Tuesday, April 19, 2011

Health Care Spending in the Light of Wisdom and Justice

Editor's NOTE:

The following opinion piece by a reader of this blog--is presented in way of adding to our understanding of the current debate in Congress with respect to altering Medicare and Medicaid.

The pespective presented by Dr. Gibbons is fairly consistent with Traditional Roman Catholic Moral Theology and is worthy of consideration. My comments follow his piece.

--Dr. J. P. Hubert

Health Care Spending in the Light of Wisdom and Justice

By:  Joel Clarke Gibbons
Logistic Research & Trading Co.
Saint Joseph, Michigan.

We have to get a few basic points in order before we are ready to weigh the pros and cons of the Republican plan, or of any plan, to change Medicare and Medicaid. I offer the following in the cause of reason and balance on this topic.


Justice demands that we accord to every person what is his or her due. That precept -- or more exactly, that definition -- covers justice in all its manifestations; between individuals, in what is called commutative or transactional justice, it defines the just claims of one party against another. It also covers claims that a person makes on his community or society, which we call distributive justice. The issue of public funding of medical treatments through programs like Medicare and Medicaid is distributive in nature, raising the question of which claims a person can legitimately make on his/her fellow citizens. He does not have the right to bankrupt them.

No person has a just claim which – if it was honored across the board for all the people – would simply break the bank. That certainly applies to claims which everyone might raise, like free food for all, but it also applies to claims which many persons would register for themselves, but which if they were available to all would find enough claimants to break the bank. So while not everyone would like to have a heart transplant, if even a fraction of citizens wanted that treatment and if as a result to public Treasury would be so drained as to force grave limitations on its other expenditures, then that is not a just claim.

No person has a just claim – a commutative right – to escape the consequences of his own folly. We nonetheless tend toward charity which softens this rule. The citizens have moreover a just expectation of charity on our part. But they do not have the right to repeated folly. St. Paul made that clear when he reminded the Thessalonians of the rule he had enforced, that whoever would not work, should not eat (II Thessalonians 3: 10).  This probably applies in some ways to how the person cares for his or her own body, but I won't go there. With regard to the economics, the citizen does not have the right to spend all his money on the good life, and expect the Treasury to pay his medical bills. The community is entitled to demand that the citizens make provisions for their own needs, and in this case, that requires them to buy some sort of insurance, or alternatively to have the personal wherewithal to pay their own bills.

We have a moral duty both to save for future needs, to the extent possible, and to develop and employ our talents to provide for us and for those who depend on is, and we do not have a just claim to be absolved of this duty. This duty follows directly from the Seventh Commandment, which enjoins us not to live by theft, because the choice to be dependent on the community, to expect to be supported by others or by the State are in fact a kind of theft.

We often say that distributive justice endows everyone with a right of sorts to an equal chance. In many areas that is the case. It endows us, for instance, with a right to basic education at public expense but of course it does not endow anyone with a right to learn as much as everyone else. How much we gain from education is governed also by our unequal endowments and by our unequal attention to the work of learning. Life however is filled with unequal opportunities right at the start. Unequal outcomes moreover quickly become unequal opportunities too. If I am unable for reasons good or bad to exploit my equal opportunity to learn nuclear physics, I will be very disadvantaged in the competition for university faculty positions. Thus the opportunity/outcome test is not nearly as revealing in practice as we had hoped it would be. Nonetheless the idea is a good one and comes down to this. It is unjust to defend inequality in opportunity – to defend artificial barriers – but it is not unjust to accept inequalities as they arise. We should always look for ways to lower barriers of inequality, both as a matter of charity and of justice, no matter what has caused them, but we accept that they are all around us no matter what we do.

In the matter of equal opportunity as it applies to medicine, it is imperative to weigh the costs and benefits of various treatments. As a very clear example, no one should have to suffer broken limbs without treatment. It is simply too easy to set them, or even to repair them surgically; this technology is widely known and available and the benefit far outweighs the cost. Even in this case however, we do not lose sight of the requirement that any particular course of treatment reasonably accomplish the purpose. There is no cost-benefit analysis that would deny that treatment, except in the most desperately poor society.

Now we move up the line to cost, invasiveness, frequency, and prognosis. As we do that, we keep track of the cost in the aggregate to the society. At some point, well above setting broken bones but almost surely before we get to the triple heart-lung-liver transplant, we run out of money and we run out of medical logic too. Cost in this, as in most cases is defined not in the absolute sense but in the economists' sense: the value of other kinds of outlays begins to swamp the value of another surgery.

At that point – and I do not mean in any way to suggest that this is easily done or that it is something we do once and for all – the just claims on society are exhausted. Everyone has a claim – depending on the wealth of the community – to basic medical care, understanding that the standard of “basic” is fundamentally economic in the sense that it hinges on the trade off between more care and more highways and other demands on the Treasury. In no sense do I vote for descriptively “basic” – i.e. minimal – care. On the contrary, we want to be as generous as possible, especially since I myself might come down with one of those really expensive needs. But there has to be a cutoff.

