by Carolyn N. Kinder
Ethical issues in managed health care overlap with economics. However, leaving health care completely to market forces is not acceptable when a great portion of the population do not have access to health care. Many people who have some form of insurance are unprotected from the heavy burden of sickness. Conventional and alternative choices in health care remind us that patient autonomy is not going away, but must be brought into balance with other ethical principles.
Health care ought to be distributed equitably. People differ in their beliefs about the value of health and medical care and their use of it as a way of achieving good health. The important of health care is to cure illness, to keep people from worrying and to enable them to adjust to their situation by providing good information.
Health care enters people’s lives at the beginning and continues to the end. Access to health care is essential to individual needs. Everyone should be able to receive an adequate level of care. What adequate care looks like depends upon the overall resources available resources society has to offer. However, society has a moral obligation to insure that everyone has access to adequate care without being fiscally overburdened.
In designing a managed heath care system; justice is one important principle. Autonomy and justice in the past have been treated as an item, because for one person to say and choose what he or she wants without regard to what others want is unfair if resources are coming from a common pool.
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In Fuja v. Benefit Trust Life Insurance Co. (18F.3d 1407 7th Cir. 1994), a
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woman with metastatic breast cancer was referred for bone marrow
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transplantation. The transplant was denied because the woman’s
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insurance contract did not cover experimental procedures. The Seventh
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Circuit Court supported Benefit Trust, seeing the ethical issue as one of
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contract interpretation. Contractual fairness is just one type of fairness.
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However, distributive justice: to each according to his need); egalitarian
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justice-to each according to what similar others receive and utilitarian
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Justice -to each according to what’s best for all) are other types. Judgin
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ethical issues by contract can integrate fairness and autonomy, but it is not
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the best way to make a decision. Employees who use contracts to make
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decisions about health care, are just as concerned about their budgets, as
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with helping their employees care for themselves or families (5).
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A different way to integrating fairness with autonomy is to be as scientific
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as possible about medicine. In Barnett v. Kaiser Foundation Health Plan,
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INC (32 F.3d413, 9th Cir 1994), a man with e-antigen positive hepatitis was
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referred for transplantation. The Kaiser Foundation Health Plan Liver
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Transplant Advisory Board denied the procedure because, the board
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said, the highly infectious disease would cause the transplant to fail and was
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Therefore, contraindicated, Mr. Barnett paid privately for the procedure an
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then sued. The Ninth U.S. Circuit Court of Appeals found in Kaiser’s
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favor. Medical criteria, it was decided, were a valid way to make medical
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judgments about efficacy and benefits (6).
Physicians, ethicists and attorneys are addressing cases that deal with decisions about the responsibilities to all managed care organizations patients. fundamental questions are being asked about what level of medical care does society owe to its citizens? The good news is that they can now begin to answer.
