Monday, October 19, 2009

Is Ethics Relevant for Health Reform?

As I sat down to prepare a talk on health reform and ethics I'll be giving soon, a Tina Turner song started to play in my head - but with "ethics" substituted for "love":
"What's ethics got to do, got to do with it?
What's ethics but a second hand emotion?"
Given the mind-numbing daily stories about twists and turns in Washington and the daft Republican rhetoric about "socialized medicine" and "death panels," an observer might conclude - "health reform is only about politics and special interests - ethics is an irrelevant second hand emotion!"

I've had that thought myself. But I think it's wrong.

There's no doubt that partisan politics and special interests are leading players in the reform process. (As an example, see here 'for an audio of Senator Jim DeMint's excitement about "breaking" President Obama and creating his "Waterloo" by defeating health reform.) But in addition to the impact of PAC money bribes and armies of lobbyists, politicians and special interests try to get their way by playing on the public's strongly held but unexamined values. From the political perspective this is "stealth ethics." From the philosophical perspective we might call it "pseudo ethics."

President Obama reported receiving a letter saying (see here for a videoclip of the President telling the story):

"I don't want government-run health care. I don't want socialized medicine. And don't touch my Medicare."

This story got a big laugh from the President's AARP audience. But it makes a deeper point about ethics and health reform. Ethical reflection isn't just a matter of asserting values. It requires bringing our values to bear on the world of facts, and, reciprocally, modifying our values as the facts may require. The joke here is that the anti-government, libertarian letter writer made the facts fit the values. Since she (it was a woman) liked Medicare, Medicare couldn't possibly be a government program!

Muddled "pseudo ethics" are stirring the reform pot in several ways. Here are two examples:

  • Health insurers are "villains." There's lots to criticize in the conduct of insurance companies and in the way we've structured our health "system" around competing insurers. But even if Mother Theresa were in charge of U.S. health care we'd need an insurance function to oversee the way we spend our funds and to seek value for money. The global condemnation of insurers abets the public fantasy that if we get rid of the villains we'll be in a paradise that requires no difficult choices.

  • From a moral perspective the aphorism "life is priceless" conveys what Albert Schweizer called "reverence for life." But as a piece of economic guidance the aphorism is psychotic. It implies that any limit that threatens life is evil. In actuality we constantly make choices that involve weighing life against other values - how much to spend on auto safety, whether to put defibrillators on every street corner, or whether the convenience of texting while driving is worth the risk to mortality (ours and others) it poses. By not distinguishing between the metaphoric meaning of "priceless" as applied to whether life should be revered and the need to use funds wisely, we again invite the body politic to remain ignorant about our ethical obligation to set limits in health care.
So ethics does have something "to do with it" - it's not just "a second hand emotion." But what's required is not shouting about values - that's easy, and accomplishes nothing. What's really needed is the much more difficult task of shuttling between values and facts - looking at the facts in light of our values, modifying those values as needed, as when the anti-government libertarian contemplates the fact that Medicare is a 44 year old government program, and developing options that serve important values to the greatest extent possible.

If the democratic process works as the founding fathers hoped it would, this is what the legislative process should strive to do with the bills that have been developed in the House and the Senate.

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