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[Woodstock Report, December 1993, no. 36]
Copyright © 1993 Woodstock Theological Center
All rights reserved
On October 13, 1993, the Woodstock Theological Center marked the mid-point of its two-year project on ethical considerations in the business and financial aspects of health care with a forum discussion of some of the dilemmas which have surfaced in the study. The three panelists were Catherine D. DeAngelis, M.D., associate dean of academic affairs and professor of pediatrics at Johns Hopkins University; Bernard R. Tresnowski, president and chief executive officer of the Blue Cross and Blue Shield Association; and John P. Langan, S.J., a senior fellow at Woodstock and Rose Kennedy Professor of Christian Ethics at the Kennedy Institute of Ethics at Georgetown University. Each of the panelists is a member of the Woodstock seminar group which produced Ethical Considerations in the Business Aspects of Health Care, Seminar in Business Ethics, (Georgetown University Press, 1995). Judy Woodruff, CNN's prime anchor and senior correspondent, moderated the panel. We present an edited and abridged version of the talks and the questions which followed. The views expressed at a Woodstock forum do not necessarily reflect the views of the Woodstock Theological Center.
Catherine D. DeAngelis, M.D., is a professor of pediatrics and an associate dean of academic affairs at the Johns Hopkins School of Medicine. She is the author of Pediatric Primary Care, editor of An Introduction to Clinical Research, and co-editor of Principles and Practice of Pediatrics. Dr. DeAngelis also holds an R.N. degree and a master's degree in public health.
As I try to function in a legitimate and ethical way in today's atmosphere of health care and as I try to prepare our young medical students for the 21st century, I feel most of the time as if we are sandwiched between ethics and economics.
There are three things that physicians want for their patients and that patients want for themselves. We all want security, or, putting it another way, universal access. We want freedom of choice, that's the American way. And we want to control our costs. The problem is this: it is impossible to do all three simultaneously and to do all three well.
The card that President Clinton showed us is a spectacular idea for providing secure health care. It is a wonderful concept that no one in America who needs care would be denied it. But that card itself does not assure access. All you have to do is look at the statistics. For example, I have just reviewed a paper showing that children who are on medical assistance make up the lowest level of immunized children in this country. They all have that card, so to speak, but they're not immunized. That causes me great agony. I am a pediatrician.
How ethical is it for the same individual to use two or three different emergency rooms in the same night for a relatively common problem? It is used the first time because the emergency room is more convenient than going to a primary care physician, even though the treatment costs three or four times as much. The same person visits a second emergency room to make sure that the first diagnosis was accurate. Then, since the second doctor didn't agree with the first doctor, there is a visit to the third doctor. How ethical is that? But this is something we see all the time.
We are victims of our high technology, the victims of our success in a way. Every one of us wants absolutely the best for ourselves and for our loved ones. But that's very costly. Everything we are doing in research and every advance we make in health care delivery increases the age of our population. That's what we want; we want to live on and on and on. In 1950, the average life span in the United States was 68. In 1990 it was 76. Research is going on and on. But with every medical advance the population ages and this contributes to the cost. There are a lot of ethical dilemmas here.
What about the role of violence? Do you know how much violence contributes to the cost of American health care? Is this a medical issue? I deal a lot with teenagers. Do you know what the three leading causes of death are for teenagers, or of anyone from ages 14 through about 40? They are: one, injuries, mostly related to automobiles, many of them related to drinking; number two, homicide; and number three, suicide.
When we talk about the ethics of health care, and the costs involved, we have to look at it from four different aspects: (1) The direct care of our patients; (2) the medical education of our young people who will continue to provide health care; (3) research; and (4) the administration to keep these three on track. All are interwoven and any decision at any level interacts and impacts significantly on the other levels. Here are just three brief examples of some ethical dilemmas.
By the end of this year, we may have isolated the special gene that accounts for about two to three percent of all the breast cancers in this country. This gene is present in only two to three percent of the cases, but there is over a 95 percent probability that a woman with the gene will develop a malignancy in her breast. The only treatment is bilateral mastectomy, removal of both breasts. Now, if you're in a managed care facility you know that this screening device is available. Are you going to use it for everyone of your women patients? If you do, and when you find the gene in the two to three percent of your population, do you then put these women through a bilateral mastectomy with all the ethical problems involved? And what about the expense? Can you afford it? Well, maybe we shouldn't be doing this. And if we shouldn't, we had better make a decision quickly because we are doing a lot of genetic research and this is only one small example.
