CONCEPTS health care, ethics
An Ethical Foundation for Health Care: An Emergency Medicine Perspective
From the Ethics Committee, Society for Academic Emergency Medicine, Lansing, Michigan.
Ethics Committee, Society for Academic Emergency Medicine
Received for publication April 28, 1992. Accepted for publication May 7, 1992. This document was developed by the Ethics Committee of the Society for Academic Emergency Medicine and approved by the Board of Directors.
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[Knopp RK, Goldfrank LR, Derse AR, SandersAB, Schmidt TB, Sklar DP, [serson KV, Adams JG, Kalbfleisch ND, Keim SM: An ethical foundation for health care: An emergencymedicine perspective. Ann EmergMed November 1992;21:1381-1387.] INTRODUCTION "Cultures can be judged in many ways, but eventually every nation in every age must be judged by this test: How did it treat people?" (C Everett Koop, Surgeon General)l The c u r r e n t US health care system is inadequate and inequitable. Between 31 and 36 million citizens have no health insurance.2,3 At any one time, as many as one in four Americans may be u n i n s u r e d or u n d e r i n s u r e d for serious i l l n e s s . 4 For emergency physicians, these faceless statistics take on a sad but familiar f o r m - - t h e single working mother with a lethargic, febrile child; the homeless alcoholic found on the street; or the middle-class family who suffers critical injuries in an automobile accident. The emergency department provides access to these patients with acute medical problems, as well as to patients who have no other access to primary health care. However, the increasing n u m b e r of u n i n s u r e d or u n d e r i n s u r e d patients seeking primary care in overcrowded EDs threatens that access. I n a recent study, 11% of patients presenting to an u r b a n ED who left without seeing a physician because of delays subsequently required hospitalization within one week. 5 When Congress enacted the Comprehensive Omnibus Budget Reconciliation Act (COBRA) in 1986 to halt the transfer of unstable emergency patients for financial reasons, a limited form of emergency access was established by mandating that any patients who presented to an ED must have a screening examination and stabilizing treatment if an emergency exists.6 Because of this law and other common-law precedents, access to emergency health care has been guaranteed to all regardless of ability to pay. Because emergency physicians must provide some health care to every patient who presents to the ED, they must deal with a difficult question: What are the limits to the care that can be provided in our overcrowded EDs? Although emergency physicians are required to treat patients with highacuity problems, they are not required by law to treat "nonemergency" patients. This places emergency physicians in a difficult position. Emergency physicians often feel an
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ethical responsibility to treat nonemergent or urgent conditions and even attempt to provide t e m p o r a r y follow-up care for uninsured patients because no effective alternative exists; insured patients do not present such dilemmas because referrals are readily available. The ethical principle of distributive justice plays a crucial role in determining how the resources of our emergency care system should be assigned. Distributive justice, defined as fairness in the allocation of the burdens and benefits of society, primarily influences the development of health policy. 7 But emergency physicians face problems of distributive justice on a daily basis when they make decisions to ration resources because of overcrowding.8, 9 With this unique perspective comes the opportunity to share our experience with other medical specialists and review the values and philosophical concepts that are the underpinning of our present system. This discussion begins with a definition of health care, without which any discussion of access to health care would be meaningless. Then we explore the ongoing philosophical debate concerning justice and the right to health care. This analysis leads naturally to a discussion of access to health care and the conflict between the values of equality and equity. The final section discusses the necessary limits to universal health care and some recommendations. In summary, we consider the following questions: W h a t is health and health care? Is health care an ethical or legal right? W h a t is "equitable access" to health care? W h a t are the limits to a society's obligation to provide health care?
HEALTH AND HEALTH CARE The World Health Organization defines health as "a state of complete physical, mental, and social well being, and not just the absence of disease or infirmity. ''10 To achieve this societal ideal would require a population free of disease, unafflicted by physical or psychological pain, spiritually aware, and emotionally well adjusted. Others have defined health as the absence of disease. Although simpler, this definition fails to characterize what constitutes a disease. By contrasting these definitions, two very different concepts of health care can be developed. If health is the absence of the disease, our medical care system is central to improving the population's health. With the World Health Organization's b r o a d e r definition, determining the physicians' responsibilities, tasks, and roles is less clear. The classic medical model does not include teenage pregnancy, air and water pollution, substance abuse, homelessness and malnutrition, all of which affect health but are often not thought of as "diseases." Rather, they are considered "social problems" that require a political or multidisciplinary solution. In reality, our medical care system is merely p a r t of a larger health care system concerned with physical and mental diseases, injury, and infirmity. Our social systems deal with other aspects of "health" through housing support, food stamps, child care, and similar programs. The overlap between these "medical" and "social" issues is considerable, yet there
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is no organized system that focuses its efforts on the total health of individuals. Health care has been defined as encompassing five areas: adequate nutrition and shelter; sanitary, safe, unpolluted living and working conditions; exercise, rest, and lifestyle considerations; preventive, curative, and rehabilitative personal medical services; and nonmedical personal and supp o r t services. 11 While recognizing the contribution of these factors toward individual health, addressing all of them is beyond the scope of this article. To consider which health care services our society should provide, we must first determine what patient behavior and environmental conditions are the responsibility of the health care system. 12 Social and medical problems are so interrelated that we must view health care as a process of treating, curing, caring for, and preventing certain social, physical, and mental problems. Therefore, we define health as a state of physical and mental well-being that facilitates the achievement of individual and societal goals. Good health over a lifetime is the comparative absence of pain and suffering, illness and disease, each of which could prevent an individual from pursuing his or her goals. 13 Emergency physicians are made keenly aware of c u r r e n t societal deficiencies when they treat patients whose physical ailments are exacerbated by a lack of nutrition, shelter, or other societal supports. Our discussion is limited to personal health care services because this is the area in which emergency physicians have the most expertise and may affect change. Although a definition of health care that will encompass all beliefs and personal values is impossible, we define personal medical services to include interventions that prevent disease, minimize morbidity from existing diseases, diagnose and cure illness, relieve pain and suffering, and provide education for the continued promotion of health.
A RIGHT TO HEALTH CARE ls health care an ethical 01" legal right? Rights involve claims or entitlements to some "good" and engender duties on the part of persons or entities, such as governments, la Individual rights promote self-respect and dignity, as well as respect for other members of society, and thus promote the evolution and survival of just societies. 15 Rights generally reflect the needs and demands of individuals that may then become claims against others. The most fundamental rights reflect those ideals that are intrinsic to being fully human, such as the right to life and hberty. These rights are sometimes called " h u m a n rights" or "absolute rights" and are protected by legal doctrine in many societies. 15,16 There are few instances in which these basic human rights may be violated. Other rights or claims reflect physical, social, or psychologic needs or societal traditions. These needs include food, clothing, shelter, education, and health care and may be considered "limited," "relative," or "nonabsohite" rights. Limited (relative) rights are often necessary for sustaining
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life; however, they c a n n o t be absolutely g u a r a n t e e d in the face of scarce resources, such as the limited organs available for t r a n s p l a n t a t i o n . Rights m a y place different types of obligations on individuals or societies a n d can be described as "negative" or "positive." A negative right protects a n i n d i v i d u a l in his or h e r p u r s u i t of a stated "good," such as the right to life, liberty, a n d security. A negative right to h e a l t h care protects individuals from interference in their p u r s u i t of h e a l t h a n d access to health care. A positive right imposes a stronger o b l i g a t i o n - a r e q u i r e m e n t for i n d i v i d u a l s or society to provide the goods or services. If i n d i v i d u a l s have a positive right to h e a l t h care, society must p r o v i d e them with " a d e q u a t e " h e a l t h care services. 17 If o u r society has the resources to meet the basic h e a l t h care needs of its citizens, we believe h e a l t h care should be considered a positive, limited right based on beneficence, the principle of doing good. By efficient m a n a g e m e n t of o u r curr e n t h e a l t h care resources, o u r society c a n provide a basic level of h e a l t h care to all its citizens a n d reaffirm a commitment to p r o v i d i n g health care to the poor a n d elderly as it did when it created the Medicaid a n d Medicare p r o g r a m s . A n o t h e r a r g u m e n t for health care as a right is based on u t i l i t a r i a n concerns, the good of society. F o r example, we provide e d u c a t i o n a l opportunities to all m e m b e r s of o u r society because it is in the best interest of society to have a literate, educated p o p u l a t i o n . Similarly, it is in the best interest of society to have its p o p u l a t i o n healthy a n d free of disease. A society that is healthy provides a p r o d u c t i v e workforce, which is good for society as a whole. It m a y be most a p p r o p r i a t e to view health care from a c o m m u n i t y r a t h e r t h a n a n i n d i v i d u a l perspective. I n d i v i d u a l rights a n d a u t o n o m y t e n d to take p r i o r i t y over the i n d i v i d u al's obligation to society. However, the p r o b l e m of allocating health care resources can n e v e r be solved if we view it only from the perspective of individual rights. 13 I n s t i t u t i o n a l i z a t i o n of a right to h e a l t h care would give individuals a valid claim for u n l i m i t e d h e a l t h care. Only the p a t i e n t ' s desires a n d medical needs would d e t e r m i n e his or h e r care. However, health care resources are finite, a n d so there m u s t be a n effective a n d equitable m e c h a n i s m for their d i s t r i b u t i o n . To assure a basic level of h e a l t h care for all, we must develop a greater sense of community a n d recognize that all individual needs m a y n o t be met as we attempt to p r o v i d e for the greater good. T h e r e f o r e , we s u p p o r t the idea that h e a l t h care is a limited ethical right.
