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Physician Integrity and the Role of Gatekeeper

presented by
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PHYSICIAN INTEGRITY AND THE ROLE OF GATEKEEPER

BY
Paul Joseph Reitemeier

A DISSERTATION

Submitted to
Michigan state University
in partial fullment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Philosophy

1991

Copyright by
PAUL JOSEPH REITEMEIER

1991

ABSTRACT
PHYSICIAN INTEGRITY AND THE ROLE OF GATEKEEPER
BY
PAUL JOSEPH REITEMEIER

Two separate problems face both providers and recipients
of health care in the United States: adequate access to care
for all persons, and a need to control the costs of providing
that care. However, as the costs of solutions to access
problems are acknowledged by economists, cost containment
becomes more difficult. As cost containment measures are
implemented, difficulties in assuring adequate access to care

are compounded.

The most persuasive re5ponse to these mutually
aggravating problems is to ration medical care. A common
feature to all rationing' mechanisms is the need for a
gatekeeping function to safeguard limited medical services and
resources. This function may be carried out either by
specially empowered individuals or be procedurally determined
by strict formula. I argue that primary care physicians ought
fulfill the role of gatekeeper using a combination of
universal guidelines together with individual "bedside"

discretion.

Several authors have rejected the suggestion that
physicians function as gatekeepers on the basis of violating
physiciansfi professional integrity' and. long’ standing
obligations to patient advocacy. My thesis is that this
position reflects an inadequate conception of integrity
generally, and.a misunderstanding of physicians' professional
obligations of patient advocacy specifically. I suggest a way
of understanding integrity that shows the moral preferability

of having primary care physicians serve as gatekeepers.

I further argue that in order for the mechanisms and
criteria for rationing to be most just, they ought to emerge
from a four step process: collective physician action, expert
analysis, public participation, and federal legislation.
Moreover, this process should originate from organized
medicine's explicit and public proposal for a guaranteed
minimum package of medical services, together with guidelines
for making discretionary bedside rationing decisions. This
solution might be understood either as a compromise or as a
synthesis of physicians' collective and political obligations,
depending on one's understanding of the nature of those
obligations. By developing a just and cost-effective program
of medical care rationing in the United States, universal and
affordable access to care will be attained and the
professional and political integrity of physicians will be

enhanced.

DEDICATION
This dissertation is dedicated to all of my teachers past and
present for they have given me the greatest gift possible, the
gift of understanding. It is especially dedicated to my wife
Katie and my parents Richard and Patricia Reitemeier, my three
greatest teachers. It is through knowing them that I have

understood most clearly the meaning of integrity.

ACKNOWLEDGEMENTS

Two people have provided immeasureable assistance to me in
writing this dissertation, so much so that it would be a moral
wrong to fail to recognize their contributions. My director,
Martin Benjamin, Ph.D., provided a steady flow of detailed
and enormously helpful comments throughout the writing process
and read complete drafts of the whole work at least four
separate times. The value of his intellectual stimulation and
unwavering encouragement cannot be overemphasized. And my
dear wife Katie, whose love and patience has been a constant
source of strength, deserves equal credit for the completion
of this project. Without her support I would very probably
never have pushed through the many disappointments and
setbacks of graduate school. My debt to her cannot be

measured.

vi

TABLE OF CONTENTS

Chapter One: Two Problems ..... . ........................ .. 1

Allocation and Rationing Defined ......................... 5

Rationing............. ........... . ..................... ..10
Overview'of the Problem ... ............. .................. 21
The Ethic of Patient Advocacy ................ .......... .. 27
Gatekeeping................................. ..... ........37
Physicians' Core Commitments ............................. 41
Outline of the Argument Structure ... ...... ............... 44
Chapter Two: Integrity . . ................. . .......... . . . . . 48
The Concept of Physician Integrity . .............. . ....... 55
The Professional Integrity of Physicians ....... .......... 57
The Elements of Physician Integrity ..................... . 61
Patient Advocacy Through Personal Care ......... .......... 68
Different Subjects of Integrity ..... . ......... . ........ .. 72
Personal Integrity ............... .............. ..... ..... 73

Individual.Professional Integrity ........................ 75

Collective Professional Integrity ................. . ...... 76
Political Integrity .. ................ . ........ . ......... . 82
Biographical Integrity ............................ .. ..... 83

vii

Internal and External Perspectives on Integrity .... ...... 88
Justice....0.00.00.00.00...0.0............OOOOOOOOOOOOOOO93

Does Political Integrity Threaten Patient Advocacy ? .... 101

Chapter Three: Fair and Universal Access to Rationed Care 103
Health Care and Equality of Opportunity ........... ..... . 104
Access to Care a Society-Wide Responsibility ... ..... .... 110
Alternatives to Rationing ............................... 114
Setting Service Limits Not a New Idea ................... 116
Medical Rationing: Responsible Denial of Desired Care ... 121
Why Rationing Has Not Been Requested .................... 127
Objections to Physician Gatekeepers ..................... 133
Moral and Political Requirements for Rationing ......... . 139

The Importance of Using the Right Process ............... 147

Chapter Four: Medical Gatekeeping ....................... 151

The Definition of Medical Gatekeeping . ....... ........... 153
The Personal Dimensions in Medical Care ...... ........... 162
The Rationing of Patient Advocacy ............... ........ 165

Chapter Five: A Four Step Compromise Proposal ........... 176

A National Health Insurance Program ..................... 178

Setting Conditions of Operation. . . . . . . . . . . . . . . . . ...... . . . 181
A.Four Step Proposal ............ ....... . ................ 182
Physicians as Citizens .................................. 184

viii

An Integrity-Preserving Compromise Between Patient
Advocacy'and Social Justice.............................. 189
Why Not Start With the Patient-Public? .................. 191
The Role of Physicians in the NHIP ...................... 193
The Special Commission .................................. 207
The Role of the Patient-Public .......................... 215
Dynamic Interplay with the Educational Structure

andprocess.OOOOOOOOOOOO0.00.00....00.000000000000000...218
Summary'and.Conclusions . ....... ......................... 220

Bibliography....... ........ ....................... ...... 223

ix

Chapter One: Two Problems

Physicians and. others involved, in 'the provision. of
medical care to patients in the U.S. are currently facing two
separate but mutually aggravating problems centering on access
to care and cost containment. The problem of access to care
is concerned with finding a way to assure that all medically
needy persons receive prompt and competent basic medical
treatment. Currently there are at least thirty million and
perhaps as many as 50 million U.S. residents whose access to
care is denied or significantly restricted by lack of medical
insurance, or inadequate insurance, and who do not qualify for
government funded care. The problem of cost containment is
concerned with finding ways to slow the growth rate of the
cost of providing medical care to patients, a rate which for
the past decade has been twice the general rate of inflation

[Callahan, 1989:905-6].

