The Uninsured Population: An Ethical Dilemma, Research Paper Example

Perhaps the single greatest issue within the health care industry today is removed from actual care: it is the disturbing reality of millions of people, employed or indigent, with no medical insurance. There are layers within this issue as well, as even preventative care, which serves to diminish the need for costly procedures should problems arise, is also out of reach for the uninsured. This scenario creates an enormous ethical consideration for nurses, bound by their professions to administer for the ill, yet as dependent upon financial factors as the patients themselves.

Background and Overview

While the health care crisis in regard to insurance is typically perceived as a modern dilemma, its history is long. Since organized health care became an industry in the United States, physicians have uniformly objected to any manner of governmental regulating or providing of insurance for the public. The precepts usually put forth, and most likely genuinely held to, were centered on the physicians’ sense that federal programs would interfere with the sanctity of the doctor/patient relationship. The more evident motivation for the opposition, however, was that the doctors objected to having to submit to a financial authority not in their control.

As noted, this national dispute took shape many decades ago: “During the Great Depression, the AMA waged a ferocious campaign to prevent federal officials from including national health insurance in the Social Security Act of 1935” (Quadagno, 2005, p. 7). Nor was the issue restricted to the U.S.; in 1963, in an unprecedented action, Saskatchewan physicians went on strike to oppose Canada’s installation of its own Medicare program. For a period of weeks, only emergency rooms were available, and poorly staffed at that. The strike was shocking, and watched with intent interest by doctors in the U.S., who looked to Canada’s situation to determine how they themselves would proceed with American Medicare.

In more recent years, the issue of the uninsured has taken on different, and truly alarming, proportions due to the economic and employment crises occurring in the U.S. Previously, the majority of physicians were perfectly content with a system whereby employers subsidized, partially or fully, the medical costs of caring for their employees. As health care has always been an expensive proposition, excellent health benefits were for many the deciding factor in career decisions, and it was not uncommon, from the 1970’s on, for people to accept a lesser wage attached to a truly comprehensive medical benefits package.

Then, as the employment markets in the nation underwent vast restructuring in the ensuing decades, outsourcing became an effective means for a business to circumvent the high price of providing insurance: “The surprisingly tepid pace of job creation in July, 2004, was attributed in part to a reluctance to hire full-time employees because of the associated costs of health insurance…” (Blair, 2007, p. 34).  The situation did not improve, as the recession years immediately ensuing led to startling levels of unemployment. As more people were out of work – and consequently uninsured – the hiring veto was far more inclined on the employers’ side, and insurance benefits were by no means a given. If joblessness was a national crisis, it was rivaled by the subsequent impact of a largely uninsured population.

Governmental action today, as in years past, seeks to at least ameliorate this disturbing circumstance, yet is consistently greeted with skepticism from the public. The situation is extreme, and not made better by today’s still-shifting patterns of employment, along with relevant and influential factors of an increasingly immigrant population. The U.S. continues to exist under a damning shadow: “Given the large number of uninsured and under-insured in this country – a  number that increases every year – we  have the greatest disparity in the world in the quality of care given to the very rich and the very poor” (Dracup, Morris, 2007). The conflict  further carries an exponential component: “ Today, more than 45 million Americans are uninsured and another 30 million are under-insured….Hospitals nationally are facing growing public scrutiny of how they bill the uninsured” (Roth, 2006, p. 528). As will be explored, this national dilemma inevitably leads to ethical considerations which go to the very heart of health care.

Relevance to the Nursing Profession

To begin to properly comprehend how the widespread lack of insurance impacts on the nursing profession, it is necessary to first examine the ethics, general circumstances, and unique attributes of the profession itself. The field is unlike any other, in that it encompasses elements of service both thoroughly professional, and socially and/or culturally influenced, and these factors weigh heavily in the equation.

Nursing is, like any occupation which is founded on the concept of providing service to others, both career and calling. The nurse must be a trained and skilled practitioner, yet must as well be within the field because it satisfies individual needs no other profession can provide. Moreover, the nurse, certainly in the public perception, walks a necessary line between layman and physician; they are equipped to understand and apply technical medical procedures, but they are as well expected to manifest nurturing aspects not within a doctor’s purview. “…The relationships nurses have with their patients, as they perform the technical skills and compassionate care of nursing, can involve both physical and emotional involvement” (Fawcett, McQueen, 2011, p. 199).

What confirms the relevance of the insurance issue to this, regrettably, is the career aspect to nursing. Noble and exalted calling that it is, it is also nonetheless a job, and one firmly entrenched in the realities of the working world. Nurses are as responsible for meeting financial obligations, both personally and in reference to their employers, as anyone else. The vast uninsured population, then, adds a complication to their careers the average working person need never confront. The salesperson sells because the customer is paying for the product, and the mechanic fixes the automobile because it is blatantly understood that the vehicle would not be entrusted to him, were payment for the services an uncertain issue.

In nursing, with insurance not present, worlds truly collide. The nurse is providing a service substantially more important than that of car repair, yet is placed in a position where the service may not be paid for, and this latter factor, as noted, is rarely a decision in the nurse’s hands. The relevance is blatant, and inherently fraught with ethical and moral considerations.

Ethical Aspects

In considering the ethical components to the above dilemma, the somewhat old-fashioned, yet fully applicable, term “duty” seems to be sounded. It relates, quite pervasively, to every aspect of the ethical issue.

It must be first acknowledged that the ethical considerations are by no means limited to the nurse. The patient who seeks medical treatment and has no insurance makes an ethical decision which will inevitably trigger that of the caregivers. They are fully aware that the medical procedures will be expensive, and that they cannot pay for them, save perhaps through a lengthily extended incremental basis, and then, typically, only partially. Moreover, few people today are unaware of the fact that unpaid services are never precisely that; it is rather a case of the provider needing to obtain the funds elsewhere: “Hospital bill collectors may hound nonpaying patients for years thereafter, and if the bills cannot be collected, costs are shifted onto everyone else” (Jacobs, Skocpol, 2010,  p.23).

Presented in this way, the portrait of the patient is not an especially commendable one. They are consciously choosing to avail themselves of services they cannot afford.  In any other arena of living and/or society, this would translate to an indisputably poor ethical posture, if not an outright criminal act.

However, this is no average scenario, nor an ordinary transaction, for nothing less than urgent, physical need dictates the choice, and the ethical question then becomes: at what point do the ethical obligations of commerce give way to the presumably greater ethical stance of a human being’s entitlement to necessary care? Evidently, people are disposed to assign the greater import to the latter consideration. In ethical terms, this is certainly justifiable; no civilized culture would deem it right to withhold medical care because of a lack of funds.

This of itself, however, introduces yet another ethical aspect. Plainly, with such a societal understanding in place, no patient actually has any real incentive to pay at all, and this leads to the initial question’s relevance to the caregivers. That is, if all parties concerned are in general agreement that the care of the patient is the undisputed priority, it is virtually impossible to determine at what point the needs of commerce are to be satisfied. The dilemma presented by the uninsured is truly a cyclical, and seemingly insurmountable, one.

Additionally, there is the inevitable ethical issue then faced by the nurse in this situation. The patient has, in a very real sense, a duty to pay, but that is not a likelihood, and the patient is still in need of medical help. The nurse’s duty is to apply their skill and dedication to perform the task of providing the help, yet the nurse is as well beholden to the physicians for whom they work, the hospital or clinic housing them, and their own, personal financial interests. All of these factors, moreover, are by no means strictly commercial agents; obviously, for the hospital to exist and for its staff to continue to aid other people, it must pay its own bills. The patient who has no insurance and seeks/accepts medical treatment, then, is setting in motion a wide array of ethical issues, all of which may have profound repercussions.

