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Freedom and Moral Diversity: The Moral Failures of Health Care in the Welfare State

Published online by Cambridge University Press:  13 January 2009

H. Tristram Engelhardt Jr
H. Tristram Engelhardt Jr
Affiliation:
Medicine and Philosophy, Baylor College of Medicine and Rice University
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Extract

In his 1993 health-care reform proposal, Bill Clinton offered health care as a civil right. If his proposal had been accepted, all Americans would have been guaranteed a basic package of health care. At the same time, they would have been forbidden to provide or purchase better basic health care, as a cost of participating in a national system to which they were compelled to contribute. A welfare entitlement would have been created and an egalitarian ethos enforced. This essay will address why such egalitarian proposals are morally unjustifiable, both in terms of the establishment of a uniform health-care welfare right, and in terms of the egalitarian constraints these proposals impose against the use of private resources in the purchase of better-quality basic health care, not to mention luxury care.

Type
Research Article
Information
Social Philosophy and Policy , Volume 14 , Issue 2 , Summer 1997 , pp. 180 - 196
Copyright
Copyright © Social Philosophy and Policy Foundation 1997

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References

1 The White House Domestic Policy Council, The President's Health Security Plan (New York: Times Books, 1993)Google Scholar, presents a robustly egalitarian blueprint for health-care policy. In its “Ethical Foundations of Health Reform,” the Clinton plan rejects a tiered system: “The system should avoid the creation of a tiered system providing care based only on differences of need, not individual or group characteristics” (p. 11). When the plan recommends that a new federal criminal statute be enacted prohibiting “the payment of bribes, gratuities or other inducements to administrators and employees of health plans, health alliances or state health care agencies” (p. 199), the goal is inter alia to proscribe payment to physicians for better basic care. The implications and the stated purpose of the plan are egalitarian. I have developed my critique of the Clinton plan in some detail elsewhere; see, for example, Engelhardt, H. Tristram Jr., “Health Care Reform: A Study in Moral Malfeasance,” journal of Medicine and Philosophy, vol. 19 (10 1994), pp. 501–16.CrossRefGoogle ScholarPubMed

2 I take it that the postmodern era is characterized by the circumstance, as a matter of sociological fact, (1) that all people do not share the same moral narrative or account, and (2) that this moral diversity is apparent and widely recognized. Moreover, as a matter of our epistemological condition, (3) there is no way to establish in purely secular terms the correct moral narrative or account without begging the question or engaging in an infinite regress, and (4) this is also widely recognized.

3 See also Engelhardt, H. Tristram Jr., Bioethics and Secular Humanism: The Search for a Common Morality (Philadelphia: Trinity Press International, 1991), esp. pp. 130–38.Google Scholar

4 See, for example, Iglehart, J. K., “Canada's Health Care System Faces Its Problems,” New England Journal of Medicine, vol. 322 (02 22, 1990), pp. 562–68CrossRefGoogle ScholarPubMed; Marmot, M. G., Smith, George D., Stansfeld, Stephen et al. , “Health Inequalities among British Civil Servants: The Whitehall II Study,” Lancet, vol. 337 (06 8, 1991), pp. 1387–93CrossRefGoogle ScholarPubMed; Schieber, G. J., Poullier, J. P., and Greenwald, L. M., “Health Spending, Delivery, and Outcomes in OECD Countries,” Health Affairs, vol. 12 (Summer 1993), pp. 120–29CrossRefGoogle ScholarPubMed; and Schieber, , Poullier, , and Greenwald, , “Health System Performance in OECD Countries, 1980–1992,” Health Affairs, vol. 13 (Fall 1994), pp. 101–12.CrossRefGoogle ScholarPubMed

5 Schieber, , Poullier, , and Greenwald, , “Health System Performance.”Google Scholar It is clear that much more would need to be said about differences among countries with regard to achieving morbidity relief. See, for example, Aaron, Henry J. and Schwartz, William B., The Painful Prescription (Washington, DC: Brookings Institution, 1984).Google Scholar

6 John Rawls invokes a hypothetical contracting position as an expository device to lay out what he takes to be the defining features of a just and voluntary society. The success of this account in producing the conclusions he wants depends on his prior characterization of the contractors' thin theory of the good, their level of aversion to risk, their absence of envy, etc. See Rawls, John, A Theory of Justice (Cambridge, MA: Harvard University Press, 1971).Google Scholar

7 If one of the worst possible outcomes is to die young, and if establishing just health-care policy on the basis of Rawls's original position leads one to adopt the maximin rule—which “tells us to rank alternatives by their worst possible outcomes: we are to adopt the alternative the worst outcome of which is superior to the worst outcomes of the others” (p. 152f.) — then it would seem that contractors in the original position would want first and foremost to protect themselves against pediatric deaths. They would want this because children who die young would count as the worst-off class, and because such deaths would most undermine fair equality of opportunity.

