13: Medical Ethics and Rationing of Health Care

For those who work in the healing professions, ethical values play a special role. The specific content of medical ethics was first formulated centuries ago, based on the sayings of Hippocrates and others. The refinement of medical ethics has continued up to the present by practicing health caregivers, health professional and religious organizations, and individual ethicists. As medical technology, health care financing, and the organization of health care transform themselves, so must the content of medical ethics change in order to acknowledge and guide new circumstances.

Over the years, participants in and observers of medical care have distilled widely shared human beliefs about healing the sick into four major ethical principles: beneficence, nonmaleficence, autonomy, and justice (Beauchamp & Childress, 2009) (Table 13-1).

Beneficence is the obligation of health care providers to help people in need.

Dr. Bueno tries to live up to the ideal of beneficence. He does not always succeed; like all physicians, he sometimes makes clinical errors. Overall, he treats his patients to the best of his ability. The principle of beneficence in the healing professions is the obligation to care for patients to the best of one’s ability.

Nonmaleficence is the duty of health care providers to do no harm.

The modern array of medical interventions has the capacity to do good or harm or both, thereby enmeshing the principle of nonmaleficence with the principle of beneficence. In the case of Mrs. Knight, the prescribing of sedatives has more potential for harm than for good, particularly because Mrs. Knight does not see her insomnia as a problem.

Autonomy is the right of a person to choose and follow his or her own plan of life and action.

The principle of autonomy adds another consideration to the interrelated principles of beneficence and nonmaleficence. Would Mr. Winter enjoy a longer life by submitting himself to aggressive cancer therapy that does harm in order to do good? Or, does he sense that the harm may exceed the good? The balance of risks and benefits confronts each physician on a daily basis (Eddy, 1990). But the decision cannot be made solely by a risk–benefit analysis; the patient’s preference is a critical addition to the equation.

Autonomy is founded in the overall desire of most human beings to control their own destiny, to have choices in life, and to live in a society that places value on individual freedom. In medical ethics, autonomy refers to the right of competent adult patients to consent to or refuse treatment. While the physician has an obligation to respect the patient’s wishes, he or she also has a duty to fully inform the patient of the probable consequences of those wishes. For children and adults unable to make medical decisions, a parent, guardian, other family member, or surrogate decision maker named in a legal document becomes the autonomous agent on behalf of the patient.

Justice refers to the ethical concept of treating everyone in a fair manner.

The principle of justice as applied to medical ethics is newer, more controversial, and harder to define than the principles of beneficence, nonmaleficence, and autonomy. In a general sense, people are treated justly when they receive what they deserve. It is unjust not to grant a medical degree to someone who completes medical school and passes all the necessary examinations. It is unjust to punish a person who did not commit a crime. In another meaning, justice refers to universal rights: to receive enough to eat, to be afforded shelter, to have access to basic medical care and education, and to be able to speak freely. If these rights are denied, justice has been violated. In yet another version, justice connotes equal opportunity: All people should have an equal chance to realize their human potential. Justice might be linked to the golden rule: Treat others as you would want others to treat you. While there is no clear agreement on the precise meaning of justice, most people would agree that the differential treatment of Joe and Josephine is unjust.

Distributive Justice

In exploring the concept of justice, one area of concern is the allocation of benefits and burdens in society. This realm of ethical thinking is called distributive justice, involving such questions as: Who receives what amount of wealth, of education, or of medical care? Who pays what amount of taxes?

The principle of justice is linked to the idea of fairness. In the arena of distributive justice, no agreement exists on what formula for allocating benefits and costs is fair. Should each person get an equal share? Should those who work harder receive more? Should the proper formula be “to each according to ability to pay,” as determined by a free market? Or “to each according to need?” In allocating costs, should each person pay an equal share or should those with greater wealth pay more? Most societies construct a mixture of these allocation formulas. Unemployment benefits consider effort (having had a job) and need (having lost the job). Welfare benefits are primarily based on need. Job promotions may be based on merit. Many goods are distributed according to ability to pay. Primary education in theory (but not always in practice) is founded on the belief that everyone should receive an equal share (Beauchamp & Childress, 2009; Jonsen et al., 2010).

