8
Limits on Care

In the last chapter, we began to address the question of the physician's ethical duties with regard to limits on patient care. This issue is well within the ambit of medical ethics, because just doctoring considers not only the particular patient's care but also the institutional structure in which that care is given. In so doing, just doctoring does not dilute the relation between doctor and patient; rather it requires physicians to engage in ethical analysis of political and economic issues that affect the care of the individual patient. Just doctoring does not decrease the ethical commitment to the patient, but it does increase the scope of considerations for medical ethics. This aspect of just doctoring distinguishes it from traditional medical ethics, as we discussed in chapter 4. In just doctoring, the blinders on institutional arrangements are removed.1

Consider again the case of an HIV carrier who also abuses drugs. I had a patient recently who was HIV infected and who had been actively "shooting up" at the time of his hospitalization. He became genuinely concerned about his situation, and while we treated his infection, he voluntarily tapered himself off the methadone therapy we had initiated. He wanted to be rid of drugs, to "straighten himself out."

He was worried, however, that he would not be able to stay away from cocaine and heroin if he went back to his home after discharge. Therefore, he asked if we could not arrange some alternative housing as well as support through addiction services. He had no money, and so we considered publicly available programs. The social worker assigned to our team put together a list of options. Unfortunately, the

upshot was that he would have a long wait before he could get into a group home, and before he could receive adequate counseling and addiction treatment. When he was discharged, his only option was to return home to the poisonous milieu from which he had fled. He was soon abusing drugs again.

Just doctoring requires that physicians consider the institutional context in which they provide care. The ethics of medicine docs not begin and end at the doors of the hospital. The commitment to the patient, based on the liberal value of equality, requires that we do everything possible for this patient's health in terms of antibiotics and wound care. It also requires that we make every effort to place him in a group home where he can get support and counseling that would help him "stay straight."

As a just doctor, I might also be required to address the fact that there are no outpatient treatment options available for my patient. Do they not exist? Are there so few because the city has little money? Is the problem simply that my hospital's social workers are not aware of options for outpatient care? Just doctoring cannot require me to invite this gentleman to come and stay with my family while he waits for a treatment bed. But it does require that I try to understand the political context of the problem and make some effort to address it.

Consider another example. I have had patients in the past who were intravenous drug users who injected filthy materials into their veins. These materials tend to lodge on the heart valves and cause infections, destroying the valves. For one patient, we replaced his own valve with an artificial one. Later the same month, the patient was readmitted with the same problem, having infected the artificial valve. Leaving aside the tort and antidiscrimination issues contained in such a policy, suppose that my hospital had instituted a policy that would not allow second operations for drug abusers who infected an artificial heart valve by using drugs. What does medical ethics demand of me in such a case?

As a physician committed to a patient's welfare, I would do everything medically possible for the patient during his hospitalization. I would even develop a set of reasons why the "no surgery" policy should not apply to this particular patient. No matter what happened in the end, however, I would, as a just doctor, also try to address the issues that gave rise to the policy. Separate from my care for the individual patient, I would have a dun, to understand the origins of such a policy, and its rationale. If I found them unacceptable, I would try

to have the policy changed. This would not supersede my advocacy for my patient. Rather, it is a natural extension of my duty to that patient.

Moreover, I am not surprised by limits on care, since I practice medicine in a liberal state. I realize that there must be limits on the resources that we as a society put into health care. This is another aspect of just doctoring that distinguishes it from traditional medical ethics. Traditional medical ethics required simply that the doctor do everything possible for the patient, whatever the cost. We can no longer afford such an attitude. We must ration scarce medical resources.

The issue of rationing has remained generally submerged in discussions of medical care in this country. We have not wanted to face it, perhaps because it is antithetical to the constant growth in health care resources upon which the industry has relied, perhaps because Americans have been unwilling to accept the notion that access to health care must be limited. In any case, just doctoring demands explicit discussion of rationing.

These are the issues to which I now turn. Perhaps the best way to address them is to review the reasons why limits on care are much more apparent in this country now than they were twenty years ago. We will also contrast our American experience with those of other liberal states, especially Canada and Great Britain. We will then outline different types of limits on care and discuss the ethical approach to each of them in the liberal state.

The Reasons for Limits: Cost Control

In chapters 3 and 4 we reviewed in some detail the historical development of health care institutions. We discussed the peculiar relationships between doctors, hospitals, and third-party insurers, and how those relationships removed physician and patient decision making from the market. I asserted that these arrangements, and the insulation of medical care from the liberal market, were doomed. In part, this change gave rise to my theory, of just doctoring. In the following two chapters, as we begin to explore the ethics of just doctoring vis-à-vis the institutions of medical care, we will at times highlight the arguments with more technical discussions of economic

arrangements, thereby supplementing some of the points of chapters 3 and 4. In particular, to understand rationing of medical care, it is necessary to understand the social costs of such care.

The past three decades have witnessed huge increases in our national health expenditures.2 These increases in health care costs have in turn led to huge increases in federal outlays for Medicare and Medicaid. For example, in 1967 the total federal expenditures for Medicare were $4.5 billion.3 In 1975, the figure was $15.6 billion, and by 1982 it had increased to $50.9 billion. In fiscal year 1987, Medicare provided health insurance coverage for 31 million Americans at a cost of $80 billion, while Medicaid covered 28 million poor Americans and the total cost to the federal government was $27.4 billion. Overall, by 1987, health care consumed 11.5 percent of the Gross National Product in the United States, compared with 8.6 percent in Canada and even less in Britain.4

Many have attributed the increases in health care costs, which have outstripped general inflation consistently over the past two decades, to the economic arrangements that exist in American medical care. They argue that the physician controls both supply and demand of health care goods. As we discussed in chapter 4, this leads to a peculiar set of economic and ethical relationships, in which the physician consistently faces moral hazards.5 The organization of hospitals compounds the risk. Indeed, M. Pauly and T. Redisch have characterized the nonprofit hospital as a physicians' cooperative that assures physician economic prerogatives.6 Since the patient is not a fully informed consumer of health care goods, she can do little to constrain health care costs. Relying until recently on federal insurance programs and private commercial insurers that reimburse at the "usual and customary, fee" level, hospitals have very little incentive to control physician behavior. Thus only the deep pockets, the commercial insurers, and the state and federal governments have any incentive to constrain health care costs. Using empirical methods, Joseph Newhouse suggests that the insurance arrangements underlying medical care in this country account for a significant proportion of the increase in health costs.7

Others have identified a number of additional contributors to the rise in hospital costs. One corollary to the moral hazard theory, concerns the number of hospital beds. Roemer's law, as it is known, holds that physicians will fill all available beds in a given geographic area.8 They can do so because they control supply and demand.