LEGAL R I 6 H T TO HEALTH CARE Ethical rights are claims or entitlements to some "good." Legal rights are those claims or entitlements that define g o v e r n m e n t a l responsibilities either to protect individuals in their p u r s u i t of a stated good (negative legal right) or to provide those goods or services (positive legal right). I n general, legal rights are ethical rights that are enforceable by government. E s t a b l i s h m e n t of a positive legal right to health
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care would obligate the g o v e r n m e n t to provide health care, to adequately f u n d that health care, to enforce the right to this care t h r o u g h use of sanctions, a n d to allow citizens to petition for redress when that right is violated. I n the U n i t e d States, there is no general or u n i v e r s a l legal right to health care. No federal statute has established such a right n o r is there a provision of the Constitution or the Bill of Rights that has b e e n i n t e r p r e t e d to s u p p o r t such a claim. However, there are limited legal rights a n d financial entitlements to some kinds of health care. These limited legal entitlements form a p a t c h w o r k of health care that the g o v e r n m e n t is legally obligated to provide, b u t huge gaps in eligibility r e m a i n . COBRA legislation established a legal right to emergency care. Medicare provides a right to health care to those 65 years of age or older, as well as those who r e q u i r e r e n a l dialysis. A n o t h e r federal p r o g r a m , Medicaid, administered by the states, was designed to p r o v i d e medical care for the indigent, b u t in most states it does n o t even cover most individuals below the federal p o v e r t y line. Other small groups, such as convicted a n d confined inmates is a n d v o l u n t a r i l y committed psychiatric patients, 19 have rights to health a n d psychiatric care. T h e r e is a federal p r o h i b i t i o n of discrimin a t i o n against patients on the basis of alcohol or drug abuse,2°,21 a n d in some j u r i s d i c t i o n s , patients c a n n o t be refused medical care on the basis of HIV infection. 22 Hawaii a n d Oregon have developed legislative reforms to provide access to health care for the poor b u t have n o t established health care as a legal right. Other i n d u s t r i a l countries have p r o v i d e d u n i v e r s a l health care t h r o u g h legislation, such as C a n a d a , 23 a n d Great Britain,24, 25 The N e t h e r l a n d s , a n d the F e d e r a l Republic of G e r m a n y . 26 The only other i n d u s t r i a l c o u n t r y besides the U n i t e d States that does not provide u n i v e r s a l health care is South Africa. 27 If a legal right to h e a l t h care is established, it must be adequately funded. Otherwise, it would be a facile b u t hollow solution to the p r o b l e m of h e a l t h care access. Ironically, US citizens have the right to legal r e p r e s e n t a t i o n if they are accused of a crime, b u t they do not have the right to be seen b y a physician if they are ill.
E Q U I T A B L E ACCESS TO HEALTH CARE E q u i t y is the ethical principle that should guide our efforts to r e s t r u c t u r e access a n d delivery of health care. " E q u i t a b l e access" to care can be i n t e r p r e t e d in several ways: equal access to care, access to whatever care a p e r s o n needs or m a y benefit from, or access to a n " a d e q u a t e " level of care. 28 Defining equity as equality implies that everyone will receive a n equal a m o u n t of health care dollars or the same level of care. However, health care needs differ among individuals, a n d even when health care needs are similar, equality may n o t be possible. The scarcity of certain medical resources, such as organs for t r a n s p l a n t a t i o n , means that some patients will die awaiting organ t r a n s p l a n t i o n while others will receive a life-prolonging t r a n s p l a n t . This is u n f o r t u n a t e b u t
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not unfair. 29 The crucial issue is to adopt a practical and equitable method for allocating health care resources. Equality is not a viable standard for accomplishing this task. The second interpretation of "equitable access" identifies individual needs or benefits as the criteria for determining care. Access to health care must be based on medical need; however, no plan for universal health care will survive if medical needs are defined solely by individual desires or preferences. Using "benefit" as the sole criterion for allocating health care resources is also problematic. Our society simply cannot afford to provide each new expensive biotechnologic discovery to all who might gain some marginal benefit. In addition, determining what constitutes a "benefit" is often an elusive endeavor. Individuals define their needs in different ways and frequently no societal consensus exists on the value of meeting different needs, so that the concept of "benefit" is rarely quantifiable. 13 Although individual need and benefit must be considerations in defining equitable access to care, they cannot be the sole criteria. The third interpretation of "equitable access" specifies that a basic or adequate level of health care be provided to all individuals. Most proposals for changing our health care system recommend providing this "decent minimum" or basic level of health care services while allowing those who wish to purchase additional services to do so. If our society agrees that every person should receive health care services regardless of his or her ability to pay, we still must determine what health care needs can and should be met, which needs have priority, how such care will be provided, and who will decide these questions. To establish an affordable universal health care system, a society must develop consensus on which medical needs are essential and what our society can afford. Such a consensus must be developed at the community or political level. The major challenge is distinguishing individual desires and preferences from societally defined essential medical needs and then determining which needs can be satisfied. Medical needs that should be covered in a universal health care system can be described as those needs that every individual will face during the course of his or her life and that are essential for functioning, as well as those needs necessary for an individual to have a fair opportunity to pursue his or her life plans. 30 Emergency care, prenatal care, and preventive care are examples of such essential needs. Basic health care does not require an open-ended obligation to satisfy all individual needs. There is a limit to the amount of societal resources that can be allocated to health care. Certain extremely expensive treatments (eg, organ transplantation) and those that provide marginal benefit might not be included. In exchange for having a system that meets the basic health care needs of all, immediate access to all forms of high technology may n o t be possible. An obvious corollary to such decisions is that the medical community
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must develop methods to determine the efficacy and, to some degree, benefit of specific interventions. Can a general description of individual needs be transformed into a group of specific services that would constitute a level of health care society should guarantee to all its citizens? Although there is widespread agreement that every person should have access to health care, the proposals regarding which specific services should be provided range from Free-tuning the current market-based system (by improving access to emergency and certain primary care services) to adopting a strictly egalitarian, regulated health care system, in which every individual would have access to the same level of services based on medical need. The delivery of health care services outside this egalitarian system would be severely restricted or nonexistent. Regardless of which system is adopted, society must define the limits of this new health care system.