How is the principle of distributive justice formulated for medical care? Throughout the history of the developed world, the concept that health care is a privilege, allocated according to ability to pay, has competed with the idea that health care is a right and should be distributed according to need. In most developed nations, the allocation of health care according to need has become the dominant political belief, as demonstrated by the passage of universal or near-universal health insurance laws. In the United States, the failure of the 100-year battle to enact national health insurance, and the widely divergent public opinions on the 2010 Affordable Care Act, attest to the ongoing debate between health care as a privilege and health care as a right (see Chapter 15).

If the overwhelming opinion in the developed world holds that health care should be allocated according to need, then all people should have equal access to a reasonable level of medical care without financial barriers (i.e., people should have a right to health care). In this chapter, we consider that the principle of distributive justice requires all people to equally receive a reasonable level of medical services based on medical need without regard to ability to pay.

Ethical dilemmas (Lo, 2013) are situations in which a provider of medical care is forced to make a decision that violates one of the four principles of medical ethics in order to adhere to another of the principles. Ethical dilemmas always involve disputes, in which both sides have an ethical underpinning to their position. Financial conflicts of interest on the part of physicians (see Chapters 4 and 10), in contrast, pit ethical behavior against individual gain and are not ethical dilemmas.

In Anthony’s case, the ethical dilemma is a conflict between beneficence and autonomy. Which principle has priority depends on the particular situation, and in this case, autonomy supersedes beneficence. If the patient were a child without sufficient knowledge or reasoning capability to make an informed choice, the physician would not be obligated to withhold transfusions, even if the family so demanded (Jonsen et al., 2010).

The case of Mr. Navarro pits the principle of autonomy against the principle of nonmaleficence. Mr. Navarro’s rightful surrogate decision maker, his wife, wants a particular course of treatment, but the neurosurgeon knows that this treatment will cause Mr. Navarro considerable harm and do him no good. In this case, nonmaleficence triumphs. Whereas patient autonomy allows the right to refuse treatment, it does not include the right to demand a harmful or ineffectual treatment.

The traditional dilemmas described in many articles and books on medical ethics feature beneficence or nonmaleficence in conflict with autonomy. In two famous ethical dilemmas, the families of Karen Ann Quinlan and Nancy Cruzan, young women with severe brain damage (persistent vegetative state) asked that physicians discontinue a respirator (in the Quinlan case) and a feeding tube (in the Cruzan case). Both cases were adjudicated in the courts. The Quinlan decision promoted the right of patients or their surrogate decision makers to withdraw treatment, even if the treatment is necessary to sustain life. The outcome of the Cruzan case placed limits on autonomy by requiring that life-supporting treatment can be withdrawn only when a patient has stated his or her wishes clearly in advance (Annas, 2005).

In 2005, the case of Terri Schiavo, for 15 years in a persistent vegetative state similar to the situations of Karen Ann Quinlan and Nancy Cruzan, made national headlines. In spite of multiple decisions of state and federal courts—up to the Supreme Courts of Florida and the United States—supporting the right of Terri Schiavo’s husband to discontinue Ms. Schiavo’s feeding tube, the US Congress, encouraged by President George Bush, passed legislation reopening the option of reinserting the feeding tube. Eventually, based on the precedents of the Quinlan and Cruzan cases, the courts prevailed and Ms. Schiavo died (Annas, 2005).

Overall, medical ethics has moved in the direction of giving priority to the principle of autonomy over that of beneficence.

In the late 20th century, a new generation of ethical dilemmas emerged, moving beyond the individual physician–patient relationship to involve the broader society. These social–ethical problems derive from the new reality that money may not be available to pay for a reasonable level of medical services for all people. When money and resources are bountiful, the issue of distri­butive justice refers to equality in medical care access and health outcomes (see Chapter 3). Is it fair that some people are unable to receive needed care because they lack money and insurance? When money and resources become scarce, the issue of justice takes on a new twist. Should limits be set on treatments given to people with high-cost medical needs, so that other people can receive basic services? If not, might health care consume so many resources that other social needs are sacrificed? If limits should be set, who decides these limits?