The introduction of new technology is perhaps an even more im-

portant reason for the increase in health care costs. Through acquisition of new technology, and by using the new technology to supplement rather than replace old technology, physicians are able to create demand (and to fill hospital beds).9 While the portion of the increase in health care costs that can be attributed to new technology is debatable, there can be little doubt that it is substantial.10 New techniques and procedures continue to be integrated into medical practice with little oversight, at least until recently.11

All these contributors to the increase in health care costs are interrelated. Consider the example of a friend's father who was recently admitted to our hospital. He had had some vague chest pressure, and his doctor thought it might be angina pain. A resting electrocardiogram was not helpful in making the diagnosis, and so an exercise tolerance test, involving electrocardiography while the patient exercises, was employed. The test was equivocal, so the doctor chose another similar exercise test, only this time the patient was injected with thallium, to enable the doctors to see any defects in the blood flow of the heart.

The exercise test with thallium was positive for ischemia, or decreased blood flow to the heart, and so the patient was referred for cardiac catheterization. Catheterization would provide us with information about specific blockages in the coronary arteries that were causing the ischemia. The patient's catheterization revealed some disease in two vessels of the heart. His doctors recommended angioplasty, or balloon dilation of the blocked vessels. He assented. The procedure went well, but on the first day after the procedure, he developed chest pain, with electrocardiographic changes. The patient's doctors told him he would have to undergo coronary artery, bypass grafting surgery. He assented, did well in the operation, and is now free of pain.

This patient was a very well educated man. In addition, his son, also very intelligent, was involved. Moreover, his son is a rising star in the litigation department of a local law firm, a position which not only garners some attention (if not respect) around the hospital, but which also trained him to ask the right questions of experts. Thus the patient and his family were as capable of being as informed as any patient can be, Nonetheless, they were almost completely dependent on the recommendations of their physicians, as most of us would be.

The physicians were not a greedy and calculating lot. Each decision they made was reasonable, each step correct. However, in the end the patient's insurer ended up with a lot of medical bills, based largely on

numerous tests that in hindsight may have been unnecessary. The point is not that hindsight is always 20/20, but that physicians will use all available technology in their decision-making process, and it is not typically a process in which the decision makers concern themselves with costs. In this manner, the American health care system's total costs have grown enormously.

Of course, others might argue that lawyers and judges are at fault for at least some of the costs of health care because fears of litigation induce physicians to do needless tests. So-called defensive medicine does not increase the quality of care, but it does decrease the possibility of suit. The influence of defensive medicine is, however, difficult to assess (see chapter 6); it may be quite great or quite small. While it is a powerful emotional argument for most physicians, they also recognize that it is very difficult to identify specific acts of defensive medicine, except, perhaps, emergency room X-rays.12 Moreover, recent investigations suggest that the threat of malpractice litigation is a bona fide deterrent of bad medical practice, and this presumably induces higher quality, care. Therefore, we might be willing to accept some defensive medicine in return for better quality care.

No matter what the cause, in the mid- to late-1970s, both state and federal governments began to address the problem of rising health care costs and unnecessary, care. One should expect little else from the liberal state. Both traditional and modern liberals recognize that the liberal state has limits. Modern liberalism, as interpreted by Rawls, guarantees certain fundamental or primary goods. These could include, for instance, housing, health care, and education. However, guarantees of primary goods do not mean that everyone receives equal amounts of those goods: the government does not guarantee that everyone will receive an education at Princeton, or a four bedroom house with a yard.

The same is true for health. While there is general agreement in the liberal state that access to basic health care should not depend on one's ability to pay, this does not mean that limitless resources can be designated for the health care industry or that every individual can expect to receive equal quantities of care. The liberal guarantee of equal concern and respect for all requires that some level of health care be available to all. It does not, however, preclude rationing health care. Nor does it preclude efforts to control costs that bring about some rationing.

This is not, of course, to say that all liberal states will pursue the

same course. Some, for instance Canada and Great Britain, envision health care as primary to individual welfare, and thus make greater efforts than the United States to provide a decent minimum of health care for all.13 Nor does this mean that these countries spend more; rather, they commit resources to less costly, perhaps more effective, care options. These approaches must be of interest to a just doctor in any liberal state, but for now let us review the American experience.

Initial American state legislative efforts to control costs emphasized rate regulation and certificate of need rules.14 The latter policy, initiative was meant to decrease the total number of hospital beds, and also to reduce and control use of technology such as CT scanners. The former, rate regulation, was intended to force hospitals to develop cost-saving measures by capping their reimbursement levels.

Since these initiatives were only partially successful, after 1980, the Reagan administration developed a two-prong cost control strategy: increasing competition in the health care market and prospective payment for Medicare. Because the Reagan administration was philosophically committed to market solutions for problems of scarce resources, the competitive strategy was especially congenial.15 While the paradigm of nonprofit hospitals had long dominated medical care, in the late 1970s and early 1980s for-profit institutions were steadily increasing their share of the market.16 The federal government encouraged the profit motive, and also encouraged innovations in health care insurance, especially health maintenance organizations (HMOs) and preferred provider organizations (PPOs).17 Advocates argued that these new organizational forms would provide administrators with incentives to control providers' clinical decision making. They would also provide the informed consumer with more choice in health insurance.18 The federal courts provided help as well.19 The new strategy appears to have developed a competitive outlook among health care administrators and certainly has accelerated the changes in the health care industry that we noted in chapter 4.20

One new policy initiative should be discussed in more detail, as it helps reveal the nature of rationing in our health care system. In 1983 the administration endorsed a prospective payment plan for Medicare hospital costs. In the past, Medicare had reimbursed hospitals on a usual and customary fee basis. This "open-pocket approach" had fueled the great increase in Medicare outlays in the late 1970s and early 1980s.