Morality, Policy, and Practice

The intrinsic nature of an ethical dilemma of this scope does not admit to a more agreeable, and easier, resolution enabled by limiting its definition and/or impact. Some ethical issues are theoretical, with no tangible effects on living; others offer only several possible means of conclusion, as in criminal justice matters. With an uninsured population requiring medical care, morality, policy and practice are inextricably connected. Furthermore, no single component may actually be affirmed as being predominant in the considerations.

This is true, despite the ostensibly greater import of the morality factor. It would seem that the ethics and the morality of treating the uninsured would dictate policy and practice. This overlooks, however, how medical policy, and how it is carried out, is a morality unto itself. Treating the sick is an activity with a moral core; the action may not be made distinct from what inspires it, and procedures involved must always reflect this foundation, or they would not be at play to begin with.

Nonetheless: hospitals and clinics need to operate, and policy must be in place to accommodate even the most baffling moral dilemmas. The policy adopted will reflect the viewed morality of the institution and, presumably, that of its staff. Interestingly, this then becomes less about what is morally right or wrong, and more about the mechanics of actual health care survival. The moral stance taken and executed by policy and practice will, through this process, determine the fate of the institution, and consequently that of the nurses and doctors.

Practice, too, exists as a potent entity within this scenario. It is, in a sense, the “go-between” of the dilemma, as it is the way in which the morality, manifested in policy, is carried out. Here, gradations may well be present, depending upon the gradations of ethical feeling within the practitioners, and specifically the nurses. One may be utterly disinclined to even address the financial conditions of a patient, and apply care only as care is indicated. Another, perhaps with more of an eye to the well-being of the institution, will assess insurance information before ascertaining any knowledge of why the patient came in. Policy, within any health care facility, is only as stringent or lax as those enforcing it. Practice, as the tangible expression of morality and policy, consequently has a substantial power to interpret, and exercise, both.

Impact on Nursing

The dilemma posed by the uninsured impacts drastically on nursing, and in more than one manner. To begin with, the nurse is, as noted, typically perceived by the patient as a liaison of sorts; they provide an understandable, accessible presence in an atmosphere often intimidating, and during conditions marked by stress for the patient. Plainly speaking, and whether at the admittance desk or within the hospital room, the nurse is the one who must directly deal with the patient’s financial status. In the former case, they must adhere to policy and explain how the institution does or does not administer to the uninsured; in the latter, they must interpret both patient response and relay critical information regarding the payment of the treatment, as dictated by their superiors.

This is a difficult position, at best. It alters the traditional role of the nurse as compassionate and familiar element to something possibly adversarial, and a patient in any mode of distress will most likely not appreciate that the nurse is simply performing their duties. Then, the policies of the institution, most likely not favorable to attending to the uninsured, may contrast sharply with the nurse’s own ideology.

A good nurse has as well a larger sense of the necessary vitality of the institution for which they work, but perhaps not always a precise knowledge of how that institution’s finances are arranged. Simply, a nurse may perceive that profit, and not merely the goal of meeting expenses, is motivating the decision to refuse treatment to the uninsured. In such a scenario, the nurse may have a perspective the organization sorely requires, and one directly relating to the institution’s financial health. As the most probable repository of patient confidence, the nurse is empowered to gain a better sense of potential, long-term damage to the institution that its directors possess.

Various Viewpoints

If there can be said to be any positive side to the dilemma of the uninsured – and isolating even one demands serious reflection – it is that necessary attention is being paid to the entire health care industry, as an industry and as an essential element of society. For long years, doctors and hospitals enjoyed a prestige that virtually elevated them to an unassailable position of authority, and those in charge of medical institutions have not been especially eager to see this armor weakened. As the uninsured issues have triggered an enormous, national inquiry into many aspects of how the medical community actually operates, abuses are discovered and prevented. There is, ultimately, no industry as pervasive and as powerful as health care that does not require public and professional, outside scrutiny.

