Philosophy / Cost Issues In Medical Ethics

Cost Issues In Medical Ethics

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Autor:  anton  16 October 2010
Tags:  Issues,  Medical,  Ethics
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Understanding the Price: Cost Issues in Medical Ethics

By: S. Michael Robinson

PHL 310


Understanding the Price: Cost Issues in Medical Ethics

Medical ethicists contend with scores of contentious and controversial issues, yet no issue affects such a broad sector of the population as issues of medical cost and cost responsibility. Beyond mere policy debate, an ethical analysis of medical costs must consider all aspects of health, from research, practice methodology, and public health policy, but also legal, social and economic factors that impact health. This document will revue these issues and focus on three core questions: Does society or the individual bear the ethical burden of cost issues, is there an ethical argument to limit liberties or privileges in the interest of reducing health costs and to what extent should cost efficiency be a factor applied when determining care?

As we enter the 21st century, experts foresee a looming crisis in providing healthcare within the United States. Government entitlements, such as Medicare and Medicaid, face impending insolvency, private employers seek to remove medical expenses to reduce costs and insurers raise premiums and co-pays, preventing many citizens from obtaining adequate healthcare. Establishing an effective and ethical response to the issues of health care remains a top priority of planners, policymakers and politicians in the coming years.


Health care carries the burden of cost. Who carries the burden of this cost faces constant debate in the fields of philosophy, economics and medicine. On one hand, the individual, who is the primary beneficiary of health care benefits, holds a responsibility to repay the costs incurred by the benefits in question. The opposite perspective views the individual as a societal component, insured to good health as a benefit of membership to the larger whole. As the individual benefits society, so society holds an obligation to provide health services to insure his or her continued productivity. Examining both extremes in detail clarifies the issues involved in health care costs.

The perspective of total individual responsibility reflects a strong belief in the autonomy of the individual from society. As a result, the individual alone must bear the burdens of his actions and choices. From a strictly individualist viewpoint, all decisions carry consequences, and to some degree the individual is liable for any outcomes experienced as a result of these choice. From this perspective, while the individual has the right to seek medical care, there is no obligation to provide care if the practitioner is unwilling. Individualism carries strong connections to natural law theory, and views society and government as artificial creations with limited rights, powers and obligations. Needless to say, from an individualist perspective, providing, managing or limiting healthcare is not among government powers or responsibilities .

A strictly individualistic generally encourages personal responsibility and places costs based on who directly receives the benefit, rather than speculating on who instigated the problem. However, this perspective carries with it implications that cause substantial problems. Because cost responsibility defaults to the primary beneficiary, it becomes difficult to transfer obligation to an injurious party in circumstances where evidence warrants redress. The individualist perspective requires a tort system to handle such disputes. This creates additional costs both for the individual (i.e. legal fees) and the medical provider. These additional costs do not provide additional health benefit, and largely inflate the cost of care. Secondly, the individualist perspective strongly emphasizes personal wealth as the determiner for access to health care. This leads to a problem in instances where misfortunes, rather than poor choices, result in health problems. In such a circumstance, there is no guarantee that the economically underprivileged will receive adequate care, despite the fact that their economic status does not reflect any ethical implication on their person. Also, the individualistic perspective fails to recognize a societal interest in the health of its citizens. Quality of health directly affects the economic, military and political aspects of a country, and thus government does posses at least some interest in public health.

Advocates of social obligation often cite historical evidence to support their claim of government and social interest in healthcare. The majority of public works created under the Roman Empire were not temples or arenas, but aqueducts, hospitals and public baths. Health impacts all layers of society and government, vested with the task of managing society, posses a clear interest in improving the health of its citizens. From the perspective of social responsibility, a government provides healthcare to individual citizens to benefit everyone. The logic for this argument may seem weak, yet it carries some very real validity. Each individual benefits society through economic activity, civic involvement and family growth. Regardless of the cause, a citizen impaired by illness cannot contribute, thus government provides health to insure the continued productivity of its constituents .

Critics of the social obligation perspective point to three very practical problems: coverage, cost management and personal consequence. The coverage under a social system may be universal, but will not cover all medical procedures. Determining the extent of that coverage can be crucial, as it can greatly limit access to needed procedures. The greatest problem is economic. Effective cost management under a social system, while not impossible, presents serious challenges. Providing universal access also includes the problem of overuse and misuse. While systematic remedies exist, many are troubled by the effect such a system would have of awareness of personal consequence. A system that provides no questions asked healthcare could encourage destructive behaviors as well as reducing personal initiative in the realms of health and economics. Likewise, it is difficult to engineer a system that fairly benefits health care providers economically.

The majority of positions within the health care debate fall between these two extremes. Through understanding what is ethically appealing about both positions, a clear idea of what would be optimum emerges. An ethical medical system must make medical care accessible to all who need it, while retaining an element of personal accountability to discourage frivolous use. While this would seem to be an easy solution, further issues complicate the quest for an ethical and functional cost management system in healthcare.