In addition to being independently difficult to solve,
these problems are mutually aggravating because as the.cost of
solutions to the problem of access to care is acknowledged,
cost containment becomes even more difficult. And as cost
containing measures are implemented in the provision of
medical care, difficulties in assuring access to care are
compounded. This conflict between access to care and cost
containment has resulted in a virtual paralysis of any kind of

policy decision at the national level and only relatively

2
minor adjustments at the level of state and institutional
decision-making, thereby enabling the status quo to continue

and with it, the worsening of each problem.

On the face of it at least, achieving equal access seems
to require driving overall medical care costs even higher; and
cutting costs appears to increase current inequalities. For
example, at least thirty million residents of the United
States currently lack adequate access to health care and do
not qualify for any of the government funded programs (Aid to
Families with Dependent Children, Medicaid, Medicare, Indian
Health Service, Veterans Health Service, etc.). IMost.of these
excluded persons are employed, but in low paying jobs which.do
not include health insurance benefits. An additional twelve
to twenty million persons have minimal medical insurance, but
would be financially ruined. if they suffered. a serious
illness. If the perceived solution to the access to care
problems for these fifty million persons is to simply absorb
them into the current government funded programs, it will
place an enormous strain on the programs' abilities to provide
that access. Without additional funding (i.e., increased tax

revenues) such absorption may not be even possible.

At the same time, if the perceived solution to containing
medical care costs is to reduce the total benefits of the

medical insurance programs (whether privately insured or

3
government funded) such reductions may effectively neutralize
the overall good of having increased the numbers of persons
eligible for such programs; more people are eligible for
medical services, but fewer services are available. If the
perceived solution is to increase copayments and deductibles
for consumers or to eliminate employer-based coverage
altogether and require employees to purchase health insurance
with after-tax dollars, it will likely prevent many persons
who live at the financial margins from access to health care.
Perhaps the :most. morally objectionable .aspect. of either
decreasing benefits or increasing consumer costs is that
neither solution will do anything to affect the current
inequities in the access to care problem. Access to care for
the wealthy or those whose employers provide policies with
generous benefits and little or no consumer costs will remain
unchanged. By simply adjusting rather than overhauling the
present system the current form and level of inequalities in

access to care will remain.

Until recently most of the needy poor have been able to
get the medical attention and service they require because
they receive that care from the same providers (medical
professionals and institutions) as the wealthy and insured
members of the community. The providers have been shifting
the costs of providing care to the poor to the non-poor in the

form of higher charges. In effect, the financially secure

4
payers have shouldered the burden of paying for the health
care of the financially indigent. The former groups include
professionals and institutions who provide uncompensated
medical treatment on a charitable basis, state and federal
governments which fund social assistance programs, and the
private employers and insurance companies which pay for the

medical treatment of employees and policy holders.

However, this strategy of shifting costs from the poor to
the nonpoor has come under careful scrutiny by large third
party payers: large corporate employers, federal and state
governments and private insurance companies. These payers
have taken dramatic steps to restrict this cost shifting by
medical providers. Cost control managers employed by the
payers constantly review medical service charges and
frequently switch providers to those with the lowest rates or
those willing to negotiate for lower rates in exchange for a
guaranteed number of enrollees. As a result of this financial
tightening, the poor are finding it increasingly difficult to
gain access to medical services. Providers are unable to
provide charity care at a net loss, and are constantly trying
to reduce their own costs while still maintaining quality.
Several approaches to this double-edged difficulty have been
suggested but the one receiving the preponderance of

discussion in the literature has been to ration medical care.

5

Allocation and Rationing Defined

The term "rationing" has been used to describe a number
of methods of distributing scarce resources. At least one
author has construed rationing in such broad terms as to
include any system that allocates scarce resources [Fuchs,
1984]. On thiS‘vieW’evenra free-market, ability-to-pay system
is a rationing system. Other authors favor reserving a
definition of rationing for those deliberate, explicit systems
of allocation that are somehow tied to an explicit system of
justice [Aaron and Schwartz, 1984; Evans, 1983]. The
difference in these definitions is important, for when
discussing public acceptance of medical care rationing, Fuchs
can claim, as he does, that it is nonsense to oppose it; the
only relevant question is whether it is to be done overtly and
fairly, or covertly and unfairly [Fuchs, 1984]. Those who
favor a more restricted conception of rationing may insist
that it is one of several choices that can be made, and then
argue for or against it as the best choice, all things

considered.

For present purposes I will define rationing as one kind
of allocation scheme with a particular set of characteristics.
But before discussing these characteristics in detail I will
first describe three general levels of allocation in terms of
macro, mid-level and micro-allocation. The key feature shared

by the different levels is a scarcity of valued resources, a

6
scarcity' which. precipitates the need. to :make .allocation
decisions. The nature of that scarcity, however, differs

among the different levels in important ways.

Macro-allocation will be used to describe the broadest
and most general level of allocation. At this level, the
allocation decisions range over virtually all categories of
goods and services which are deemed essential for an
individual's securing a ndnimum equality of opportunity in
contemporary society, and for which the demand exceeds the
supply. Since there are multiple categories of goods and
services and the resources required to produce and distribute
them are general resources, the actual scarcity of items in
one category is relative rather than absolute; decisions about
what percentage of the total resources will be dedicated to
one category might be made differently if the decision makers

elected to do so, simply by making cross-category transfers.

For example, if Congress decided to allocate five percent
of the federal budget to defense and ten percent to federally
supported health care programs, that would be an instance of
macro-allocation, since the actual distribution of resources
could be made quite differently. Similarly, when individual
state legislatures decide how much of the state budget to
allocate to Medicaid and other state funded health care and

how much to highways, those too are macro-allocative

7
decisions. Finally, even private corporations make macro-
allocative decisions in the sense that the leadership of the
corporation decides what percentage of pre-tax earnings will
be dedicated to employee wages, what to health care benefits,
what to retirement, research, community service, etc. In
short, macro-allocation refers to the decisions to distribute
general resources in one particular way among several

possibilities.

Mid-level allocation will refer to decisions about how
the total resources dedicated to a particular category are
then further subdivided among all the possible options. For
example, in the category of health care, mid-level allocation
decisions address what percentage of the resources for health
care are apportioned to trauma care, neonatology, geriatric
medicine, education, research, etc. In the category of law
enforcement such decisions determine what percentage of
resources are dedicated. to :recruitment and. training, to
weapons, to community service, etc. As in macro-allocation,
the scarcity at this mid-level is relative; different
distributions could be made within the overall categorical

budget if the decision makers elected to do so.

The term micro-allocation will be reserved for resource
allocation decisions at the most basic level, that of

particular goods and services allocated among particular

8
persons. At this level the scarcity which precipitates
allocation decisions is determined by the prior macro and mid-
level allocation decisions and is absolute; there are
empirically limited resources to be used and the possibility
of transferring resources from one area of consumption (i.e.
consumer) to another does not generally exist, and.if it.does,
it will be very difficult to accomplish. An example of micro-
allocation in health care is the decision which of several
needy patients will receive the one available organ for

transplantation.

