Woolhandler on the ethics of reform
Ethical Questions in the Reform of Health and Medical Care
The President’s Council on Bioethics
June 26, 2008
Chairman Edmund Pellegrino: This afternoon we’re going to look at the ethical questions from the point of view of people who are involved in designing and propagating and thinking about various programs to which we referred.
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Chairman Pellegrino: I’m going to move ahead and ask each of these panelists to briefly state why they think — I hope this isn’t too aggressive a question — why they think the program that they’re most closely associated with is a morally acceptable one.
Stephanie Woolhandler, M.D: Well, I think that the single-payer proposal is the only ethical one on the table because it’s the only one with proven effectiveness. I think that many of these proposals up here are known to be ineffective. They’ve been tried, and they failed. Perhaps the best you could say about some of them is they’re an experimental treatment. So I just think if we’re concerned about 18,000 deaths each year from lack of health insurance, we’re actually obligated from a moral point of view to go with something that’s proven, which would be some form of nonprofit national health insurance.
Len Nichols, Ph.D.: — my interpretation of Leviticus… In my view, health care has become like food, a unique gift. We absolutely know people will die without it. It was unacceptable to let people starve back then. It’s unacceptable to let people go without health care now. In my view, those are morally equivalent. But what I love about the gleaning metaphor in Leviticus is that it does not say, “Give the same amount of food to every person.” It does not say, “Give all the food to one person who happens to be hungry.” It does not say, “Bring the poor home and cook for them.” It says, “Leave the food in the field, and the poor have to go get it.” So there’s a mutual obligation. There’s a mutual responsibility, and that’s why I see that reflected perfectly in the combination of personal responsibility, including individual mandate to purchase, and shared responsibility, that is, to make it possible for each individual to achieve their own objective.
James Capretta: Well, I think the program I put forward is the ethically appropriate way to proceed for several reasons. First and foremost, the more that financial resources are put in the hands of patients and consumers to make decisions, the more the system is responsive to those patients and consumers. …it’s the most practically plausible and workable approach. …it doesn’t cede to the federal government all centralized control. And, finally, controlling costs is either a matter of efficiency or queuing, in a sense. And market incentives, financial incentives with oversight can get to more efficiency, trying to do things where people decide on their own that this is less valuable than the price we’ve been paying and not doing it anymore.
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Dr. Schneider: And many of the people have spoken with extraordinary confidence and force and have been quite willing to say that the alternatives to their program are highly unsatisfactory. These arguments are all based on data and empirical evidence and arguments that we are entirely incompetent to evaluate.
Dr. Woolhandler: I don’t understand your point. Why would you be incompetent to evaluate these arguments?
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Dr. Woolhandler: I’m again just a little amazed at the comment that this group is not prepared to decide on these questions. There are so many IQ points in this room, and people spend so much time thinking about ethics. I mean, the material I present is not rocket science. The Rand study is not rocket science, either. There’s a book about this [holding her fingers about an inch apart] thick that you could probably read in an evening if you want to read it yourself. So I think saying we’re not prepared to decide is actually saying we’re going to step away from a problem that we recognize is very serious and is resulting in 50 deaths today as we meet here and 18,000 deaths a year in the United States.
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Prof. Lawler: Dr. Woolhandler seemed to have this ethical theory that when it comes to medical care there should be no exchange of money. So co-pays are immoral. Deductibles are immoral. Whereas your other two, to some extent or another, think actually to introduce a bit of cash here is helpful because understanding yourself as a consumer makes the person delivering the product more responsive and introduces choice.
Dr. Woolhandler: I’ve seen people die because of co-payments and deductibles. Co-payments and deductibles were studied in the Rand experiment. They’ve been studied a couple of times in Canada where they’ve introduced small co-payments and deductibles, and they always have the same effect. Rich people are not affected by them a bit. Low-income people get less care. They get less elective unnecessary care. They also get less life-saving and completely necessary care, and that’s the basis on which I think they’re immoral.
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Prof. Dresser: For Dr. Woolhandler , I’m probably mangling this philosophically, but I think Kant said, “Ought implies can.” And so, you know, I love your idea, and if I were queen of the world or the US I would say, “Okay. Go for it.” But I just wonder, if it’s not realistic in this country, then it’s a placebo. So how do you think we’re going to get from here to where you are politically?
Dr. Woolhandler: Well, I think the argument you’re making is politics is the art of the possible. But I actually disagree with that. I actually think politics is the art of creating the possible, and what’s possible is what people believe is possible.
So who would have believed before Rosa Parks that we would have a civil rights movement and a Civil Rights Act? Who would have believed in the mid-1980s that the Soviet Union was about to collapse?
So you can’t just sit here and say based on what you’re seeing today that no change is possible. We’ve got to create the possible, which I think is a challenge to this group and, you know, partly why I reacted so strongly to the suggestion you couldn’t understand it or come to grips with it.
You have tremendous moral suasion. You have the power as a group to make a statement that universal health care is the only ethical policy alternative and that the only proven way to get universal health care is through nonprofit national health insurance.
If you went public with that, you would be creating the possible. You know, you would be creating the possible and helping people believe that this real change is possible. And when I look at those polls about the American people, the American people say they want national health insurance.
It’s not that the people don’t agree. It’s the insurance industry that’s blocked this from debate. They’ve used their full political power and economic power to block it and, frankly, the pharmaceutical industry, as well. And they’ve always opposed this.
And when I first got in this business I was shocked about the pharmaceutical industry opposing it. Well, it turns out they knew something that the American people just learned later, which is every nation with national health insurance negotiates for price discounts on drugs. They knew that, and they were completely and totally opposed to any sort of national health insurance covering drugs because they were going to get lower prices.
So we’ve got the American people endorsing it. We’ve got some very powerful folks opposing it. We need to get it on the agenda, and (it’s) the one real power you have and you can use it, or you can turn your back and say, “We don’t understand this.” You can use that power to put this on the political agenda.
http://www.bioethics.gov/transcripts/june08/session3.html
continued:
http://www.bioethics.gov/transcripts/june08/session4.html
Comment:
By Don McCanne, MD
After the November election, it is expected that the President’s Council on Bioethics will release a report on ethical considerations for reforming health care.
The Council was formed in 2001 in response to the controversy over President Bush’s decision to deny funds for embryonic stem cell research. With a touch of irony for which this administration is famous, many thought that political ethics were compromised in the selection of supposed ethicists who had already expressed biases incompatible with the ability to objectively assess important issues of bioethics. When one of the members of the Council states that they are incompetent to assess the ethical issues in the reform proposals, it does make you wonder.
It is difficult to know what the report will state, but some of the more enlightened members of the Council clearly do understand the moral imperative behind Steffie Woolhandler’s message. It would be nice if their views, based on actual ethical principles, would prevail in the final report. Regardless, it is really Steffie’s message that is important.