Equal Access to Health Care- -Ethical Issues in Determining Public Policy
A
CCESS TO HEALTH CARE is influenced by individual health needs, financial resources, and the health care delivery system. Each of these factors may be affected by the prevailing public policy established by federal, state, or local government. Technological developments, chronic illness, and the aging population each have an independent as well as an interrelated impact on access to health care and the delivery of health services. Nurses can influence the development of meaningful, ethically sound policy. Many new technologies have been developed in the health care field recently; the most well-known deliver a significant benefit to a smaller number of persons at high cost. These developments are known as “big-ticket” medical technologies. In the bioethical sense, a utilitarian objection could be raised that greater aggregate medical benefits could be achieved by investing resources in alternative technologies. It may also be claimed that using big-ticket technology rather than alternatives is unjust or unfair. Applying the principle of justice in the health care system has implications for both access and resource allocation. Daniels (1989) suggests that “justice will require us to make decisions about which technologies and services it is more important to disseminate under conditions of moderate scarcity.” Chronic illnesses have been considered a health care challenge since the 1930s. The bioethical theory of the autonomy paradigm composed of the medical model of illness, the physician-patient relationship or “contractual model,” and the individualistic person, requires substantial revision in the context of chronic illnesses. Rather than viewing disease as a time-limited enemy, chronic illness is a component of the person’s overall state of being. The concept of autonomy in chronic illnesses is something that grows out of the provider-patient relationship rather than something that presides over it. Other bioethical principles to be applied to chronic ill-
ness are justice and equity relative to differential access to health care and allocation of resources for a broad range of health, social, educational, counseling, and rehabilitative services. Consideration in establishing public policy must be given to priority setting regarding services for chronic illnesses due to the potentially massive expenditures for health care in this area (Jennings, Callahan, & Caplan, 1988). The trend toward an increasingly large aging population demands some of the same ethical considerations as for chronic illnesses, but there are also some distinctions. A significant ethical consideration centers on the biomedical issue of when to treat and when to terminate treatment. This question is also interrelated with the impact of the technological advancements that provide the treatment modalities. Age has been suggested as a medical biographical standard to be used relative to the prognosis of treatment outcome. The morality of age as a standard must be considered, including when medical care should be limited to relief of suffering rather than resistance to death. Government has had a continuing and substantive role in determining public policy and allocating substantial resources. Health care expenditures nationally exceed 10 per cent of the gross national product, and more than 50 per cent are publicly funded. Since millions of people are still denied access to care, public policy should address a nationalized health care system that reforms and controls both the financing and delivery system formulated with the strong consideration of ethical principles. At the macroallocative level, there is a scarcity of health care resources. Without direct governmental policy decisions, de facto rationing of services is occurring at the microallocative level in the marketplace (Morreim, 1988). In achieving an ethical policy decision, the values of society as a whole must be identified and a consensus established as a basis for these public policies.
References LOISMCCARRON,BSN, JD Program SpeciahtfPlannev Anoka County Community Health and Social Services 403 Jackson St Anoka, MN 55303 copyright
0
199 1 by W.B.
Saunders
Company
8755-7223/91/0702-0001$03.00/O
Journal of Profxiona;
Nursing, Vol 7, No 2 (March-April),
Daniels, N. (1989). Justice and the dissemination of big ticket technologies. In J. Arms and N. Rhoden, Ethical issues in modern medicine, (3rd ed., pp. 5 10-515. Mountain View, CA: Mayfield. Jennings, B., Callahan, D., & Caplan, A. (1988). Ethical challenges of chronic illness. Hastings Center Report, 18, 4-14. Morreim, E. (1988). Cost containment: Challenging fidelity and justice. Hastings Center Report, 18, 20-21.
199 1: p 7 1
71
A
CCESS TO HEALTH CARE is influenced by individual health needs, financial resources, and the health care delivery system. Each of these factors may be affected by the prevailing public policy established by federal, state, or local government. Technological developments, chronic illness, and the aging population each have an independent as well as an interrelated impact on access to health care and the delivery of health services. Nurses can influence the development of meaningful, ethically sound policy. Many new technologies have been developed in the health care field recently; the most well-known deliver a significant benefit to a smaller number of persons at high cost. These developments are known as “big-ticket” medical technologies. In the bioethical sense, a utilitarian objection could be raised that greater aggregate medical benefits could be achieved by investing resources in alternative technologies. It may also be claimed that using big-ticket technology rather than alternatives is unjust or unfair. Applying the principle of justice in the health care system has implications for both access and resource allocation. Daniels (1989) suggests that “justice will require us to make decisions about which technologies and services it is more important to disseminate under conditions of moderate scarcity.” Chronic illnesses have been considered a health care challenge since the 1930s. The bioethical theory of the autonomy paradigm composed of the medical model of illness, the physician-patient relationship or “contractual model,” and the individualistic person, requires substantial revision in the context of chronic illnesses. Rather than viewing disease as a time-limited enemy, chronic illness is a component of the person’s overall state of being. The concept of autonomy in chronic illnesses is something that grows out of the provider-patient relationship rather than something that presides over it. Other bioethical principles to be applied to chronic ill-
ness are justice and equity relative to differential access to health care and allocation of resources for a broad range of health, social, educational, counseling, and rehabilitative services. Consideration in establishing public policy must be given to priority setting regarding services for chronic illnesses due to the potentially massive expenditures for health care in this area (Jennings, Callahan, & Caplan, 1988). The trend toward an increasingly large aging population demands some of the same ethical considerations as for chronic illnesses, but there are also some distinctions. A significant ethical consideration centers on the biomedical issue of when to treat and when to terminate treatment. This question is also interrelated with the impact of the technological advancements that provide the treatment modalities. Age has been suggested as a medical biographical standard to be used relative to the prognosis of treatment outcome. The morality of age as a standard must be considered, including when medical care should be limited to relief of suffering rather than resistance to death. Government has had a continuing and substantive role in determining public policy and allocating substantial resources. Health care expenditures nationally exceed 10 per cent of the gross national product, and more than 50 per cent are publicly funded. Since millions of people are still denied access to care, public policy should address a nationalized health care system that reforms and controls both the financing and delivery system formulated with the strong consideration of ethical principles. At the macroallocative level, there is a scarcity of health care resources. Without direct governmental policy decisions, de facto rationing of services is occurring at the microallocative level in the marketplace (Morreim, 1988). In achieving an ethical policy decision, the values of society as a whole must be identified and a consensus established as a basis for these public policies.
References LOISMCCARRON,BSN, JD Program SpeciahtfPlannev Anoka County Community Health and Social Services 403 Jackson St Anoka, MN 55303 copyright
0
199 1 by W.B.
Saunders
Company
8755-7223/91/0702-0001$03.00/O
Journal of Profxiona;
Nursing, Vol 7, No 2 (March-April),
Daniels, N. (1989). Justice and the dissemination of big ticket technologies. In J. Arms and N. Rhoden, Ethical issues in modern medicine, (3rd ed., pp. 5 10-515. Mountain View, CA: Mayfield. Jennings, B., Callahan, D., & Caplan, A. (1988). Ethical challenges of chronic illness. Hastings Center Report, 18, 4-14. Morreim, E. (1988). Cost containment: Challenging fidelity and justice. Hastings Center Report, 18, 20-21.
199 1: p 7 1
71