L I M I T S ON HEALTH CARE Health care resources include the facilities, personnel, and equipment to maintain good health and prevent, diagnose, and treat illness and injury. With limited health care resources and increasing demand for services, explicit rationing is necessary. Our c u r r e n t system has de facto rationing, with physicians, administrators, or government allocating resources to the problems they see as most crucial. Even with this implicit rationing, health care expenditures continue to rise much more rapidly than measurable improvements in our health. Can we afford this? We have made a long-term allocation of our national productive power to health care and have not reaped the full economic or social benefits. 31 Limiting health care expenditures requires an understanding of how we allocate health care resources, including where allocation decisions occur, who makes the decisions, and how they are made. The allocation of health care resources occurs at two levels--societal and personal. Resource allocation at the societal level is macroallocation. The first decision to be made at the societal level is how much of our resources should be allocated to health care. At 13%, health care accounts for a greater percentage of our gross national product than that of any other country. We cannot continue to increase the percentage of expenditures on health care in the c u r r e n t manner, especially if the result does not justify the cost. Education, infrastructure repairs, and other societal needs compete with health care as priorities for government spending. However, by providing social improvements such as housing and education, health care expenditures may actually be reduced. After determining what percentage of our resources should be spent on health care, we must determine what percentage should be allocated for preventive care, acute care, long-term care, etc. We should also develop strategies to reduce or limit expenditures for new technologies or pharmaceuticals
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unless they result in overall cost savings or replace other services considered less beneficial from a societal perspective. Microallocation of health care resources involves decisions at the personal level between physicians and patients. When all critical care beds are filled and two critically ill patients come to the ED, how do physicians decide whether a patient should be moved out of the ICU to make room for one of the new arrivals or whether the new patients must wait in the overcrowded ED until a bed becomes available? The difference between macro- and microallocation systems creates a continqlng tension between the ethical values of distributive justice and beneficence. Distributive justice is the ethical principle that p r i m a r i l y guides allocation decisions at the macroallocation level. Beneficence is the ethical principle that p r i m a r i l y guides decisions at the microallocation level. At the societal level, we have a duty to allocate r~sources fairly. Establishing a universal health care system in which society guarantees a basic level of health care services is essential for distributive justice. However, at the level of the physician-patient relationship, the physician has the duty to be an advocate for the patient's best interests. The two ethical principles come into conflict at the bedside. A 650-g neonate born precipitously in the ED after a 23-week gestation requires resuscitation and intensive care expenditures that can exceed several h u n d r e d thousand dollars. Many such neonates will not survive, and many who do will have severe medical and social problems. That money could provide many people with basic health care services that they currently cannot afford. But the emergency physician and the neonatologist involved in the resuscitation of a p r e m a t u r e infant must consider the best interests of their patient as their p r i m a r y duty and not the societal benefits from improved basic preventive, emergency, and p r i m a r y health care for unknown others. Although we indicate that distributive justice guides macroallocation decisions, beneficence also must be considered in such decisions. Similarly, beneficence guides the physician's decision in microallocation decisions. However, physicians cannot totally ignore distributive justice. The conflict between these principles is an everyday occurrence in our EDs and ICUs. Greater use of advanced directives and p r a c tice guidelines may help resolve some of the dilemmas physicians face in balancing the best interests of the patient with society's interest in an equitable distribution of health care resources. The only equitable method for resolving the conflict between society's duty to ensure distributive justice and the physician's duty to the patient's best interests is for the m a j o r decisions on allocating health care resources to occur at the societal level. This preserves the principle of distributive justice, with patients receiving essential care without an unreasonable loss of personal resources, but with societal limits on what care is available (at least through the regulated health care system). Allocation decisions in our c u r r e n t
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health care system are made in reaction to individual patients and p a r t i c u l a r problems. To develop an equitable health care system, the driving force must be societal needs and not individual needs. Callahan ~3 outlined and prioritized the essential elements for basic health care while also recognizing the limits our society faces. His outline is similar to other definitions of health care. However, he prioritized the elements of his system in a way that others do not. He saw health care as divided into two m a j o r categories. 13 Interventions in the first category would be funded because they make the greatest contribution to the common good. Included in this category are provision of care in its most basic form (eg, relief of pain, care for the dying), preventive care, emergency care, and curative care (eg, antibiotics for the treatment of infectious disease). The second category includes advanced forms of medical cure or restoration such as chemotherapy or extensive rehabilitation and highly advanced technologic t h e r a p y such as organ transplants or open-heart surgery. Funding of services in the second category would be based on a reasonable allocation of resources for health care comp a r e d with other societal obligations and would be considered only if there were resources available after funding the services outlined in the first category. To define a basic health care system, society must first identify those values that should guide these important decisions. Callahan suggested an allocation system that is based on defined values. R a t h e r than criticize specific parts of his proposal, it should be considered an example of how to develop an equitable allocation system. Public discussion of priorities for health resource allocation and definition of medical needs is essential to apply distributive justice. 11 Society's rationing of limited resources would thereby become explicit. Health care needs must be prioritized objectively and then matched with society's (legislature's) ability to fund basic health care. Some health care services would not be funded; this outcome could either be accepted or the public could develop a mechanism to address intolerable inadequacies. Services not covered in the basic health care system could be p u r c h a s e d by individuals able to afford them. Once allocation decisions are made at the societal level, microallocation of specific health care interventions must occur. To define essential health care interventions, the benefits, burdens, and costs associated with each intervention must be determined.32 Some might criticize the inclusion of cost as a criterion to influence such decisions. However, if costs are not considered, basic health care services would include any intervention that could possibly produce a benefit. 32 To determine what constitutes essential basic health care, the following p r o c e d u r e is suggested: "Identify specific interventions, patient indications and protocols; estimate their benefits, harms and costs (compared with specific alternatives); and weigh the benefits versus harms and costs. ''32 Establishing such a prioritization of services is
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essential for an equitable system and identifying the best method for accomplishing this is the c u r r e n t dilemma. In 1989, the Oregon Senate passed the Oregon Basic Health Services Act, a novel plan to improve overall access to basic care while rationing existing coverage of Medicaid recipients. Prioritization was based on three principles: equity among those not insured, explicit rationing, and a combination of expert analysis and open political debate to determine community values. 33 The plan's explicit rationing produced much of the controversy: Some specific services for Medicaid recipients would be cut to allow universal access for all poor patients. Although all p o o r patients would be treated equally, the system is criticized as lacking e q u i t y - the poor do not have access to the same services as insured patients. Additionally, established prioritization for elderly Medicaid patients seems to discriminate on the basis of age against poor women and children, n Despite its shortcomings, many feel that this plan should be a starting point in the evolution of pragmatic public health care delivery plans. Hawaii's governo r states that Hawaii has 100% access to and 98% coverage for the basic health care needs of its citizens. 34 Hawaii has a 15-year experience with an employeebased insurance p r o g r a m in which unemployed individuals (approximately 5%) are covered by the state on a sliding scale. Hawaii boasts the nation's lowest infant mortality rate; the lowest p r e m a t u r e mortality rate for h e a r t disease, lung disease, and b r e a s t cancer; and the lowest hospital bed costs (two-thirds the national average). 35 The Hawaii experience reveals that universal access to basic health care is affordable and can provide health benefits to society. Although not perfect, this system affords equitable access to basic health c a r e - - s o m e t h i n g that most other states do not. Regardless of the basic health care plan that is adopted, society must assure itself that the financial resources allocated to provide essential medical services are not used for unnecessary costs such as excessive governmental and insurance industry administrative costs that are estimated to consume almost 25% 36 of c u r r e n t health care expenditures, prohibitively high malpractice insurance premiums, and expenses for medical interventions of unproven benefit (including "defensive" medicine). A reform of our medical malpractice system is necessary. Canadian medical malpractice costs p e r physician are approximately 85% less than those of US physicians. 37 Limited use of contingency fees, infrequent use of juries, limitations of awards for pain and suffering, and requirements that the losing p a r t y b e a r the cost of litigation account for the reduced costs. 37 Physicians are essential participants in any efforts to reform the health care system. However, for physicians to have credibility in such a project, medicine must put its own house in order. Ethical and legal abuses by physicians have been documented repeatedly. These include fraudulent medical billing, 38 conflict of interest problems involving physicians investing in businesses to which they i n a p p r o p r i a t e l y refer patients,39 acceptance of lavish gifts from p h a r m a c e u -
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tical companies, and an unwillingness to identify impaired or incompetent physicians who endanger patient safety. The AMA has developed reforms to address several of these issues. What is most required, however, is responsible ethical behavior by individual physicians. The public will trust physicians' plans to help reform the health care system when the profession resolves its own problems.