The issue of prevention in healthcare seems almost a non-issue. The fact that prevention and health maintenance reduce healthcare costs dramatically finds little opposition. However, the length to which society can regulate behavior in an effort to encourage public health faces extreme controversy. Recent bans on smoking in public, attempts to remove soda from schools and efforts to create health oriented communities all limit personal liberties for this goal. Can the reductions in healthcare costs justify intrusion into individual decisions regarding lifestyle?

As little as fifty years ago, such a debate would seem almost a non-issue. As medical advances remove infectious disease from the key causes of mortality, lifestyle related ailments such as heart disease, cancer and obesity become serious issues. The changes in the modern work environment from semi active factory labor to sedentary office work exacerbate the effects of these diseases. As reliance on the automobile increases, daily physical activity falls to almost zero, creating a serious impact on physical fitness. The impact of these factors on health costs over the life of an individual dramatically increases with each generation, culminating in an epidemic of obesity throughout the industrialized world .

As a result, both public and private health agencies have undertaken steps to reduce negative factors from American lifestyles. However, many cite the need for institution wide reform at the very core of health insurance. Proposals have varied, including extending health coverage to include physical fitness programs and smoking cessation aids. The institutional focus on medical response versus health risk management seems to be shifting in the face of mounting health costs.

One of the most contentious claims suggests restructuring entire communities. In 2004, the CDC released a report on the health impact of suburban sprawl on health, along with suggested remedies . Urging a total redesign of the American community, the CDC recommended increased emphasis on mass transit and rezoning communities to resemble an urban model. While local zoning laws grant local government the authority to implement these plans, few communities have acted on the suggestions. Even seemingly minor reforms have met with political opposition, illustrating the conflict people feel between good health and the invasion of their personal autonomy.

From the perspective of social obligation, these sacrifices serve as the price of provided health care. As with insurance companies, it follows logically that any cost absorbed by the government creates with it an abdication of certain freedoms by the individual. While overall it is in the best interest of the individual, any reform must be crafted in relation to privilege. In the case of forbidding soda in a public school, while some may complain, there is no ethical obligation to allow unhealthy behaviors within the schools themselves. Likewise, future policy should focus on encouraging healthy behavior without legislating behavior . As such, even if socially provided, health care remains a privilege.


Future medical advances may forever change the very nature of human existence. No longer must one turn to the pages of science fiction for medical technology that borders on the miraculous. Despite this, we must never forget that there is enormous cost related to these discoveries; Costs for research, testing, training and implementation easily climb into the billions. In any health care system, a serious ethical issue emerges between cost effectiveness and absolute effect. Many frightening conditions and ailments have effective treatments available, but all to often the cost of these treatments remains prohibitive. The ethical question of determining access to, as well as development of, effective treatments questions the very value of life itself.

Resources devoted to medical research consume resources that could treat patients. Beyond ethics, the practical question of waste becomes very real when dealing with limited resources. Ethics returns to the equation once a new medical product or technique is marketed. Particularly with new pharmaceuticals, millions of dollars pay, not for research or treatment, but for advertising and marketing. While many defend the practice, noting it is most prevalent among non-vital, lifestyle enhancing drugs, such as Viagra, these dollars spent increase the cost of drugs across the board. These costs do not return a health benefit yet limit accessibility to medicine .

Even with proven procedures, scarcity requires that efficient use of medical resources have at least some priority in treating patients. MRI technology carries numerous advantages in diagnosing injury and even illness. However, the technology is expensive to install and operate, leading many to question how frequently doctors should utilize MRIs as a diagnostic tool. Private Insurers often face negative public opinion for refusing to authorize certain tests and procedures. However, without clearly defined medical regulations as to what circumstances warrant what treatment, defraying costs without harming the potential recovery of the patient becomes a game of opinions and guess work. The individualized nature of medicine makes implementation of broad solutions difficult, especially is patient wellness (rightly) remains the chief priority .

Finding new solutions to reduce waste and enhance the dollar-to-care ratio requires changing much of the systemic nature of the current system. The system as it exists arose from small-scale private initiatives and patchwork reforms, creating a Frankenstein's monster of bureaucracy, liability and management. Finding a path of reform, or indeed an entirely new system that can create a just distribution of medical costs will take much analysis. Despite popular opinion in the United States, overall health within the U.S. scores poorly compared to other countries, regardless of system. In 1972, a landmark study by the RAND Corporation found a marked increase in cost efficiency in a cost sharing system. Under the cost sharing system, the insured pay a minimal deductible, but carry responsibility for medical costs to a preset dollar limit per visit. The result of this experiment showed that patients were generally reluctant to seek unnecessary care. Health amongst the patients remained comparable to a person on a traditional co-pay system, with a small decrease in dental, optical and blood pressure maintenance care .

Dealing with cost in any field is a question of sacrifice. The most basic economic concept of cost also recognizes the opportunity cost. Ethical understanding of cost issues requires the understanding that the opportunity cost of a poor decision is quality of life, or even life itself. The price we must pay for health consists not only of dollar amounts, but lifestyle choices, social awareness and effort. Looking forward, there are many hard choices for medical professionals, policy makers and citizens regarding the future of medical care in this country. Only with a firm understanding of the costs can we craft a better, more ethical system.


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