Healthcare Ethics: Universal Coverage, Abortion, and Euthanasia

Universal Healthcare and Ethical Frameworks

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 consequentialist and deontological perspectives (Daniels, 1). A consequentialist approach could focus on the net gains to 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, by contrast, 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, provided that all persons have access at minimum to preventative medicine — tests and screenings — as well as any necessary medical procedure. However, the current profit-driven system is unethical from both a deontological and consequentialist point of view. Society benefits from having fewer people burden the system with preventable problems that could have been mitigated with affordable healthcare, and also benefits from promoting an ethic of social justice more generally.

Resource Allocation and Distributive Justice

Some arguments framed against universal healthcare assume that healthcare resources are limited and presume that, in such a situation, access should be market-driven rather than rights-driven. Assuming that healthcare resources are finite, macro-allocation effectively serves 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 research and development of products for which they can receive a ready return on investment — rather than being 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 sole exception of Medicare.

Like education, healthcare is a basic human right that promotes a high quality of life within society. Therefore, healthcare should be publicly funded. Framing coverage as "mandatory" makes it seem coercive; in fact, coverage should be framed similarly to education, in which each person has equal access to the same basic provisions. Healthcare resources are also allocated on a micro-level, referring more to procedural justice in healthcare. Distributive and procedural justice can coexist within 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 professionals, while 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, AMA members recognize that doctors, and especially insurers, would theoretically profit less from socialized medicine. A socialized system would not, however, preclude doctors from earning additional income from patients willing to pay out of pocket for treatments or services not deemed "essential" under a single-payer system. Doctors who oppose universal coverage on spurious and self-interested grounds are, in fact, violating the core ethical tenets of medicine.

An abundance of financial and human resources could be liberated through a streamlined healthcare system that eliminates inefficiency in the insurance and pharmaceutical industries. If these resources were freed, expensive procedures would become more affordable. Both utilitarian and Kantian approaches show that equitable, needs-based rationing is good for society as a whole. It is categorically unethical to withhold treatment from someone, as doing so entails allowing a person to suffer needlessly. Given that the greatest number of people in society are of modest means, providing the utilitarian ideal of the greatest good for the greatest number means universal coverage with no denial of even expensive operations. Organs should be harvested by default — that is, a person should be required to opt out of organ donation rather than opt in — in order to ensure a readily available supply of vital organs. There is no ethical reason this should not be so; a person who feels strongly about not donating their organs retains every right to refuse. Thus, individual autonomy is preserved while the common good is also promoted.

It would certainly be preferable to have universal access first, but universal access may still be a long way off. Furthermore, new drugs and treatments regularly come to market before universal access is established, without any ethical questions being raised about only the wealthy being able to afford them. Doctors have an ethical obligation to promote health at both the personal and public level — principles embedded in the Hippocratic Oath (Summers). They have every right to run a business and earn a profit, but should also be obliged to provide a social service that includes lower-cost screenings and other public health needs. Doctors do spend considerable sums on their education, and those costs will eventually be offset over the course of a career — even one that includes mandatory public service work. 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 or more years of training reflects, on some level, a genuine interest in and affinity for medical practice.

Abortion Rights and Patient Autonomy

There are no sound logical reasons to prevent access to family planning services, including abortion. An abortion does not constitute the killing of a human being, even though this is the line of thinking most commonly advanced by the anti-abortion cohort (Patil, Dode, and Ahirrao, 2014, p. 548). Therefore, there is no ethical problem with abortion. In fact, there is an ethical problem with banning abortion, because doing so forces a person to carry an unwanted pregnancy to term. "To compel women to bear unwanted children is a form of ethical despotism" (Patil, Dode, and Ahirrao, 2014, p. 548). From both deontological and utilitarian ethical perspectives, disallowing abortion is an infringement on human rights.

The medical profession demonstrates far greater respect for human life when it empowers individuals to make important choices for themselves. Abortion must 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 and do not constitute valid ethical reasoning. The medical profession suffers far more from failing to provide safe abortions than it does from allowing a vocal group of religiously motivated individuals to dictate what others may do with their bodies. Legal abortion does not infringe on the rights of those who personally believe abortion is unethical. Illegal abortion, on the other hand, infringes on the rights of both the living and, by extension, any future interests. The abortion debate also illustrates important philosophical distinctions between positive and negative rights.

The decision to abort following a genetic test is a matter of personal choice, which is why this issue centers on the principle of patient autonomy (Patil, Dode, and Ahirrao, 2014; Summers, n.d.). It is certainly preferable to abort than to neglect a child after birth. Mandatory counseling in such cases is always advisable. Sometimes people need to reframe their choices, and counseling can help them do so. Counseling should not be issued with the goal of influencing or coercing the patient, but simply to help the parent or parents recognize the values and beliefs underlying their emotions and decision-making. Because their choice is consequential and irreversible, 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 equally obliged to counsel a pregnant woman who is placing the fetus at risk, just as the doctor is obliged to counsel a woman who is placing herself at risk. Coercive behavior is not ethically tenable given the overarching principle of patient autonomy. If the patient's problems are related to substance abuse, the doctor remains constrained by the ethical principles of privacy and confidentiality (Summers). Counseling can and should include offering the woman information about terminating the pregnancy. It is in the best interests of both the fetus and the mother to have this option available. If the woman appears to be using abortion as a form of birth control, she may be offered the option of long-term contraception as an alternative.

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. and 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., and 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