As a matter of justice, no person should be denied any kind of medical treatment that he or she is prepared to pay for out of his own pocket, or to pay for from the voluntary donations of other citizens. If there is some kind of treatment that costs a billion dollars, only billionaires will have it. Well, let that be a reminder of just how nice it is to be a billionaire, although realistically speaking no one would want to suffer from whatever might require such a treatment. In justice we cannot out of envy prevent anyone from treating himself – in effect – nor can we hold him hostage to exorbitant claims to pay for our medical care. From time to time the proposition is advanced that equality of access implies that access be identical for all persons. That would be a manifest perversion of justice.

Distributive justice is sometimes framed as an exception to transactional justice, but that is never correct. In reality, there is only one kind of justice. The Lord God created society for the benefit of the people, and thus they have just claims on it. Society has duties under the moral law. The most obvious of these duties is to secure for us the demands of transactional justice: to defend our rights to life, liberty, and the pursuit of happiness when they are infringed by our neighbors, which is to say that in practice, the guarantee of transactional justice is itself an example of distributive justice. Of equal merit however are the just claims that we have on the society; and in rich societies like ours, those claims can be defined in very generous terms. These are the claims of fairness and of fellowship, and of concern for our neighbors and for the solidarity of the community.

Justice always ensures to the poor an adequate living and to the infirm the care and solicitude of the community. The claims we have individually on the community are of course only the reflection of claims it has on us, and while we are entitled to grumble, we must in justice submit and pay our taxes and do whatever else is needed and right. This is never an engine for extortion and jealousy, because that would pit communal justice against the rights of the person. It is for that reason that the claims of the citizen for public support must be weighed on a scale of reason, and in light of all the demands on the Treasury.


So what does this say about changing Medicare? It says that the cost of Medicare is in principle limited, as is everything else in life, and that the society has duties both to respond to just claims against it, and to deny unjust claims on its generosity. At this time, medicine has undergone such revolutionary change, carrying with it extraordinary benefits and costs that it is exceedingly difficult to know where to draw the line. At what point do claims cease to be fair and just, and become exploitative? Justice demands that we collectively put our heads together in an honest attempt to discern where this very elusive line is hiding. It implies also that attempts to uncover the line and to calibrate it in practical and financial terms cannot be and should not be thought of in moralistic terms alone. The moral demand of justice itself sets us to the task of finding the answers.

Wisdom is the virtue that leads us to find the best course of action under all kinds of particular circumstances. It serves justice, because justice really is blind. Justice doesn’t know what works medically from what doesn’t work, and that “working” and “not working” are not simple, blanket judgements but are specific to each case. Justice doesn’t know either medicine or the technical details of any of the myriad other goods that press their demands on the Treasury. It is for wisdom to inform justice, and in that sense we concede that justice is not sufficient, but there is no escape from it.


Dr. J. P. Hubert's Comments:

I am largely in agreement with Dr. Gibbons. Some additions and commentary follow:

Justice is only one criterion/virtue by which to consider the question of whether to change Medicare, Medicaid or any other federally funded government program—in the light of reason. As Dr. Gibbon's suggests, other criteria are important as well, for example, 1) societal expectations based upon accepted practices people have come to rely upon, 2) the precepts of the common morality which flow from the Natural Moral Law e.g. (do good, avoid evil, treat your neighbor fairly and so forth) 3) available resources, 4) best practices based upon documented outcomes in the case of health care and 5) comparative cost analyses of US vs.: other developed nation’s health care costs among others.

With regard to the issue of what to do about those procedures that are controversial, extremely expensive or demanded by the patient: it is important to note that medical recommendations must be made only after applying stringent criteria which include a consideration of alternative therapies as well as expected outcomes when performed in settings capable of “best practices.”

It is not appropriate to deny care simply because it is very expensive and high-tech., but it must be demonstrably shown to be a better choice than any other alternative and associated with reasonable morbidity/morality. The “cut-off” is not simply based on economics but must also be based upon stringent medical/surgical criteria in order to avoid unnecessary morbidity/mortality and waste.

A critical issue in this debate is the fact that the private health insurance industry has a virtual monopoly over American Health Care which was reflected in the ommision of an effective "Public Option" from the bill passed and signed by President Obama last year. Similarly, the pharmaceutical industry lobby is so strong that the federal government has not been allowed to negotiate over the price of drugs. Finally, the entire financial reimbursement scheme should be addressed as well. These are all defects which must be fixed if we are to solve our health care problems and reduce the budget deficit and national debt.

This is a very complex topic, one which would require an extended essay to “flesh-out.”  We encourage comments.

No comments: