ethical analysis of us healthcare 2009 ethical evaluation of u.s. health care james a. foster, ph.d...

Ethical analysis of US healthcare 2009

Ethical Evaluation of U.S. Health Care

James A. Foster, Ph.D

Professor, Biological Sciences and PhilosophyInitiative for Bioinformatics & Evolutionary STudies (IBEST)

Ethical analysis of US healthcare JAF © 2009

How to analyze ethics?

1. Ask “normative” questions• Is the current U.S. health care system ethically acceptable?

• Is the proposed U.S. health care system ethically acceptable?

2. Identify major affected parties

3. Score questions for each party with respect to major ethical categories

• Well being and happiness

• Liberty, autonomy, independence

• Justice, fairness✦ Summarize results, identify caveats


2. Major affected parties

People• Americans with adequate insurance• Americans without adequate insurance• Health care providers (doctors, nurses,

pharmacists, psychologists, etc.) Institutions

• Health delivery groups- The medical profession- Hospitals, care delivery centers

• Economic groups- Employers/employees- Insurance companies- Pharmaceuticals/suppliers

• Governments


The full analysis


3. Score each item (extract)

Is the current health care system in the US ethically acceptable?

Party Well Being Liberty JusticeAmerican/w adequate insurance

•most expensive in world (16% GDP)•very low quality (WHO: 37/191 performance; 72/191 outcomes)•1st in responsiveness (WHO)

•treatment dictated by insurance policies•few choices for insurance or treatment (lack of interstate competition; few providers)

•Leaves out 47 million

Americans without adequate insurance

•leading cause of bankruptcy44,000 deaths/yr

•Little choice over insurance or provider

•116 million inadequate insurance

Health care providers (doctors, psychologists, nurses, etc.)

•family doctors, nurses poorly paid, overworked •overworked specialists (very) well paid

•time skewed to paperwork•incentives to over testing •can only accept patients with adequate insurance

•poor and rural areas underserved•vast disparity in quality of available services

Insurance companies

•high profits •near total choice of what to cover

•high profits, especially to executives and lobbyists

Conclusion: highly unethical unless business rights dominate


3. Score each item (extract)Is the proposed US health care system ethically acceptable?

Party Well Being Liberty JusticeHealth care providers

•more personal fulfillment•reward for outcomes•less demand/profit for some specialty services

•freedom to choose type and location of practice•Can’t refuse treatment based on ability to pay

•less disparity between different types of practice•less disparity in quality/availability of services

Employers/employees

•reduced expense•fewer bankruptcies•happier, more productive employees

•choice of health insurance providers ("public option")•Can’t refuse to provide benefits

•even playing field for small businesses

Insurance companies

•more incentive for efficiency•reduced profits

•less choice of what to cover and to what extent

•more competition ("public option")

Governments •reduced budget deficit (short term, state, long term, federal)•ability to reallocate state funds to education, infrastructure, etc.•federal deficit (short term)

•more flexibility in priorities•ability to “opt out”

•poor and rural states disproportionately benefit(note: good for Idaho, though unjust)

Conclusion: moderately ethical unless corporate rights dominate


Is the current health care system in the US ethically acceptable?

YES (11) NO (31)


Is the proposed US health care system ethically acceptable?

YES (45) NO (16)


5. Summarize

Current system is clearly unethicalProposed system is ethically superior to

current systemCaveats: we are assuming that

• Individual and small business liberty (“choice”) and well being are more important than other considerations

• Individual liberty, well-being, and justice are more important than corporate autonomy

• Insurance company well-being is not the most important consideration

ethical analysis of us healthcare 2009 ethical evaluation of u.s. health care james a. foster, ph.d...

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