SUMMARY 1. W h a t is health and health care? Health is a state of physical and mental well-being that facilitates the achievement of individual and societal goals. Good health over a lifetime is the comparative absence of pain and suffering, illness and disease, each of which could prevent people from pursuing their goals. Health care includes those services that provide adequate nutrition and shelter; sanitary, safe, unpolluted living and working conditions; personal medical services; and nonmedical personal and support services. The medical community can best address the area of personal medical services, which includes interventions to prevent disease, minimize morbidity from existing diseases, diagnose and cure illness, relieve pain and suffering, and provide education for the continued promotion of health. Society must also provide health care services such as adequate nutrition, shelter, and education about health care issues, including prevention that could result in reduced expenditures for curative services. 2. Is health care an e t h i c a l or legal right? At this time, there is no legal right to universal health care in the United States, although there is a patchwork of limited legislated rights to health care benefits for some citizens. Ethically, there is a right to health care; however, it is a limited right best expressed as a societal obligation to provide care r a t h e r than an open-ended individual right to receive any and all health care resources on demand. In restructuring our health care system, our society must identify the values that will serve as the foundation for our health care system. A health care system that stresses societal r a t h e r than individual priorities is essential. 3. W h a t is " e q u i t a b l e a c c e s s " to health care? A just health care plan must provide equitable access to a p p r o p r i a t e preventive, emergency and p r i m a r y care, curative care with societally defined limits, and long-term care that includes convalescent care, care for the dying, and the relief of pain and suffering. 4. W h a t are the limits to a society's obligation to provide health care? Society should provide all Americans with a basic level of health care that includes affordable services defined by society as essential. Extremely expensive services such as organ transplantation would be provided only if sufficient funding is available after basic health care services have been provided. Rationing is a reality in our health care system. Health expenditure priorities must be explicit and guided by the ethical principle of distributive justice and equity.
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Efforts must be made to eliminate costs that do not contribute directly to patient care or quality assurance, such as excessive administrative costs including those associated with c u r r e n t insurance systems, u n p r o v e n medical procedures, unrealistic malpractice insurance premiums, physician self-referrals, and fraudulent billing practices. An equitable allocation of societal resources would not permit such a large share of the resources earmarked for health care to be diverted in this manner. The individual physician can and should participate as an advocate in efforts to improve our health care system. For physicians to become involved in decisions about the just distribution of health resources, they must be free of incentives for personal enrichment from these same health resources. Specific actions that individual physicians can take include direct personal communication with political representatives, speaking out on systemic or individual injustices on the b r o a d e r health care issues defined in this article, and recognizing the value of personal efforts in improving individual patient care and societal responsibility for patient care.
20. US PL 91-616, Part C, Section 321 A&B and subsequent amendments. 21, US PL 92-255, Section 407 A&B and subsequent amendments. 22. See, eg, Wisconsin Statutes Annotated 1991 Section 146.024, Discrimination related to Acquired Immunodeficiency Syndrome. 23. Iglehart JK: Medical Care Act of 1971: Canada's health system faces its problems. N Engl J Med 1990;322:562-568. 24, Fry J: Medicine in Three Societies. A Comparison of Medical Care in the USSR,USA, and UK. Aylesbury, United Kingdom, Medical and Technical Publishing Ltd, 1969, p 17. 25. Warden J: Patients first. Br MedJ 1991;303:1153. 26. Irkman-Liff BL: Health insurance values and implementation in The Netherlands and the Federal Republic of Germany: An alternative path to universal coverage. JAMA 1991;265:2496-2502. 27. Hall MA, Ellman IM: Health Law and Ethics. 1990. Nutshell Series. St Paul, Minnesota, West Publishing Company, p 98. 28. Nielsen K: Autonomy, equality and e just health care system, in Mappes TA, Zembatty JS (ed): Biomedical Ethics. New York, McGraw Hill, 1991. 29. Engelhardt T: The Foundation of Bioethics. New York, Oxford University Press, 1986. 30. Daniels N: Is the Oregon rationing plan fair? JAMA 1991;265:2232-2235. 31. Blumenthal D: The timing and course of health care reform. N Engl J Med 1991;325:198-200, 32. Eddy D: What care is essential? What services are basic? JAMA 1991;265:782-787. 33. Emson HE: Down the Oregon Trail--The way for Canada? Can MedAssoe J 1991;145:1441-1443.
REFERENCES 1. Keep CE, Shaefer FA: WhateverHappened to the Human Race?ed 2. Westchester, Illinois, Crossway Books,1983.
34. Egan T: Hawaii shows it can offer health insurance for all. New York Times,July 23, 1991.
2. Meyer ME: A revised look atthe number of uninsured Americans, Health Affairs 1989.
35. Waihee JD: Hawafi's Health Care System. State of Hawaii Department of Health, Department of Health Communication Office, 1991.
3. Nelson C, Short K: Health Insurance Coverage 1980-88.Washington, DC, US Department of the Census 1990. Current Population Reports, Household Economic Studies Series, P-70, no 17.
36. Woolhandler S. Himmelstein DU: The deteriorating administrative efficiency of the US health care system. NEnglJMed1991;324:1253-1255.
4. Friedman E: The uninsured. JAMA 1991;265:2491-2495.
37. Coyte PC, Bewees DN, Trebilcock LLM: Medical malpractice--The Canadian experience. N Engl J Med 1991; 342:89-93.
5. Baker OW, Stevens CD, Brook OH: Patients who leave a public hospital emergency department without being seen by a physician. JAMA 1991;266:1085-1098.
38. New York Times,December 29, 1991.
6. Enfield LM, Skier DP: Patient dumping in the emergency department: Renewed interest in an ,old problem. Am J Law Med 1988;13:561-595. 7. Jameton A: Moral problems on a social scale, in 6orovitz S (ed): Moral Problems in Medicine. Englewood Cliffs, New Jersey, Prentice Hall, 1976, p 422-429.
39. Igiehart JK: Efforts to address the problem of physician self-referral. N EnglJ Med 1991;325:1820-1824. The authors acknowledge the contributions of Jacek Franaszek, MD, Mary Ann Schropp, and Patricia J Miller.
8. Lowe RA, Young GP, Renke B, et al: Indigent health care in emergency medicine: An academic perspective. Ann Emerg Med 1991;20:790-794. 9. Sanders A, Oerse A, Knopp R, et el: ACEP ethics manual. Ann Emerg Med 1991;20:1153-1162. 10. Preamble to the Constitution of the World Health Organization.Adopted by the International Health Conference, New York, 1946, Off. Rec. Wld Health Org. 2, 100. 11. Daniels N: Just Health Care, New York, Cambridge University Press, 1985. 12. Brook RH: Health, health insurance and the uninsured. JAMA 1991;265:2998-3002. 13. Callahan D: What Kind of Life, NewYork, Simon end Schuster, 1990. 14. Feinberg J: Social Philosophy. Englewood Cliffs, New Jersey, Prentice-Hall, 1973, p 84-97. 15. Feinberg J: The nature and value of rights, in Gorovitz S (ed): Moral Problems in Medicine. Englewood Cliffs, New Jersey, Prentice-Hall, 1976, p 454-467. 16. Pellegrino ED: The social ethics of primary care: The relationship between a human need and an obligation of society. Mt Sinai J Med 1978;45:593-601. 17. Moskep JC: Rawlsian justice and a human right to health care. JMedPhil 1983;8:329-338. 18. Estelle v Gamble,429 US 96 (1976). 19. Wyatt vAderhol~ 503 F2d 1312,1974.
