Should Benefit to Individuals Outweigh Good for Groups?

Society must realize that health care resources are limited and then must use them rationally. Fairly, too?

Medical ethicists believe the United States needs to have a forthright public debate about how to spend limited health care resources wisely. We simply can’t pay for everything, so we must — as a country — decide what is worth paying for and what isn’t, they argue.

Can consumer-directed plans, with their emphasis on giving people a stake in health care costs, play a role in forming that public discussion?

They just might, says James Sabin, MD, a medical ethicist and psychiatrist who runs the ethics advisory group at Harvard Pilgrim Health Care. “The consumer-driven idea has the potential of being a kind of schooling for consumers, guiding them toward thinking in value-oriented terms about health care.”

People are not going to shop for acute hospital care for crushing chest pain, he says. “But they will think about things such as, ‘If I’m getting an elective MRI, how much does it cost at different sites and is there a differential value, and if so, how much is it worth?’ That will be a good thing.”

For several decades, insurance has insulated people from coming to grips with the need to make trade-offs, Sabin says. If society can see the ethical need to make values-based choices, rather than believing that health care resources are unlimited, “that’s a step forward.”

Yet the problem with consumer-directed health care is that it only requires people to think individually — rather than collectively — about health care choices, says Leonard M. Fleck, PhD, a professor of philosophy and medical ethics at Michigan State University. “We can’t as a moral and a practical matter decide individually what kind of rationing choices we’d be willing to embrace,” he says. “You need some kind of consistency and coherence with regard to the kinds of rationing decisions that need to be made, and I’m not confident that an individualized consumer-directed mode is the way to bring that about.”

Consumers’ ignorance about prices and the fact that they sometimes seek care that is unnecessary — both of which the new plans are designed to address — are only a small part of the problem of escalating health care costs, says Karen Gervais, PhD, director of the Minnesota Center for Health Care Ethics. “I don’t think it’s going to do a great deal of good to educate consumers about cost. When you are sick, you can’t control your utilization.”

Some people, however, may become activists based on their individual experiences, Sabin suggests. “They are going to ask important questions.”

To make a real difference, consumers need to be educated about and involved in much larger policy questions — such as when it is appropriate for an insurance company to begin covering a new device or procedure — rather than how much an MRI costs, Gervais says. Insurers are often pressured to pay for expensive, unproven treatments, which has a huge impact on the cost of health care, she explains. “If consumers could really see what that choice amounts to and what the cost and patient safety implications are, they might think it through differently. It’s a huge educational task, and can’t be delivered in sound bites. It needs a good, solid conversation.”

The moral issue that is at stake for these public discussions is health care justice, says Fleck. “Even though this year we will probably spend about $1.6 trillion on health care, that doesn’t buy everything that is needed in the way of health care for all Americans. We have 43 million uninsured, a lot who are underinsured and a lot who are denied health care because they can’t afford it. Other people spend extravagantly — often public Medicare and Medicaid dollars — on health care that is only marginally beneficial, as when patients demand heavily advertised drugs from their physicians when generic versions would work equally well at a small fraction of the cost. There is something that is fundamentally unjust about that state of affairs. A society that is just and caring ought to do better than that.”

Special Issue on Consumer-Directed Health Care