Very quietly, Congress enacted a prospective payment system in

Title 6 of the Social Security, Amendments of 1983.21 Since under the new system, hospitals would receive only a predetermined amount of payment for the care of a patient with a particular kind of problem, the amendments created new incentives for hospitals to limit the amount of care provided each hospital day, and to limit the number of hospital days. Prospective payment thus represented a revolutionary change in hospital services reimbursement under Medicare.22 It appears that the prospective payment system has indeed led to a moderation in the rise in Medicare costs.23

Many have questioned the justice of prospective payment systems.24 They argue that prospective payment is unjust because it can lead to rationing of care, the burden of which falls disproportionately on a few. For example, prospective payment creates incentives for hospitals to move patients out as quickly as possible. This means that patients will be transferred to nursing homes with more expediency, and that patients in nursing homes will be sicker than patients in nursing homes in the past. Those who are sick, but not sick enough to warrant further hospitalization, may receive poorer quality, care than they would have received had they stayed in the hospital.25

In other words, prospective payment represents rationing.26 In particular, its cost-cutting measures decrease access to health care for elderly patients. We as a society arc unwilling to provide the open-ended care for the elderly that was offered in the "usual and customary, fee" financing relationships. This fact must be clearly understood by all who are involved in promulgating similar regulations. While the liberal state is not in theory, opposed to rationing access to care, it is opposed to rationing of health care when that rationing fails to provide equal concern and respect for all individuals. Prospective payment means that elderly individuals will have fewer resources committed to their care than will other individuals. This is acceptable to the liberal state so long as the burden falls rather evenly among the elderly. Justice is served so long as there is some equity in rationing measures.

It is of great importance, however, that rationing in programs like prospective payment is not hidden from public view lest the equality. and fairness issues also remain concealed. Thus physicians should recognize that cost cutting involves rationing and that concern for patients requires that the cost cutting not fall disproportionately on certain minorities. A primary concern of just doctoring must be that rationing is openly recognized and that any unfairness or inequality it creates must be addressed. For example, prospective payment should

be scrutinized closely, to discern whether it unfairly limits care. Since it lacks a "severity. of illness" correction factor, it may be that the more severely ill will receive less care than do others—that is, there will be unintended inequality, in care. Therefore, medical ethics as just doctoring encourages efforts to bring about a more just system of prospective payment, for example one that takes into account severity of illness.27

This viewpoint differs considerably from traditional medical ethics. The ethics of beneficence inherently opposes any cost control in which physicians play a role. Those who support a theory of beneficence argue that patients, not costs, must come first.28 In other words, since the patient comes first, the physicians cannot involve themselves in efforts to reduce the total cost of health care, especially efforts that affect clinical decision making. This attitude, which we discussed in detail in chapter 4, goes hand-in-hand with the isolation of the physician from considerations of justice and of political and economic issues. It is the attitude, I have argued, that led physicians to promote a system of health care that depended, unrealistically, on unlimited resources.

I believe physicians must put the beneficence model behind them. Medical ethics as just doctoring requires that physicians consider the political context in which care occurs. This includes consideration by physicians of the need to moderate health care costs. Thus physicians must accept prospective payment and other similar regulations. Their ethical duty is not to resist the effort to control costs. Rather, one's duty as a just doctor is to help make those cost controls work in the best possible manner, and also to ensure that cost control is as good and just as possible.29 One must openly recognize it as rationing, and must help to ensure that the rationing is fair.

Rationing is in essence a social decision to limit resources available to some so that others can benefit. Prospective payment means that the government spends less on medical care for Medicare beneficiaries. Presumably, other social programs will benefit. Nonetheless, we cannot deny that rationing does limit the negative freedom of specific groups of people. As discussed in chapters 5 and 6, one goal of just doctoring has been to constrain the ways in which doctors limit patients' negative freedom. Thus recognition of the relationship of just doctoring to cost control raises some new questions. What role should physicians play in more explicit forms of rationing, apart from cost control measures?

Perhaps even more to the point, should physicians advocate new models of health care delivery that provide a more equal level of care for all citizens? Does a Canadian model featuring fee controls and central financing make better medical ethical sense in a liberal state? For now, we will leave aside this more fundamental question and explore the physician's role in rationing in our own American health care system.

Limits on Care at the End of Life

Until recently in this country, we have not been concerned about the issue of physician-imposed limits on patient care. Discussion has focused instead on the right of the patient to refuse care. Over the past few decades, we have witnessed a steady evolution of society's attitude toward the care of the terminally ill, an evolution that has supported patients' negative freedom. The limits of patient autonomy, the role of the family's substituted judgment, and the prerogatives of physicians have been openly debated. Courts have endorsed the notion that patients' decisions to limit care should be respected. These cases have largely been based on respect for the patient's autonomy, and are consistent with decisions on informed consent.

The details of this evolution are revealing. In the decision In re Quinlan, the New Jersey Supreme Court became the first court to allow withdrawal of lift support from an incompetent person.30 Since Karen Quinlan's own views on continued life support were somewhat unclear, the court recognized that a substituted judgment could be made on her behalf by a family member, in this case her father.31 Many other courts have followed the Quinlan precedent with regard to withdrawal of a variety of medical therapies.32 Most recently this right of refusal has been applied to such "ordinary" supports as feeding tubes.33 Other courts have reiterated that competent patients should be able to refuse therapy, and that an incompetent patient's previously stated wishes involving life support should be honored.34

These court decisions have tended to reassure physicians that the law countenances withdrawal of care, especially after the Massachusetts

Supreme Judicial Court, and several legal academics, clarified the intention of that court's ruling in Saikewicz.35 Again, it is quite clear that the courts in most of these cases were basing their decisions on the patient's autonomy, not on the prerogatives of the medical profession. In other words, concerns about the negative freedom of the patient not reiterations of the positive freedom of the physicians, led the law as integrity to endorse patient desires for limits on care. Thus the liberal state permits self-assumed limits on care for individual citizens. Physicians were able to accept these rulings because, in theory, they were committed above all to the patient.

There are, however, strains within this apparent consensus. Although the judges' opinions in court cases clearly indicated that it was the patient's liberty, not the physician's paternalism, which drove the decisions, it appears that physicians may have misinterpreted the message. The clear intention of the courts notwithstanding, physicians have begun discussing guidelines for terminating such care as ventilators36 and renal dialysis without emphasizing the importance of the patient's wishes.37 There are now articles that suggest that physicians need not consult patients about treatment for "no code" status if the physician deems such therapy to lack medical benefit.38 Some physicians argue that doctors should consider not "offering" patients cardiopulmonary resuscitation and, by implication, other life support measures when such therapy seems to them inappropriate for the patient.39

Physicians have also begun to report on their clinical experience with decisions to overrule patients', or their families', wishes for continued "full care." One group of doctors acknowledge that they have issued unofficial orders not to revive dying patients that violate the patients' and families' express wishes.40 I, myself, have reviewed cases in which a hospital ethics committee limited patients care against their, or their families, stated preference.41

The reasoning that underlies decisions by doctors to overrule patients or their families is explicitly ethical and emphasizes the principle of beneficence.42 Physicians believe, quite reasonably, that patients have no right to demand medical care that is without benefit.43 They also argue that care should be limited when it is futile.44 Thus they argue that it is in the patient's best interest to limit care at times, no matter what the patient, or the incompetent patient's family, says. As in informed consent, this line of reasoning demonstrates how beneficence theories of medical ethics can lead to great disrespect for patient

autonomy. The "physician knows best" attitude leads to replacement of patient negative freedom with doctor positive freedom.

