Parties affected
Wellbeing
Autonomy
Justice
V Status Quo
Is the current US health care system ethically acceptable?
V People
* American with adequate insurance
- most expensive in world (16% GDP)
- among least quality in industrialized world (infant mortality, 42nd life expentency)
- WHO: 1st in responsiveness; 37/191 in performance; 72/191 in outcomes
- treatment dictated by insurance policies
- few choices for insurance or treatment (lack of interstate competition; few providers)
- available to 2/3 people
Conclusion: highly unethical, by any measure
* Americans without adequate insurance
- leading cause of bankruptcy
- 44,000 deaths/yr
- no choice or insurance or provider
- 47 million w/o insurance
- 116 million/w inadequate insurance
- emergency room increases total costs, reduces services
Conclusion: highly unethical, by any measure
* Health care providers (doctors, nurses, psychologists, etc.)
- family doctors poorly paid, overworked
- nurses underpaid, overworked
- specialists (very) well paid
- medical practices' time skewed toward paperwork
- incentives to over testing
- procedures dictated by malpractice suit risk
- providers can only accept patients with acceptable insurance
- poor and rural areas can't support health care providers
- vast disparity in quality of available services

Conclusion: highly unethical, by any measure
* Non-citizens living in US
- poorly treated, if treated
- none
- no legal recourse
Conclusion: not applicable, since the health care measures only address health care for citizens
V Institutions
V Health delivery groups
* Medical profession
- less human, more mechanical profession
- highly constrained by insurance company policy
- incentive to avoid poor, rural areas
Conclusion: highly unethical, by any measure
* Hospitals
- significant diversion of funds to protect from lawsuits
- more bureaucratic, less flexible
- more emergency service required
- skewed toward private hospitals that cater to the "elite"
Conclusion: highly unethical, by any measure
V Economic groups
* Employers/employees
- significant expense
- reduction in economic productivity
- leading cause of bankruptcy
- lower quality of coverage
- right/ability to choose not to offer/accept insurance
- significant burden for small businesses
Conclusion: Highly unethical, unless autonomy trumps all other considerations
* Insurance companies
- high profits
- near total choice of what to cover and to what extent
- high profits, especially to executives and lobbyists
Conclusion: Moderately ethical if money and independence are virtues that trump and justice
* Pharmaceuticals/suppliers
- high profits
- best science in the world
- rules of clinical trials, safety guidelines restrict ability to develop new treatments
- marketing practices restricted
(note: these are ethical benefits for consumers)
- ability to recover development and trial costs
- marketing practices require adequate information
- trial practice requires ethical practices
Conclusion: Moderately ethical unless ease of business is more ethically important than any other considerations
* Governments
- significant cost, budget shortfalls
- reallocation of funding, staffing, effort from education, police, infrastructure
- mandated constraint on priorities
- loss of ability for strategic planning
- poor and rural states disproportionately affected
Conclusion: highly unethical unless private profit is the most important ethical consideration, trumping all other constituencies and concerns
V Reform
Is the proposed US health care system ethically acceptable?
V People
* American with adequate insurance
- increases number of insured, access to health care
- simply health care decision making
- incentives for personalized diagnosis and treatment (more family doctors)
- less quality/availability for very small number of high end or optional procedures
- more choices of providers (with "public option") in short term
- may reduce choices of providers in long term, by reducing profitability of insurance businesses
- more access to health care
- less disparity in health care
- motivation for treatment shifted from payment to outcomes
- more resources available for charitable giving

* Americans without adequate insurance (5 million)
- greatly reduced numbers
- requires a smaller safety net, so more effective safety net
- more choices available, even if not chosen (with "public option")
- any lack of access to health care is unjust
* Health care providers
- more personal fulfillment by working for patients rather than insurance companies
- better allocation of resources to better performing providers
- less demand/profit for some specialty services
- greater freedom to choose where to practice
- greater freedom to choose type of practice
- less ability to refuse treatment based on ability to pay
- less disparity between different types of practice
- less disparity in quality/availability of services
* Non-citizens living in US
- poorly treated, if treated
- none
- no legal recourse
Conclusion: not applicable, since the health care measures only address health care for citizens
V Institutions
V Health delivery groups
* Medical profession
- more time for patients, more human profession
- more care-focused and hence rewarding
- More freedom to choose speciality
- More freedom to choose type of practice
- less disparity between professionals
Conclusion: highly ethical, by any measure
* Hospitals
- less cost for malpractice protection
- (possibly) lower profits
- greater emergency service flexibility
- fewer insurance procedures
- Reduced disparity between private hospitals and public, rural, hospitals
Conclusion: highly ethical, unless profits are moral obligations that trump all other considerations
V Economic groups
* Employers/employees
- reduced expense
- increased in economic productivity
- fewer bankruptcies
- happier, more productive employees
- increased choice of health insurance providers (with "public option")
- loss of ability to refuse to provide benefits
- more even playing field for small businesses
Conclusion: highly ethical, unless employer rights trump all other considerations
* Insurance companies
- more incentive for efficiency
- reduced profits
- less choice of what to cover and to what extent
- more competition between insurance providers (with "public option")
Conclusion: Moderately ethical if efficiency and competition are ethically more important than profits and independence
* Pharmaceuticals/suppliers
- best science in the world
- more incentive for efficiency
- reduced profits
- rules of clinical trials, safety guidelines restrict ability to develop new treatments
- marketing practices restricted
(note: these are ethical benefits for consumers)
- marketing practices require adequate information
- trial practice requires ethical practices
- less ability to recover development and trial costs
Conclusion: Neutral
* Governments
- reduced budget deficit (long term, federal)
- reduced budget deficit (short term, state)
- increased budget deficit (short term, federal)
- ability to reallocate funds to education, business support, infrastructure
- more flexibility in choosing priorities
- ability to "opt out" (House version)
- poor and rural states disproportionately benefit
(note: good for Idaho, though unjust)
Conclusion: highly ethical, but with potential short term federal cost