It is, however, the negative side to the dilemma of the uninsured which captures most public attention, not least of which because so much of the public is among that grouping. Those insured see the uninsured crisis as an added, and unfair, expense; logic dictates that they must pay for those who can’t, in higher fees, and this breeds serious resentment against both uninsured and the system itself. Meanwhile, those without insurance are typically gripped by great fears, even when their health is sound. Most are not eager to receive care they cannot pay for, and this very ethical feeling creates a resentment all its own. The uninsured, certainly as much as the insured, have good reason to note how costly medical care is. An inability to pay the bills by no means translates to being unmindful of them.

Opinions, however, are somewhat moot, given the enormity of the problem. Whatever good emanates from it, even to the extent of reform rendering a lack of insurance an obsolete concern, nonetheless stems from a drastic and culturally unhealthy state of being. Plainly speaking, the issue of the uninsured is an ongoing disaster, and one affecting virtually every segment of the population.

Implications and Recommendations

Today’s nurse is obligated to enter their profession with a solid awareness of the dilemma of the uninsured, and an eye to how this problem is addressed in whatever venue they choose to practice. Acknowledging that the power to decide admittance is not within their hands, the nurse must accept this as a determining factor in taking on a position. There can be no doubt; in one form or another, the dilemma will manifest itself in their work, and they must both adopt a position which best reflects their own feelings regarding it, and place themselves in an institution most in accord with these feelings.

In broader terms, the one thing that must end, in regard to the government’s addressing of the issue of the uninsured, is the dangerous, and ultimately unsatisfactory, halfway measures made thus far. No administration within the past few decades has not conceded that the problem of the uninsured is vast, yet each has approached it in a woefully inadequate fashion, including the current one: “Even the Patient Protection and Affordable Care Act of 2010 will only extend insurance coverage to 32 million consumers…and many of its insurance provisions do not take effect until 2114” (Jansson, 2011, p. 100).

For nurses, and for the public, it is essential that a dilemma of this magnitude finally be treated as such. Health care effects absolutely every citizen. As employment continues to fluctuate, even a marked improvement in its rates no longer translates to automatic health care benefits. The government must use its utmost resources to develop a plan, perhaps modeled on another nation’s successful one, of incorporating a socialized, national coverage. It will be, of necessity, complex and costly: “…A strategy that strengthens primary care capacity and emphasizes health protection would improve health status, reduce inequities, and lower costs” (Milstein, et al., 2010).  It is nonetheless essential. No civilized nation may claim to be civilized without such a plan, and the United States must take advantage of the international models in existence to perfect one to meet the needs of its people.

References

Blair, J. D. (2007.) Strategic Thinking and Entrepreneurial Action in the Health Care Industry. San Diego, CA: Emerald Group Publishing.

Dracup, K., and Morris, P. E. (November, 2007.) “Global Poverty: A Challenge for Critical  Care.”  American Journal of Critical Care, Vol. 16, No. 6,  p. 528 – 530. Retrieved February 5,  2011.

Fawcett, J. T. N., and McQueen, A. (2011.) Perspectives on Cancer Care. Ames, IO: John Wiley and Sons, Ltd.

Jacobs, L. R., and Skocpol, T. (2010.) Health Care Reform and American Politics. New York, NY: Oxford University Press.

Jansson, B. S. (2011.) Improving Health Care through Advocacy: A Guide for the Health and Helping Professions. Hoboken, NJ: John Wiley and Sons, Inc.

Milstein, B., Homer, J., and Hirsch, G. (March, 2010.) “Analyzing Health Reform Strategies with a Dynamic Simulation Model.” American Journal of Public Health, Vol. 100, No. 5, p. 811 – 815 Retrieved February 4, 2011.

Quadagno, J. S. (2005.) One Nation, Uninsured: Why the U. S. Has No National Health Insurance. New York, NY: Oxford University Press.

Roth, P. B. (February, 2006.) “Managing the Uninsured within a Community Network.” Annals of Family Medicine, Vol. 4, No. 1, p. 528 – 531. Retrieved February 5, 2011.