Courts have now begun to reiterate that decisions about limitations on care are a matter of patient autonomy. As such, they are nontransferable. Thus a New York court has recently required previously made explicit statements reflecting a firm commitment of the patient him- or herself before allowing termination of life support for an incompetent individual.45 More importantly, the Supreme Court has recently ruled that the federal constitutional privacy rights cannot be used to justify withdrawal of support for a patient in a persistent vegetative state unless the patient's wishes were clearly stated.46

These decisions should provide some warning to physicians that limits on care for individual patients are a matter of individual autonomy. Rationing based on an individual physician's judgment that further care has little likelihood of increasing the patient's potential for survival, or of increasing the number of "quality" days the patient will live, is not explicitly linked to a concern for scarce medical resources, and should not be allowed. The law will step forward to restrict physician's prerogative through decisions like Cruzan. It is hoped that such decisions will also prompt more health professionals to discuss with patients their desires for "heroic measures" and crystallize these desires in "living wills."47

Nonetheless, the concept of limits on care for the elderly should be a part of society's concern about scarce resources.48 Over the past decade, several studies have shown that persons who are dying tend to consume a disproportionate amount of scarce medical resources.49 For instance, one study showed that 5.9 percent of Medicare beneficiaries who died in 1978 required nearly 28 percent of all Medicare reimbursement for that year. Moreover, many individuals who receive intensive care in hospitals, that is very expensive care, die soon after their discharge from the hospital.50 Recent research suggests that increased hospital use does not, in aggregate, lead to greater life expectancy.51 Thus the provision of hospital care for the elderly is a likely target for those who would try to decrease the overall costs of medical care by rationing resources.

As we discussed, this sort of reallocation is strictly within the bounds of the liberal state. Limiting care for the elderly will create more funds, presumably, for health care for others. Moreover, we might be able to provide better preventive and primary care to a larger group of individuals by limiting intensive care for elderly patients.

Thus limits on care demonstrate equal concern and respect for all individuals in that the resources now used disproportionately by some, the elderly, are redistributed to others.

But, this kind of reallocation raises a serious question: should the individual physician be able to make this kind of decision? Do we as a society want physicians making controversial decisions about terminating care? Should we continue to allow the erosion of the once widely accepted notion that a competent patient or the family of an incompetent patient determines the nature of limits on care?52

I believe that the answer must be no, for at least two reasons. First, we must recognize that the doctor-patient relationship does not occur in a world ruled only by ideals of justice and ethics. Rather, it operates in a much more emotionally charged environment. The intellectual and physical weaknesses of human beings, both doctor and patient, are constant companions of medical care.53

Second, as we discussed in chapter 5, doctors have not in general demonstrated their willingness to communicate openly with patients. This is especially true in the cases of patients who are critically ill. Several studies have demonstrated how little discussion there is with patients about "life and death" issues.54 Perhaps some of the most striking findings of my review of an ethics committee's experience were those situations in which the treating physicians had assumed that their patients were incompetent, while the ethics committee found the patients rational and reasonable in their requests for "full care."

All of this indicates that the isolated doctor-patient relationship lacks a basis for decisions about limiting care without patient or family consent. Physicians can too easily fail to understand the irrational impulses that contribute to their actions; they assume they are certain even when they cannot be. Therefore it seems a very bad idea to grant physicians greater authority in decisions to limit care by leaving allocation decisions totally within the doctor-patient relationship.

If not the physician alone, then who else should decide when scarce resources demand cutbacks in care? Rationing of care for the elderly involves issues that all concerned about medical ethics, indeed all citizens of the liberal state, must now address. It seems to me that physician decisions must be made within guidelines developed by a broad social consensus.

Given the gravity of the decisions to limit care, and the importance of this issue to all members of society, it follows that there should be general social participation in the development of a rationing program.

The effort to limit care for the elderly will generate controversies of great importance to the liberal state, because that effort strikes at the heart of liberalism—the trade-offs between negative freedom and equal concern and respect for each citizen. Limits on care will mean that some individuals will be denied care, even care they can afford (and might have saved for) so that others can receive more care in the future. Developing guidelines acceptable to the democratic majority, will require broad input, especially from patients and their advocates. The wider the participation, the more readily acceptable will be the results. Therefore, efforts will have to be made to submit such issues to the public at large, or at least to their representatives in legislatures. This process will be critical to the just resolution of rationing.

The development of just guidelines is not an easy task. While an across-the-board prohibition on intensive care for those over the age of eighty, such as that proposed by Daniel Callahan, makes great sense in terms of being simple and just, this alternative may not be efficient.55 For example, some eighty year olds are still very vigorous, and some people under the age of sixty-five may be quite debilitated. This means that intensive care for debilitated individuals under the age of sixty-five will save fewer days of enjoyable life than would intensive care for abler patients over the age of seventy-five (that is, assuming we can define what is enjoyable about one's life). Thus the physically vigorous elderly person may be someone we want to support with life-extending treatment whereas we would not do so for many younger but debilitated people. All these issues must be studied and debated.56

In a book concerned primarily with medical ethics, we must ask again, what should the role of physicians be in the debate on the rationing of care? On the one hand, I have argued that it is foolish to think that physicians will not play a role in cost cutting. Specifically, I have asserted that prospective payment mechanisms will influence physicians' decision making and that it is important for them to be aware of such influences. On the other hand, I have said it is not a good idea to allow physicians to make ad hoc decisions about limits on care for elderly patients, for this gives them far too much authority. These seemingly contradictory arguments are really two sides of the same coin. In issues of rationing—whether we are talking about prospective payment plans or the limitation of care for the elderly—there should be guidelines for the physician to follow.

For the practice of medicine in a prospective payment program,

those guidelines are fairly clear-cut. The physician must provide good quality care, despite incentives for discharging patients earlier than might be done under other reimbursement arrangements. To fail to meet the standard of care would be to violate ethical imperatives as well as to open the physician to charges of malpractice.