In this case it is not possible that the patients who do
not receive the organ are somehow compensated by receiving
something else, perhaps of lower quality. If they need and do
not get the organ they may die as a result. Another and more
dramatic example is the allocative decision of which patient
will first receive needed services from the only available
physician, nurse or allied.health.professional. In some cases
the reason for the delay in getting professional attention may
be the result of shortages caused by non-service related but
nonetheless important competing needs, e.g. , rest or meal
breaks, vacation schedules which decrease available personnel,

etc..

It is important to note that all three levels of

allocation decisions sometimes include tradeoffs between the

9
needs of current, identifiable persons and the anticipated
needs of future, presently unidentifiable persons. At the
level of micro-allocation decisions, however, the human
consequences of making individual decisions are much more
apparent. For example, if a physician decides to give the
last available intensive care bed to a seriously, but not
critically, ill patient, she will thereby render the bed
unavailable to other patients. Should a critically ill patient
subsequently arrive in need of an ICU bed, that physician will
face the consequences of her earlier allocation decision in a
more direct and personal way than would a mid-level or macro-
level decision maker who had decided (at a distance) how many

ICU beds that institution would maintain.

For present purposes the use of these three allocation
terms in the area of health care may now be understood to

involve the following conceptual divisions.

MACRO-ALLOCATION: the allocation of financial resources
dedicated exclusively to health care expenditures as a
percentage of the total financial resources distributed by the
various bodies of decision makers (federal, state, corporate,

individual, etc.). 1

 

1' The national total for this figure for 1989 was
approximately 604.1 billion dollars or 11.6 percent of the
GNP. This was an 11.1 percent increase in dollars from the
1988 level, and as a percentage of the GNP, a 0.4 % gain (11.2
to 11.4 percent) [Lazenby and Letsch, 1990].

10
MID-LEVEL ALLOCATION: the allocation of total health care
resources among specific health care programs and utilization
areas in both.public and.private arenas of health care. 'These
decisions will include how much goes to patient care
expenditures, research, education, malpractice payments and
insurance premiums, physical properties and operation costs,

employee payroll and benefits, etc.

MICRO-ALLOCATION: the allocation decisions made "at the
bedside" which.directly affect individual.patients in terms of
the specific health care goods and services which are provided
and which are withheld or denied. These allocation decisions
may be made according to specific and explicit institutional
policies, implicit traditions, individual judgments or a

combination of all three.

Rationing
I now will turn to a more detailed discussion of the

characteristics which are specific to rationing and which
distinguish it as a particular kind of allocation decision at
each of these three levels. I will use the conception of
rationing similar to that favored.by.Aaron and Schwartz [1984]
and Evans [1983] as noted above and defined by Webster as

a share, especially as determined by

supply: the allotted.or permitted amount.

To distribute or divide (as commodities

in short supply) in an equitable manner

so as to achieve a particular object (as
maximum production of particular items).

11

[Webster, 1983, my emphasis].

It is useful to note in this context that the Latin root
of "ration", ratio, also serves as the origin for "rational"
and "rationale" and involves reason and computation as part of
its meaning(s). In addition, tolact rationally implies.a sense
of intentional and directed action for some purpose» As'Wolff
observes,

There is something like a law of historical

development--one of the very few--to the effect

that once a matter of major social importance
becomes an object of decision, it never reverts to

the status of fact of nature or unintended

consequence. This might also be called the law of

the progress of rationality, for there is a

fundamental sense of the term "rational" in which

"to be rational" means "to be the author of one's

actions, to act rather than to be acted upon." To

become more rational, in this root sense, means to
transform into ends things which previously were

not ends. [Wolff, 1968:90, cited in Newton, 1982]

I note these connections to draw attention to the fact
that decisions of rationing in medical care will be understood
here as grounded in explicit, clear and morally justifiable
reasons. Moreover, these reasons will reflect the accurate
measurement and assessment of both the absolute and relative

scarcity of specific medical resources as measured against the

current level of basic medical needs and demands.

Rationing is a drastic means of distribution of highly
valued and widely needed goods and commodities and as such

ought not be instituted except as a last resort to assure fair

12
and judicious disbursement and to prevent public discord.
Reagan has succinctly characterized rationing in the following
way:

. . .rationing can be summarized as a system of

deliberate choices about the sharing of health care

resources among persons (i.e. who gets what care,

and in what order of priority) on grounds that go

beyond an individual patient's clinically defined

needs; the criteria specifically include both
comparative medical need and social equity.[Reagan,

1988:1151]

A.brief reflection reveals that rationing defined.in this
way is not new to either medical care or U.S. residents. In
virtually every developed country explicit rationing of
medical resources and services is a regular feature of routine
medical care, and the various rationing processes instituted
have been well discussed [Aaron and Schwartz, 1984]. In the
U.S. rationing of at least some goods and services is not a
neW'experience either, though.past occasions.have for the most
part occurred in non-medical contexts; gasoline in the early
19705,2 and coffee, sugar and gasoline during World War II.
Rationing in the medical care context has had an identifiable

presence sufficient to generate its own descriptive

terminology, "triage".

Triage is the system of prioritizing medical care needs

among the physically ill and injured when.not.all of the needs

 

2Recall the long lines at filling stations (especially on
the eastern seaboard) with allocation limits per vehicle and
filling restricted to alternate days of the week based on the
last number of the vehicle's license plate.

13
can be met. The three most common situations in which the
need for triage arises are military battlefields, natural or
human caused disaster situations, and on a smaller scale,
overcrowding of hospital emergency rooms, especially in rural
areas where transport to another facility is not possible.
Cases requiring triage decisions are generally initiated when
the available medical resources are overwhelmed by the demand
placed on them and some method of prioritizing among the
various patients' medical needs must be instituted so as to
maximize the medical effectiveness and just distribution of
the medical care. Under these circumstances classification is
concerned with three groups: those patients who will live
without treatment of any kind; those who are expected to die
no matter what treatment is provided; and the priority group,
those who will survive only if given adequate care. Similarly
in the allocation of organs for transplantation, the focus and
intent is on two main factors: likelihood of success and

fairness to all needy patients.

In both of these situations difficult choices have to be
made, and the criteria used are not always deemed the most
just retrospectively. The fairness of triage as an allocation
system to the persons who are the patients (both those treated
and those denied treatment) is supposed rather than
demonstrated; no poll is ever taken requesting verification of

acceptance of the decisions as fair. Fairness or equity

14
enters, hypothetically at least, in assuming that all persons
would endorse triage as fair if they were in a position
similar to Rawls' original position, behind a veil of
ignorance [Rawls, 1971]. Nonetheless, there is no question
about the need to rationally allocate under these
circumstances of limited resources relative to demand, whether
using triage or some other system of priority setting in

allocation.

