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.