In the case of the physician's decision to limit care, however, the guidelines are far from clear. A physician using her clinical judgment is on familiar ground when faced with decisions on standard of care for illnesses. She is much less prepared when trying to decide about futility of care, even less so when trying to integrate considerations of quality of life and costs of therapy. Therefore, physicians' prerogatives to ration care (in the form of decisions to limit care for the elderly against their wishes) should be restricted. Just doctors need the support of social consensus before becoming involved in this form of rationing.

While we want to curtail physician decision making in this area, physicians should still be involved in the policy debate. Indeed, physician viewpoints will be particularly valuable in the process of developing a consensus. More to the point, physicians have an ethical duty, as just doctors, to help society develop fair guidelines. Physicians are committed to protecting patients and to maintaining the status of health care as a cooperative sphere within the liberal state. In addition, however, physicians as just doctors realize that there are social limits on the expenditure of funds for health care. Allocation decisions will have an impact on both individual patients and the health care industry. Physicians must therefore address such decisions and help society reach the most just allocation. As L. Churchill suggests, then, physicians should play an active role in the "macro" allocation decisions, and then honestly apply the guidelines developed to particular decisions on rationing.57 They should also invite the oversight of non-physicians, Perhaps using ethics committees to review a sample of the bedside allocation decisions. Openness and honesty, are critical. Just physicians must be willing to separate their role in the larger debate on rationing from the decisions they make for each patient.

What form will the larger debate take? This is very difficult to say with regard to rationing based on age. Discussions in this area have only begun, and there are clearly many problems to be resolved.58 Rather than try to specify the nature of allocation decisions based on age, it is perhaps easier to move to an area in which we have had more explicit and detailed discussions of rationing. That area is organ trans-

plantation. A brief review of the history of organ transplantation in this country can help define the role of just doctoring in the development of rationing guidelines.

Rationing Organs

The procurement of human organs for transplantation provides perhaps the clearest example of rationing of health care goods in our society. Nowhere else is it as clear that a liberal state must trade off the negative freedom of individuals for the virtue of equal concern and respect. Scarce organs must be allocated according to explicit criteria. Economics and ethics interact very directly.

The transplantation of organs involves very expensive technology. There are indeed serious questions surrounding the cost-effectiveness of transplantation. Although it is an example of truly impressive technology and is potentially quite useful, one must continually ask whether widespread transplantation of organs is something that is good for society. Hence, transplantation is an obvious target for social rationing.

The history of organ transplantation in this country reveals that the government has played a central role in rationing decisions.59 Most important, the government has financed the transplantation of organs, beginning with kidneys in 1972.60 The End Stage Renal Disease Program stipulates that kidney transplants are to be paid for by the federal government under Medicare. This financing has led to the underwriting of nearly eight thousand kidney transplantations per year in the United States.61 In the mid-1980s, when it became clear that the immunosuppressant drug cyclosporine would increase the survival rate of organ transplant patients, the federal government developed further legislation on the financing of organ transplantations. The National Organ Transplantation Act of 1984 formed a task force to deal with policy issues underlying organ procurement and distribution. In addition, it created the Organ Procurement and Transplantation Network.62 The Act also banned the purchase and sales of human organs. In 1986, Congress again addressed issues of organ transplantation. This legislation established new rules for the procurement of organs. More important, it required that all transplantation programs must

meet a certain set of detailed requirements, including rules regarding staffing patterns and qualifications of surgeons, as well as appropriate survival rates for the patients.

These efforts by the federal government to finance and regulate transplantation address the allocation of scarce resources. For kidney transplantation, the federal government has decided to deal with scarcity by underwriting. However, this program costs more than $300 million per year. Since the costs of kidney transplantations have been so great, the government has been reticent about underwriting in a similar fashion the transplantation of hearts, livers, or bone marrow. Instead, the government has opted for a patchwork of volunteer efforts, matched by spotty funding for certain centers and governed by the statutes noted above.63 In particular, the federal government has been reluctant to underwrite transplantation on a broad basis until it is clear that the therapy is no longer experimental.

This has been particularly true in regard to heart and liver transplantation. Although heart transplantation sparked a great deal of interest in the late 1960s, survival rates were miserable and many centers abandoned the procedure.64 Several researchers did, however, continue to explore heart transplantation and immunosuppression. In particular, Dr. Norman Shumway at Stanford University Medical Center carefully worked out the technical and medical aspects of the transplantation process. Given his increasing success, and the declaration by certain Blue Cross programs that the transplantation process was no longer experimental, the Department of Health and Human Services decided to undertake a complete study of the efficacy of heart transplantation.65 Following on this study, the Health Care Financing Administration (HCFA) began to fund a limited number of heart transplantations in certain centers that could demonstrate good patient outcome. In particular, the HCFA would only pay for heart transplantations of disabled individuals, and would only pay for them at cardiac transplantation programs that had documented evidence of twelve or more surviving patients in the previous two years.66 The same sort of story has evolved for liver transplantation, although its annals have often included more melodramatic episodes.67

In summary, decisions involving organ transplantation in this country reveal a certain admirable rationality. The End Stage Renal Disease program was thought, at the time it was instituted, to be a relatively efficient and not very expensive alternative. The government would simply underwrite the cost of transplantation. With hindsight, it is

now clear that the renal disease program is inordinately expensive; indeed, it is probably not a program that the federal government would underwrite today. While the government is unwilling to pull the rug out from under those who now expect transplantation (and dialysis), the lesson has been learned. Heart transplantation and liver transplantation will only be underwritten insofar as their efficacy can be demonstrated. The government has very carefully selected criteria for underwriting transplantation. Since the procedure is so expensive and since private financing is unavailable in the majority of cases, the government's tightening of its purse strings limits its availability. The government has thus made an explicit decision to ration heart and liver transplantations until it is clear that these procedures are cost effective. In other words, the liberal state has declared that it will not decrease the negative freedom of individuals through higher taxes so that procedures which may not be cost effective can be completed.

