26 Jun 2009

Sample Essay: Healthcare Ethics

Introduction

Ethics speaks primarily to the right and wrong in human relationships. It is from the study of ethics and, consequently, a better understanding of moral principles, that society may hope to enhance the sense of tolerance, fairness, compassion, and sensitivity to another’s pain and thereby improve aspects of human behavior that place humans in a separate niche in biological history. Ethical questions, especially as they apply to medicine, have become common topics of discussion during the past twenty years. Bitter disputes have arisen regarding abortion, suicide, human experimentation, as well as the management of the dying patient and the severely disabled newborn. Today, the American health care has grown into a multi-billion dollar industry controlled by large corporations. It is clear that various ethical issues associated with delivering heath care services to patients get overridden by monetary interests.

Economic / Financial

In the past 50 years, few sectors of the U.S. economy have escaped the periodic ravages of recession. The health-care industry is a notable exception. Since 1950 hospitals and other health-related enterprises have experienced uninterrupted, indeed meteoric, expansion. Between 1950 and 1982 national health expenditures increased more than 25-fold, reaching $322 billion per year, and the proportion of the GNP accounted for by the health sector increased from 4.4 to 10.5 percent. During the 1970s health-care employment increased from 4.2 to 7.5 million workers, accounting for one seventh of all new jobs in the United States. Moreover, these trends continued through the recession of the early 1980s and 1990s. The fast pace of hospital expansion is indicated by the fact that in 1980 the average age of hospital capital assets stood at an all time low of 7 years, as compared to 15 years for the service sector as a whole and 23 years for capital in manufacturing industries.

Strikingly, the conquest of the main killers of the young (infectious diseases) was largely complete in the United States by the time the health-care sector began its explosive growth, and was clearly due to improvements in the standard of living and public health measures rather than curative medicine. The spectacular expansion of health facilities which occurred after the era of the main advances in life expectancy has been accompanied by massive government spending on curative medical care, a singular neglect of public health and preventive measures (which currently account for less than 3 percent of health expenditures), and very modest improvements in health. Moreover, many Americans lack access to the most basic medical services. The United States shares with South Africa the dubious distinction of being the only developed countries without universal health insurance. Despite the widely heralded Medicaid and Medicare programs, 25 million Americans lack health insurance of any kind, 40 percent of infants and toddlers are not fully vaccinated, and the elderly now spend as large a proportion of their incomes for health care as they did before the passage of Medicare. The paradox of vast increases in health care resources which are funded largely by the government yet fail to provide the services most critical to the improvement of health puzzles bourgeois health-policy analysts. An understanding of the role of health care in the accumulation of capital can help to unravel this mystery, forecast future trends, and focus the work of the left in this field.

Economics of health care

In the best of all possible worlds both economic efficiency and commitment to the individual patient would govern the delivery of medical care. In the real world the conflict between these two factors is increasingly disrupting the health professions. On the one hand, the traditional primary allegiance of health-care providers is to their individual patients: they cannot deny patients something they think would genuinely help. The doctor’s Hippocratic oath illustrates this. On the other hand, we all endorse the sensible goal of economic efficiency, getting the greatest value from our resources. We want to get the most health for our health-care dollars and to obtain as much value from every extra bit we invest in medicine as we could get by using the required resources on something else entirely. In economists’ jargon, we want to minimize our opportunity costs.

This conflict is sharpened considerably by the financial context of modern medicine. Once a patient is insured, the patient’s interest typically lies in receiving the best possible medical care regardless of whether the resources thus used might produce greater benefit elsewhere. The moral and professional allegiance of clinicians then seems to collide head-on with wider economic efficiency. Efficiency will sooner or later call for restricting care that would benefit individual patients. This is “hard efficiency”: it is surely not just the elimination of waste, and it leaves the health economist at seemingly irreconcilable odds with clinicians and their oath.

