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Individuals have a moral duty to buy health insurance, three bioethicists say

Supporters of the Affordable Healthcare Act
REUTERS/Joshua Roberts
Supporters of the Affordable Care Act gathered in front of the Supreme Court before the court's announcement of the legality of the law on June 28.

In a provocative commentary published this week in the Journal of the American Medical Association (JAMA), three bioethicists argue that the individual mandate of the Affordable Care Act (ACA) — the requirement that everybody who can afford it must purchase health insurance — is morally appropriate.

In fact, argue NIH Clinical Center bioethicists Tina Rulli and David Wendler and University of Pennsylvania bioethicist Dr. Ezekiel Emanuel, it is the moral duty of individuals to reduce certain burdens they pose on others, including the financial burden of asking others to pick up the cost of their emergency medical care.

Many individuals forgo health insurance assuming they will not need medical care. However, everyone is at substantial risk of needing medical care — even young adults. Fifteen percent of 18- to 29-year-olds have asthma, arthritis, cancer, diabetes, heart disease, or hypertension. More than half of these individuals are overweight or obese. In 2007, there were 2.6 million live births among women aged 18 to 29 years. One-fourth of all human immunodeficiency virus/AIDS diagnoses occurred in 20- to 29-year-olds. Almost 24% of 18- to 29-year-olds received treatment in an emergency department during the past year.

Routine acute care and emergency care are expensive. The cost of delivering a newborn ranges from $9,600 for a vaginal delivery to more than $21,000 for a cesarean delivery with complications. The average cost for an appendectomy is $15,850. Unless uninsured individuals pay out of pocket or incur debt, these expenses are passed on to hospitals, clinics, physicians, insured individuals, and taxpayers. In the aggregate, uncompensated care poses an enormous financial burden, totaling an estimated $56 billion in 2008.

Individuals cannot just say that they want to waive their right to health care, the authors of the commentary add, because doing so then places an unfair burden on physicians in emergency medical situations.

Even if individuals can waive their right to health care, it does not follow that physicians may decline to rescue them. If a motorcyclist who has waived the right to health care is involved in a crash, physicians should not stand by and allow the individual to bleed to death. A physician's duty to provide acute and emergency care is not grounded solely in individuals' right to be rescued; it is a requirement of benevolence and compassion at the core of medicine.

Declining to force a blood transfusion on an objecting Jehovah's Witness respects that individual's autonomous choices and values. In contrast, allowing motorcyclists who desire assistance to die simply because they failed to buy health insurance is morally unacceptable.

Opponents of the ACA's individual mandate have argued "that requiring people to contribute to the collective good is inconsistent with respect for individual liberty" and that appealing to the collective good "could justify requiring individuals to buy gym memberships or eat broccoli," write Rulli, Emanuel and Wendler.

But, they conclude, "because physicians and hospitals have a duty to rescue the uninsured by providing acute and emergency care, individuals have a corresponding duty to purchase insurance to cover the costs of this care. Requiring individuals to meet this obligation is consistent with respect for individual liberty and does not imply that they must buy gym memberships or eat broccoli."

You’ll find the commentary on the JAMA website.

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Comments (9)

They make a good point, and yet…

For a dozen years in Colorado I had no health insurance at all except for some dental coverage. I made inquiries every year, and every year, an individual policy the provided benefits similar to – not quite as good, but similar to – the health insurance provided by my employer before I retired would have cost me the equivalent of a second house payment.

I couldn’t come close to affording it.

Once I’d been diagnosed and treated surgically for skin cancer (I paid for the treatment myself), health insurance wasn’t available at any price. Preexisting condition, you know, and cancer in any form is anathema to health insurers.

Now that I’m a certified old person, I’m covered by Medicare for the basics, but what’s euphemistically called “supplemental” insurance remains far too costly unless I’m willing, once again, to take on a second house payment. I still can’t afford that, so I’m waiting to see what the “insurance exchange” produces in Minnesota and other states. I’ve never been particularly interested in affordable health insurance. What I’m interested in is affordable health CARE, whether paid for by some third party or out of my own pocket. It remains an elusive goal.

Lots of moral obligations go unfulfilled

People also have the moral obligation to care for the children they create; to contribute for the public services they consume; not to be a burden on their neighbors.

I'm hoping to hear more about this kind of discussion occuring.

Three bioethicists defining morality in the medical marketplace

"Morally appropriate", moral "duty" are phrases that may feel good; right and honorable in the initial use of the terms because they suggest a certain absolute nature, higher plain of thinking; godlike in its moral demand..

.But "moral' is a word that 'appropriately' implies; assumes health costs are morally insured also...medical industrial complex, physician... heal thyself first?