None of this, however, sheds much light on the role of physicians in the allocation of scarce resources like organs. It is notable that in other societies, physicians play a particularly central role in the rationing of renal dialysis and kidney transplantation. For instance, in Great Britain, rationing is undertaken at the level of the general, or primary care, practitioner. British practitioners employ few explicit criteria when making these decisions. William Schwartz and Henry Aaron relate that an English consultant, when queried why he had not recommended renal dialysis for a particular patient, replied, "Everyone over 55 is a bit crumbly." In other words, such patients are not really suitable candidates for therapy.68 General practitioners in Great Britain receive signals from nephrologists at major regional centers on the guidelines for transplantation, and they translate these into rationalizations for individual patients.69

While this is the approach in one liberal state, it docs not seem to be the best approach for all liberal states, and is not necessarily a model for just doctoring. The theory of just doctoring involves equal concern and respect for all individuals, as well as consideration of each individual's negative freedom. The use of rationalizations for individual patients, while acceptable in some liberal states, would not be acceptable in ours and would not be acceptable for just doctoring. Open communication as well as altruistic commitment to individual patients is what converts health care into a sphere of moral activity within the liberal state. Thus, just doctors must be honest with their patients about criteria for organ transplantation.

As we concluded in the previous section, the best role for physicians is twofold. First, they should help society develop guidelines for rationing; second, they should honestly apply these guidelines to clinical practice. Physicians have long been involved in the development of such criteria. For instance, in the early 1960s when renal dialysis was just beginning, the artificial kidney center at Swedish Hospital in Seattle, Washington, developed an admission and policy committee. This committee was given charge of decisions about which patients would be granted access to the small number of available dialysis machines. The committee, including several physicians, developed a set of criteria that included marital status, number of dependents, occupation, future potential, and past performances.70 Applying these explicit criteria was quite difficult. Moreover, some of the criteria seemed to be biased in favor of patients who were similar to those individuals who served on the committee. Nonetheless, this approach suggests a role for physicians, at least with regard to biological criteria.

As noted above, we have largely abandoned rationing of kidneys or dialysis. The federal government underwrites the effort. Most individuals who have many medical indications for and no medical contraindication to transplantation can be referred for procedures. The same is not true for heart or liver transplantation. In these cases, all disabled individuals who fit the Medicare criteria must queue up at designated centers and wait for available hearts or livers. Acceptance at these centers must be and is based on severity of the patient's disease, a biological criterion that doctors are best equipped to assess. Thus the just doctor's role should be to monitor the queue and ensure that the line is formed according to severity of the illness, and not according to other factors such as ability to pay, or ability to donate funds to a nonprofit institution.71 This is one aspect of the role of just doctoring in rationing of organs.

The example of bone marrow transplantation reveals another aspect of the role of just doctoring with regard to transplant rationing. Bone marrow transplantation involves providing new bone marrow for those suffering from certain types of cancer. These individuals undergo chemotherapy, which eradicates their cancer burden, but also kills all off the fast-growing cells in the bone marrow. Therefore, they require transplantation of bone marrow after the chemotherapy has eradicated the cancer. This therapy is used most frequently in tumors of the blood-forming system, such as leukemia and multiple myeloma.

One of the biological issues that distinguishes bone marrow trans-

plantation from other forms of transplantation is the abundance of bone marrow. Unlike transplantation of the liver or heart, and in some ways unlike kidney transplantation, bone marrow transplantation does not involve the use of scarce organs (although finding an appropriate match can sometimes be difficult). Moreover, donating bone marrow does not significantly impair the donor. Therefore, there is no scarcity of potential donors as there is for heart or liver transplantation.

As a result, the rationing of bone marrow transplantation has tended to revolve around the health care expenditures required for this technology. Unlike heart and liver transplants, debates on bone marrow transplantation emphasize the total cost of the procedure, rather than the ethical issues surrounding the harvesting of organs or the solicitation of organ donations. It reflects primarily allocation decisions, not the rationing aspects of scarce organs. Like other forms of transplantation, bone marrow transplantation is very expensive. Costs for treatment of lymphoma or leukemia using bone marrow transplantation methods range from $100,000 to $250,000. Many insurers are unwilling to pay for such expensive therapy. Moreover, medical centers that provide bone marrow transplantation are often unwilling to undertake the process unless the patient can provide a large down payment. Yet bone marrow transplantation is now accepted therapy for various types of leukemia and lymphoma. Moreover, long-term survival rates are quite good, especially in treatment. Perhaps most important, bone marrow transplantation is used in certain types of refractory pediatric leukemias.72

The federal government has not assumed a specific role in bone marrow transplantation and docs not underwrite its costs as the government has done for renal transplantation through the End Stage Renal Disease Program. Nor does the federal government regulate the centers that perform bone marrow transplantations in the same manner in which it regulates those that perform heart and liver transplantations. Thus bone marrow transplantation has been left to the control of administrators, scientists, and physicians at the various teaching centers that have pursued this technology.

Like other forms of organ transplantation, the costs associated with bone marrow transplantation have led to emotionally charged individual cases. Consider, for instance, a case from late 1987 in Oregon. A seven-year-old boy with leukemia required a bone marrow transplantation. However, the Oregon legislature had curtailed Medicaid funding for heart, liver, pancreas, and bone marrow transplant pa-

tients, owing to a fiscal shortfall. As a result, the seven-year-old was denied transplantation. Private fund-raising efforts fell short of the $100,000 necessary to guarantee the transplantation. The child died. There is little doubt that his death was related to rationing of health care resources.

The Oregon legislature was well prepared for the public outcry surrounding this case. Since the early 1980s, grass roots organizations in Oregon had attempted to increase public understanding of allocation decisions of health care. In 1982, a conference involving these groups posed two important questions: "How does society value expensive curative medical care relative to preventive services being progressively curtailed in government budget?" and "Can the present implicit rationing of health care be made explicit and concur with community values?"73 After this conference, committees organized a series of town meetings. During several hundred meetings, thousands of citizens exchanged opinions and educated themselves.74 There can be little doubt that the impact of these grass roots agencies played a role in the framing of the problem by the Oregon legislature, and led to the decision to curtail funding for transplants.

Recently, the Oregon legislature has passed a law that would require the governor to appoint a commission to develop a prioritized list of medical services funded by state Medicaid programs. This commission would be guided by citizen input. In return for restrictions on services, the law loosens somewhat stringent eligibility standards for Medicaid, and increases by 77,000 the number of people who are covered by Medicaid. Part of the plan depends on developing scientific data on treatment outcomes and the effectiveness of certain therapies. Only with these data will the commission be able to develop an appropriately prioritized list.