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An Ethical Foundation for Health Care: An Emergency Medicine Perspective
From the Ethics Committee, Society for Academic Emergency Medicine, Lansing, Michigan.
Ethics Committee, Society for Academic Emergency Medicine
Received for publication April 28, 1992. Accepted for publication May 7, 1992. This document was developed by the Ethics Committee of the Society for Academic Emergency Medicine and approved by the Board of Directors.
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[Knopp RK, Goldfrank LR, Derse AR, SandersAB, Schmidt TB, Sklar DP, [serson KV, Adams JG, Kalbfleisch ND, Keim SM: An ethical foundation for health care: An emergencymedicine perspective. Ann EmergMed November 1992;21:1381-1387.] INTRODUCTION "Cultures can be judged in many ways, but eventually every nation in every age must be judged by this test: How did it treat people?" (C Everett Koop, Surgeon General)l The c u r r e n t US health care system is inadequate and inequitable. Between 31 and 36 million citizens have no health insurance.2,3 At any one time, as many as one in four Americans may be u n i n s u r e d or u n d e r i n s u r e d for serious i l l n e s s . 4 For emergency physicians, these faceless statistics take on a sad but familiar f o r m - - t h e single working mother with a lethargic, febrile child; the homeless alcoholic found on the street; or the middle-class family who suffers critical injuries in an automobile accident. The emergency department provides access to these patients with acute medical problems, as well as to patients who have no other access to primary health care. However, the increasing n u m b e r of u n i n s u r e d or u n d e r i n s u r e d patients seeking primary care in overcrowded EDs threatens that access. I n a recent study, 11% of patients presenting to an u r b a n ED who left without seeing a physician because of delays subsequently required hospitalization within one week. 5 When Congress enacted the Comprehensive Omnibus Budget Reconciliation Act (COBRA) in 1986 to halt the transfer of unstable emergency patients for financial reasons, a limited form of emergency access was established by mandating that any patients who presented to an ED must have a screening examination and stabilizing treatment if an emergency exists.6 Because of this law and other common-law precedents, access to emergency health care has been guaranteed to all regardless of ability to pay. Because emergency physicians must provide some health care to every patient who presents to the ED, they must deal with a difficult question: What are the limits to the care that can be provided in our overcrowded EDs? Although emergency physicians are required to treat patients with highacuity problems, they are not required by law to treat "nonemergency" patients. This places emergency physicians in a difficult position. Emergency physicians often feel an
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ethical responsibility to treat nonemergent or urgent conditions and even attempt to provide t e m p o r a r y follow-up care for uninsured patients because no effective alternative exists; insured patients do not present such dilemmas because referrals are readily available. The ethical principle of distributive justice plays a crucial role in determining how the resources of our emergency care system should be assigned. Distributive justice, defined as fairness in the allocation of the burdens and benefits of society, primarily influences the development of health policy. 7 But emergency physicians face problems of distributive justice on a daily basis when they make decisions to ration resources because of overcrowding.8, 9 With this unique perspective comes the opportunity to share our experience with other medical specialists and review the values and philosophical concepts that are the underpinning of our present system. This discussion begins with a definition of health care, without which any discussion of access to health care would be meaningless. Then we explore the ongoing philosophical debate concerning justice and the right to health care. This analysis leads naturally to a discussion of access to health care and the conflict between the values of equality and equity. The final section discusses the necessary limits to universal health care and some recommendations. In summary, we consider the following questions: W h a t is health and health care? Is health care an ethical or legal right? W h a t is "equitable access" to health care? W h a t are the limits to a society's obligation to provide health care?
HEALTH AND HEALTH CARE The World Health Organization defines health as "a state of complete physical, mental, and social well being, and not just the absence of disease or infirmity. ''10 To achieve this societal ideal would require a population free of disease, unafflicted by physical or psychological pain, spiritually aware, and emotionally well adjusted. Others have defined health as the absence of disease. Although simpler, this definition fails to characterize what constitutes a disease. By contrasting these definitions, two very different concepts of health care can be developed. If health is the absence of the disease, our medical care system is central to improving the population's health. With the World Health Organization's b r o a d e r definition, determining the physicians' responsibilities, tasks, and roles is less clear. The classic medical model does not include teenage pregnancy, air and water pollution, substance abuse, homelessness and malnutrition, all of which affect health but are often not thought of as "diseases." Rather, they are considered "social problems" that require a political or multidisciplinary solution. In reality, our medical care system is merely p a r t of a larger health care system concerned with physical and mental diseases, injury, and infirmity. Our social systems deal with other aspects of "health" through housing support, food stamps, child care, and similar programs. The overlap between these "medical" and "social" issues is considerable, yet there
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is no organized system that focuses its efforts on the total health of individuals. Health care has been defined as encompassing five areas: adequate nutrition and shelter; sanitary, safe, unpolluted living and working conditions; exercise, rest, and lifestyle considerations; preventive, curative, and rehabilitative personal medical services; and nonmedical personal and supp o r t services. 11 While recognizing the contribution of these factors toward individual health, addressing all of them is beyond the scope of this article. To consider which health care services our society should provide, we must first determine what patient behavior and environmental conditions are the responsibility of the health care system. 12 Social and medical problems are so interrelated that we must view health care as a process of treating, curing, caring for, and preventing certain social, physical, and mental problems. Therefore, we define health as a state of physical and mental well-being that facilitates the achievement of individual and societal goals. Good health over a lifetime is the comparative absence of pain and suffering, illness and disease, each of which could prevent an individual from pursuing his or her goals. 13 Emergency physicians are made keenly aware of c u r r e n t societal deficiencies when they treat patients whose physical ailments are exacerbated by a lack of nutrition, shelter, or other societal supports. Our discussion is limited to personal health care services because this is the area in which emergency physicians have the most expertise and may affect change. Although a definition of health care that will encompass all beliefs and personal values is impossible, we define personal medical services to include interventions that prevent disease, minimize morbidity from existing diseases, diagnose and cure illness, relieve pain and suffering, and provide education for the continued promotion of health.
A RIGHT TO HEALTH CARE ls health care an ethical 01" legal right? Rights involve claims or entitlements to some "good" and engender duties on the part of persons or entities, such as governments, la Individual rights promote self-respect and dignity, as well as respect for other members of society, and thus promote the evolution and survival of just societies. 15 Rights generally reflect the needs and demands of individuals that may then become claims against others. The most fundamental rights reflect those ideals that are intrinsic to being fully human, such as the right to life and hberty. These rights are sometimes called " h u m a n rights" or "absolute rights" and are protected by legal doctrine in many societies. 15,16 There are few instances in which these basic human rights may be violated. Other rights or claims reflect physical, social, or psychologic needs or societal traditions. These needs include food, clothing, shelter, education, and health care and may be considered "limited," "relative," or "nonabsohite" rights. Limited (relative) rights are often necessary for sustaining
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life; however, they c a n n o t be absolutely g u a r a n t e e d in the face of scarce resources, such as the limited organs available for t r a n s p l a n t a t i o n . Rights m a y place different types of obligations on individuals or societies a n d can be described as "negative" or "positive." A negative right protects a n i n d i v i d u a l in his or h e r p u r s u i t of a stated "good," such as the right to life, liberty, a n d security. A negative right to h e a l t h care protects individuals from interference in their p u r s u i t of h e a l t h a n d access to health care. A positive right imposes a stronger o b l i g a t i o n - a r e q u i r e m e n t for i n d i v i d u a l s or society to provide the goods or services. If i n d i v i d u a l s have a positive right to h e a l t h care, society must p r o v i d e them with " a d e q u a t e " h e a l t h care services. 17 If o u r society has the resources to meet the basic h e a l t h care needs of its citizens, we believe h e a l t h care should be considered a positive, limited right based on beneficence, the principle of doing good. By efficient m a n a g e m e n t of o u r curr e n t h e a l t h care resources, o u r society c a n provide a basic level of h e a l t h care to all its citizens a n d reaffirm a commitment to p r o v i d i n g health care to the poor a n d elderly as it did when it created the Medicaid a n d Medicare p r o g r a m s . A n o t h e r a r g u m e n t for health care as a right is based on u t i l i t a r i a n concerns, the good of society. F o r example, we provide e d u c a t i o n a l opportunities to all m e m b e r s of o u r society because it is in the best interest of society to have a literate, educated p o p u l a t i o n . Similarly, it is in the best interest of society to have its p o p u l a t i o n healthy a n d free of disease. A society that is healthy provides a p r o d u c t i v e workforce, which is good for society as a whole. It m a y be most a p p r o p r i a t e to view health care from a c o m m u n i t y r a t h e r t h a n a n i n d i v i d u a l perspective. I n d i v i d u a l rights a n d a u t o n o m y t e n d to take p r i o r i t y over the i n d i v i d u al's obligation to society. However, the p r o b l e m of allocating health care resources can n e v e r be solved if we view it only from the perspective of individual rights. 13 I n s t i t u t i o n a l i z a t i o n of a right to h e a l t h care would give individuals a valid claim for u n l i m i t e d h e a l t h care. Only the p a t i e n t ' s desires a n d medical needs would d e t e r m i n e his or h e r care. However, health care resources are finite, a n d so there m u s t be a n effective a n d equitable m e c h a n i s m for their d i s t r i b u t i o n . To assure a basic level of h e a l t h care for all, we must develop a greater sense of community a n d recognize that all individual needs m a y n o t be met as we attempt to p r o v i d e for the greater good. T h e r e f o r e , we s u p p o r t the idea that h e a l t h care is a limited ethical right.
