How to Avoid Flying Blind

March-April 1997

BY: CHARLES J. DOUGHERTY, PhD

To Truly Improve U.S. Healthcare, Leaders Must Consider Seven Moral Values

Dr. Dougherty is vice president for academic affairs, Creighton University, Omaha.


Summary

To genuinely improve U.S. healthcare, we must base it on seven moral values familiar to Americans:

  • Preserving individual dignity. Patients have a right to information about their medical condition and a right to participate in decisions about treatment. Society should make a basic package of healthcare available to all who need it.
  • Caring for patients' welfare. As providers are obliged to have compassion for patients' suffering, they should also put patients' interests above their own and avoid conflicts of interest.
  • Protecting the least well-off. Many who are poor, less educated, or members of racial or ethnic minorities bear disproportionate burdens of morbidity and mortality. They should receive care that compensates for those disadvantages.
  • Seeking the common good. Our society has a strong disposition toward excessive individualism. We need greater emphasis on public health and preventive measures, as well as more opportunities for the public to help shape the healthcare system.
  • Containing healthcare costs. Waste is offensive both economically and morally. We can contain costs only by grappling explicitly with the need for healthcare rationing, which should be applied according to ethical criteria.
  • Retaining a sense of responsibility. Society can help renew a sense of responsibility by anchoring it in the concept of subsidiarity, according to which the best government is the least government necessary to perform its appropriate tasks.
  • Establishing high standards of quality. Providers should pursue excellence as measured by improved medical outcomes, uniform use of appropriate procedures, and increased consumer satisfaction. Quality-of-life judgments can be useful in making healthcare decisions, especially for persons who are dying.

In spite of the collapse of systemic reform efforts, the healthcare system is in a period of rapid transition. The real energy for change is now in the marketplace, where economic, political, and cultural forces converge.

These changes raise special challenges in the areas of access, cost control, and quality. More than 40 million Americans are uninsured and will remain so into the foreseeable future; indeed, these numbers are increasing. Lack of insurance creates significant barriers to care, frustrates efforts to improve health status, and leads to unnecessary suffering and premature death. Market changes are exacerbating these access problems. New competitive pressures on providers make commitment to uncompensated care less attractive than before—and far more dangerous economically.

Nevertheless, the practical successes of nations in Europe, Asia, North America, and Australia (and, despite its problems, of Medicare) indicate that nations can provide a basic package of care to all their citizens with acceptable standards of quality and at reasonable costs. Can the United States return to a reform agenda? If so, the path back must be charted with reference to America's most important moral values.

The Importance of Moral Values
Values are states of affairs taken to be intrinsically desirable. An important subset of values, moral values, are implicit throughout human activity. Although they may seem abstract, moral values are also practical because they guide behavior and give human life a sense of direction and purpose.

Values are taught to children at early ages and reinforced by culture in general. In the United States such values have been largely shaped by the Judeo-Christian tradition in religion and by the European Enlightenment in secular thinking.

How do America's moral values relate to its healthcare? We might picture contemporary healthcare as an airplane flying through a storm. The storm—the tumultuous healthcare market—is tossing the plane and threatening to drive it off course. What the plane needs most is stable directional equipment—a solid sense of moral values.

Basic Moral Values for Healthcare
Change is a fact. But genuine reform of U.S. healthcare must be based on seven moral values familiar to Americans.

Preserving Individual Dignity Respect for persons, one of this nation's most significant moral values, is grounded in a conception of human dignity. This concept—derived from both the Judeo-Christian and the Enlightenment traditions—holds that each individual has a special, incalculably great value, a value to be distinguished in principle from the price of things.

Respect for individual human dignity in the healthcare arena has given rise to the doctrine of informed consent, which protects patients' self-determination by ensuring that they are voluntary participants in their own healthcare. Patients have the right to information about medical conditions and available treatments and the right to refuse some treatments or to decline healthcare altogether.

Another important consequence of commitment to human dignity is the claim of a right to a basic package of healthcare services for all persons. This claim provides the moral framework for insistence on universal coverage.

Caring for Patients' Welfare The moral value of caring is at the heart of healthcare. One dimension of caring is compassion, healthcare providers' ability to "feel with" the suffering of their patients. Another is fiduciary responsibility, providers' obligation to put the interests of patients above their own and, when possible, to avoid conflicts of interest.

Many pressures in the contemporary healthcare system, especially the increasing tendency to treat healthcare like a business, threaten to undermine the ability of providers to keep the care in healthcare. The new pressures threaten to pit providers' financial interests against patients' medical interests. This is especially clear in managed care's incentives to undertreat patients.