The new fiscal reality has spawned two related dilemmas.

1. The first involves a conflict between the duty of the physician to follow the principles of beneficence and nonmaleficence and the growing sentiment that physicians should pay attention to issues of distributive justice. In the case of the Lakeberg twins, the hospital and surgeons adhered strictly to the principle of beneficence: Even a remote chance of aiding one twin was seen as worthwhile. The hospital could have balked, arguing that its funding of the surgery would be unfairly shifted to other payers. The surgeons could have declined to operate on the grounds that the money spent on the Lakebergs could have been better used by patients with a greater chance of survival. But, the surgeons could argue, who can guarantee that the money saved would have gone to better use?

2. The second category of social–ethical dilemma is the conflict between the individual patient’s right to autonomy and society’s claim to distributive justice. In the Lakeberg case, individual autonomy won out. The Lakeberg parents could have decided that spending $1 million of society’s money on a less than 1% chance of saving one of two infants was excessive and could indirectly harm other patients.

Physicians take up the practice of medicine with a recognition that they have a duty to help and not harm their patients. Individuals claim a right to health care and do not want others to restrict that care. Yet the principle of distributive justice (recognizing that resources for health care are limited and should be fairly allocated among the entire population) might lead to physicians denying legitimate services or patients setting aside rightful claims to treatment.

The basis for the principle of justice is the desire shared by many human beings to live in a civilized society. To live in a state of harmony, each person must balance the concerns of the individual with the needs of the larger community. There is no right or wrong answer to the question of whether the Lakeberg surgery should have been done, but the surgery must be seen as a choice. The $1 million spent on the twins might have been spent on immunizing 10,000 children, with greater overall benefit. When health resources are scarce, the principle of justice creates ethical dilemmas that touch many people beyond those involved in an individual physician–patient relationship. The imperatives of cost control have thrust the principle of justice to the forefront of health policy in the debate over rationing.

The general public and the media often view rationing as a limitation of medical care such that “not all care expected to be beneficial is provided to all patients” (Aaron & Schwartz, 1984). Such a view only partially explains the concept of rationing. More precisely, rationing means a conscious policy of equitably distributing needed resources that are in limited supply (Reagan, 1988) (Table 13-2). Under this definition, only the last two cases presented above can be considered rationing. In the first case, Dr. Wall did not feel that the MRI was a resource needed by Betty Ailes. In the second, Vacant Hospital’s refusal to care for Perry Hiler was simply a decision on the part of a private institution to place its financial well-being above a patient’s health; there was no scarcity of health care resources. In the heart transplant and intensive care unit cases, in contrast, donor hearts and intensive care unit beds were in fact scarce. For Mr. Delacour, the scarcity was nationwide and prolonged; for Dr. Intensivo, the scarcity was within a particular hospital at a particular time. In both cases, decisions had to be made regarding the allocation of those resources.

During World War II, insufficient gasoline was available to both power the military machine and satisfy the demands of automobile owners in the United States. The government rationed gasoline, giving priority to the military, yet allowing each civilian to obtain a limited amount of fuel. In a rural area, there may be a shortage of health care providers; in an overcrowded urban public hospital, there may be an insufficient number of beds; in the transplant arena, donor organs are truly in short supply. These are cases of commodity scarcity, wherein specific items are in limited supply.

The United States is a nation with an adequate supply of hospital beds and physicians in most communities; commodity scarcity in health care is the exception (e.g., scarcity of primary care resources is a reality). But a different kind of health resource is becoming scarce, and that is money. Those who pay the bills are insistent that the flow of money into the health sector be restricted. Most discussions of health care rationing presume fiscal scarcity, not commodity scarcity.

In summary, rationing in medical care means the limitation of resources, including money, going to health care such that not all care expected to be beneficial is provided to all patients, and the fair distribution of these limited resources.

While fiscal scarcity is the more common form of resource limitation, commodity scarcity provides an instructive example of the interaction of ethics and rationing.

In 1951, the first kidney transplant was performed in Massachusetts. But it was in 1967, when Dr. Christiaan Barnard sewed a living heart into the chest of a person suffering end-stage cardiac disease, that modern medicine fully entered the age of transplantation. Since that time, thousands of people have been kept alive for many years by transplantation of the kidneys, hearts, lungs, and livers of their fellow human beings. In 2014, 17,000 kidney, 2,600 heart, 6,700 liver, and 1,900 lung transplants were performed in the United States. Transplants are truly life saving in most cases. Seventy to eighty percent of patients receiving heart, liver, or kidney transplants survive at least 5 years after transplantation (http://optn.transplant.hrsa.gov).

Transplantation of organs is both a medical miracle and an ethical watershed. It has generated debate on such questions as these: When are people really dead (so that their organs can be harvested for use in transplantation)? What is the responsibility of the families of brain-dead people to allow their organs to be harvested? Who pays and who is paid for organ transplants? Who should receive organs that are in short supply? We will focus only on the last of these issues.

The number of persons on the national waiting list for organ transplants rose from 16,000 in 1988 to 135,000 in 2015. The number of organs that could be harvested each year falls far short of the number needed. As a result, 21 patients in the United States die each day awaiting organs.

Transplantation presents a classic case of commodity scarcity: there is insufficient supply to meet demand. Explicit rationing, which is a system that determines who gets organs and who does not, is inevitable. For heart, lung, and liver transplants, rationing is all or nothing: those who receive organs may live, while those who do not will die.

Given the supply and demand imbalance, which potential transplant patients actually receive new organs? In the early 1980s, the major heart transplant center at Stanford University excluded people with “a history of alcoholism, job instability, antisocial behavior, or psychiatric illness,” and required transplant recipients to enjoy “a stable, rewarding family and/or vocational environment.” Stanford’s recipients had a better than 50% chance of surviving 5 years, signifying that acceptance or rejection from the program was a matter of life and death. The US Department of Health and Human Services was concerned about Stanford’s selection criteria, which favored those middle-class or wealthy people with satisfying jobs. Moreover, the $100,000 cost restricted heart transplants to those with insurance coverage or ability to pay out of pocket. Both the social and economic criteria for access to this life-saving surgery raised serious issues of distributive justice.

Following the passage of the National Organ Transplantation Act of 1984, the federal government designated the United Network for Organ Sharing (UNOS) as a national system for matching donated organs and potential recipients (www.unos.org). According to the Task Force on Organ Transplantation (1986), organ allocation should be governed by medical criteria, with the major factors being urgency of need and probability of success. The Task Force recommended that if two or more patients are equally good candidates for an organ according to the medical criteria, length of time on the waiting list is the fairest way to make the final selection. Overall, UNOS follows these recommendations, placing potential recipients of organ transplants on its computerized waiting list. Recipients are prioritized according to a point scale based on severity of illness, time on the waiting list, and probability of a successful outcome. A serious attempt has been made to allocate scarce organs on the basis of justice criteria. But haunting the ethics of the prioritization process is the issue of ability to pay. In 2011, the average kidney transplant cost $263,000 and heart transplant $998,000. Persons needing a transplant are often rejected if they lack health insurance coverage (Ansell et al., 2014).

During the 1980s, technologic advances in medicine combined with the rapid rise in health care costs led to the belief that medical care rationing was upon us. However, great differences separate the case of organ transplants from that of medical care as a whole.

1. Medical care in general is not a scarce resource; in most population centers, facilities and personnel are overabundant.

2. Whereas a nationwide structure is in place to decide who will receive a transplant, no such structure exists for medical care as a whole.

While, Dr. Ernest can be praised for attempting to reduce costs without sacrificing quality, her cost savings had no impact on overall national health care expenditures. Nor were the savings used to provide more childhood immunizations or to hire a physician assistant for a nearby rural community without any health care provider. In the United States, there is no structure within which to effect a trade-off between savings in one area and benefits in another. According to analyst Joshua Wiener,

In the United States, persuading physicians to save money on one patient in order to improve services for someone else is as illogical as telling a child to eat all the food on the plate because children in Africa are starving (Cassel, 1985).

In order for health care providers like Dr. Ernest to make their cost savings socially useful, two things are needed: a closed system of health care funding, whether governmental through a global budget or private through a network of HMOs; and a decision-making structure with responsibility to allocate budgets to health care interventions in a fair manner.

For the purposes of the following discussion, let us assume that the United States is in a position of fiscal scarcity and that a mechanism exists to fairly allocate medical care resources from one individual or population group to another. Which ethical conflicts arise between beneficence, nonmaleficence, and autonomy on the one hand and justice (equitable distribution of resources) on the other?

Is rationing the same as cost containment? We have defined rationing in medical care as the limitation of resources, including money, going to medical care such that not all care expected to be beneficial is provided to all patients, and the fair distribution of these limited resources. While the limitation of money going to medical care is cost containment, not all cost containment reduces beneficial care to patients. In the case of Limittown, both options for saving $5 million can be considered cost containment, but only denial of coverage for bone marrow transplants requires rationing. Consolidating MRI scanning at a single facility would allow the same number of scans to be performed, but at a substantially lower cost. Rationing is associated with painful cost control (reducing effective medical care), but cost containment (see Chapter 8) can be either painful or painless (not reducing effective medical care) (Table 13-3). The extent of unnecessary care and administrative waste strongly suggests that the United States does not need to ration effective medical services (Berwick & Hackbarth, 2012). To maximize beneficence and autonomy without violating distributive justice, no rationing of beneficial services should take place until all wasteful practices are curtailed; painless cost control should precede painful cost control.

Care Provided to Profoundly Ill People

A hotly debated issue is the amount of health care that should be provided to the profoundly and incurably ill. Were Lula Rogers’ caregivers right to prolong a life that had value to her? Or were they prolonging Ms. Rogers’ suffering and denying her a peaceful death? Should cost be a factor in such decisions, or should such matters of life and death be governed by autonomy, beneficence, and nonmaleficence alone?

Twenty-eight percent of Medicare’s budget is spent on people in their last 6 months of life (Pasternak, 2013). Of elderly people dying in 2009, 52% died in the hospital or nursing home; 34% died at home (Teno et al., 2013). Patients in hospice programs have lower end-of-life costs than those not in hospice programs (Obermeyer et al., 2014), and family members of patients receiving hospice care at home are more satisfied with the care than families of patients dying in hospitals or nursing homes (Teno et al., 2004). Thus reduced expenditures can go hand in hand with better care. If these savings could be transferred to more efficacious therapies for other people, then improving the care of the incurably ill could promote all four of the ethical principles—beneficence, nonmaleficence, autonomy, and distributive justice.

Cost containment does not equal rationing, and eliminating administrative waste, medical waste, and unwanted interventions for the profoundly and incurably ill before rationing needed services best realizes the principles of beneficence and justice. However, if rationing of truly beneficial services were needed, the issues become more difficult. If a health care system or program must compromise beneficence because of true fiscal scarcity, how can this compromise be made in a manner that yields the least harm and allocates the harm in the fairest possible way?

In the event of rationing, science is the best guide: the providing or withholding of care is ideally determined by the probability that the treatment will maximize benefits and minimize harm, that is by the criterion of medical effectiveness. Radiation therapy can often cure Hodgkin’s disease, but chemotherapy is unlikely to provide much benefit to people with advanced pancreatic cancer. If rationing is needed and only one of these therapies can be offered, a decision based on the criterion of medical effectiveness would allow for the treatment of Hodgkin’s disease but not of terminal pancreatic cancer.

If intervention A increases person-years of reasonable-quality life more than intervention B, intervention A is more medically effective. The cost of the two interventions is not considered. Cost effectiveness adds dollars to the equation: If intervention A increases person-years of reasonable-quality life per dollar spent more than intervention B, it is more cost effective. Which is a better standard for rationing medical care: medical effectiveness or cost effectiveness?

