Ethical Health Care Issues, Research Paper Example

Introduction

In the complex and typically controversial arena of ethical practices in health care, perhaps no subject generates as much debate as that of refusal of care due to lack of insurance or other financial liabilities.  On a basic level, such refusal appears unconscionable, and blatantly contrary to the guiding ethics of the medical profession.  Moreover, this controversy enjoys the further distinction of being defined by economic considerations, which usually are perceived as removed from actual ethics.  As the following will demonstrate, however, refusal of health care based on likelihood of payment is not quite as cut and dried an issue as it may appear, for the welfare of all must be considered.  In particular, the principles of justice and non-maleficence come into play, as no health care practitioner or facility exists apart from the larger society requiring care.  Nonetheless, when the various factors are examined, the inescapable reality remains that denying crucially needed health care because of financial matters, when that care may be administered, defies the most foundational ethics of the medical profession.

Ethical Principles and Discussion

To begin, the principle of autonomy may appear to exist apart from such an investigation.  In autonomy, there is a specific acknowledgment of the patient’s right to make all decisions regarding their welfare, and it is to be reasonably supposed that any patient would choose to procure health care services whenever the service seems indicated.  Such an ethical principle, in fact, seems to apply before any cost issues arise; illness or discomfort is evident, and the patient then comprehends that help must be sought.  Ironically, however, autonomy does not occur in a vacuum, and this right or privilege is inextricably linked to the ethical principle of beneficence.   This then creates opportunities of ambiguity, if not outright debate, in regard to a physician electing to deny care because of financial concerns (Shahian, Normand  2385).   If finances should not actually dictate decisions to render treatment, as it is generally agreed they should not, there remains the unfortunate reality that they are a very real factor in both the patient’s and the physician’s decision-making processes.  For example, beneficence mandates that only the patient’s well-being must be the determinant in providing care, yet the principle of autonomy complicates the scenario.  In past eras, it was typically the physician who was charged with assessing the need for care.  If this enabled unfortunate levels of paternalism, it nonetheless simplified the decision making, and the physician would be most enabled to assess the actual need of the patient (Shahian, Normand  2385).   In today’s more patient-centered ideologies, however, beneficence becomes merged with autonomy, as the patient takes on more responsibility in determining need.  More exactly, as the average person holds to the concept of beneficence, they are more likely to seek care when care is not necessarily required, which then ignores financial demands.  Conversely, the adept physician is better equipped to calculate ability to pay with degree of need.   This appears to be a somewhat ruthless process, but there is nothing inherently unethical in being partially guided by economic factors.  They may, in fact, allow for determinations otherwise too difficult to make, when health care need is questionable.  It may then be seen that a generalized view of beneficence, intrinsically removed from pragmatic concerns, may function with patient autonomy to demand care largely unnecessary and, when ability to pay is lacking, injurious to the health care community.

Not unexpectedly, this arena of controversy is amplified by the ethical principle of justice.  This ethic in place, there must be an awareness manifested of the physician’s responsibilities to the surrounding community, as well as to the individual patient, and finances clearly play an important role here.  To deny care to a patient in actual need and unable to pay is, as noted, irrefutably unconscionable.  When, however, as just discussed regarding patient perception and autonomy, the need is debatable, so too is the denial subject to interpretation.   There are, plainly, pressing realities constricting the capabilities of health care providers everywhere, even as President Obama’s new initiatives are shifting the components.  Money, more than ever before, is a critical concern for facilities.  In April of 2009, the American Hospital Association reported that a survey found that nine out of ten hospitals were compelled to reduce service because of economic conditions, and more than half of the hospitals had significantly cut staffing (Redlener, Grant  2203).   It is tempting to think, when discussing ethical issues in health care, that such affairs must not be allowed to sway ethical choices.  Right must remain right, which translates to access to treatment for all, no matter the costs incurred.  Justice, however, demands a more pragmatic approach.  If, for example, a physician accommodates uninsured patients consistently, they are then obligated to raise costs elsewhere, which equates to an injustice for those able to pay.  Such a course also creates a probability of no longer being able to sustain a practice, which clearly denies the entire community of a health care resource.

Here, then, and as with beneficence combining with autonomy to generate ethical complications, non-maleficence impacts with justice.  There are the ethical obligations of the physician with regard to the individual patient, but no ethical guideline attributes greater value to these than to those of the surrounding population.  Then, and interestingly, actual financial issues may work to generate opportunities for greater justice.  For example, as medical facilities seek to provide health care under economic duress, investigation ensues as to saving costs.  This alone has prompted an emphasis on proactive care among physicians.  When preventive care and early interventions are in place, health care providers greatly reduce the activity of one of the most costly health care vehicles: the emergency room (Epstein, Turka, Birnbaum, & Koretzky  2846).  Then, any emphasis on prevention inherently goes to beneficence and non-maleficence for the society as a whole, in that the health care itself moves more into its realm and lessens the need for drastic, and consequently expensive, procedures.  None of this, of course, remotely goes to ethically justifying the refusal to treat a patient because of inability to pay. Nonetheless, all of it serves to reinforce that, in the complex sphere of health care, financial matters illustrate necessary perceptions in regard to ethics.

Conclusion

The principles of beneficence, autonomy, justice, and non-maleficence do not, singly or in unison, unalterably render refusal of treatment a breach of ethics.  Each may be interpreted as subject to import in such cases, as even beneficence may be served when a physician determines that, a patient’s autonomous decision notwithstanding, care that patient cannot afford is also unnecessary.  It may be regrettable, but health care relies on commercial interests, no matter its foundation as an ethically-based service.  Consequently, the decision to withhold treatment because of inability to pay may not necessarily be an unethical practice in certain circumstances, and particularly when wider concerns are considered.

That said, the more stringent reality is that the principle of beneficence must apply whenever there is actual need of care, and must transcend any economic consideration.  This has been a mainstay of the profession since Hippocrates, and is not subject to moderation when need is apparent: “Physicians have a responsibility to promote the welfare of their patients, by both doing good and actively avoiding potential harm”  (Shahian, Normand  2384).  If autonomy and justice create fields of ambiguity within the subject, they do so only when the care in question is not critical, or when there is the luxury of implementing other courses.  In more direct circumstances, and irrefutably, to deny care because a patient is not insured or cannot pay is to disregard the core ethic guiding all of responsible health care.

References

Epstein, Jonathan A., Turka, Laurence A., Birnbaum, Morris, & Koretzky, Gary. (2009). “The     Physician’s Voice in the Health Care Debate.” The Journal of Clinical Investigation,  119 (10), 2846.  Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2752093/

Redlener, Irwin, & Grant, Roy. (2009). “America’s Safety Net and Health Care Reform – What Lies  Ahead?” New England Journal of Medicine, 361 (23), 201-2204.  Retrieved from  http://www.ncbi.nlm.nih.gov/pubmed/19955523

Shahian, David M., & Normand, Sharon-Lisa T.  (2012).  “Autonomy, Beneficence, Justice, and            the Limits of Provider Profiling.”  Journal of the American College of Cardiology, 59 (25), 2383-2386. Retrieved from http://content.onlinejacc.org/article.aspx?articleid=1208660