Rationing in general becomes necessary whenever two
conditions are present: (1) a significantly greater demand is
placed on certain resources than can be met by the available
supply and that imbalance is expected to persist for some
minimum and perhaps indefinite time, and (2) the scarce

resources are necessary for meeting basic needs.

The first condition of excess demand must persist over
some minimum period of time sufficient to create a genuine
concern by policy makers, for otherwise the public demand
could be met by a combination of queuing and patience. The
second condition distinguishes between goods and resources
which, though desired by the majority of persons in society,
are not essential to their routine functioning or minimum
comfort level under normal conditions, e.g., gasoline versus
a new automobile. Commodities which are widely needed or

desired and which would be widely purchased if sufficient

15
supplies were available must be rationed to prevent public
discord and risk civil disobedience, e.g., gasoline, sugar,
coffee, and in the military, cigarettes. Individuals who do
not desire or need these commodities for personal consumption
are nonetheless entitled to their fair share of them, and may
trade, sell or barter their ration of them for other, more
personally valued goods. There is obviously some degree of
arbitrariness in the designation of some goods as essential
and others as nonessential needs. As Daniel Callahan has
observed, "need.is not a fixed, objective standard at all, nor
can it ever be. It is culture and technology dependent and

ever attached to subjective desires" [Callahan, 1989:906].

For the most part, commodities which fulfill basic non-
medical needs constitute a small and comparatively inexpensive
set of goods which can be distributed by a variety of
mechanisms through local community centers. These goods are
those which are both necessary for all or most individuals to
have an equal opportunity to pursue their own conception of
the good (whatever form that conception may take) and are in
chronically short supply. Examples of the most common basic
goods and.how the rationing needs are met are food (food stamp
programs and soup kitchens), clothing (welfare and social

assistance programs) and shelter (housing projects)3. There

 

3Strictly speaking there is no central distributional
agency for these programs. The food stamp program originates
in the U.S. Department of Agriculture and has a standardized

16
are also the basic needs of a minimum level of education
(public primary and secondary schools) and legal defense from

criminal charges (public defenders office).

The chief distinguishing features between these programs
and a medical care rationing program are the scope of the
needs for resources and ‘the {associated. affordability' of
meeting those needs. I argue in Chapters Three and Five that
a rationing' program for’ medical care that is just and
efficient will have to be national in scope whereas at least
some other distribution programs can make just and efficient
allocation decisions variously in ways that reflect different
local needs, e.g., housing and clothing for persons in the
northern climates compared to those in the warmer southern
states. Such variations in resource allocation. do not
necessarily reflect injustice or inefficiency in the program
since persons' needs vary with different locations. However,
other things being equal, they do make social assistance
programs more expensive in some areas than others. The need
for medical care also varies widely among persons but not
typically because of geographic residence. If a just and

efficient national program of medical care rationing is

 

allotment of vouchers for eligible recipients. However, the
eligibility requirements vary among different states which is
handled through state welfare offices. Similarly, the shelter
programs for the homeless have recently moved away from
construction. of Ihousing' projects in favor of subsidized
payment of rental costs, the eligibility for which is also
handled through local and state housing authorities.

17
instituted it will have to account for the variable needs
among persons and find a way to meet some reasonable
conception of those needs fairly and efficiently. Other, non-
essential goods and services which are desired by significant
numbers of persons are left to market mechanisms (i.e.,
ability to pay) for distribution, e.g., football tickets and

haircuts.

From the perspective of distributive justice, however,
the market mechanism alone is not adequate for the fair
distribution of essential goods which are in short supply; If
the general availability of these goods were left solely to
market influences, wealthy persons would be able to acquire
disproportionate reserves of these essential goods and use
that advantage to manipulate those who need but cannot afford
them. When the threat or risk of such manipulation of many
persons by a comparative few is deemed imminent and unfair by
the political leaders, rationing mechanisms emerge as the most
just means of assuring an equitable distribution of these
basic goods. "Rationing connotes a national judgment that
goods should be distributed according to collective standards
of priority and fairness, rather than solely according to
ability to pay" [Rosenblatt, 1981]. The perceived necessity
for and justification of rationing then is not only economic
but also moral in nature. If rationing is a morally justified

response to the need to allocate scarce resources in high

18
demand, it must also be designed and carried out in a morally

defensible way.

As Reagan has noted, two further points should be drawn
out in this regard [Reagan, 1988:1150]. First, rationing is
not primarily a response to a money problem but one of
empirical scarcity of material goods and services and
therefore cannot be resolved by a pricing system. One
objection sometimes heard is that this is not the case in
health care because the scarcity is not always absolute: many
needs could be met through simple re-allocation of resources
from one category to another at either the macro or mid-levels
of allocation. However, though there may exist a logical
possibility of making decisions differently at these levels
and thereby obviating the need to ration scarce health care
goods by producing more of them, it is not a practical
suggestion. The reason it is not practical is that the other
non-medical care categories of goods and needs are important
in their own right, and tradeoffs among them will be made only

within limited ranges.

For example, it is sometimes suggested that the health
care allocation problems could all be solved if Congress were
to re-allocate to health care a significant portion of what is
currently going to defense expenditures. However, the defense

needs of the nation, in the eyes of the members of Congress,

19
are, all things considered, very real needs which require
their own dedicated resources. Large-scale tradeoffs between
health care and missiles are simply not going to be seriously
considered, even if it could be accomplished financially. To
argue that they ought be exchanged is not a practical
position, even if it is ethically attractive when considered

under ideal conditions.

The second point about rationing is that in order for it
to be morally defensible rationing must be a deliberate,
explicit and public decision by responsible representatives
from the community to institute a distribution policy in the
general public interest and, not to serve the financial
interests of any select interested parties [Daniels, 1991].
As a general point about rationing desired goods, this is as
true in the case of health care as it is concerning highly
valued football tickets. In the latter example, the demands
on resources are predictably episodic rather than chronic, and
the "needy" public is only a small percentage of the
population. The differences are significant in some respects,
but the desire for fairness to all concerned parties is
similar in the two contexts. One obvious difference is that
every ticket has the same ability to fully meet the need of
every person desiring one. The same is not true of health
care services, where there is huge variation in the needs of

different individuals, as well as in the quality of the

20

services provided to meet those needs.

Since the early 19705 the problem of rationing medical
resources has beenuwidely'discussed.and.at least.eighteen ways
of rationing have been suggested [Churchill, 1987]. While
many authors have focused on general economic arguments for
rationing, others have centered on the effect rationing at the
level of micro-allocation may have on physicians and their
relationships with their patients [Abrams, 1986; Angell, 1985;
Fuchs, 1984; Jecker, 1990; Levinsky, 1984; Pellegrino, 1986;

Veatch, 1985, 1987, 1988].