8 The claim here is not that disruptive disputes divide polities with regard to health-care allocations and/or delivery. Rather, the claim is that there are real and substantive moral disagreements, even when they may not preclude the imposition of a particular health-care policy. The debates regarding abortion, physician-assisted suicide, and egalitarian healthcare policy present these differences even when they do not rule out the possibility of governance.

9 For a study of the meaning of equality, see Temkin, Larry S., Inequality (New York: Oxford University Press, 1993), esp. pp. 157–90, 292–307.Google Scholar

10 One might interpret the so-called Oregon proposal as driven by an egalitarianism of altruism. Oregon proposed limiting the range of health-care resources available to Medicaid recipients so that all the poor could be covered. The proposal was that all the poor should be insured, although (1) Medicaid recipients would not receive the same level of health care as previously, and (2) the affluent would be able to purchase better basic care, as well as luxury care (i.e., there would be a tiered provision of health.care with a limited package for the poor and with the affluent left free to purchase whatever they wished and could afford). For discussions regarding the plan, see Strosberg, Martin A., Wiener, Joshua M., and Baker, Robert, eds., Rationing America's Medical Care: The Oregon Plan and Beyond (Washington, DC: Brookings Institution, 1992).Google Scholar

11 Schieber, , Poullier, , and Greenwald, , “Health System Performance.”Google Scholar

12 Although a judgment may be made to provide only a certain amount of resources to avoid particular risks of disability and death, when confronted with a particular person actually facing that disability or risk of death, groups will often provide much higher levels of resources. Even if a particular treatment is not considered to be obligatory (given its high cost and low yield), when a particular patient could possibly benefit from the treatment, there may be the inclination to rescue the patient, thus distorting policy developed for the prudent use of communal resources. For a treatment of the difficulties faced in health-care policy when confronted by particular individuals in need of medical rescue, see Morreim, E. Haavi, “Of Rescue and Responsibility: Learning to Live with Limits,” Journal of Medicine and Philosophy, vol. 19 (1994), pp. 455–70.CrossRefGoogle ScholarPubMed

13 Norman Daniels provides a justification of an egalitarian approach to health care that, in the service of equality of opportunity, advances arguments for proscribing the purchase of better basic diagnostic and therapeutic interventions. See Daniels, Norman, Just Health Care (New York: Cambridge University Press, 1985)CrossRefGoogle ScholarPubMed. Daniels was among the advisory members of the White House Task Force on National Health Reform, which developed President Clinton's 1993 health-care reform proposal. See also Brock, Dan and Daniels, Norman, “Ethical Foundations of the Clinton Administration's Proposed Health Care System,” Journal of the American Medical Association, vol. 271 (04 20, 1994), pp. 1189–96.CrossRefGoogle ScholarPubMed

14 For a discussion of different approaches to how health-care needs may generate rights, see Bole, Thomas J. III and Bondeson, William B., eds., Rights to Health Care (Dordrecht: Kluwer Academic Publishers, 1991)CrossRefGoogle Scholar. See also Morreim, E. Haavi, Balancing Act (Washington, DC: Georgetown University Press, 1995)Google Scholar; and Engelhardt, H. Tristram Jr., and Rie, Michael A., “Intensive Care Units, Scarce Resources, and Conflicting Principles of Justice,” Journal of the American Medical Association, vol. 255, no. 9 (03 7, 1986), pp. 1159–64.CrossRefGoogle ScholarPubMed

15 Engelhardt, H. Tristram Jr., “Sittlichkeit and Post-Modernity: An Hegelian Reconsideration of the State,” in Hegel Reconsidered: Beyond Metaphysics and the Authoritarian State, ed. Engelhardt, H. Tristram Jr., and Pinkard, Terry (Dordrecht: Kluwer Academic Publishers, 1994), pp. 211–24.CrossRefGoogle Scholar

16 The term “natural and social lotteries” identifies the natural and social forces that advantage and disadvantage individuals irrespective of their deserts: some live long and healthy lives, while others contract serious diseases and die young (examples of the natural lottery); some inherit fortunes, while others are born destitute (examples of the social lottery).