If money were not scarce, medical effectiveness (maximizing benefit and minimizing harm) would be the ideal standard upon which to ration care (i.e., the less effective the therapy, the lower its priority on the list of treatments to be offered). But it is unrealistic to pretend that costs can be ignored (Garber & Sox, 2010). Suppose that bone marrow transplantation saves as many person-years of life by treating advanced cancers as does doxycycline by curing pneumonia. The former costs $250,000, while the latter can be obtained for $25. There is no reason to ration doxycycline, as its cost is negligible, whereas to make bone marrow transplantation similarly accessible is costly. Thus consideration of costs is essential if rationing were needed.

Rationing for Society as a Whole

In 1991, Dr. David Eddy (1991a) published a compelling article entitled “The individual vs society: Is there a conflict?” Dr. Eddy posed the preceding case of Mrs. Smith. If medical care must be rationed, it seems logical to spend funds on mammography rather than HDC-ABMT because the former intervention is more cost effective. Dr. Eddy did not confine his analysis to cost effectiveness, however, but moved on to the ethical issues.

Physicians generally care for patients in Dr. Eddy’s second position—when they are sick. But if the cost of treating those in the second position reduces resources available to prevent illness for the far larger number of people in the first position (who may not be seeing physicians because they feel fine), the individual principles of beneficence and autonomy are superseding the societal principle of justice. One could even say that choosing for individuals in the second position violates beneficence for those in the first position. On the other hand, if all resources go to those in the first position (e.g., to cost-effective screening rather than expensive treatment for those with life-threatening disease), injustice is committed in the other direction by ignoring the costly needs of the very ill.

Clearly, no ideal method of rationing medical care exists. Thus all efforts should be made to control costs painlessly before resorting to the painful limitation of effective medical care. But if rationing is inevitable, a balance must be struck among many legitimate needs: the concerns of healthy people for illness prevention, the imperative for acutely sick people to obtain diagnosis and treatment, and the obligation to provide care and comfort to those with untreatable chronic illness.

Rationing within One Health Program: The Oregon Health Plan

The previous discussion of rationing medical care nationwide presumes a mechanism that redirects savings from interventions not performed toward more cost-effective services. In fact, such a mechanism does not exist nationwide. Only in specific medical care programs do we find a decision-making apparatus for allocating expenditures. One example was the Oregon Health Plan (Bodenheimer, 1997).

In 1994, Oregon added 100,000 poor uninsured Oregonians to its Medicaid program. To control costs, a prioritized list of services was developed, and the state legislature decided how many services would be covered. The prioritized list was based on how much improvement in quantity and quality of life the treatment was likely to produce. The final list contained 745 condition–treatment pairs, and the State of Oregon paid for items above line 574 on the list; conditions below that line were not covered (Kilborn, 1999). What are some of the Oregon Health Plan’s ethical implications?

1. The plan was more than a rationing proposal; its chief feature was to extend health care coverage to 100,000 more people. That aspect of the Oregon plan promotes the principle of justice.

2. Another positive feature of the plan was its attempt to prioritize medical care services on the basis of effectiveness, which, if rationing is needed, is a reasonable method for deciding which services to eliminate.

Other features of the Oregon plan must be viewed as negatively impacting distributive justice, or equal access to care without regard for ability to pay.

1. In 1996, 12% of beneficiaries reported being denied services because they were below the line on the priority list. Of those, 78% reported that the denial had worsened their health (Mitchell & Bentley, 2000). Medical services were rationed for Oregon’s poor but not for anyone else.

2. The plan targeted beneficial medical services in a state with considerable medical waste. In 1988, many areas of Oregon had average hospital occupancy rates below 50%. The closing of unneeded hospital beds could have saved $50 million per year, enough to pay for some of the treatments eliminated in the plan (Fisher et al., 1992). Oregon did not exhaust its options for painless cost control before proceeding to potentially painful rationing.

By 2004, the Oregon Health Plan had unraveled (Oberlander, 2006). The state entered a period of budgetary woes, new premiums and copays were instituted, and Oregon Health Plan enrollees responded by dropping out of the program. But the bold experiment in rational rationing remains alive in the minds of health care policymakers.