Whether individual physicians make particular,
substantive rationing decisions or merely carry out the
rationing function according to rules or formulas'developed.by
others is important from a moral point of view, for several
commentators have argued that physician-based rationing is
antithetical to the Hippocratic tradition of caregiving and
patient advocacy. One part of my thesis is that the nature of
this conflict is generally misunderstood. When it is properly
focused and analyzed a middle ground emerges which, all things
considered, provides a more just and efficient approach to the
problems than physicians' opting exclusively for either
patient advocacy (access to care) or cost containment at the

expense of the other.

21

Oygrview of The Problem

If we accept that some form of medical resource rationing
is economically necessary in the United States as a solution
to the conflict between equal access and cost containment (I
will provide a brief argument to this effect in Chapter
Three), it becomes immediately evident that some criteria will
have to be devised to serve as the rules or guidelines for
rationing medical resources. Once the criteria are selected
they must then be applied, and it is in the application of
such rationing criteria that the problem I want to address
arises. If medical care rationing is generally to work, there
will have to be some circumstances in which particular persons
at the individual patient-care level must reluctantly say to
particular prospective patients, "I'm sorry but we cannot
treat you because you cannot pay for the treatment and you do
not qualify for subsidized treatment as specified by the

rationing criteria".

When one has to say this to»a person who requests medical
attention, the nice clean theories conceived. in {distant
offices and board rooms encounter the messy real world of
doctors, patients, and illness. It is one thing for a car
dealer to tell prospective customers that their financing has
been denied and they will have to go home on the bus and find
some other way to get around. But it is something else

entirely for a physician to have to tell the same thing to

22
patients when the physician knows the consequence is not
merely the inconvenience of getting around on a bus or
bicycle, but may be a serious risk to his or her health and

well-being, and possibly even his or her life.

In Oregon, for example, an experiment in a version of
health care rationing is currently being developed [OHSC,
1991]. Under that program the major illnesses and disorders
have been rank ordered into 709 groupings of diagnosis and
treatment pairs. Depending on how far down the ordered list
the state legislature decides to provide funding, physicians
will or will not be able to provide specific health services
to their Medicaid patients (the program only applies to non-
elderly Medicaid beneficiaries). It is safe to say that the
lowest ranked illnesses and disorders will not be funded and
patients with these afflictions will be denied medical
treatment for them. Treatment of the same patients for higher
ranked disorders will still be possible however, and.that sort
of treatment discrimination is the sort of problem all hard
rationing mechanisms face. The difficulty is that it is the
physician at the point of care who actually faces the
consequences of such decisions about.what.will and.will not be
funded, not the legislators who cast the deciding votes on the

matter.

23

A few examples will illustrate the point here; among the
709 ranked diagnosis and treatment pairs, the Oregon Health
Services Commission has ranked medical treatment for amytropic
lateral sclerosis (ALS) 609, liver transplant for hepatic
cancer and intrahepatic bile ducts 610, life support for low
birth weight (<500 grams) and premature infants (<23 weeks
gestation) 708. An interesting and controversial ranking
difference is between that for liver transplants for patients
with cirrhosis without mention of alcoholism (366) and for

patients with alcoholism (690).

When designing a program for medical care rationing these
sorts of decisions and tradeoffs must be addressed and some
decision made about how securely to close the gate to medical
treatment to prevent the resources from being dispensed for
what could be viewed as (comparatively) wasteful reasons. At
the same time, there must be a recognition that if the rules
are drawn so rigidly so as to exclude discretionary judgment
and individual decision making, there will be a number of
patients whose serious illnesses will not be diagnosed and
their opportunities for survival or the restoration of well-
being through early detection and treatment will be foregone.
The gate must be able to swing in both directions, and the
role of the gatekeeper understood as that of both treatment

enabler as well as treatment denier.

24

To some extent several kinds of micro-allocation of
medical resources are already occurring in the U.S. but there
are relevant differences between what is happening now and an
explicit, public, national and rational program of health care
rationing. For example, physicians who refuse to accept
Medicare or Medicaid patients because of lower compensation
rates, or who perform "wallet biopsies" to determine how much
health care a particular patient "needs", might be said to be
rationing health care by those mechanisms. But there are two
significant differences between such practices and the
elements necessary for a morally justified system of rationing

outlined above.

First, such physicians are more the exception than the
rule and therefore cannot be cited as an example of how an
overall national plan for health care allocation might work.
Second, and more importantly, the refusals by such physicians
to treat certain patients are based not on a morally
defensible conception of distributive justice and the need for
fiscal solvency, but on personal greed. They are not
participating in a recognized and public system of health care
allocation that is deemed fair to all parties, as is required
of the various proposals for medical care rationing as a
matter of social justice in health care policy. They are
perhaps instances of resource ‘micro-allocation, but not

rationing in the sense I use the term.

25

So the problem of medical care rationing is not new, but
it has taken on a much larger scope in the last few years.
Rationing may soon become part of routine medical care. One
important difficulty is finding a way to ground the specific
criteria for allocating health care goods and services which
will reinforce the justification for making rationing
decisions generally. A second difficulty is that even if we
could find the "ideal" criteria to use, I will argue it would
still be necessary to involve physicians in individual
rationing decisions as both the severity of medical conditions
and cumulative effects of multiple conditions or disorders can
only be accurately assessed on an individualized basis [Aaron

and Schwartz, 1984, 1990].

Yet no matter what form of rationing criteria is
eventually selected, so long as there are specific eligibility
requirements for medical care, so long as a line is going to
be drawn somewhere, there are going to be people left out of
the medical care net because they "just missed" qualifying.
Architects of the various rationing mechanisms that have been
suggested are aware of this problem, and they try to avoid
drawing lines that exclude large numbers of people who are
likely to object both vocally and publicly to being left out.
If you let enough people fall outside of the health care net
and.you do so for a long enough time, the social upheaval that

results will turn against the designers and implementers of

26
the rationing system, initially through bad press and
eventually through civil unrestd‘ anetheless, at least some
patients will be left out; they will have to be left out if
the rationing is to be effective in meeting its two principal
objectives of assuring a fair distribution of health care
resources (access to care) and containing medical care costs.
And that is precisely where the moral conflict involving

physicians comes into play.

The moral grounding of the various rationing mechanisms
that have been proposed at the level of micro-allocation
involves conceptions of justice that are thought to provide
more equitable access to medical care. This point is missed
by many who object to physician involvement in medical care
rationing, the most notable of whom is perhaps Norman Levinsky
[Levinsky, 1984]. Levinsky argues that there is an
inescapable moral conflict facing the physicians, a conflict
which cannot be resolved without significant losses to both
the physicians and their patients in terms of the ethic of

patient advocacy.

 

‘The preliminary ranking of health services produced by
the Oregon Health Services Commission drew such extensive
criticism the OHSC modified its procedure and included
significantly more input from the public[New York Times, July
9, 1990 section A:17].

