Redrawing the ethics map.

Abstract

Medical ethics, as it is usually understood, is a map to a world I am not familiar with and cannot follow. It describes a very different world from the world of public budgets. The ethics of delivering health care is a different "moral universe" from the ethics of funding health care. Because of this, the existing map is leading to increasingly unethical public policy results. Medical ethics needs to be revised if it is to provide meaningful guides to future health policy. We need a new ethics map. You cannot build an ethical code for a publicly funded system around the assumptions that "cost is never a consideration" and that the focus of moral concern must be solely on the individual. Most health care is paid for with pooled funds, either taxpayer or insurance, and you cannot distribute pooled funds by focusing on one patient at a time. Pooled funds must maximize the health of the pool. Cost is always a consideration. Most medical ethics, however, assume that resources are unlimited and that the sole issue is the interest of the individual patient. Indeed, some ethicists claim that "medical ethics becomes interesting and relevant only when it abandons the ephemeral realm of theory and abstract speculations and gets down to practical questions raised by real, everyday problems of health and illness ... It is real-life, flesh-and-blood cases which raise fundamental questions."[1] Laudatory words, but not the language of public policy. Such a view, highlighting individual needs and ignoring costs, violates the first rule of public policy, which is to maximize the general good using limited funds. Constructing a public budget is a process of trade-offs and priority setting, and it would be public policy malpractice to ignore costs. Indeed, Rudolph Klein suggests from the British perspective that "It is unethical to ignore costs."[2] As Allan Williams has perceptively remarked, "anyone who says that no account should be paid to costs is really saying that no account should be paid to the sacrifices imposed on others."[3] The "moral unit" of a physician is the patient, while the moral unit of public policy is all citizens. It took John Kitzhaber, a physician-politician, to point out to a disbelieving nation that as an office holder he was responsible both for those covered and for those not covered, and he had to consider not only Coby Howard's need for a transplant, but also the state's duty to all of the medically indigent. He was not arguing for a two-tiered system; he was trying to maximize limited public funds in the only health care program for the medically indigent that the state had legislated. It made more ethical sense to him as a public policymaker to cover all the medically indigent and ration what was subsidized, not who was subsidized. "Last dollar" rationing was preferable to leaving medically indigent people outside of Medicaid. Additionally, public policy doesn't have the luxury of focusing on one policy area (or funding one program) at a time. Everything is on the table, all the time. As General George Marshall said during World War II, "When deciding what to do one is also deciding what not to do." I cannot express my frustration at sitting in a hospital ethics meeting, agonizing over whether to recognize a living will and knowing that within blocks there are medically indigent citizens with very restricted access to any health care. Doctors on their way to work drive on streets filled with potholes. They drive past crumbling schools in an inadequately policed part of the city while sanctimoniously telling themselves that they will never let cost be a consideration in health care. How do I justify $150,000 for each year of life gained by CPR in the hospital, knowing that in my world $150,000 funds five school teachers for a year? Should I be proud of a system that kept Rita Green alive but comatose for forty-two years in Washington, D.C., which has the nation's highest infant mortality rate? …