Ethics panel may back universal coverage, ponders access as a "moral imperative"
A presidential committee explored the ethics of health system reform and plans to release a report later this year
By Kevin B. O‘Reilly
AMNews staff
PROFESSIONAL ISSUES
Aug. 4, 2008.
Chicago — A panel appointed by President Bush that met here in June appears set to endorse some form of societal obligation to provide health care access to all.
The meeting was part of the President’s Council on Bioethics initiative examining the ethical underpinnings of approaches to reforming the nation’s health system and covering the estimated 47 million uninsured Americans. A report is likely to be issued after the November election.
Bush established the council in November 2001 to advise him after his decision to deny federal funds for research using newly created human embryonic stem cells met with fierce opposition. The council’s first chair, Leon Kass, MD, PhD, primarily focused the group’s attention on the ethical implications of scientific advancements such as cloning and assisted reproductive technology.
But in remarks before the panel in June, current chair Edmund D. Pellegrino, MD, made clear that he believes health system reform also has ethical dimensions. “What kind of society do we want to be?” he asked. “Are our values reflected in the way we’ve authorized and delivered this element of the flourishing of human beings?”
In an interview, Dr. Pellegrino said the goal of the council is not to recommend any political party’s plan but to lay out in “an orderly, systematic and critical way” the ethical implications of various approaches on access to care, medical innovation, and individual freedom and responsibility.
“We will not be lecturing people on what’s right and wrong,” said Dr. Pellegrino, a spry 88-year-old widely recognized as a father of bioethics and the founding editor of the Journal of Medicine and Philosophy.
Despite Dr. Pellegrino’s view, there was plenty of pushback from members of the conservative-leaning council.
Health system reform is “a black hole — once you get in it, you never get out,” said Gilbert Meilaender, PhD, professor of Christian ethics at Valparaiso University in Indiana. “The more we try to fully elaborate all the principles that might be involved in reforming the health care system, the more hopeless and black hole-ish things get.”
Carl E. Schneider, JD, a bioethicist at the University of Michigan, agreed, saying the council — composed primarily of physicians, ethicists and legal scholars with little expertise in economics or health policy — was out of its depth. The reform plans are “all based on data and empirical evidence that we are entirely incompetent to evaluate,” he said.
Meilaender said the council might be able to argue that providing care to those who cannot afford it is a “moral imperative.” A majority of the council seemed to agree that society has a duty to provide everyone with access to health care.
A draft of the council’s report notes “growing support for the claim that the problem of the uninsured is a moral problem for a prosperous society that strives to provide some measure of equality of opportunity.”
The major split, the report said, comes when discussion moves to “how best to solve this problem.” That division was reflected in panelists who spoke before the council on behalf of options such as a Massachusetts-style, individual health insurance mandate and a more market-oriented approach.
Steffie Woolhandler, MD, MPH, argued that the single-payer model prevails around the world in countries that provide better access to care at lower cost than the U.S. system. “I think single payer is the only morally acceptable reform choice, because it’s the only effective one on the table,” said Dr. Woolhandler, a primary care doctor who co-founded Physicians for a National Health Program in 1986. “If we’re concerned about the 18,000 deaths a year due to uninsurance, then we are morally obligated to go with a plan that has been shown to work.”
Other panelists were reluctant to declare their proposals morally superior, and there was no apparent consensus among council members about which proposal would best improve access to care.
Laurie Zoloth, PhD, director of the Center for Bioethics, Science and Society at Northwestern University’s Feinberg School of Medicine, Chicago, attended the council meeting as an observer. She believes, based on panelists’ discussions, that the panel will issue a report endorsing the principle of universal access to care. She said the statement would mean a lot coming from a panel appointed by Bush.
“The more people who say universal health care is a moral imperative, the better our society is,” she said.
Last fall, the AMA’s Ethical Force Program published an essay in the Hastings Center Report outlining a consensus framework for reform proposals. According to the report, reforms should ensure that everyone has adequate health care benefits established through an ethical process in a system that is financially sustainable over time and makes clear the responsibilities of doctors, patients, payers and society.
At its June Annual Meeting, the AMA House of Delegates adopted policy seeking to replace the tax deduction for employer-provided health insurance with tax credits and an exemption for health insurance spending from state and federal payroll taxes. Expanding coverage for the uninsured also tops the AMA’s legislative agenda.