27

The Ethic of Patient Advocacy

It is possible that when individual physicians consider
the general distribution of health care resources as detached
and disinterested observers, they may be convinced by ethical
(i.e. justice) and economic arguments of the need to make
micro-allocation decisions. They may perhaps even be
persuaded by the philosophic cogency of one or more specific
micro-allocation mechanisms. But such ideological convictions
are small solace when physicians must re-engage the world as
practitioners and, at least on occasion, are required to turn
away some of their own patients from their professional care.
Indeed, Levinsky has stated that such tradeoffs must not be
made as a matter of professional medical ethics. "Physicians
are required to do everything that they believe may benefit
each patient 'without regard to costs or other societal
considerations." [Levinsky, 1984:1573]. On Levinsky's view,
physicians are faced with a conflict between their social
obligations of cooperating with and even implementing the
micro-allocation decisions and their professional obligations
of patient advocacy; iLevinsky's solution is for physicians to
forego what may be their social obligations in favor of their

professional ones.

However, the conflict between these obligations in some
cases may be only apparent and not real. Levinsky and others

who object to physician involvement in micro-allocation

28
believe that such involvement threatens the very profession of
medicine as traditionally conceived, for it undermines the
security patients feel when relying on their physicians as
their personal advocates to do what is best for them as
individuals seeking medical care. Depending on the specific
characteristics of the micro-allocation program adopted, a
physician may be required to deny medical care to a patient
whom she knows in deference to another patient whom she does
not know anything about, or perhaps for some future patient
who is presently unidentifiable. According to some
commentators such a requirement is in direct conflict with the

ethic of individual patient advocacy.

Patient advocacy is a long standing and appropriate
ethical dimension of the professional responsibilities of
physicians. It is concerned principally with the promotion
and protection of the personal interests of patients as
individuals insofar as this can be accomplished through
competent professional medical care. It is important to note
in this regard that patients' interests may sometimes be best
served more by sincerely caring for them as persons and their
well-being than by providing a pharmacologic or surgical
intervention, e.g. , attending to the personal emotional needs
of a patient whose condition is not responsive to medical
intervention. It is to emphasize the 'care' part rather than

the 'medical' part of medical care. But there is considerably

29
more to the ethic of patient advocacy than merely providing

competent and compassionate medical care.

Consider the following scenario. A physician is scheduled
to see a particular patient in clinic at a certain time. The
reason for the visit is to evaluate the patient's response to
a medicine for a serious, though currently controlled heart
disease. But an emergency occurs which calls the physician
away from her scheduled appointments and commands her
attention to a life threatening situation involving another
patient. The emergency requires so much time that the patient
with heart disease must reschedule his appointment. How is
that patient to understand the physician's actions under these
circumstances? Did the physician do something professionally
wrong or improper by deciding to attend to the emergency
rather than her scheduled appointments? WOuld it make any
difference if the emergency care victim is not already a
patient of the physician's but a total stranger? The ethic
of patient advocacy, if it is to be useful and. widely
compelling to physicians and patients, should be able to

answer these questions.

The intuitive and correct answer is that the physician
did do the appropriate thing in attending to the more serious
medical case at the expense of delaying--not foregoing

altogether-~the less serious case. The reason we acknowledge

 

30
this as the correct answer turns on the fact that we recognize
it is possible that we could be the patient with the medical
emergency and if we were, we would certainly expect the
physician would attend to our immediate needs in an effort to
save our life. Moreover, to wish the opposite action, that
our personal medical needs take precedence over those of any
other persons simply because we have the prior agreement
(clinic appointment) with the physician is to unjustly place
ourselves at the center of the moral community by demanding
that our needs be satisfied without regard to the needs of

others.

Such a rule would clearly not meet the requirements of
Kant's categorical imperative. The usual explanation is that
such. a rule ‘would fail Kant's self-defeating test. when
examined through the principle of universalization. That is,
given that the members of the moral community are all rational
agents, we rationally ought not adopt any rule which would not
be rationally accepted by each agent as universally binding.
Thus, if we accept the primacy of the claims for medical
attention by those who have appointments over those whose need
arises from unexpected emergencies, we risk defeating our own
interests in the event that we (or by extension, a loved one)
suffer some medical emergency. Kant's conclusion is to make
the opposite rule a moral law: as rational agents we must

accept the primacy of the emergency patient's claim for

31
medical attention over our own (non-emergency) needs. It is a
moral conclusion which is demanded by self-interested reason

itself.

Now let us change the facts of the case slightly. What
if the same delay was caused not by an emergency case but a
series of smaller delays in seeing other patients earlier in
the day? How ought the patient with heart disease view the
physician's actions then? If the reasons for the earlier
delays were to assuage significant health concerns patients
had, or provide more detailed instructions concerning
medications, diets or treatments, rational patients who were
asked to reschedule their appointments as a result of those
delays might well empathize with the other patients and.accept
the physician's decision as unfortunate, but not inappropriate
or unfair. As in the first case, their reasoning would be
that if the places were reversed, they’ would want the

physician to behave in the same way.

As persons who are episodically patients, we recognize
that at times there will have to be tradeoffs made of one
patient's needs against another's and we accept it as part of
modern medical practice. We hope and expect our physician
will keep our'needs in mind as well as those of other persons,
and use good judgment in making tradeoffs when they become

necessary. That explains why if the delay in seeing a given

32
patient is caused by the physician taking an unscheduled nap,
or consulting with her personal investment broker, there would
be a justified feeling of being neglected by the physician on
the part of the patient whose care was delayed. The patient
might well think the physician had done something wrong
relative to the ethic of patient advocacy in acting as she
did. In short, a fair and balanced understanding of the ethic
of patient advocacy recognizes and accepts the inevitability
of occasional delays in seeing patients and requires good
judgment by physicians in making appropriate tradeoffs. That
is the basis for entrusting wide authority to physicians to
make those judgments. Moreover, if the allocation system of
health care included rationing as the product of an explicit,
public, fair and necessary mechanism which was endorsed by the
vast majority of the public, then one reason I am not treated
unfairly by the rationing system if, according to it, my
doctor says I cannot have access to a certain type of care is
that I have, as a citizen, endorsed this system. When viewed
this way, the ethic of patient advocacy is a highly valued
dimension of the more general doctor-patient relationship. It
is not to be understood as constrained by the rationing system
but, in light of the universal need to ration, more highly

valued because of it.

Given this understanding of the ethic of patient advocacy

and the benefits to patients which arise from it, the

33
difficulty with relying solely on mechanical or formulary
micro-allocation decisions is obvious: physicians may be made
the handmaidens of the allocation mechanism and not allowed to
make independent and patient-specific decisions. While the
tradeoffs between life-threatening emergencies versus
medication monitoring cases are easily resolved, some other
tradeoffs may be decided on much less clear--or clearly moral-

-grounds.

Examples drawn from the so-called "managed care" delivery
system will illustrate the sorts of tensions I have in mind
here. Suppose a psychiatrist is under contract with a Health
Maintenance Organization (HMO). In exchange for a guaranteed
minimum number of regular patients, the psychiatrist agrees to
abide by the HMO's established procedures of pretreatment
authorization and. the capitation limits for annual

expenditures.

