An Ethical Set of Health Care Institutions

Since health care is a sphere of cooperative activity that is especially important in demonstrating the liberal state's commitment to equal concern and respect for all its members, access to health care is of great importance. It follows that physicians should consider it part of their ethical duty to help work out the appropriate mix of market and nonmarket concepts in designing a framework for health care that provides equitable access. Physicians must consider, however, not only the concerns of patients and their access to health care, but also the availability of resources in society and the limits on care that must be tolerated. In this country, for instance, we have just witnessed the gutting of a catastrophic health program that was to provide long-term care for elderly patients as well as protection from the crushing financial consequences of their illness. The rationale for the cutbacks is concern for cost and the sense that government can no longer avoid fiscal responsibility. Therefore, it is unlikely that there will be huge new resources available for health care.

Those physicians who accept medical ethics as just doctoring must participate in an effort to define what constitutes adequate access to health care in light of limited resources. Physicians must help society decide what sorts of medical problems should be addressed for all patients. For instance, what kind of elective operations should be made available to all individuals? Certainly, resections of breast cancers are procedures which should be available to all. However, the same is probably not true of cosmetic reduction mammoplasty. Between these poles are a great number of other procedures and diagnostic modalities. The state should fund some of these in order to grant all citizens in the liberal state access to a level of adequate health.

The critical role for physicians is to define this spectrum and decide where the threshold for public financing lies. Thus physicians have a very important role to play in the problem of access to health care. Their clinical knowledge and sense of concern for the patient must be integrated into the development of lists of procedures to which the liberal state guarantees access.

Of course, American physicians and state governments have been determining adequate levels of care for some time. Consider, for in-

stance, the case of Weaver v. Reagen.59 Weaver and his coplaintiffs suffered from diseases caused by the human immunodeficiency virus. They sued the Missouri Medicaid program because the Missouri government had decided not to list the drug (AZT) under the program. In essence, this meant that the state had refused to consider AZT as a medication to which individuals should have equal access; the state was unwilling to pay for AZT for Medicaid recipients.

The plaintiffs argued that the Medicaid law requires that drugs such as AZT, which have been proven effective for a disease, should be on the Medicaid drug list. The state countered that perhaps AZT was nor indicated for individuals who, while infected with HIV, did not meet the criteria of AIDS. In response, the plaintiffs had numerous expert physicians testify that indeed AZT was indicated for all individuals infected with HIV whether or not they had AIDS. These physicians, then, were testifying that a particular medication was indicated for a particular condition and in addition, that the medication should be available to all patients under the Medicaid law. The court found in favor of the plaintiffs, granting summary judgment and allowing all who qualify for Medicaid access to this medication. Thus, in an ad hoc fashion in the courts, physicians have helped determine what constitutes adequate levels of care. What is needed, however, is a more systematic approach by the medical profession.

But, to a certain extent, efforts such as those pursued in Weaver are simple tinkering. Just doctoring's commitment to adequate access requires that physicians address the financing and delivery of health care. In addition to helping to determine the definition of adequate levels of health care, physicians should participate in the development of the institutions that will guarantee that access. Physicians cannot sit on the sidelines and allow economists and politicians alone to determine these issues. The central and most special part of being a physician is to care for those who are sick. This sense of care involves commitment that goes beyond relationships typically expected within a liberal state. It gives physicians a special ethical, and thus a special political, perspective. As a result, physicians must act as advocates for the patient in designing institutions that guarantee access to an adequate level of health care.

Just doctoring must value universal and adequate access to health care. However, as we saw in previous chapters, it opposes dominating physician control over the financing and delivery of health care. The commitment to access argues for a positive right to health care. The

opposition to physician dominance lends to a regulated, but competitive, medical marketplace. Can these, on first glance, conflicting options be accommodated by health care in a liberal state? I think the answer is yes, as a review of some other liberal states' experience can suggest.