How do we adjust to what is a maldistribution, geographically and by specialties, in health care today by the providers? Is 50 percent primary care physicians or generalists the right combination? This figure has been pulled out of the air. And what about the use of nurse practitioners and physician's assistants, who provide wonderful care? How ethical is it to say that they are more cost effective? If you look at the statistics, it's probably a wash. They are probably more cost effective because they cost the same but they spend more time with the patient. But try to get the point across to people that nurse practitioners are absolutely wonderful.
My husband is a developmental neuropsychiatrist, a child psychiatrist who deals with children with developmental disabilities. He spent an hour and 45 minutes last night on the telephone trying to convince people that a 14-year-old girl who is quite violent should not leave the hospital. The insurance company argued that her diagnosis was worth three days in the hospital, and that's all it would allow. The girl would have to be discharged. My husband said, "I can't do that." But he couldn't talk anybody out of it and the company said, "Well, you keep her in there, then send us the record and we'll decide." But the girl's mother said, "Dr. Harris, I can't afford it. If insurance won't pay for it, I can't afford the extra days in the hospital."
So, he and the mother decided that she should sign her daughter out against medical advice. All night my husband sat by the phone and this morning he called the mother to make sure that the child didn't injure somebody last night. That's another kind of ethical dilemma. All of us have to understand that there are many sides to this huge dilemma of health care provision in this country and that the bottom line for all of us really should be what's best for the patient. How are we going to accomplish that?
Bernard R. Tresnowski is president and chief executive officer of the Blue Cross and Blue Shield Association, the coordinating organization for the 71 independent Blue Cross and Blue Shield plans. Mr. Tresnowski has a master's degree in public health and hospital administration.
The administration and the Congress are currently engaged in a long and very arduous process of producing a legislative framework for health care that will impact the lives of the American people more profoundly than anything in our history. Underlying that debate are many ethical considerations that reflect the fundamental values of the principal players in the financing and delivery of health care. I would like to share with you one person's view of those values on the part of people at large, health care providers, and the government. I will exaggerate a bit to make a point.
The American people are basically driven by a belief in their own immortality. As one author noted, "They harbor the fantasy that suffering and disease can be eliminated." The public often forgets that disease is inextricably intertwined with health, that aging is not a disease that can be treated, and that death is not an event that can be postponed indefinitely. On a practical level, consumers have been taught to want good health care regardless of their ability to pay. They want free choice of doctors and hospitals so they can get the best available care and medical technology, and they also want to be free from the fear of being impoverished by the high cost of serious illness.
What about the providers? Well, the providers want to maximize their income and, at the same time, achieve a sense of professional accomplishment for a job well done. And while doing that they want to preserve their professional freedom and their institutions. And what about the insurers? The insurers want a strong competitive position based upon public acceptance. They are driven increasingly by profitability and growth unfettered by restrictive regulations. The employers who pay most of the bill are driven fundamentally by the need to compete successfully in their industry. They, too, seek profitability and growth and realize that their success, in large part, is determined by high productivity, by a healthy and well-motivated work force.
And finally, the government seeks to legislate broad scale social programs and tax policies that improve social and economic behavior. Increasingly, what the government looks for is more support and less criticism of its current tax-supported health programs, primarily Medicare and Medicaid.
What does this set of underlying values tell us about what we will hear over the next year? It tells us there are going to be a lot of contradictions that must be resolved. It is clear that each of the parties I have described makes decisions to serve its self interests and, therefore, you begin to see the contradictions. All pursue their own goals and no one wants to make basic choices that consider the long-term interests of the total health system. Indeed, we have taught ourselves to resolve contradictions by denying them. This can be seen in the criticism that describes the imperfections and inefficiencies in the market for health care services.
The assertion is made that consumers are not informed. And it's true that for a market to function the consumer needs to make informed choices. But how can the consumer be motivated if he or she is not a part of the economic transaction? Should we resolve this contradiction by engaging the consumer in the economic risks either at the point of service or in the purchase of the health benefit program? Our tradition runs contrary to that. We have taught consumers to value first dollar coverage and comprehensiveness of benefits. In fact, the consumer's principal representative, organized labor, continues to promote broad and full benefits, oppose tax caps, and seek universal health insurance paid for by tax dollars.
Another contradiction is apparent in the behavior of doctors, hospitals, and other providers. We all know that we badly need the greater integration of health care delivery in a way that promotes responsibility for both the clinical and the cost aspects of care. At least in theory the staff model HMO offers this framework. But staff model HMOs or coordinated delivery systems are not widespread and probably never will be. Thus, for structural restraints we substitute a myriad of interventions into the practice of medicine and we call it "managed care." And we become engaged in a game of adaptation in which the providers are motivated by survival and their desire to maximize income, while everybody else is trying to manipulate them in the process.