The psychiatrist sees a patient who complains of a two
week history of episodic amnesia and the psychiatrist
determines that the patient should have a CAT scan to rule out
a subdural hematoma or other serious brain lesion. If the
psychiatrist is seeing the patient on referral from.one of the
HMO's primary care physicians, she can do one of two things.
She can order the tests and have their costs debited against

the annual capitation limit she is allowed by the contractual

34
arrangement with the HMO administration, or she can recommend
to the referring primary care physician that the tests be
done, and have that physician absorb the costs of the tests.
It is an important choice for if either physician exceeds the
annual capitation of medical expenditures he or she may be
required to pay for the excess out of personal compensation
that.would.otherwise:be granted for professional services. If
the primary care physician refuses to order the tests, he may
try to tell the patient that he cannot order them, or cannot
afford to order them on his budget, and that the specialist
refused to do so. .Alternatively, he may elect not to tell the
patient the tests were recommended, and hope for the best,
i.e. that the tests would not have uncovered anything

requiring further evaluation and treatments.

This arrangement renders the role of gatekeeper a kind of
hot potato to be tossed among physicians under contract with
a managed care organization. With these sorts of behind the
scenes maneuvers going on, the patient risks being harmed not
only from the consequences of being denied what the
physician(s) deem to be appropriate care, but from the
deception and alienation such manipulative maneuvering entails
and the adversarial tensions which develop among physicians as
a result. In that sense, such arrangements are harmful to the

participating physicians as well as the patients.

 

5I owe this illustrative example to Susan Boust, M.D.

35

It will not console the physician simply to ignore the
feeling of frustration welling up inside her and tell herself
that "There is nothing I can do. The decision is not mine to
make. I cannot be expected to pay for the care of patients
whose medical needs are not part of their coverage plan.
Besides, all things considered, it is.best,.fOr'(distributive)
justice is better served this way". She is likely to feel
angry and frustrated and perhaps even victimized by the HMO's
allocation system and will have great difficulty explaining to
her patient who cannot afford the expensive diagnostic

intervention that all they can do is wait and hope.

Strict adherence to a mechanical, bureaucratically
administered micro-allocation method fails to account for the
real life tensions and mutual desires for effective medical
care that are a substantive part of the doctor-patient
relationship. Insofar as a micro-allocation mechanism has
this effect it is unlikely to be embraced by physicians who,
in trying to remain faithful patient advocates and avoid this
outcome, may very well be tempted to manipulate the system in
their own favor, justifying it on the grounds of allegiance to
a "higher" good; the ethic of patient advocacy [Caplan, 1988;
Morreim, 1988]. Consequently, such.an allocation mechanism is
unlikely to function effectively and therefore will not serve
its intended purpose of assuring social justice through micro-

allocation.

36

The important point to notice here is that what drives
the ethic of patient advocacy and makes it appear so
intuitively attractive to Levinsky and others is the sense of
justice which it appears to embody. Specifically, it is the
personal, although unspecified conception of justice that is
held by the physician who must make the decision of whom to
treat and whom to delay in getting treatment. Whatever the
outcome of that decision, Levinsky accepts the appropriateness
of the physician making it because he apparently feels that,
all things considered, justice is better served this wayu But
such a conclusion is to focus for purposes of moral assessment
on the personal decision maker rather than the process or
social outcome of these decisions. Reliance on physicians as
the correct decision makers, not only of medical treatment
choices but also of how matters of justice ought play out in
the sphere of medical resource allocation, carries a risk of
error and abuse. In the end, such a system depends for its
moral rightness on the ability of individual physicians to
perceive the correct decision, and their personal and
professional integrity to make it. Historically, American
physicians have not always warranted such public trust
[Harris, 1966]. Moreover, it is also extremely difficult to
gauge larger social or macro-level effects at the bedside.
Even if each physician were a model of saintly virtue, the

overall aggregate allocation pattern which results might be

37

quite indefensible from a more impersonal perspective.6

a in
Gatekeeping, like rationing, is more familiar in non-
medical contexts than medical ones and is generally accepted
as a necessary function in the distribution of scarce
resources. 'There are many kinds.of gatekeepers in society but
for these purposes a single example will suffice to illuminate
the relevant characteristics of the role and some of the

difficulties inherent in it.

Admission to institutions of higher education typically
requires that interested persons complete a complex
application process with several elements which then is
reviewed by an admissions committee. Though specific fees,
qualifications, and certifications are routinely required,
there are also provisions for waivers of some or all such
requirements under special circumstances. The final decision
in each case comes down to a small group of individuals who
are empowered by the leadership of the institution to make
these judgments. By having both clear admission requirements
and judicious admissions officers with. strong senses of
professional responsibility and integrity, the institution is
able to select high caliber students of wide—ranging abilities

and in turn, is able to offer a high quality education, which

 

6I owe this point to Martin Benjamin.

38

is sought by many more applicants each year.

When the number of qualified applicants as measured by
the admission requirements exceeds the availability of
entering class seats, the admissions committee functions as
the gatekeeper to the resources of the institution.as a‘whole.
The committee may on occasion elect to admit some applicants
whose grades and/or test scores are not on par with other
applicants, but who bring other valued characteristics to the
student body, e.g. geographic, ethnic or racial diversity,
experience living' in foreign [countries, special talents,
skills or experiences which will enrich and enliven the
student body as a whole. Such discretion also recognizes the
limitations of test scores as predictors of success in some
cases--especially students forced to attend substandard
schools or growing up in particularly adverse circumstances.
Other nonstandard applicants may be admitted out of a
commitment to improve the welfare of certain disadvantaged
individuals who exhibit a reasonable, if perhaps marginal,
promise of success, relative to the other applicants. The
role of gatekeeper in this context is aimed at serving the
multiple and various needs of the institution as a whole as
well as those of the pool of applicants. Depending on the
size and popularity of the institution the role of gatekeeper
may be one of enabling most applicants to enroll, or of

denying the majority who seek admission and enabling only a

39
fraction to enroll’. Since the "gate" swings in both
directions, the role of gatekeeper must be understood to have
two distinct functions at the same time; one of denying access
to some who seek admission, and one of enabling access to

others.

What makes this type of gatekeeping a difficult function
to fulfill is the realization that throughout the process of
selecting some and rejecting others, mistakes will
occasionally be made in both regards and less than optimal
results will sometimes obtain. Some students who show good
promise of success will fail their classes, commit crimes,
suffer serious illnesses, or otherwise not complete their
educational projects as originally intended and expected.
Other applicants who were denied admission will prove--
elsewhere-«to have been extremely capable and would have
brought a wealth of talent and ability to the institution, if
only the gatekeepers had been able to foresee this. But
hindsight is always a clear-eyed vision and gatekeepers cannot
function effectively if they hold unreasonably high standards
in their work. What is required is that they be careful and
conscientious in their work, and learn from whatever avoidable

mistakes they make. Such a system even with its ineliminable

 

7The University of Arkansas admitted 99% of its
applicants in 1985 while Stanford University admitted only 15%
of its applicants in the same year. [Fiske, 1985 cited in
Rosovsky, 1990;60].

