Healthcare obligations and access to treatment

Healthcare is one of the most important arenas for applied ethics and social justice. The concept of universal healthcare can be considered from a number of different ethical standpoints including consequential and deontological perspectives (Daniels 1). An ethical consequentialist approach could focus on the net gains to the society from offering universal healthcare coverage to all persons, or the net gains of improved overall quality of life in a more equitable society. Deontological ethics stress the importance of equal access as a fundamental human right.

Because the medical profession as a whole is comprised of individual doctors, each doctor or healthcare worker is required to perform pro bono service at some point during their career in order to promote the value of social justice in medicine. As Daniels points out, there is no way to ensure one hundred percent health equity, given that sociological factors impact health outcomes (1). A multi-tiered system is an effective interim solution, providing that all persons at least have access to preventative medicine (tests and screenings) as well as any necessary medical procedure. However, the current profit-driven system is unethical—both from a deontological and consequentialist point of view. The society benefits from having fewer people burden the system with preventative problems that could have been mitigated with affordable healthcare, and also benefits from promoting an ethic of social justice more generally.
Some of the arguments framed against universal healthcare assume that healthcare resources are limited, and presume that in such a situation, access should be market-driven and not rights-driven. Assuming that healthcare resources are finite and limited, macro-allocation serves effectively as a rationing of those resources (Scheunemann and White 1625). Resources tend to be allocated according to market forces, as when pharmaceutical companies invest in the research and development of products for which they can receive a ready return on investment, more so than they are driven by the desire to cure diseases. The present allocation of public health resources is complex and driven by politics and social norms; the United States has no single-payer system that allocates taxpayer funds to healthcare with the only exception being Medicare.
Like education, healthcare is a basic human right that promotes a high quality of life within the society. Therefore, healthcare should be something that is publically funded. Framing coverage as “mandatory” makes it seem coercive; in fact, coverage should be framed in a similar way as education, in which each person has equal access to the same basic coverage. Healthcare resources are also allocated on a micro-level, referring more to the procedural justice in healthcare. Distributive and procedural justice can coexist in an ethical model. There is no need to choose between the two. Patients have a right to procedural justice in their daily dealings with healthcare institutions and professions, but distributive justice principles ensure that no person can be denied an essential service.
The AMA might claim to oppose public healthcare out of fear that the state could interfere with case-by-case decisions, an unfounded fear given the success of socialized medicine programs in other countries. More likely, the members of the AMA know that doctors and especially insurers would theoretically profit less from socialized medicine. A socialized system would, however, not preclude doctors from earning additional money from customers willing to pay out of pocket for treatments or services that are not deemed “essential” through a single-payer system. Certainly doctors are violating the core ethical tenets of medicine when they oppose universal coverage based on spurious and selfish principles.
In fact, an abundance of financial and human resources can be liberated via a streamlined healthcare system that eliminates the bloat in the insurance and pharmaceutical industries. If these resources were freed, then the expensive procedures mentioned in the question would be made more affordable. Both the utilitarian and Kantian approaches show that equitable, needs-based rationing is good for the society as a whole. It is unethical categorically to withhold treatment from someone because it would entail allowing a person to suffer needlessly. Given the greatest number of people in society are of modest means, providing the utilitarian ideal of the greatest good for the greatest number of people means universal coverage and no denial even of expensive operations. Organs should be harvested by default. A person needs to opt out of organ donation, rather than opt in, to ensure a readily available supply of vital organs. There is no ethical reason why this should not be so; a person who feels strongly about not having their organs removed for whatever reason has the right to refuse. Thus, there is no infringement on autonomy, while the common good is also promoted.