As we discussed in previous chapters, however, the appropriateness of procedures can be very difficult to gauge. There has been very little research into variation in care between geographic regions, but the evidence we do have indicates that appropriateness is an ill-defined concept in medical care.75 For instance, there is very little information on the cost effectiveness or appropriateness of bone marrow transplantation.76 Moreover, it is unclear how many days of our lives are saved per dollar in bone marrow transplantation, as opposed to more preventive services. These vexing problems lie ahead for the Oregon commission now attempting to rank various procedures according to cost effectiveness.77

Nonetheless, the consideration of bone marrow transplantation by grass roots organizations, such as those which have developed in Oregon and other states, provides us with a rational approach to the rationing of health care within the liberal state. Perhaps more important for our purposes, these models suggest explicit roles for medical ethics as just doctoring. As I have argued, just doctoring involves altruistic concerns for the individual patient, as well as respect for that patient's rights and negative freedom. Moreover, the just doctor must show equal concern and respect for the entire class of patients. Finally, just doctoring moves medical ethics beyond the simple doctor-patient relationship, without abandoning the patient for greater societal goods.

Now consider the just doctor who is caring for a seven-year-old child with leukemia. It appears that bone marrow transplantation may prolong the child's life, perhaps even bring about a cure. However, the child's family is poor and the child qualifies only for Medicaid. Moreover, Medicaid in the state where the child lives will not fund bone marrow transplantation. What should a just doctor do? One answer might be that this just doctor should organize fund-raising efforts and try to raise the $100,000 necessary to purchase this child's bone marrow transplantation. Another answer might be that the physician should lobby the medical center to obtain free care for his patient. However, this might trespass the physician's commitment to equal concern and respect for all patients. Why should this one patient receive special treatment at the medical center that is unavailable to other poor children? Indeed, there may be little that the individual physician can do for a child facing death from leukemia.

Just doctoring, however, requires that physicians address the larger social issues. Since we live in a liberal state and since the liberal democracy determines how funds are to be allocated, the just doctor must realize that there will no doubt be limits on the availability of health care. But, the just doctor should assure that whenever those limits do occur, they are distributed in a way that reflects the values central to liberalism, values that solidly the sense of medical care as ethical and altruistic. Joining in grass roots organizations, helping to engage the public's attention, and helping to form lists of priorities are ways in which physicians can discharge their duties as just doctors. Physicians should be encouraged to join these popular movements and to urge their own patients to become involved in these efforts. Encouraging the public's interest and developing priorities in the alloca-

tion of scarce resources is an acknowledgment by members of the liberal state that they themselves must decide how society allocates those resources. Moreover, this kind of participatory democracy emphasizes that health care is a collective good and that priorities in health care must be established by all members of society, not just doctors or politicians. So I would argue that just doctoring goes hand in hand with grass roots efforts to help citizens understand and discuss rationing decisions.

Just doctoring makes an additional ethical demand in this area. This is not a duty that all physicians can discharge, but all should be committed to it. That is, physicians must begin to develop information about the appropriateness and efficacy of individual procedures. For too long the development of health care technology has been driven by the personal interests of researchers and the imperatives of the market. We now have huge numbers of therapies and diagnostic tools in our technological armamentaria. It is time we begin to evaluate these seriously and to provide the kind of baseline data that individual citizens and grass roots organizations will need to prioritize allocations of health resources. Thus, as we mentioned in chapter 5, physicians must be willing to participate in trials that define efficacy and appropriateness.

Rationing, Health Insurance, and the Poor

Clearly, rationing of health care resources does not fall evenly within society. The child who died of leukemia in Oregon died because his family was unable to afford transplantation. Had he lived in a wealthy family, the $100,000 necessary to obtain his therapy would have been available. Access to health care in this country is a matter, in many circumstances, of financial status. The poor will likely bear the brunt of rationing. The ethical physician must be aware that there are limits on health care resources and that these limits lead to rationing. In addition, she must be concerned that rationing of resources primarily affects the poor. It follows that rationing based on ability to pay should be a major concern of medical ethics as just

doctoring. Before we address this problem, it is necessary to review again the manner in which we finance health care in this country.

In chapter 3, we noted that health insurance is a relatively recent development in this country. By the beginning of the 1950s, however, 40 million people were enrolled in private hospital insurance plans, and by the mid 1960s, Blue Cross had an enrollment of 67.2 million people, or 37 percent of the civilian population under age sixty-five, while commercial insurance companies provided for 100 million people, or 57 percent of the civilian population under sixty-five.78 Commercial health insurers benefitted from tax laws that treated health insurance contributions from employers as a tax-exempt fringe benefit.79 By the early 1960s, the combination of health insurance, not-for-profit hospitals, and physicians as private contractors dominated the organization of medical care, as we discussed in chapters 3 and 4.

Following the Democratic landslide in the 1964 elections, it was clear that the public favored a Medicare initiative that would provide comprehensive health insurance for the elderly. As related by David Blumenthal, Congressman Wilbur Mills, working closely with the administration's Wilbur Cohen, put together a compromise program that covered both hospital and physician's services, but made physician's coverage voluntary rather than compulsory.

At present, Medicare provides health insurance for all who are eligible for Social Security, old age, and disability insurance programs.80 Eligibility is also extended to nearly all elderly individuals not covered under the Social Security program and certain others with end-stage renal disease.81 There is no cost to enroll in Part A of Medicare, but to enroll in Part B, one must pay monthly premiums.82 Medicare has consistently paid for reasonable and necessary services for the sick, including new technologies to treat illness.83 Its reimbursement structure is enormously dependent on the individuals and organizations that act as intermediaries and contractors for payment of services.84

At the same time Congress enacted the Medicare legislation, it also created the Medicaid program.85 Essentially, Medicaid provides matching funds from general federal revenues for states that choose to provide health care assistance to low-income families, especially welfare recipients. Two of the primary eligibility criteria for Medicaid are incorporated from standards of two other cash assistance programs, Aid to Families with Dependent Children (AFDC) and Supplemental Security Income (SSI).86 In addition, states can make Medicaid available to the "medically needy."

All states have AFDC programs that provide cash assistance to single-parent families. Federal law requires that the states provide Medicaid funds to all AFDC recipients. Moreover, states have the option of extending benefits to "those eligible for assistance but institutionalized; those who would be eligible if child care costs were paid from earnings rather than through social service plans; and those eligible for but not receiving AFDC."87 Individuals covered through this set of eligibility criteria account for slightly less than 25 percent of Medicaid expenditures.

Disabled persons of any age and low-income elderly persons qualify for Supplemental Security Income (SSI). People eligible for SSI are also generally eligible for Medicaid, although states can impose stricter eligibility criteria for Medicaid.88 The same set of extensions that apply to AFDC also apply to SSI.89 Fifty percent of Medicaid expenditures go to those eligible through SSI criteria.