Rationing within One Institution: Intensive Care

Resources may be scarce throughout an entire nation or within a small hospital. Macroallocation refers to the amount and distribution of resources within a society, whereas microallocation refers to resource constraints at the level of an individual physician or institution. Macroallocation decisions may be more significant, affecting thousands or millions of people. Microallocation choices can be more acute, bringing ethical dilemmas into stark, uncompromising focus and placing issues of resource allocation squarely in the lap of the practicing physician. The microallocation choice involving Ms. Wilson incorporates all four ethical principles, which must be weighed and acted on within minutes: (1) Beneficence: For whom? This ideal cannot be realized for both patients. (2) Nonmaleficence: If Ms. Wilson is removed from the respirator, harm is done to her, but the price of not harming her is great for Mr. Ford. (3) Autonomy: Withdrawal of therapy requires the consent of the patient or family, which is impossible in Ms. Wilson’s case. (4) Justice: Should resources be distributed on a first-come first-served basis or according to need?

These are tragic decisions. Many physicians would remove Ms. Wilson from the respirator and make all efforts to save Mr. Ford. The main consideration would be medical effectiveness: Ms. Wilson’s chance of living more than a few months is slim, while Mr. Ford could be cured and live for many decades.

Less stark but similar decisions face physicians on a daily basis. On a busy day, which patients get more of the physician’s time? In a public hospital with an MRI waiting list, when should a physician call the radiologist and argue for an urgent scan, thereby pushing other people down on the waiting list? Situations involving microallocation demonstrate why, in real life, health care professionals are forced to balance the interests of one patient against those of another and the interests of individuals against the imperatives of society.

Most people in the United States believe that health care should be a right. But how much health care? If every person has a right to all beneficial health care, the nation may be unable to pay the bill or may be forced to limit other rights such as education or fire and police protection. One approach to this problem is to limit the health care right to a basic package of services. (In the case of Don Rich’s ACO, angiography for stable angina pectoris is not within the basic package.) Any services beyond the basics can be purchased by individuals who choose to spend their own money. This solution creates an ethical problem. If a service that does produce medical benefit is not included in the basic package or is denied by an insurance company medical director, that service becomes available only to those who can afford it. Where should society draw the line between a basic level of care that should be equally available to all, and “more than basic” services that may be purchased according to individual ability and willingness to pay (Eddy, 1991b)? Unless the basic package covers all beneficial health services, the principle of distributive justice, that all people equally receive a reasonable level of medical services without regard to ability to pay, will be compromised.

The principle of distributive justice holds that young and healthy people should pay more in health costs than they use in health services so that older and less healthy people can receive health services at a reasonable cost. Even from the perspective of one’s own long-term self-interest, it makes sense to pay more for health care while young and healthy, and to benefit when advanced age creates a greater risk of becoming sick.

A much-discussed issue involves individuals whose behavior, particularly smoking, eating unhealthy diets, and drinking alcohol in excess, is seen as contributing to their ill health.

One view holds that individuals who fall sick as a result of high-risk behavior such as smoking, substance abuse including use of alcohol, and consumption of high-fat foods are entirely responsible for their behavior and should pay higher health insurance premiums. Opponents of this idea see it as “blaming the victim” and argue that high-risk behaviors have a complex causation that may involve genetic, social, and environmental factors. They cite a number of facts to support their position. The food industry spends billions of dollars each year on television advertising; the average child sees thousands of food commercials each year, most of them for products with poor nutritional value. The tobacco industry heavily advertises to teenagers. Illegal drug use is associated with poverty, hopelessness, and easy availability of drugs. Some evidence finds a genetic predisposition to alcoholism. To the extent that individuals are not entirely at fault for high-risk behaviors, it would be unfair to charge them more for health insurance. On the other hand, it seems sensible that users of tobacco and alcohol pay through taxes on those products.

The predicament of limited resources has been likened to a herd of cattle grazing on a common pasture. The total grazing area may be regarded as the entirety of economic resources in the United States. A smaller pasture, the medical commons, comprises that portion of the grazing area dedicated to health care. The herd represents the nation’s physicians, using the resources of the commons in the process of providing care to patients. Physicians, guided by medicine’s moral imperative to “do everything possible for the patient,” continually attempt to extend the borders of the medical commons. But communities outside the medical commons have legitimate claims to societal resources and view the herd as encroaching on resources needed for other pursuits (Grumbach & Bodenheimer, 1990).