And what about the contradictions for the health insurers? I think that has to be viewed both in the context of the insurers' historical antecedents and what we see in the current environment. In the mid-1930s, during the beginning of private health coverage, there was a widespread belief that health care services were not insurable. The commercial insurance companies stayed away from the field because they believed it was hazardous; they called it a moral hazard. So Blue Cross and Blue Shield plans sprung up all over the United States in that period as community-based, not-for-profit, prepayment organizations and, at least initially, enjoyed a very large risk pool with community rating and regulatory protection. The Blue Cross and Blue Shield plans were thus inspired to undertake social objectives and, in fact, brought health care to millions and millions of Americans.
But today the picture has changed significantly. The combination of intense competition, 1,500 health insurance carriers in the marketplace, and escalating health care costs have forced all insurers to survive in the market by greater risk selection. In other words, you compete not on your ability to influence the behavior of those who deliver care, but you compete on your ability to take only the healthy and the young into your risk pool. Now clearly you can understand that behavior from a near-term business strategy, but I have to tell you it's a long-term prescription for disaster in the health insurance industry. And that is why it is the centerpiece the President is proposing in the changes.
What about the employer? The employers' contradictions have been the most painful in my judgement. In the last ten years employers have been shocked to learn that business and public policy decisions that were made in the late 40s or in the 50s to provide health benefits are simply not suited to the present, a time of slower economic growth and intensive competition in international markets. Now, if you attempt to unravel four decades of established expectations on the part of workers by challenging the efficiency of the system of health care delivery and its financing, you'll meet enormous resistance.
America's industrial leaders need to decide between a government managed health care system, or one that operates in an efficient market. If their philosophical instincts lead them to a more efficient market, which it probably should, they need the courage to change their employer health benefits in order to promote that objective.
What about the government? This contradiction expresses itself in the strain that government experiences in balancing social justice on the one hand and the affordability of health care services on the other hand. If you don't believe that, think about how this was dramatically brought home to us in the catastrophic health care benefit program for the Medicare population: it was passed by the Congress and then rescinded by the Congress! What that taught us is that government should not attempt to do more than it can reasonably accomplish. Its primary role is to assure access to health care services to citizens who lack it and to pay the fair cost of those services. Beyond that, government should oversee the health care market to insure safety and quality and to correct any deficiency.
Finally, as all of us citizens in this country follow next year's health care debate, these symptoms and contradictions will become even sharper. Choices for change must recognize these contradictions in a way that enables all the key players to participate in a cooperative strategy to reform the system. That means they're going to have to think about the fundamental values that have driven their behavior up to this point.
John P. Langan, S.J., is a senior fellow at the Woodstock Theological Center and is Rose Kennedy professor of Christian ethics, Kennedy Institute of Ethics and the department of philosophy at Georgetown University. He is the editor of Catholic Universities in Church and Society: A Dialogue on Ex corde Ecclesiae and co-editor of Ethics, Trust, and the Professions.
About a year ago I spoke to a group of business executives and began with the observation that most of us probably began our lives in hospital nurseries and most of us will probably end our lives in nursing homes. It was a reminder that we begin and end as people dependent on the health care system. The system is at the beginning, at the end, and it is all around us. It's a matter of quite central concern.
I visit nursing homes myself for a couple of reasons. Partly out of a sense of responsibility because I'm on the board of a health care system which includes a number of nursing homes and partly because my mother resides in one. The youngest resident in the nursing home where my mother lives is a young man who was injured in a football accident six years ago. He was covered by insurance of sorts. But the insurance company that was covering the high school and its athletic program went out of business a year ago. There are allegations of fraud, as yet unresolved, but whatever the case, the payments stopped. The family, which was already in considerable financial difficulty, faces an insoluble problem. They've raised $40,000 from friends, neighbors, high school classmates, and so on. But they're struggling.
It's always risky to generalize from single cases. I mention this case simply to focus attention on the importance of being concerned about the business ethics of people in the health care field, the providers and the insurers. Whether the doctors will continue to be the central players or not, they certainly will continue to have a quite indispensable responsibility. We have in the health care field a diversity of players and a diversity of ethical responsibilities. Although some of the players are very big, they're not invulnerable. They can get into deep difficulty. We have had some experience of that locally. We simply can't take them for granted. We have to be concerned with their economic well-being as well as their ethical standards.
We also need to recognize that we are dealing tonight with a genuinely scary subject, because we're talking about people under conditions of great vulnerability, great uncertainty. They're confronted with what may well be the largest financial outlays that they ever have to make in their lives and they're not sure of how to make their decisions. They very much need the reassurance that the health care system itself is a morally sound environment and that it's not simply just a business.