Finally, twenty-nine states provide coverage to the "medically needy." To qualify as medically needy, the medical expenses incurred by a family must be large enough to reduce their income to a specified level.90 Federal law prohibits setting the "spend down" level below 133 percent of the maximum AFDC payment in the state. Many states set the spend down level considerably higher. Recently, Congress has expanded and mandated Medicaid coverage for pregnant women.91

As might be expected, the Medicaid program creates a federal patchwork of health coverage for the poor. Because the eligibility criteria for Medicaid are tied to AFDC and SSI, eligibility reflects the extent of state commitment to these two other cash assistance programs. For instance, the maximum monthly AFDC benefit for a family of four in Mississippi is $120.00; in New York it is $676.00. in Texas, only 25 percent of poor children were covered by Medicaid in 1980, whereas in Massachusetts, 72 percent of poor children were so covered.92 In those states without medically needy programs, the coverage through Medicaid is especially spotty.93 In addition, federal welfare and Medicaid changes enacted by the Reagan administration in 1981 led to cutbacks in Medicaid eligibility.94 Thus Medicaid provides coverage for only about 40 percent of those living below the poverty line.

In summary, while explosive growth of commercial health insurance provided the funds necessary to pay for increasing hospital and provider costs, there were still concerns about access to care in the early 1960s. The Medicare program provided fairly comprehensive federal assistance for the elderly ill. On the other hand, the federal Medicaid

grants to states created rather patchy coverage for the indigent who are sick. This means that lack of insurance continues to be a troubling problem for our country and that many—especially the uninsured—have little access to health care.

Another way to look at Medicare and Medicaid is from the point of view of liberal justice. In the early 1960s, the United States was concerned about the inequality that existed in access to health care, especially for the poor and the elderly. As a result, new taxes developed revenues that were used for the development of programs to assist the poor and the elderly in their purchase of health care. Our government decided to encumber the negative freedom of individuals with more taxes on income in order that greater equality in access to health care could be developed.

While the patchwork approach of Medicaid seemed appropriate in the mid-1960s, we are now again concerned with problems of inequality in access to health care. The health care sphere or vocation does not contribute to cooperation within the liberal state when it is weakened by serious inequities. Rationing based on ability to pay affronts the altruistic notions of medical care. The growing concern about access to health care must be all that much greater for just doctors, who are committed to the altruism of the health care.

The concern about the problem of the uninsured has led to numerous estimates of the extent of insurance coverage.95 The estimates of the sources of insurance are generally consistent.96 Nearly 65 percent of the population receive their insurance through their employment. Medicaid provides coverage for 8.1 percent of the population. CHAMPUS, the federal health care system for members of the military and their dependents, provides another 4.2 percent of coverage.

While the number of uninsured people is generally recognized as having increased throughout the past decade, it is not clear exactly how many Americans are without health insurance.97 In the summer of 1989, the preliminary March 1988 Current Population Survey (CPS) results were published.98 The CPS, which has been conducted each month by the Bureau of Census continuously since 1942, now estimates that there were a total of 31.1 million Americans lacking health insurance during 1987.99

Concerns about access to care has spawned debate in this country about the benefits of government sponsored comprehensive health insurance. As noted above, unions and certain groups within the Democratic party have long advocated national health insurance.100 Many

advocates, however, became pessimistic about the cause in the aftermath of the Carter administration's failure to enact even preliminary, legislation. In the last few years, coincident with revelations of the scope of the uninsured problem, there has been renewed interest.

Although there are a number of different approaches to universal health coverage, few have proposed a British-style National Health Service for the United States.101 More attention has focused on legislation that requires all employers to provide health insurance to employees.102 Others recommend the Canadian approach, which leaves many current institutional structures in place but features comprehensive public insurance and global budgeting for physicians and hospitals.103 But proposals are viewed by many in the business community as extraordinarily expensive and unrealistic.104 Indeed, the debate about the problems of the uninsured continues to be driven largely by concerns over cost containment in medical care and the role of government in constraining these costs.105

Of course, the new emphases on profit and prospective payment mean that the health care industry is generally less able to subsidize nonpaying patients with revenues earned from paying patients.106 More often, it appears that for-profit hospitals prefer to shift care for those without insurance to public and large municipal hospitals.107 Without the cross-subsidies they had traditionally relied upon, even these large municipal hospitals feel the bind of the increasingly cost-conscious environment. This means that there are strong incentives to avoid hospitalizing those without insurance, and to discharge those without insurance as quickly as possible. The same set of constraints also applies to health care providers outside of hospitals. Thus concerns about health care costs have led to strategies which, in theory at least, ration the availability of health care for those without insurance.

This means that rationing of care will not be limited to large-ticket therapies like bone marrow transplantation. While it is true that states may decide to trade-off funding for transplants in order to increase access to preventive and prenatal care, even without such highly visible "swaps," rationing will occur. The lack of public funding for those unable to buy insurance could lead to more limited access to a large number of services. This is not a small problem.

What position should just doctoring take on rationing of care based on the ability to pay? We have said that physicians should not be involved in private decisions about rationing. Rather, they should apply fairly distinct guidelines that have been developed by broad social

consensus. Moreover, I have argued that physicians should take part in the development of this consensus, and should urge their patients to become involved in setting priorities.

This should also be the position just doctoring takes on the quiet rationing of care based on availability of insurance. It follows as well that physicians should not tolerate private rationing by hospitals or health care providers that is based on ability to pay. The inequalities in access to health care based on ability to pay should be considered publicly and with the input of physicians' altruistic concerns about patients. It may be that after public consideration of these issues, some inequalities may still remain. Even the commitment to equal concern and respect will not eradicate all substantive inequalities. The just doctor realizes this. In addition, however, she realizes it is ethically wrong and unjust to allow the burden of health care costs to fall on the poor through the likely unintentional operation of our medical system. Rather than fuming about their patients' inability to buy appropriate medicine, as I have done in the past, just doctors have an ethical commitment to review the health care industry and question publicly those aspects that lead to inequality of access.

Indeed, physicians and all health care workers in a liberal state have an ethical duty, under just doctoring, to realize that limits on care are part of overall allocation decisions, and that these decisions are framed by methods of financing and delivering care.108 Moreover, we in the United States must realize that other liberal states have taken other approaches. Health care cost increases, as we have seen, are at least in part attributable to the manner in which health care is financed. Perhaps changes in financing would bring about more equal access and less need for rationing policies without requiring commitment of new resources.109