The reason the cost of routine and emergency care

is so expensive is because of costs imposed on the system by politicians.

What if we were able to remove the cost of unnecessary tests and gigantic malpractice insurance premiums that physicians need to pay in order to protect themselves from an army of ambulance chasers?

What if people were allowed to buy health insurance from any company in the industry the same way we all buy auto insurance? Ads for auto insurance companies dominate the evening television schedule and they differentiate themselves from their competitors by promising lower prices and better service. When was the last time you saw an ad for a health insuance company that promised lower price and better service than their national competitors?

What if people could buy health insurance the way people can buy auto insurance in that you are allowed choose from several levels of coverage, each with a corresponding price?

For example, what if young people were allowed to buy health insurance that only covers hospitalization for a catastrophe, such as a major injury or illness but didn't cover rountine exams and procedures that they would otherwise pay for out of pocket?

Or what if people didn't have to pay for an insurance policy that included the cost of birth control or pregnancy or hair replacement or any number of maladies that will never apply to them?

We don't expect our auto insurance to cover gasline or oil changes or even tune-ups. We save our claims for something serious, like an accident. The same concept could be applied to health care.

The reason health care and health insurance is so expensive is because politicians have passed laws that virtually require them to be. We need people who are willing to overhaul the antiquated laws imposed by the politicians, and not pass laws that force everyone to pay higher and higher costs for coverage they don't want or need.

This is so divorced from

This is so divorced from reality it's sad.

Ray you might be surprised at how affordable

and available insurance is getting since the act was enacted.

We are in our 60's one of us has what is called co morbidity conditions which are probably the same ones most people have if they live long enough and have found what I consider very reasonable health care. No where near our house payment for the two of us and we have a very small mortgage.

Dennis you apparently haven't looked lately either. I think you will find those options pretty much available.

Yes we could use more competition in Minnesota but right now that is controlled by the state not the feds so that's who you should be talking to. However since we are notoriously plump but fairly healthy we might want to see that they use a state statistic for determining rates rather than national.

Moral obligations

Indeed, I’d be interested in the application of ethics to other segments of life and fields of endeavor, especially in the corporate world. What are Jamie Dimon's ethics, for example? Or Lloyd Blankfein's? That said, however, I can hear Mr. Swift wading into the moral obligation swamp, with appropriate gurgling as the muck of delusional selfishness rises relentless around him…

It’s not difficult to think of “moral” circumstances that might make it impossible for someone to care for their children, or to contribute to the society in some measure to compensate for the public resources they consume, or that might make them a burden to their neighbors through no fault of their own (though being a burden on your neighbors often has more to do with the neighbors than the person being characterized as a burden).

Since morality is always socially defined, discussions of what’s “moral” and what isn’t are fraught with opportunities for misunderstanding and exaggeration, not to mention prejudices of one kind or another. One might argue, for example, that Mr. Tester’s commentary is an example of just that.

Our current system – before ACA takes effect, and in place for decades before the Heritage Institute and Mitt Romney even imagined an insurance exchange or an insurance mandate – provides for most, if not all, of what Mr. Tester seems to desire. At present, you can buy health insurance from any company you choose, though it might be more expensive than you’d like. Unless, of course, you have a preexisting condition, in which case you may not be able to get health insurance at all. That health insurance companies don’t mention price when they advertise is merely an example of the exercise of exactly the choice of words and images that advertising agencies in this country have been perfecting for more than a century. Health insurance companies are paying those agencies a fortune to do just that.

You’re also currently allowed – in some markets, even encouraged – to choose several/many levels of coverage, depending upon the insurance company you choose. It’s also possible to purchase health insurance that’s carefully tailored to your individual specifications, so you don’t pay for coverages you don’t need or want – like hair replacement or Viagra.

All of that is possible now. It’s expensive because health insurance companies have spent massive amounts of money lobbying to get the laws written to suit them, just as other large corporations do. Medicine has morphed from public service to capitalist enterprise in the past few decades, and when prices are driven by the desire to make a profit, why, prices tend to go up.

Even if/when the ACA insurance exchanges go into effect, it’s my understanding that the whole point of those exchanges is to provide opportunities for health insurance consumers to choose from among many companies and levels of coverage (and payment) to suit their particular desires and budgets.

The reform itself is not

The reform itself is not popular, but if you ask Americans about the individual aspects of the reform, they like them. This suggests to me that Americans, as usual, are uninformed about the details and have swallowed the spin.

competition has never been at it's core anything but destructive

Competition is good competition is great
Competition keeps us on our toes
Completion will keep us from being late
Competition gaurantees a brand new hose
Some brand new clothes
A health life
A shinny knife
Unless you lose

But the rules are it's your own fault