In Great Britain, a national health service was created after the Second World War. The National Health Service removed a great deal of the inequalities to access and probably also tended to hold down health care costs. This is one model for the liberal state. The modern liberal can accept government control over certain functions of the economy, if it is necessary to bring about equal concern and respect. Of course, getting rid of the market does entail certain costs, and in Great Britain these costs are now being reexamined. The Conservative government wishes, for efficiency's sake, to reintroduce some market concepts in medical care and is committed to modifying the National Health Service.60 It is instructive for our argument that many British physicians are opposed to these changes in the National Health Service, as they feel they may lead to greater inequalities in the provision of health care.61

The Canadian model may be more pertinent to the United States, as more and more physicians are realizing.62 Since the 1950s, Canadians have moved to universal access by turning over the financing of health care to the government. Universal access has been in place since 1976.63 In essence, the provincial governments, supported in part by federal government grants, engage in global budgeting with private, not-for-profit hospitals, on a prospective basis. There is no reimbursement to individual patients. Private physician-owned laboratories, and radiology centers do exist, but provinces control them by restricting their ability to bill the provincial plan, Specific schedules for physician fees are hammered out annually by representatives of the provincial governments and physician professional associations.

This approach has led to admirable savings, keeping the percentage of the Canadian GNP devoted to health care down to 8.6 percent. America, meanwhile, spends $604 billion a year on health care or more than 11 percent of its GNP.64 If we could pare our health spending down to Canadian levels, the savings would amount to greater than $100 billion.

How docs Canada obtain universal access at lower cost? There are several explanations. First, administrative/bureaucratic expenditures are greatly reduced by naming a single payer, the provincial govern-

ment.65 Second, given the global budgeting, including capital costs, provincial governments are able to effect control over hospital costs and technology use. Finally, the negotiation with physicians over fees keeps professional costs in check. The result is that Canadians use less intense resources for hospitalized patients, with no discernible decrease in the quality of outcomes.66

What is the physician's role in this system? They still make all treatment decisions and retain many professional prerogatives. Indeed, most are quite satisfied, even though there has been some labor/industrial strife.67 Nonetheless, the government represents a counter weight to unlimited physician control over supply and demand.

From the viewpoint of just doctoring, there is much to admire in the Canadian model. It brings about lower costs and universal access. Moreover, it helps limit the moral hazards faced by physicians. This is not to say all American physicians will support it. Indeed, as acute an observer as Alain Enthoven has argued that the main obstacle to a Canadian model in the United States is the opposition of physicians.68 Canadian physicians' incomes, especially for procedure-oriented specialists, are lower than those of their American counterparts. Of course, just doctoring, and its sense of commitment to patients, requires physicians to go beyond their narrow self-interest, and ask what the most ethical approach is to health care institutions. The Canadian model of universal access and governmental oversight fulfills many of the criteria set by just doctoring for health care institutions.

The Canadian model focuses on health care financing. The delivery still occurs through nonprofit private institutions and independent physicians. Perhaps other forms of delivery might make better sense for the American liberal state. For example, Alain Enthoven and Richard Kronick have advocated a consumer's choice health plan that includes universal health insurance. Two elements are critical to this plan.69 First, the authors retain the competition among different sorts of managed care plans, so as to bring about cost efficiency and good quality care. Second, they recommend using an 8 percent payroll tax on the wages of all workers without health care insurance to fund broader coverage under Medicare and Medicaid. Certain cost-saving devices such as copayments and cost sharing would be included in this plan, thus keeping in place many of the attributes of our present system of health care, while both encouraging competition and increasing funds available to ensure that all individuals have access to some level of health care.

Perhaps the competitive elements of the Enthovan-Kronick plan could be married to the Canadian financing model, which would bring about the competition of a marketplace with assurance of universal access, both quite attractive from a just doctoring viewpoint.70 Physicians would play a public, ethical role in this health care system, helping to determine levels of adequate access, and policing competitive forces to ensure that some patients do not suffer from market efficiency.71

I cannot sketch this health plan in detail in this book; that is for another day. My point is that physician's concern for others does not only apply to the individual doctor-patient relationship. A just doctor cannot be satisfied if only her particular patients have access to health care. Her sense of what is moral or ethical must be affronted if there are patients, even patients of other physicians, who lack access to a decent minimum of health care. Concerns for individual patients should translate into concerns for the class of all patients. Therefore, physicians should not assume the general posture of other citizens in the liberal state when analyzing the policy options in regard to health care. They must respond with the same commitment they display in their relations with their own patients. In this manner, the communitarian value of medical care will be appropriately affirmed, helping to develop the most appropriate means for bringing about access to adequate health care.