Mandated insurance, cost-effectiveness, and the ethics of care

Tina Rulli, Zeke Emanuel, and David Wendler have an interesting piece in JAMA about the 'moral duty to purchase health care'. I will comment on their argument, and then argue that this obligation generates a correlative obligation of providers to supply efficient, affordable healthcare. 

Rulli argue that citizens have

a duty to buy health insurance based on the moral duty individuals have to reduce certain burdens they pose on others. Because physicians and hospitals have a duty to rescue the uninsured by providing acute and emergency care, individuals have a corresponding duty to purchase insurance to cover the costs of this care. Requiring individuals to meet this obligation is consistent with respect for individual liberty...

Someone might imagine that they can opt out of insurance with the promise not to seek care they cannot afford, should they need it in the future. But emergency room personnel will treat you regardless, because they are not bound by your promise and they are bound by their duty to care for you. Emergency and acute care services have, then, the non-excludeable property of a public good, in that you cannot limit the use of these services to those who pay for them. If this analogy is correct, the obligation to purchase insurance is like a tax to support lighthouses, the military, or the police (now why does that argument seem familiar?).

I'll accept that there is such a duty, but I'm not happy with some details of the argument. First, is it so clear that most providers accept a duty to provide acute care, or is this in practice limited to emergency rooms? If it's really the latter, there are many acute conditions for which it is at the very least difficult to get care if you are uninsured and indigent.

Second, the obligation may be "consistent with respect for individual liberty" but it is nevertheless an infringement of liberty. I think it is a reasonable infringement, and would argue that this reduction in my choice is compensated by the ways that access to health care expands my capabilities. But it is important to keep the books straight on infringements of liberty, and I think "consistent with respect" glosses over what is really going on.

Anyway, I agree that the basic structure of society imposes a duty on caregivers to rescue and therefore a duty on citizens to insure. However, providers now need to consider their "moral duty... to reduce certain burdens they pose on others." Specifically, they are suppliers of a service that their fellow citizens are forced to buy, and every instance of waste, inefficiency, and overtreatment is a burden providers impose on others by increasing the cost of insurance. 

This is one reason why the American College of Physicians Ethics Manual (reviewed by Emanuel here) states that 

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians' considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches.

This statement was controversial. But a provider's practice does not affect only the patient in the room. Because rescue and insurance are built in to our society, that practice affects all of us. 

(h/t Dr. Brad Flansbaum @brad_flansbau)

Comments

[GeorgeNYC]

You know, whenI was growing up I thought that the moniker "intellectual" necessarily implied someone who was using his or her mind to create a better world. Silly me. We had not yet discovered "libertarians." My goodness we sure see enslavement everywhere except in front of our faces.