There are really three different roles for health-care providers. One we might call the professional role, which focuses on the interpersonal provision of medical care to individuals. It can have a strong pastoral flavor and it's carried on by a self-regulating profession. Secondly, there is the role of the health care provider as the person who pursues research, the man or woman in the white coat who tries to shape the provision of health care on a day-to-day basis in the light of the best available scientific and medical knowledge. The third role of the health care provider is as an economic agent and decision maker. Each of these roles brings with it significant moral responsibilities.
It is a mistake to think that the ethical problems and dilemmas of the health care system would be resolved by enacting the Clinton program or any alternative program. There are contradictions of values and expectations on the part of the various participants in health care. They will not be resolved neatly by legislative solutions. Our expectations of the medical profession and the health care system have been very high, and we often failed to recognize the changes that have been going on in the business, economic, and social matrix within which health care is delivered.
We have moved from small businesses to large businesses within the health care field, from a pattern of individual practice to group practices in hospitals and elsewhere. We have moved from community hospitals rooted in a particular place and tradition to the development of very large chains. We had a recent merger that will give us a chain of something like 140 hospitals. This size and complexity puts pressure on our efforts to recognize traditional values and make them effective.
In his recent speech, the President listed six values. We could break them down in different ways. We need to preserve professional discretion and autonomy, accountability to payers, accountability to and responsibility for patients. We need to maintain a sense of fiduciary responsibility, to cultivate a regard for truth. We need to maintain standards of fairness, care in the use of resources, and respect for the autonomy and personal values of patients. As we look at what we have now and at the stresses that the system is under and the possible alternatives, we need to be looking at all of these values, recognizing that no system will find it easy to harmonize all of them. No system will be free of contradiction. We have to show a certain patience and realism as well as a certain skepticism about the proposed remedies.
We are not dealing with a set of problems that can be solved tidily by a small set of principles that will yield univocal answers. We will be caught in a whole series of value balancing situations. And we will need to encourage health care providers to be patient with that process and to be able to engage in it in a thoughtful and responsible way. The health care system is an enormous economic enterprise. But it is vastly more than an economic enterprise. It comes intimately close to us as persons. And we can't think of medicine simply as something to be sold anymore than we would think about love as something to be sold, or justice as something to be bought. It is, indeed, a business, but it has to be seen as vastly more than that, and it will always have a profoundly ethical character that can be given a rich, religious interpretation.
Ms. Woodruff: The premise of President Clinton's proposal is that everyone in this country should have access to health care. And beyond that, employers have a responsibility to play a role by either providing coverage for their employees or by participating in a fund that goes to those who are not employed. Is this a sound premise for the President to be pursuing?
Mr. Tresnowski: Well, people quarrel about the means for getting there but I don't know that anybody is against universal coverage. One has to keep in mind that 85 percent of the population already has access to health care. So, while we are concerned for the 15 percent, let's not forget that we have a system of health care in this country that covers most of the population.
The real problem, of course, is that health care costs almost a trillion dollars a year. Now, even if the President is correct that we can squeeze out some of the fat to pay for the 15 percent, the things that drive the costs, technology, the aging of the population, inflation, still remain. It is a very large economic enterprise with a lot of financial pressure built around it. God bless the President and his objective, but how we get there is a very, very difficult question to answer. I have great sympathy for the Congress on this one, I really do.
Ms. Woodruff: Is it really the role of the government to be tinkering with the system so that we can get to that 15 percent?
Mr. Tresnowski: I think the government has a role to play. I was one of the founders of the Jackson Hole Group, the coalition of professionals that crafted the "managed care" approach to health care. Our notion when we sat down ten years ago in Jackson Hole was that we needed to clean up the industry, and so we coined the term "managed competition." It sounds like an oxymoron, I know, but we were borrowing an idea from the Securities and Exchange Commission, which provides government oversight of an important economic component of our society. We said, why can't we do that with health care? Why not have something that provides supervision and makes the market function appropriately? For a whole lot of reasons, however, our concept has been drastically changed. We don't know how it will play out in the end.
Father Langan: I would agree that universal access is now a broadly recognized moral imperative. This whole debate would be regarded as a failure if we do not institute some system of universal access. But at what level? And with what limitations? This is a difficult policy matter. But there is also the question about who pays. I think we have to go with a mixed program. It is important that individuals pay something. But reliance on employers ought to be a fundamental building block of the system. The specific problem now is that people lose their health care benefits when they become unemployed. This compounds the misery. And losing one's job is itself very likely to have an adverse impact on a person's health. We will wind up, I hope, with a judicious mixture of government and employer contributions.