17 See, for example, Beito, David T., “‘This Enormous Army’: The Mutual Aid Tradition of American Fraternal Societies before the Twentieth Century,” elsewhere in this volume.Google Scholar

18 Wright, Virginia Baxter, “Will Quitting Smoking Help Medicare Solve Its Financial Problems?” Inquiry, vol. 23 (Spring 1986), pp. 76–82.Google ScholarPubMed

19 Because of disagreements regarding the proper moral response to inequality, people in good conscience buy into private health-care provision or go to other countries to secure treatment, as occurs with Canadians, egalitarians to the contrary notwithstanding.

20 For a study of the ambiguities involved in appeals to societal consensus for the authorization of health-care policy, see Engelhardt, H. Tristram Jr., “Consensus: How Much Can We Hope For?” in Bayertz, Kurt, ed., The Concept of Moral Consensus (Dordrecht: Kluwer Academic Publishers, 1994), pp. 19–40.CrossRefGoogle Scholar

21 Though there is no canonical content-full secular moral standard, it does not follow that such a standard is not available through revelation; see Engelhardt, H. Tristram Jr., “Moral Content, Tradition, and Grace: Rethinking the Possibility of a Christian Bioethics,” Christian Bioethics: Non-Ecumenical Studies in Medical Morality, vol. 1 (1995), pp. 29–47.CrossRefGoogle ScholarPubMed

22 MacIntyre, Alasdair, Whose Justice? Which Rationality? (Notre Dame, IN: University of Notre Dame Press, 1988).Google Scholar

23 I have explored these issues at length in The Foundations of Bioethics, 2d ed (New York: Oxford University Press, 1996), esp. pp. 67–72.Google Scholar

24 Moral constraints do exist within secular morality; they are derived from the right-making character of appeals to permission as the only source of authority in secular public policy. Even if all do not listen to God, and if reason cannot disclose a canonical content-full moral vision, one can still derive authority from common agreement, that is, from permission. See Engelhardt, , The Foundations of Bioethics, pp. 135–88.Google Scholar

25 Though the appeal to permission has content-full implications, it does not presuppose any particular content-full account of the good or the right. It does not involve a choice among different rankings of goods, preferences, or right-making conditions. In this sense, the appeal to permission does not involve even a thin account of the good or of the right (of the sort which Rawls, for example, offers in his thin theory pf the good, which does involve a lexical ordering of goods; see Rawls, , A Theory of justice, pp. 39ff.).Google Scholar

26 Nozick, Robert, Anarchy, State, and Utopia (New York: Basic Books, 1974), pp. 26–30.Google Scholar

27 I do not here explore the considerable difficulties faced in providing a general secular moral justification for taxation. Instead, attention is directed to how one ought to proceed in using common resources, presuming that they can be acquired legitimately. For my treatment of issues bearing on the legitimacy of taxation, see The Foundations of Bioethics, pp. 154–80.Google Scholar

28 Here focus is given only to the proposal of providing the indigent with a sum of money that can be expended only for health care. At stake is the freedom from the need to establish any particular medical morality in order to provide a voucher or a health-care purchase account (the provision of funds to the indigent for the purchase of health care). Either option—a voucher system or a purchase-account system—would allow recipients to choose among a number of competing morally and medically diverse health-care systems. A healthcare purchase account has the further secular moral advantage of providing the indigent with cash, so that they may more freely choose among the different health-care service options available. In this essay no attempt is made to explore the various proposals that have been advanced regarding medical savings accounts. For a recent review of the debates in this matter, see Keeler, Emmett, Malkin, Jesse, Goldman, Dana, and Buchanan, Joan, “Can Medical Savings Accounts for the Nonelderly Reduce Health Care Costs?” Journal of the American Medical Association, vol. 275, no. 21 (06 5, 1996), pp. 1666–71.CrossRefGoogle ScholarPubMed

29 The Roman Catholic account of the line between obligatory and non-obligatory care, between ordinary and extraordinary care, includes an acknowledgment of the appropriateness of inequalities in levels of care due to social status, usually correlated with wealth. See, for example, Cronin, Daniel A., “The Moral Law in Regard to the Ordinary and Extraordinary Means of Conserving Life,” in Conserving Human Life, ed. Smith, Russell E. (Braintree, MA: Pope John XXIII Center, 1989), pp. 1–145.Google Scholar

30 Engelhardt, H. Tristram Jr., “Vecchiaia, eutanasia, e diversità morale: La creazione di opzioni morali nell' assistenza sanitaria,” Bioetica, 1995, pp. 74–84.Google Scholar

31 These considerations require the repeal of statutory constraints on the purchase of better basic care of the sort that currently exist with respect to Medicare.

32 Significant mortality protection appears achievable at a rather minimal level of investment in health care; see Schieber, , Poullier, , and Greenwald, , “Health System Performance.”Google Scholar