Protecting the Least Well-off Protection of the least well-off is a moral value and serving their healthcare needs a consequent moral imperative. Many Americans—especially those who are poor, less educated, or members of racial and ethnic minorities—have been underserved by the healthcare system and bear disproportionate burdens of morbidity and mortality. Such persons will become even more vulnerable as the healthcare system is changed by market forces. They will have to rely on others to advocate for them.

Our ability to protect the least well-off has been weakened by increased coarseness and selfishness in our national life and the marked tendency to devolve into "two Americas": a successful, optimistic, largely white majority versus a defeated, alienated, nonwhite minority. Universal access to healthcare would go a long way toward the realization of the value of protecting the least well-off. But members of these groups require more than equal treatment to compensate for the health status disadvantages they have experienced historically and that they continue to experience.

Seeking the Common Good Balance demands that the moral value of respect for the dignity of each individual be yoked to the moral value of service to the common good.

Unfortunately, our society has a strong disposition toward excessive individualism. This disposition sometimes leads us to forget that the American healthcare system has deep social roots. It is based on clinical practice, experimentation, and science that has been accumulated and shared over generations. The system has benefited in particular from important public investments in the second half of the twentieth century, especially in the construction of hospitals, education of doctors, and funding of care for the elderly. The moral value of service to the common good underscores the need for greater emphasis on public health and preventive measures and for more opportunities for the public to help shape the healthcare system.

Containing Healthcare Costs The need to contain costs is not only an economic imperative, but also an important moral value. Waste is offensive economically but also wrong morally. We must contain costs while we expand access and maintain quality—but we can accomplish these goals only by grappling explicitly with the need to ration healthcare.

In fact, rationing occurs now in the healthcare system. By adopting more explicit forms of rationing, we will have an opportunity to apply conscious ethical criteria. Rationing should:

  • Be done in the context of universal coverage for basic care
  • Serve the common good
  • Protect those who are most vulnerable
  • Guard such important intangibles as caring and trust
  • Set priorities openly and avoid invidious discrimination
  • Observe the Golden Rule, according to which those who ration must themselves be subject to rationing

Retaining a Sense of Responsibility A common-sense moral intuition tells us that freedom and rights entail responsibility. Yet many trends in contemporary American society tend to undermine a robust sense of responsibility: an increasing disposition to regard moral agents as victims, the pressures of large bureaucracies, and the marked litigiousness throughout society.

A renewed sense of moral responsibility can be anchored by the concept of subsidiarity, which directs that responsibilities follow the logic of appropriate assignment of tasks. Responsibility begins with individuals and moves to larger organizations only as lesser ones are unable to perform tasks that must be accomplished. Therefore, the best government is the least government necessary to performing its appropriate tasks.

Acknowledging the importance of responsibility means grappling with the difficult metaphysical problem of freedom versus determinism. There is no easy resolution to this conceptual tension, but in healthcare it is prudent to emphasize freedom and responsibility in the areas of health education, prevention, and policy development and to adopt a more deterministic view of individuals in clinical contexts. Persons are free when they are urged to stop smoking, determined when they suffer from lung cancer, regardless of the cause.

Establishing High Standards of Quality The drive for excellence is an important moral value. This occurs in social organizations as well as in individuals. The drive for excellence in healthcare is frequently centered on the notion of "quality." An inevitably elusive concept, quality can nevertheless be measured in part by improved medical outcomes, uniform use of appropriate procedures in the delivery of services, and increased consumer satisfaction.

Quality as a form of general excellence is also involved in the concept of "quality of life" as a criterion for making healthcare decisions, especially for the dying. In such contexts, a spectrum of positions can be identified—ranging from a vitalism that holds that all human life, regardless of quality, has inherent value, to a form of nihilism that denies value to human life below some level of quality. Interpreted not as judgments about the value of life but as a way to assess the reasonableness of medical interventions, quality-of-life judgements can be useful for striking a balance between these extreme positions. Attaining balance—the classical "golden mean"—is itself a form of excellence closely identified with the achievement of virtue.

Moral Values Must Guide Changes
The moral values listed here may not be the only important ones at stake in the changing healthcare system. They are offered as a contribution to the larger national conversation about who we are as a people and what can be expected from healthcare and the healthcare system.

Remember that metaphorical airplane described earlier? Economic, political, and cultural concerns will continue to buffet the healthcare system like a storm—but they cannot provide a fundamental sense of direction. Only moral values can do that. Only if moral values chart the course can we be confident that a changing healthcare system will be a genuinely improving system.

 

Copyright © 1997 by the Catholic Health Association of the United States
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