When each side in such a stark conflict has so much intuitive appeal, it is hardly surprising that the ensuing debate is heated. The traditional conception of loyalty to the individual patient even if that leads to sacrificing some of the overall value of resources gets ardently defended even by those who call for identifying and curtailing unnecessary procedures.

The push for hard efficiency won’t abate easily. Even if unnecessary procedures are better identified and curtailed, eradicating them is only a onetime saving. All historical trends point to continued growth in doubts about whether any and all care that serves the medical need of the patient is worth the money it costs. Randomized clinical trials will be telling more, not less, about the touch-and-go margins of effective care — what might possibly do a patient some good but is statistically and economically a dubious bargain. Both the range of options provided by medical technology and the age of the population will continue to increase faster than per capita income. Healthcare pressures on government and business budgets will grow, not diminish.

The lines of the continuing prospective debate may thus seem drawn already. Shouldn’t we come clean in our ethics and either honestly sacrifice commitment to the individual patient or frankly relent in the push for efficiency? Yet such a choice is bleak; we will swallow neither option without a moral gasp. Maybe we can avoid having to abandon either side, or perhaps we can at least reduce the force of their collision. Clinicians should be able to keep their oath of commitment to patients while at the same time taking much of larger economic efficiency to heart.

Politics

This century has witnessed the transformation of American medicine from cottage industry to large-scale capitalist enterprise. The health-care industry has received massive government subsidies, and has been largely exempt from the competition characteristic of many other sectors. Until now, any medical product has been guaranteed a virtually unlimited market. However, this expansion is giving rise to a contradiction between the health-care industry and other industries. In the past the capitalist class encouraged the growth of the health sector, but as the health-care industry expands, employee health benefits increase in cost and have by now become a major cost of production. In 1980 U.S. corporations were spending more than $65 billion a year for employee health benefits, and Chrysler executives were complaining that Blue Cross had become that company’s largest supplier. Corporate leaders have also begun to express concern about the increasing proportion of state and federal budgets devoted to Medicaid and Medicare.

Soaring health-care costs thus are becoming a major concern for the capitalist class as a whole. It is moving to curtail the special privileges which have allowed the health-care sector to reap greater profits and expand more rapidly than the rest of capitalist industry. The entry of the Business Roundtable into the health-care scene coincided with the start of government initiatives to end the privileged position enjoyed by the health-care industry. Federal grants for hospital capital projects were phased out starting in 1975, though the hospital industry was easily able to compensate for this loss by increasing its used of tax-exempt bonds. Other early efforts to contain health-care costs under the Nixon and Carter regimes were equally unsuccessful. However, more recent government attempts to rein in the health-care sector have more bite. As a reporter for the Boston Globe remarked, “The Business Roundtable’s decision to get serious about hospital cost control marked the turning point in the debate. Until then, the issue had been the province of insiders, the most influential of whom had more of a stake in the status quo [the continuing expansion of the health-care industry] than in cost containment.”

Under pressure from the business community, New York, New Jersey, and Massachusetts, among other states, have passed legislation sharply limiting hospital revenues. The Reagan administration has proposed the elimination of tax exemptions for health insurance and hospital bonds. Medicaid payments have been drastically cut, making it difficult for hospitals and doctors to profit from Medicaid patients. Perhaps most important, the basic structures of the payment systems for Medicare and Medicaid are being radically altered. Hospitals will no longer be paid for each individual test, procedure, or day of care. Instead, under Medicare the hospital will receive a fixed lump sum determined by the patient’s diagnosis. For instance, Medicare might pay a hospital $2,800 to care for a patient with pneumonia, no matter how long he or she stayed in the hospital or what tests or drugs were used. For the first time hospitals will profit by providing fewer services to each patient.

The incentive to do less is of course not new in health care. It is a central feature of so-called Health Maintenance Organizations (HMOs) which are increasingly popular among large corporate employers. The first, and still largest, HMO was started by Kaiser Industries to lower the costs of health care for its workers in massive New Deal construction projects like the Grand Coulee Dam. HMOs collect a lump sum in advance which covers all services delivered. Physicians are salaried and often share in any profits realized because of savings on patient care. Contrary to much recent propaganda, HMOs usually neglect preventive care, since cost savings due to prevention are most often realized after the patient has retired (either because of age or disability) and hence has lost his/her membership in the HMO. HMOs economize by emphasizing less personal and lower cost “industrial” style care, and erecting barriers to access which discourage members from seeking care.

Thus both government initiatives and corporate policies are forcing changes in the organization of health services. Capitalist rationalization and efficiency is replacing the ideology of “care and cure no matter the cost.” And changes on the horizon promise to complete the transformation of medical care into commodity production. Health care will be a product offered for sale on the market. Hospitals and HMOs will compete in offering corporations, the lowest priced health care which will maintain the productivity of their workers, and government the barest essentials of health care which will keep the unemployed, disabled, and retired from revolt. The state seems ready to forsake its role in assuring that health care resources are provided where needed. As a recent study by the Brookings Institution put it, “Congress has abandoned the principle that medical care should be provided whenever it is needed, that cost should not be considered when life or health is at stake.”

Competition

Medicine will increasingly be asked, “Does your practice improve the productivity and tranquility of the work force?” No more will doctors and hospitals be allowed to collect for every useless operation and superfluous machine. No more will health care for the “non-productive” poor, disabled, and elderly be lavishly financed by the state for the benefit of the private health-care sector. To be sure, the health-care industry will be allowed a handsome profit, but one in line with the rest of capitalists industry.

Already care for patients with a particular diagnosis is referred to as a “product line,” and administrators vie to manipulate these “product lines” to maximize profits and assure the survival of their hospital in the increasingly competitive hospital market. The extent to which the ideology of commodity production has come to dominate health-care administration is evident in the titles of some recent articles in the hospital administration trade journal Modern Healthcare: “Surgical Lasers Can Generate Profit If Volume of Use Can Be Guaranteed,” “Baxter Shows Hospitals How to Use Cost Data to Prepare for Price Competition,” “Managing Along Product Lines Is Key to Hospital Profits Under DRG [Medicare] System,” “Fixed Payment Rates Force Hospitals to Reassess ICUs,” and “Medical Records’ New Financial Role Dramatically Shifts Hospital Priorities.” This last article explains that under new insurance regulations, “The medical records department supplies the base information to interpret the medical stay into a financial picture,” and anticipates that “helping their hospitals collect billions of dollars in federal reimbursement will become the top priority of medical records departments. In the past, the department concentrated on maintaining accurate record for ongoing patient care.”

Social

The commodification of health care will have important repercussion for health-care workers and patients. Competition among health-care institutions will increase and result in the elimination of smaller scale, more personal and human sources of care. Health care will be monopolized by large corporations, employing thousands of workers organized to deliver care in an increasingly mechanized factory-like environment, with little human contact or understanding. Thus the familiar petty-bourgeois local doctor is already being replaced by “MediStop” centers staffed by anonymous employees providing technical interventions which keep working people at work and treat others as cheaply as possible. Care of the “non-productive” poor and elderly, and interventions aimed at improving quality of life or psychological well-being will receive short shrift. Public-health efforts to prevent the main modern-day health problems, such as heart disease and cancer, are likely to be crippled because such chronic diseases primarily affect workers in their non-productive post-retirement years.

Health-care workers will find themselves cogs within huge and growing enterprises. Administrators armed with elaborate computer systems will monitor and control day-to-day medical practice, dictating what tests and treatments are allowed for a given “product line” (disease). Physicians, in the past independent entrepreneurs, will serve as highly paid supervisors. For the first time, in 1982, more doctors in the United States were salaried than self-employed. For non-physician personnel the changes may be more painful if less dramatic. Hospitals will have more incentives to limit labor costs by holding down both wages and the number of workers. The proportion of health spending devoted to labor costs, which fell by more than 10 percent during the 1970s, will fall even more rapidly as machines replace many workers. Unions will increasingly be under attack.

Technology

The complexity of ethical dilemmas and resultant clamor will become more bewildering as technology continues to advance. We are facing a time when an egg and a sperm with desirable genetic attributes will be brought together in a Petri dish, nourished until transplanted into the uterus of a future mother, all according to parameters spelled out in a computer containing lists of potential donors. The ethical issues surrounding a surrogate mother are simple compared to those that all of us will face in the future. It has become a moot point whether ethically we should or should not move along certain potentially dangerous lines of research. The fact is that we will continue all areas of research and thus will be in need of greater understanding of ethics involved in the application of our knowledge. In order to clarify the fundamental premises upon which ethical decisions must rest, we need to stand back and assess our situation, free from the burdens of tradition, dogma, or gut reaction that limit our thinking.

As K. D. Clouser so pointedly expresses it, “Medical ethics is no big deal … it is simply ethics applied to a particular area of our lives … it is the ‘old ethics’ trying to find its way around in new, very puzzling circumstances.”[1]

Conclusion

The health care industry is one of the biggest and profitable business sectors in America. Americans spend more and more money on health care year after year, yet, the quality of services may not increase so dramatically and the ethics of medicine usually tends to be ignored in such a thriving sector of the US economy. The enormous sums now spent on health care are sufficient to assure health workers a decent standard of living, provide high quality curative medical services to all in the United States, enormously increase efforts in prevention and relevant research, and meet our now neglected international responsibilities in health. The issue is not lack of money but capitalist irrationality and waste: the insurance industry and armies of administrators which together devour 25 percent of all health-care spending, the billions of dollars of profits and advertising by drug and equipment suppliers, the massive duplication and maldistribution of facilities, and the greed and ideological bias of physicians which leads to millions of unneeded operations and tests, the proliferation of capital intensive treatments, and the neglect of non-technical (and hence unprofitable) therapies. Still, I sincerely believe that the pressure coming from various social groups is having and will have an even greater impact on the development of health care ethics, therefore, improving the quality of medical services.

Bibliography

K. Danner Clouser, “Medical Ethics: Some Uses, Abuses, and Limitations,” The New England Journal of Medicine 293, no. 8 ( August 21, 1975): 384.

Expenditures by John K Iglehart (The New England Journal Of Medicine, Jan. 7, 1999.  Volume 340:70-76).

Health Premiums to Jump Again Next Year: Insurance Rate Hikes in Area, Nation Likely to Be in Double Digits, Data Suggest by Bill Brubaker (Washington Post, June 24, 2003; PageE04).  Based on data from multiple sources, it appears that this will be the fourth year of premium increases in a row.

Why Are Local Healthcare Costs among the Highest in the Nation?  By John Dorschner (The Miami Herald, July 21, 2003).  An examination of the possible factors involved in high cost of health care in South Florida.

Health-Care Costs to Rise in 2004: Employers are expecting increase of 12%, fifth year in a row of double-digit gains by Vanessa Fuhrmans (The Wall Street Journal, September 29, 2003).  Many employers will shift some of the cost to employees.

Healthcare Costs Are Up.  Here Are The Culprits. By David R. Francis (The Christian Science Monitor, December 15, 2003).  Overview of the parts of the health care system that have become expensive.

Tough Trade-offs: Medical Bills, Family Finances and Access to Care by Jessica H. May and Peter J. Cunningham (Center for Studying Health System Change, Issue Brief number 85, June, 2004).  This study examines the difficulty both insured and uninsured Americans have in paying their medical bills, and how that difficulty affects access to care.


[1] K. Danner Clouser, “Medical Ethics: Some Uses, Abuses, and Limitations,” The New England Journal of Medicine 293, no. 8 ( August 21, 1975): 384.

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