Dr. DeAngelis: We could easily solve the problem of the 15 percent who don't have access and we could control the cost very simply also. The only question is what are the 85 percent willing to give up in order to cover the other 15 percent? And, then, what are the 100 percent willing to give up so that the costs are controlled? That is the basic issue. Everybody says yes, we all want this, but let the other person pay for it. Obviously, then, this is an issue for every single person in the United States.
Are you willing to wait a month or two or three for an elective procedure? Are you willing for someone to say, "No, your child can't have a kidney transplant?" Are you willing to say, "No, we're not going to do the research that's going to identify the gene for breast cancer?" If we are willing to say, "Okay, let's sit down right now and decide what we're going to do and what we're not going to do," we can solve it. The problem is that we are such a heterogeneous population. And we are very spoiled. Every one of us has to ask ourselves what are we going to give up so that everybody will have something. That's a very Christian kind of thing.
Ms. Woodruff: Let me play devil's advocate. If the capitalist economic structure that this country has is one of the things that has made it one of the greatest nations, if not the greatest nation on earth, why not let the free market system fix itself, with some adjustments for the 15 percent who are uninsured? If government or anybody gets in and tries to change the system in a major way, you may end up with a worse situation in which decisions are not made in peoples' best interest.
Father Langan: Well, I think we have to expect that almost any program is going to have some significant negative impact on people. But it's worth remembering that a lot of the pressure for change actually comes from corporate America which finds the provision of health care benefits increasingly a drag in the larger competitive international economic arena. So we can look on this program as protection of our capitalist enterprise in terms of preserving both its competition and its moral legitimacy. I also think that we have a very complicated system that doesn't obey the principles of any one economic theory. There are market imperfections. There are people who are not really functioning the way consumers are supposed to function in an open market because the system is responsive to a very wide range of pressures. Moreover, health care is a funny mix of an enterprise and a profession. One of my concerns is to preserve the values of the profession while acknowledging that it's embedded in an economic matrix in which the enterprise element is very important.
Ms. Woodruff: How do you do that, when so often, at the intersection, there are two diametrically different sets of interests?
Mr. Tresnowski: There are many things that need to be changed. Let me just pick one piece in this puzzle that I'm most familiar with and that's insurance. What has evolved in this country is an insurance industry that functions under casualty insurance principles. But health care does not fit into insurance environment; it can't function under those rules. Social insurance is its appropriate environment. You can't have insurers-of-last-resort sitting there getting the worst risks, because they will go out of business one of these days. They simply won't be able to survive financially. You have to equalize, you have to set up a level playing field. The only vehicle we have in this country for doing that is statute and regulation.
Dr. DeAngelis: It is interesting to see what capitalistic enterprise has done to us in medicine and where it will take us if we do not tinker with it. And I do think we need to tinker with it. Take one example. Right now everybody agrees that we need more generalists. But I have spent my whole career almost apologizing for being a generalist. I was told that I was committing professional suicide to go back to Johns Hopkins as a generalist.
Why are people surprised, then, that there are so few generalists? Medical students come to Hopkins to be doctors. They want to help people. And what happens? They enter the system and they look around. They see that I can spend an hour with the parents of a patient, carefully explaining something to them that will involve a minor surgical procedure, perhaps a biopsy. I am with them before the biopsy, which takes 20 minutes. After the biopsy, I explain what happened. So, I have spent maybe four or five hours with the patient and the parents. The surgeon spends maybe 15 minutes and an anesthesiologist spends 20 minutes.
The students see that the reimbursement for my five hours of service is about one-sixth that of the surgeon and about one-fifth that of the anesthesiologist. So they say, "I don't understand this." And I say, "I don't either, you explain it to me."
Now, if this capitalistic system is working the right way, why don't we pay for what we value? How can we say we value one thing yet pay for something else? This is what we need to tinker with.
Audience: If the system gets tinkered with, will would-be doctors conclude that medicine isn't a good profession to be in anymore? Will we lose the quality of our doctors?
Dr. DeAngelis: I cannot imagine a time in this country when people will not value what a physician does. I tell our medical students the first day they come to us, you've got to remember that in many cases you'll be the first one to see new life come into this world and in many cases you are going to be the last one that someone's ever going to see in this world. And you'll deal with all of life in between.
If you go into medicine for the right reasons, if you truly go into medicine because you want to help people, you are not going to starve to death. People are always going to value what you have to give them because what you have to give them is something very special. And, yes, you may not make as much as some businessperson or baseball player or golf professional. But that's not why you go into medicine. If people come into medicine because it's a good business, I'd rather not have them in medicine.