideration to the interrelated principles of beneficence and nonmaleficence. Would Mr. Winter enjoy a longer life by submitting himself to aggressive cancer therapy that does harm in order to do good? Or does he sense that the harm may exceed the good? The balance of risks and benefits confronts each physician on a daily basis (Eddy, 1990). But the decision cannot be made solely by a risk–benefit analysis; the patient's preference is a critical addition to the equation.
Autonomy is founded in the overall desire of most human beings to control their own destiny, to have choices in life, and to live in a society that places value on individual freedom. In medical ethics, autonomy refers to the right of competent adult patients to consent to or refuse treatment. While the physician has an obligation to respect the patient's wishes, he or she also has a duty to fully inform the patient of the probable consequences of those wishes. For children and for adults unable to make medical decisions, a parent, guardian, other family member, or surrogate decision maker named in a legal document becomes the autonomous agent on behalf of the patient.
Justice refers to the ethical concept of treating everyone in a fair manner.
Joe, a white businessman in the suburbs, suffers crushing chest pain and within 5 minutes is taken to a nearby private emergency room, where he receives immediate coronary angioplasty and state-of-the-art treatment for a heart attack. Five miles away, in a poor neighborhood, Josephine, an African-American woman, experiences severe chest pain, calls 911, waits 25 minutes for help to arrive, and is brought to a public hospital whose emergency department staff is attending to five other acutely ill patients. Before receiving appropriate attention, she suffers an arrhythmia and dies.
The principle of justice as applied to medical ethics is newer, more controversial, and harder to define than the principles of beneficence, nonmaleficence, and autonomy. In a general sense, people are treated justly when they receive what they deserve. It is unjust not to grant a medical degree to someone who completes medical school and passes all the necessary examinations. It is unjust to punish a person who did not commit a crime. In another meaning, justice refers to universal rights: to receive enough to eat, to be afforded shelter, to have access to basic medical care and education, and to be able to speak freely. If these rights are denied, justice has been violated. In yet another version, justice connotes equal opportunity: All people should have an equal chance to realize their human potential. Justice might be linked to the golden rule: Treat others as you would want others to treat you. While there is no clear agreement on the precise meaning of justice, most people would agree that the differential treatment of Joe and Josephine is unjust.
In exploring the concept of justice, one area of concern is the allocation of benefits and burdens in society. This realm of ethical thinking is called distributive justice, and it involves such questions as: Who receives what amount of wealth, of education, or of medical care? Who pays what amount of taxes?
The principle of justice is linked to the idea of fairness. In the arena of distributive justice, no agreement exists on what formula for allocating benefits and costs is fair. Should each person get an equal share? Should those who work harder receive more? Should the proper formula be "to each according to ability to pay," as determined by a free market? Or "to each according to need?" In allocating costs, should each person pay an equal share or should those with greater wealth pay more? Most societies construct a mixture of these allocation formulas. Unemployment benefits consider effort (having had a job) and need (having lost the job). Welfare benefits are primarily based on need. Job promotions may be based on merit. Many goods are distributed according to ability to pay. Primary education in theory (but not always in practice) is founded on the belief that everyone should receive an equal share (Beauchamp and Childress, 2001; Jonsen et al, 1998).
How is the principle of distributive justice formulated for medical care? Throughout the history of the developed world, the concept that health care is a privilege that should be allocated according to ability to pay has competed with the idea that health care is a right and should be distributed according to need. In most developed nations, the allocation of health care according to need has become the dominant political belief, as demonstrated by the passage of universal or near-universal health insurance laws. In the United States, the failure of the 100-year battle to enact national health insurance attests to the ongoing debate between ability to pay and need (see Chapter 15). The majority of the general public, in contrast to powerful interest groups with greater influence on the political process, for decades has endorsed the idea that basic health care should be allocated according to need (Blendon and Benson, 2001).
If the overwhelming opinion in the developed world holds that health care should be allocated according to need, then all people should have equal access to a reasonable level of medical care without financial barriers (ie, people should have a right to health care). In this chapter, therefore, we consider that the principle of distributive justice requires all people to equally receive a reasonable level of medical services based on medical need without regard to ability to pay.