LEGAL R I 6 H T TO HEALTH CARE Ethical rights are claims or entitlements to some "good." Legal rights are those claims or entitlements that define g o v e r n m e n t a l responsibilities either to protect individuals in their p u r s u i t of a stated good (negative legal right) or to provide those goods or services (positive legal right). I n general, legal rights are ethical rights that are enforceable by government. E s t a b l i s h m e n t of a positive legal right to health
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care would obligate the g o v e r n m e n t to provide health care, to adequately f u n d that health care, to enforce the right to this care t h r o u g h use of sanctions, a n d to allow citizens to petition for redress when that right is violated. I n the U n i t e d States, there is no general or u n i v e r s a l legal right to health care. No federal statute has established such a right n o r is there a provision of the Constitution or the Bill of Rights that has b e e n i n t e r p r e t e d to s u p p o r t such a claim. However, there are limited legal rights a n d financial entitlements to some kinds of health care. These limited legal entitlements form a p a t c h w o r k of health care that the g o v e r n m e n t is legally obligated to provide, b u t huge gaps in eligibility r e m a i n . COBRA legislation established a legal right to emergency care. Medicare provides a right to health care to those 65 years of age or older, as well as those who r e q u i r e r e n a l dialysis. A n o t h e r federal p r o g r a m , Medicaid, administered by the states, was designed to p r o v i d e medical care for the indigent, b u t in most states it does n o t even cover most individuals below the federal p o v e r t y line. Other small groups, such as convicted a n d confined inmates is a n d v o l u n t a r i l y committed psychiatric patients, 19 have rights to health a n d psychiatric care. T h e r e is a federal p r o h i b i t i o n of discrimin a t i o n against patients on the basis of alcohol or drug abuse,2°,21 a n d in some j u r i s d i c t i o n s , patients c a n n o t be refused medical care on the basis of HIV infection. 22 Hawaii a n d Oregon have developed legislative reforms to provide access to health care for the poor b u t have n o t established health care as a legal right. Other i n d u s t r i a l countries have p r o v i d e d u n i v e r s a l health care t h r o u g h legislation, such as C a n a d a , 23 a n d Great Britain,24, 25 The N e t h e r l a n d s , a n d the F e d e r a l Republic of G e r m a n y . 26 The only other i n d u s t r i a l c o u n t r y besides the U n i t e d States that does not provide u n i v e r s a l health care is South Africa. 27 If a legal right to h e a l t h care is established, it must be adequately funded. Otherwise, it would be a facile b u t hollow solution to the p r o b l e m of h e a l t h care access. Ironically, US citizens have the right to legal r e p r e s e n t a t i o n if they are accused of a crime, b u t they do not have the right to be seen b y a physician if they are ill.
E Q U I T A B L E ACCESS TO HEALTH CARE E q u i t y is the ethical principle that should guide our efforts to r e s t r u c t u r e access a n d delivery of health care. " E q u i t a b l e access" to care can be i n t e r p r e t e d in several ways: equal access to care, access to whatever care a p e r s o n needs or m a y benefit from, or access to a n " a d e q u a t e " level of care. 28 Defining equity as equality implies that everyone will receive a n equal a m o u n t of health care dollars or the same level of care. However, health care needs differ among individuals, a n d even when health care needs are similar, equality may n o t be possible. The scarcity of certain medical resources, such as organs for t r a n s p l a n t a t i o n , means that some patients will die awaiting organ t r a n s p l a n t i o n while others will receive a life-prolonging t r a n s p l a n t . This is u n f o r t u n a t e b u t
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not unfair. 29 The crucial issue is to adopt a practical and equitable method for allocating health care resources. Equality is not a viable standard for accomplishing this task. The second interpretation of "equitable access" identifies individual needs or benefits as the criteria for determining care. Access to health care must be based on medical need; however, no plan for universal health care will survive if medical needs are defined solely by individual desires or preferences. Using "benefit" as the sole criterion for allocating health care resources is also problematic. Our society simply cannot afford to provide each new expensive biotechnologic discovery to all who might gain some marginal benefit. In addition, determining what constitutes a "benefit" is often an elusive endeavor. Individuals define their needs in different ways and frequently no societal consensus exists on the value of meeting different needs, so that the concept of "benefit" is rarely quantifiable. 13 Although individual need and benefit must be considerations in defining equitable access to care, they cannot be the sole criteria. The third interpretation of "equitable access" specifies that a basic or adequate level of health care be provided to all individuals. Most proposals for changing our health care system recommend providing this "decent minimum" or basic level of health care services while allowing those who wish to purchase additional services to do so. If our society agrees that every person should receive health care services regardless of his or her ability to pay, we still must determine what health care needs can and should be met, which needs have priority, how such care will be provided, and who will decide these questions. To establish an affordable universal health care system, a society must develop consensus on which medical needs are essential and what our society can afford. Such a consensus must be developed at the community or political level. The major challenge is distinguishing individual desires and preferences from societally defined essential medical needs and then determining which needs can be satisfied. Medical needs that should be covered in a universal health care system can be described as those needs that every individual will face during the course of his or her life and that are essential for functioning, as well as those needs necessary for an individual to have a fair opportunity to pursue his or her life plans. 30 Emergency care, prenatal care, and preventive care are examples of such essential needs. Basic health care does not require an open-ended obligation to satisfy all individual needs. There is a limit to the amount of societal resources that can be allocated to health care. Certain extremely expensive treatments (eg, organ transplantation) and those that provide marginal benefit might not be included. In exchange for having a system that meets the basic health care needs of all, immediate access to all forms of high technology may n o t be possible. An obvious corollary to such decisions is that the medical community
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must develop methods to determine the efficacy and, to some degree, benefit of specific interventions. Can a general description of individual needs be transformed into a group of specific services that would constitute a level of health care society should guarantee to all its citizens? Although there is widespread agreement that every person should have access to health care, the proposals regarding which specific services should be provided range from Free-tuning the current market-based system (by improving access to emergency and certain primary care services) to adopting a strictly egalitarian, regulated health care system, in which every individual would have access to the same level of services based on medical need. The delivery of health care services outside this egalitarian system would be severely restricted or nonexistent. Regardless of which system is adopted, society must define the limits of this new health care system.