Yes, it would be preferable to have universal access first but universal access might be a long way away. Besides, new drugs and treatments come on the market prior to universal access—without any ethical questions being raised about only the wealthy being able to afford them. Doctors do have an ethical obligation to promote health at the personal but also the public level, principles that are embedded in the Hippocratic Oath (Summers). They have every right to run a business and make profit too, but should also be obliged to provide a social service that includes lower-cost provisions of screenings and other public health needs. Doctors do spend an exorbitant amount of money on their education, and those costs will eventually be offset through the course of a career—even a career that includes some mandatory public service work. Yes, the cost of medical education can and should be subsidized, perhaps on a needs-based basis. Doctors are generally not motivated to enter medical school for financial reasons; otherwise they would simply become entrepreneurs. Eight years or more of training reveals on some level an interest in and affinity for medical practice.
7.
There are zero logical reasons to prevent access to family planning services including abortion. An abortion is not killing a human being, even this is the line of thinking most commonly used by the anti-abortion cohort (Patil, Dode & Ahirrao, 2014, p. 548). Therefore, there is no ethical problem with abortion whatsoever. In fact, there is an ethical problem with banning abortion because banning abortion forces a person to carry an unwanted child to term. “To compel women to bear unwanted children is a form of ethical despotism,” (Patil, Dode & Ahirrao, 2014, p. 548). From both deontological and utilitarian ethical perspective, disallowing abortion is an infringement on human rights.
The medical profession demonstrates a lot more respect for human life when empowering individuals to make these types of important choices for themselves. Abortion basically needs to be framed as a human right. No one has the right to force a person to have a child. Slippery slope arguments are inherently illogical, anyway. The medical profession suffers far more from not providing safe abortions than for allowing a shrill group of religiously minded individuals to dictate what other people can do. Legal abortion does not infringe on the rights of those who believe that abortion is unethical. On the other hand, illegal abortion does infringe on the rights of both the unborn and the living. The abortion issue illustrates some of the philosophical differences between positive and negative rights, too.
If a doctor does not wish to provide an abortion, that doctor has every right to defer to a colleague. Similarly, a pharmacist has the right to personally refuse access to birth control and morning after pills—but they pharmacy itself cannot have such a policy. In other words, institutions cannot pass anti-abortion policies but individual practitioners have every right to contentiously object. Mandatory training in abortion is a good idea, though, because a doctor’s views might change when faced with a life-threatening situation. For example, a doctor who contentiously objects might eventually be confronted with a situation in which the abortion saves the life of the woman or might have compassion on a woman who was just raped. If the doctor should decide that the fully-grown human being is worth something and wants to save her life, then the doctor might actually want to perform the abortion. This kind of situation might only come up in rural or isolated areas in which there is only one doctor available and there is no option to defer the case to a colleague. However, in most cases there will always be another doctor who is willing to perform the procedure or another pharmacists at the same institution who is willing to issue the pills. The doctor and pharmacist should always be legally obliged to defer the case; their license depends on the ethic of patient autonomy.
The decision to abort after a genetic test is a matter of personal choice, which is why this issue is about the principle of patient autonomy (Patil, Dode & Ahirrao, 2014; Summers, n.d.). It is certainly better to abort than to neglect the child after it has been born. Of course, mandatory counseling in these cases is always a good idea. Sometimes people need to reframe their choices and counseling can help them do so. Counseling should not be issued with a goal of influencing them or coercing, but simply to help the parent(s) recognize the values and beliefs undergirding their emotions and cognitions. Their choice is irreversible and the consequences are high, so it makes sense to empower them with information and self-awareness.
The doctor is ethically obliged to treat the patient. A fetus is not the patient. However, the doctor is ethically obliged to counsel a pregnant woman who is placing the fetus at risk, every bit as much as the doctor is ethically obliged to counsel a woman who is putting herself at risk. Coercive behavior is not, however, ethically tenable because of the overarching principle of patient autonomy. If the patient’s problems are related to substance abuse, the doctor is still constrained by the ethical principle of privacy and confidentiality (Summers). Counseling can and should include offering the woman information about aborting the child. It is in the best interests of both the fetus and the mother to have this option. If the woman seems to be using abortion as a form of birth control, then she may be offered the option of long-term birth control as an alternative.