Who decides the magnitude of the medical commons, that is, the resources devoted to health care? Physicians and other health care providers, whose interventions on behalf of their patients add up to the totality of medical resources used? The sum of individual consumer choices operating through a free market? Health insurance plans, watching over their particular piece of the commons? Or government, using the political process to set budgetary limits on the entire health care system?

Traditionally, physicians and patients have had a great deal to say about the size of the medical commons. In the United States, the medical commons traditionally has been an open range. The quantity and price of medical visits, hospital days, surgeries, diagnostic studies, and pharmaceuticals determine the total costs of medical care. This is not the case in other nations, where government health care budgets constitute a “fence” around the medical commons, setting a clear limit on the quantity of resources available. Some advocates of fence-building in the United States have considered parceling the medical commons into numerous subpastures, each representing an HMO or Accountable Care Organization (see Chapter 6) working within the constraints of fixed, prepaid budgets. Not all pastures would be equal in size, and the fences might have holes, allowing patients to purchase additional services outside the organized systems of care.

Ethical considerations play a role in both open and closed medical care systems. In the United States open range, the principles of beneficence and autonomy have the upper hand, tending toward an expanding, though not equitable, system. Fenced-in systems, in contrast, balance the more expansive principles of beneficence and autonomy with the demands of distributive justice in order to allocate resources within the medical commons.

If the United States moves toward a more fenced-in medical commons, decisions will be needed about who gets what. Do all 90-year-old people with multiple organ failure receive kidney dialysis that may extend their lives only a few months? Are very low–birth-weight infants afforded neonatal intensive care even with a small chance of leading a normal life? Do individual physicians, interacting with their patients, have the final say in making these decisions? Should societal bodies such as government, commissions of interested parties, or professional associations set the rules?

Microallocation issues come down to daily clinical decisions about which individual patients will receive what types of care (Lo, 2013). Physicians and other caregivers may well recoil from the prospect of “bedside rationing,” believing that allocative decision making unduly compromises their commitment to the principles of beneficence and autonomy. Levinsky has argued that physicians must maintain their single-mindedness in maximizing care for each patient:

Yet if physicians abstain from the arena of macroallocation decision making, who is to decide? Currently, these decisions are often made by medical directors of private insurance companies and the leaders of the Medicare and Medicaid programs. Studies have documented that such decisions vary from plan to plan, and even within a single insurance plan, a medical director may make different decisions on different days for similar patients (Light, 1994). If physicians refuse to accept two masters, then medicine will be granting allocation decisions to insurance company and governmental officials. Physicians and other health professionals will continue to face individual patient responsibilities but will find it difficult to escape the obligation to balance the wishes of individual patients against the larger needs of society.

If physicians are to serve two masters (i.e., to maintain their dedication to individual patients while at the same time responsibly managing resources), they need rules to assist them. These rules should operate at both a population and an individual level. At the population level, society should ideally decide which general treatments are to be collectively paid for through the process of universal health insurance. At the individual level, rules are needed to guide decisions about the prioritization of resources for specific patients. The workings of organ transplantation provide a model of how physicians can serve two masters: They do everything possible to procure organs for their transplant patients, but also accept the rules of the system that attempt to allocate organs in a fair manner (Benjamin et al., 1994). The modern health care professional is caught in a global ethical dilemma. On the one hand, patients and their families expect the best that modern technology can offer, paid for through private or public insurance. The imperatives of beneficence, nonmaleficence, and autonomy rule the bedside. On the other hand, grave injustices take place on a daily basis: An uninsured young person with a curable illness is unable to pay for care, while an insured, bedridden individual who had a stroke incurs vast medical bills during the last weeks of her ebbing life. Should not the physician at the stroke patient’s bedside be concerned about both patients? However this dilemma is resolved, the principle of justice will relentlessly peek at the physician from under the bed.