L I M I T S ON HEALTH CARE Health care resources include the facilities, personnel, and equipment to maintain good health and prevent, diagnose, and treat illness and injury. With limited health care resources and increasing demand for services, explicit rationing is necessary. Our c u r r e n t system has de facto rationing, with physicians, administrators, or government allocating resources to the problems they see as most crucial. Even with this implicit rationing, health care expenditures continue to rise much more rapidly than measurable improvements in our health. Can we afford this? We have made a long-term allocation of our national productive power to health care and have not reaped the full economic or social benefits. 31 Limiting health care expenditures requires an understanding of how we allocate health care resources, including where allocation decisions occur, who makes the decisions, and how they are made. The allocation of health care resources occurs at two levels--societal and personal. Resource allocation at the societal level is macroallocation. The first decision to be made at the societal level is how much of our resources should be allocated to health care. At 13%, health care accounts for a greater percentage of our gross national product than that of any other country. We cannot continue to increase the percentage of expenditures on health care in the c u r r e n t manner, especially if the result does not justify the cost. Education, infrastructure repairs, and other societal needs compete with health care as priorities for government spending. However, by providing social improvements such as housing and education, health care expenditures may actually be reduced. After determining what percentage of our resources should be spent on health care, we must determine what percentage should be allocated for preventive care, acute care, long-term care, etc. We should also develop strategies to reduce or limit expenditures for new technologies or pharmaceuticals
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unless they result in overall cost savings or replace other services considered less beneficial from a societal perspective. Microallocation of health care resources involves decisions at the personal level between physicians and patients. When all critical care beds are filled and two critically ill patients come to the ED, how do physicians decide whether a patient should be moved out of the ICU to make room for one of the new arrivals or whether the new patients must wait in the overcrowded ED until a bed becomes available? The difference between macro- and microallocation systems creates a continqlng tension between the ethical values of distributive justice and beneficence. Distributive justice is the ethical principle that p r i m a r i l y guides allocation decisions at the macroallocation level. Beneficence is the ethical principle that p r i m a r i l y guides decisions at the microallocation level. At the societal level, we have a duty to allocate r~sources fairly. Establishing a universal health care system in which society guarantees a basic level of health care services is essential for distributive justice. However, at the level of the physician-patient relationship, the physician has the duty to be an advocate for the patient's best interests. The two ethical principles come into conflict at the bedside. A 650-g neonate born precipitously in the ED after a 23-week gestation requires resuscitation and intensive care expenditures that can exceed several h u n d r e d thousand dollars. Many such neonates will not survive, and many who do will have severe medical and social problems. That money could provide many people with basic health care services that they currently cannot afford. But the emergency physician and the neonatologist involved in the resuscitation of a p r e m a t u r e infant must consider the best interests of their patient as their p r i m a r y duty and not the societal benefits from improved basic preventive, emergency, and p r i m a r y health care for unknown others. Although we indicate that distributive justice guides macroallocation decisions, beneficence also must be considered in such decisions. Similarly, beneficence guides the physician's decision in microallocation decisions. However, physicians cannot totally ignore distributive justice. The conflict between these principles is an everyday occurrence in our EDs and ICUs. Greater use of advanced directives and p r a c tice guidelines may help resolve some of the dilemmas physicians face in balancing the best interests of the patient with society's interest in an equitable distribution of health care resources. The only equitable method for resolving the conflict between society's duty to ensure distributive justice and the physician's duty to the patient's best interests is for the m a j o r decisions on allocating health care resources to occur at the societal level. This preserves the principle of distributive justice, with patients receiving essential care without an unreasonable loss of personal resources, but with societal limits on what care is available (at least through the regulated health care system). Allocation decisions in our c u r r e n t
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health care system are made in reaction to individual patients and p a r t i c u l a r problems. To develop an equitable health care system, the driving force must be societal needs and not individual needs. Callahan ~3 outlined and prioritized the essential elements for basic health care while also recognizing the limits our society faces. His outline is similar to other definitions of health care. However, he prioritized the elements of his system in a way that others do not. He saw health care as divided into two m a j o r categories. 13 Interventions in the first category would be funded because they make the greatest contribution to the common good. Included in this category are provision of care in its most basic form (eg, relief of pain, care for the dying), preventive care, emergency care, and curative care (eg, antibiotics for the treatment of infectious disease). The second category includes advanced forms of medical cure or restoration such as chemotherapy or extensive rehabilitation and highly advanced technologic t h e r a p y such as organ transplants or open-heart surgery. Funding of services in the second category would be based on a reasonable allocation of resources for health care comp a r e d with other societal obligations and would be considered only if there were resources available after funding the services outlined in the first category. To define a basic health care system, society must first identify those values that should guide these important decisions. Callahan suggested an allocation system that is based on defined values. R a t h e r than criticize specific parts of his proposal, it should be considered an example of how to develop an equitable allocation system. Public discussion of priorities for health resource allocation and definition of medical needs is essential to apply distributive justice. 11 Society's rationing of limited resources would thereby become explicit. Health care needs must be prioritized objectively and then matched with society's (legislature's) ability to fund basic health care. Some health care services would not be funded; this outcome could either be accepted or the public could develop a mechanism to address intolerable inadequacies. Services not covered in the basic health care system could be p u r c h a s e d by individuals able to afford them. Once allocation decisions are made at the societal level, microallocation of specific health care interventions must occur. To define essential health care interventions, the benefits, burdens, and costs associated with each intervention must be determined.32 Some might criticize the inclusion of cost as a criterion to influence such decisions. However, if costs are not considered, basic health care services would include any intervention that could possibly produce a benefit. 32 To determine what constitutes essential basic health care, the following p r o c e d u r e is suggested: "Identify specific interventions, patient indications and protocols; estimate their benefits, harms and costs (compared with specific alternatives); and weigh the benefits versus harms and costs. ''32 Establishing such a prioritization of services is
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essential for an equitable system and identifying the best method for accomplishing this is the c u r r e n t dilemma. In 1989, the Oregon Senate passed the Oregon Basic Health Services Act, a novel plan to improve overall access to basic care while rationing existing coverage of Medicaid recipients. Prioritization was based on three principles: equity among those not insured, explicit rationing, and a combination of expert analysis and open political debate to determine community values. 33 The plan's explicit rationing produced much of the controversy: Some specific services for Medicaid recipients would be cut to allow universal access for all poor patients. Although all p o o r patients would be treated equally, the system is criticized as lacking e q u i t y - the poor do not have access to the same services as insured patients. Additionally, established prioritization for elderly Medicaid patients seems to discriminate on the basis of age against poor women and children, n Despite its shortcomings, many feel that this plan should be a starting point in the evolution of pragmatic public health care delivery plans. Hawaii's governo r states that Hawaii has 100% access to and 98% coverage for the basic health care needs of its citizens. 34 Hawaii has a 15-year experience with an employeebased insurance p r o g r a m in which unemployed individuals (approximately 5%) are covered by the state on a sliding scale. Hawaii boasts the nation's lowest infant mortality rate; the lowest p r e m a t u r e mortality rate for h e a r t disease, lung disease, and b r e a s t cancer; and the lowest hospital bed costs (two-thirds the national average). 35 The Hawaii experience reveals that universal access to basic health care is affordable and can provide health benefits to society. Although not perfect, this system affords equitable access to basic health c a r e - - s o m e t h i n g that most other states do not. Regardless of the basic health care plan that is adopted, society must assure itself that the financial resources allocated to provide essential medical services are not used for unnecessary costs such as excessive governmental and insurance industry administrative costs that are estimated to consume almost 25% 36 of c u r r e n t health care expenditures, prohibitively high malpractice insurance premiums, and expenses for medical interventions of unproven benefit (including "defensive" medicine). A reform of our medical malpractice system is necessary. Canadian medical malpractice costs p e r physician are approximately 85% less than those of US physicians. 37 Limited use of contingency fees, infrequent use of juries, limitations of awards for pain and suffering, and requirements that the losing p a r t y b e a r the cost of litigation account for the reduced costs. 37 Physicians are essential participants in any efforts to reform the health care system. However, for physicians to have credibility in such a project, medicine must put its own house in order. Ethical and legal abuses by physicians have been documented repeatedly. These include fraudulent medical billing, 38 conflict of interest problems involving physicians investing in businesses to which they i n a p p r o p r i a t e l y refer patients,39 acceptance of lavish gifts from p h a r m a c e u -
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tical companies, and an unwillingness to identify impaired or incompetent physicians who endanger patient safety. The AMA has developed reforms to address several of these issues. What is most required, however, is responsible ethical behavior by individual physicians. The public will trust physicians' plans to help reform the health care system when the profession resolves its own problems.