12.
Every person has the right to die with dignity. Euthanasia is a matter of personal autonomy and self-determination (Nunes, & Rego, 2016). When faced with a terminal illness, a person should not be condemned to suffer just because some people view life as being “sacred.” Even if life is considered “sacred,” then quality of life would naturally take precedence over quantity anyway. Slippery slope arguments are logically fallacious, and should not enter into any intelligent discussions about the issue of doctor-assisted suicide. In fact, condemning a patient to suffer by withholding access to viable treatment violates several ethical principles including patient autonomy, beneficence, and non-maleficence. Yes, physician-assisted suicide violates the Hippocratic Oath, but the Oath has many anachronistic elements and only provides loose guidelines for the provision of medical services. Each euthanasia case can be determined on its own merits. The carefully regulated conditions would preclude hasty decisions to end a life.
Although the overall ethical framework and end result might seem the same, there are important differences between active and passive euthanasia, and between euthanasia and physician-assisted suicide. A much clearer distinction exists between voluntary and involuntary euthanasia, with the latter clearly violating the most fundamental tenets of medical ethics. A physician may be in a position to know whether or not a person has any chance of recovery. In most cases involving physician-assisted suicide, the patient’s condition has deteriorated to the point where death is immanent and bound to be painful. The administration of drugs to hasten death achieves the healthcare objective of beneficence, without conflicting with non-maleficence. Morphine drips serve a similar function in alleviating suffering, and the medical community should reframe discussions to allow for a more tolerant policy to support patient wishes in cases like these. In fact, some of the uses of morphine drips are not qualitatively different from physician-assisted suicide. The different terminology might be related more to insurance coverage. When a patient expressly refuses life-sustaining treatments or issues advance directives, the medical community also has a legal obligation to follow those orders unless there were extenuating circumstances. This ethical imperative falls under the rubric of patient autonomy and self-determination (Summers, n.d.).
If the parents want the child to be alleviated of its suffering via the administration of a lethal injection, then the healthcare team might need to oblige those wishes. The physician on the case might be able to offer a more educated guess as to the child’s chance of survival. If chance of survival is none, then it is certainly a compassionate choice to alleviate suffering rather than allowing the body to deteriorate over the course of ten days. As long as the parents consent, legal and active euthanasia is a legal option, particularly as the child does not have legal or moral agency—the child does not have the competency or capacity to make a choice.
Euthanasia is also an issue that can be addressed within the overall context of hospice and palliative care. Hospice care allows people who have been diagnosed with a terminal condition to have access to treatments, services, and conditions that promote comfort and wellbeing. Palliative care may be insufficient in alleviating suffering, which is why “public policies should address the issue of improving the access and delivery of palliative care,” (Nunes & Rego, 2016), p. 1). Another benefit of hospice care is that it promotes acceptance of death, and allows the family to begin the process of healing. Not treating pneumonia or any other treatable condition could pose ethical conundrums if the patient is suffering as a result. Yet if the patient has consented to hospice care, the patient has already come to term with their mortality. Consenting to hospice care does entail consent to at least a passive form of euthanasia. Therefore, allowing an infection like pneumonia to take its course falls within the ethical parameters of hospice care. Some patients may wish to more clearly outline the parameters of their hospice care, such as consenting to treatment interventions for something like pneumonia but not for their presenting condition.
It is also important to understand euthanasia from the perspective of procedural justice and the protection of patient rights through legal means. Advance directives like DNR orders offer the patient the opportunity to express wishes, preventing ethical problems from arising should that person experience loss of consciousness or incapacitation. As Whealan (n.d.) points out, advance directives reduce the burden of care from the population; advance directives also reduce the “emotional costs” of care the family endures (p. 2). For this reason, patients should expressly state as soon as possible in their adult lives their wishes related to euthanasia or DNR. The advance directives can also prevent conflicts of interest with the family members. In all cases, the advance directives do need to be honored regardless of the opinions of the healthcare workers or any other family member. The Terry Schiavo situation illustrates the problems that arise if advance directives are not made legally binding. However, due to the inconsistencies in care and administrative policies and the lack of electronic records, some patients may inadvertently not have their DNR orders honored. It is important to have all advance directives clearly input into a patient’s chart. Of course, each case should be treated differently and physicians may find that extenuating circumstances require a more flexible approach to whether to implement the advance directive. The patient should ideally appoint a proxy to make crucial decisions, to help physicians make decisions when the advance directive only vaguely applies to the medical situation or condition.




References

Daniels, Norman. “Justice and Access to Health Care.” Stanford Encyclopedia of Philosophy. Sept 29, 2008. https://plato.stanford.edu/entries/justice-healthcareaccess/
Dye-Whealan, M. (n.d.). Advance directives. http://depts.washington.edu/pharm543/documents/schedule/5543%20MDW%20Advance%20Directives.pdf
Nunes, R. & Rego, G. (2016). Euthanasia: A challenge to medical ethics. J Clin Res Bioeth 7:1000282. doi: 10.4172/2155-9627.1000282
Patil, A.B., Dode, P. & Ahirrao, A. (2014). Medical ethics in abortion. Indian Journal of Clinical Practice 25(6). http://medind.nic.in/iaa/t14/i11/iaat14i11p544.pdf
Scheunemann, Leslie P. and White, Douglas B. “The Ethics and Reality of Rationing in Medicine.” Chest, Vol. 140, No. 6, 2011, pp. 1625-1632.
Summers, J. (n.d.). Principles of healthcare ethics. http://samples.jbpub.com/9781449665357/Chapter2.pdf