SUMMARY 1. W h a t is health and health care? Health is a state of physical and mental well-being that facilitates the achievement of individual and societal goals. Good health over a lifetime is the comparative absence of pain and suffering, illness and disease, each of which could prevent people from pursuing their goals. Health care includes those services that provide adequate nutrition and shelter; sanitary, safe, unpolluted living and working conditions; personal medical services; and nonmedical personal and support services. The medical community can best address the area of personal medical services, which includes interventions to prevent disease, minimize morbidity from existing diseases, diagnose and cure illness, relieve pain and suffering, and provide education for the continued promotion of health. Society must also provide health care services such as adequate nutrition, shelter, and education about health care issues, including prevention that could result in reduced expenditures for curative services. 2. Is health care an e t h i c a l or legal right? At this time, there is no legal right to universal health care in the United States, although there is a patchwork of limited legislated rights to health care benefits for some citizens. Ethically, there is a right to health care; however, it is a limited right best expressed as a societal obligation to provide care r a t h e r than an open-ended individual right to receive any and all health care resources on demand. In restructuring our health care system, our society must identify the values that will serve as the foundation for our health care system. A health care system that stresses societal r a t h e r than individual priorities is essential. 3. W h a t is " e q u i t a b l e a c c e s s " to health care? A just health care plan must provide equitable access to a p p r o p r i a t e preventive, emergency and p r i m a r y care, curative care with societally defined limits, and long-term care that includes convalescent care, care for the dying, and the relief of pain and suffering. 4. W h a t are the limits to a society's obligation to provide health care? Society should provide all Americans with a basic level of health care that includes affordable services defined by society as essential. Extremely expensive services such as organ transplantation would be provided only if sufficient funding is available after basic health care services have been provided. Rationing is a reality in our health care system. Health expenditure priorities must be explicit and guided by the ethical principle of distributive justice and equity.
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Efforts must be made to eliminate costs that do not contribute directly to patient care or quality assurance, such as excessive administrative costs including those associated with c u r r e n t insurance systems, u n p r o v e n medical procedures, unrealistic malpractice insurance premiums, physician self-referrals, and fraudulent billing practices. An equitable allocation of societal resources would not permit such a large share of the resources earmarked for health care to be diverted in this manner. The individual physician can and should participate as an advocate in efforts to improve our health care system. For physicians to become involved in decisions about the just distribution of health resources, they must be free of incentives for personal enrichment from these same health resources. Specific actions that individual physicians can take include direct personal communication with political representatives, speaking out on systemic or individual injustices on the b r o a d e r health care issues defined in this article, and recognizing the value of personal efforts in improving individual patient care and societal responsibility for patient care.
20. US PL 91-616, Part C, Section 321 A&B and subsequent amendments. 21, US PL 92-255, Section 407 A&B and subsequent amendments. 22. See, eg, Wisconsin Statutes Annotated 1991 Section 146.024, Discrimination related to Acquired Immunodeficiency Syndrome. 23. Iglehart JK: Medical Care Act of 1971: Canada's health system faces its problems. N Engl J Med 1990;322:562-568. 24, Fry J: Medicine in Three Societies. A Comparison of Medical Care in the USSR,USA, and UK. Aylesbury, United Kingdom, Medical and Technical Publishing Ltd, 1969, p 17. 25. Warden J: Patients first. Br MedJ 1991;303:1153. 26. Irkman-Liff BL: Health insurance values and implementation in The Netherlands and the Federal Republic of Germany: An alternative path to universal coverage. JAMA 1991;265:2496-2502. 27. Hall MA, Ellman IM: Health Law and Ethics. 1990. Nutshell Series. St Paul, Minnesota, West Publishing Company, p 98. 28. Nielsen K: Autonomy, equality and e just health care system, in Mappes TA, Zembatty JS (ed): Biomedical Ethics. New York, McGraw Hill, 1991. 29. Engelhardt T: The Foundation of Bioethics. New York, Oxford University Press, 1986. 30. Daniels N: Is the Oregon rationing plan fair? JAMA 1991;265:2232-2235. 31. Blumenthal D: The timing and course of health care reform. N Engl J Med 1991;325:198-200, 32. Eddy D: What care is essential? What services are basic? JAMA 1991;265:782-787. 33. Emson HE: Down the Oregon Trail--The way for Canada? Can MedAssoe J 1991;145:1441-1443.
REFERENCES 1. Keep CE, Shaefer FA: WhateverHappened to the Human Race?ed 2. Westchester, Illinois, Crossway Books,1983.
34. Egan T: Hawaii shows it can offer health insurance for all. New York Times,July 23, 1991.
2. Meyer ME: A revised look atthe number of uninsured Americans, Health Affairs 1989.
35. Waihee JD: Hawafi's Health Care System. State of Hawaii Department of Health, Department of Health Communication Office, 1991.
3. Nelson C, Short K: Health Insurance Coverage 1980-88.Washington, DC, US Department of the Census 1990. Current Population Reports, Household Economic Studies Series, P-70, no 17.
36. Woolhandler S. Himmelstein DU: The deteriorating administrative efficiency of the US health care system. NEnglJMed1991;324:1253-1255.
4. Friedman E: The uninsured. JAMA 1991;265:2491-2495.
37. Coyte PC, Bewees DN, Trebilcock LLM: Medical malpractice--The Canadian experience. N Engl J Med 1991; 342:89-93.
5. Baker OW, Stevens CD, Brook OH: Patients who leave a public hospital emergency department without being seen by a physician. JAMA 1991;266:1085-1098.
38. New York Times,December 29, 1991.
6. Enfield LM, Skier DP: Patient dumping in the emergency department: Renewed interest in an ,old problem. Am J Law Med 1988;13:561-595. 7. Jameton A: Moral problems on a social scale, in 6orovitz S (ed): Moral Problems in Medicine. Englewood Cliffs, New Jersey, Prentice Hall, 1976, p 422-429.
39. Igiehart JK: Efforts to address the problem of physician self-referral. N EnglJ Med 1991;325:1820-1824. The authors acknowledge the contributions of Jacek Franaszek, MD, Mary Ann Schropp, and Patricia J Miller.
8. Lowe RA, Young GP, Renke B, et al: Indigent health care in emergency medicine: An academic perspective. Ann Emerg Med 1991;20:790-794. 9. Sanders A, Oerse A, Knopp R, et el: ACEP ethics manual. Ann Emerg Med 1991;20:1153-1162. 10. Preamble to the Constitution of the World Health Organization.Adopted by the International Health Conference, New York, 1946, Off. Rec. Wld Health Org. 2, 100. 11. Daniels N: Just Health Care, New York, Cambridge University Press, 1985. 12. Brook RH: Health, health insurance and the uninsured. JAMA 1991;265:2998-3002. 13. Callahan D: What Kind of Life, NewYork, Simon end Schuster, 1990. 14. Feinberg J: Social Philosophy. Englewood Cliffs, New Jersey, Prentice-Hall, 1973, p 84-97. 15. Feinberg J: The nature and value of rights, in Gorovitz S (ed): Moral Problems in Medicine. Englewood Cliffs, New Jersey, Prentice-Hall, 1976, p 454-467. 16. Pellegrino ED: The social ethics of primary care: The relationship between a human need and an obligation of society. Mt Sinai J Med 1978;45:593-601. 17. Moskep JC: Rawlsian justice and a human right to health care. JMedPhil 1983;8:329-338. 18. Estelle v Gamble,429 US 96 (1976). 19. Wyatt vAderhol~ 503 F2d 1312,1974.
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