40
errors is all things considered nonetheless preferable (in the
sense of being more effective or just) to a more objective but
"gatekeeperless" system that relies on nothing more than test
scores or grades or some formula combining the two. The same

point can be made analogously in the medical context.

As gatekeepers, physicians8 in systems rationing health
care are expected to fulfill the role of rationing medical
care to individual patients, recognizing that by enabling some
to receive care, other medically needy patients may not be
granted access to at least some forms of care, and will suffer
the consequences of that denial. Difficult as that role is,
it is all things considered'preferable to a set of determinate
rationing criteria set at a distance by bureaucrats and
bureaucratic physicians who will unavoidably be insensitive to
important medical variables among patients with similar but
not identical complaints or diagnoses. When these personal
and often subtle differences are sufficient to move the
responsible physicians to decide that some form of medical
care treatment ought be initiated, the rationing system must
be sufficiently flexible to enable treatment to commence. An
example may be a patient in a physician's office for chest

pains and shortness of breath who does not have any objective

 

3 In the medical care context, physicians, nurses and
institutional administrators have been suggested as possible
gatekeepers to the medical services, but for my purposes I
will discuss only physicians in that capacity.

41
clinical findings indicating heart failure, but nonetheless
appears to the physician to be quite ill. The rationing
system which requires the physician to act as gatekeeper to
the medical resources must also allow, indeed require the
physician to exercise responsible clinical judgment and
discretion in determining whether such a patient needs to be
admitted to the hospital for a cardiac workup. As in the case
of the college admissions, to have a distant and
bureaucratically administered system make such decisions on
rigid objective indications is worse both functionally and
morally than a system that allows more room for the operation

of judgment and discretion.

Finding a moral justification for having physicians
fulfill the role of gatekeeper will require a careful
examination and appraisal of the core commitments of
physicians. These commitments will have various but related
objects: their personal understanding of moral good, their
professional heritage, their community, their patients, the
patient population as a whole, and the multiple subjects of

integrity affects these core commitments.

Physicians' Core Commitments
Physicians are typically both medical professionals,
committed to serving the needs of the sick and suffering, and

citizens, concerned with living in and contributing to a just

A - ...-

 

42
and fair society. This dual role carries with it a double set
of values, some of which may at times come into conflict and
create in individual physicians an internal moral tension. :rt
is an internal as opposed to external tension because it
exists wholly within a single individual (though other
physicians share the same tension), rather' than. between
individuals. It is not that the physician feels she is right
and is fighting some clear opponent who is wrong, but rather
that she is being pulled in opposite directions by two sets of

values, neither of which she is willing to abandon.

On one hand she is part of a professional tradition which
has placed promoting the medical care interests of individual
patients at the top of the list of professional obligations.
This ethic of patient advocacy seems to require that when
treating a patient the physician's professional duty is to
provide all appropriate medical care for that patient to the
best of her professional abilities. On the other hand, as a
member of a just and fair society strapped with unrestrained
increases in health care costs which threaten the health
and/or economic stability of significant numbers of persons,
she has obligations as a citizen to participate in efforts to
recover control of those costs in a just and fair manner.
This social obligation seems to imply that if medical care
rationing does in fact become common in the United States as

it has in almost every other western industrialized country

43
(Hollowman, 1983), the physician is obligated to participate

in the rationing.

Physicians are not alone in experiencing this tension
between serving the interests of their patients and that of
the community at large. Assuming some form of a national
health insurance program is democratically adopted, their
patients will also share a similar tension; as citizens they
will have endorsed a rationing system of health care with the
understanding that the system may one day include denying them
access to desired care. The question at hand is whether the
physician's traditional role of patient advocate ought become
further constrained or even replaced by another role: that of

gatekeeper to medical resources.

The conflict.which emerges at the intersection of the two
sets of values and obligations pertaining to patient advocacy
and gatekeeping appears to threaten the professional integrity
of the physicians who are caught between them (see Chapter
Two). If they blindly adhere to their duties toward patient
advocacy there is little prospect for justly and efficiently
controlling medical care costs, and we can expect an increase
in the number of persons who are unable to gain access to
needed.medical care, currently estimated to be in excess of 30
million persons. If physicians focus exclusively on their

duties as citizens and embrace hard, impersonal rationing

44
postures, there will likely arise deep seated resentment and
mistrust of them as professionals who no longer appear
committed to the ethic of patient advocacy. This study is an
examination of the sources of this conflict and a search for
a morally acceptable middle ground between these two sets of

conflicting obligations.

Qgtline 9f the Argument Structure

I have in this chapter outlined the main problem I will
address and indicated its importance and difficulty. I have
defined and discussed. the ‘meaning of rationing, patient
advocacy and gatekeeping in the context of allocating health
care resources. The main problem concerns the conflict facing
physicians as individual patient advocates and as gatekeepers
to medical resources who often must make bedside decisions
with unknown social consequences. 'This problem.centers on the
tensions among core commitments physicians have to both their
patients and their society and turns on how these commitments

can lead physicians into serious, internal moral conflict.

In Chapter Two I introduce the notion of integrity as it
applies to physicians in their multiple capacities, as»private
persons, professionals, and as citizens and. discuss why
integrity is morally important in each of these roles. I
examine four key elements to professional integrity for

physicians, and show how their professional integrity may be

45
partially but not fully understood as a commitment to what
Fried.calls personal care [Fried, 1974]. I distinguish between
internal and external perspectives of professional integrity,
and discuss the social dimensions inherent in the integrity of

persons as individuals.and.as:members of various collectives.

In Chapter Three I explore the concept of medical care
rationing, and explain why even though there is a huge problem
of access to health care due to uncontrolled costs, there is
currently no loud public demand for rationing. I then discuss
the connection between rationing and the notions of patient
advocacy and political integrity (i.e., integrity of an
individual conceived as a member of a polis or community) for
physicians. I expand on the discussion in the first chapter
of why the two-tiered approach of having physicians merely
implement a rationing mechanism that has been determined by
others is unworkable. I explain why there is an ineliminable
need for a public and broad-based (but not unanimous)
consensus for rationing. I further explain how any morally
defensible system of health care rationing requires making
decisions at the bedside, thereby necessarily involving
physicians (or other authoritative health care providers) in

the rationing of care to patients.

Chapter Four contains a discussion of the concept of

gatekeeping in both of its functions of enabling and denying

46
access to medical care for patients“ Gatekeeping, I argue, is
required by each of the various rationing mechanisms. I then
discuss the doctor-patient relationship and the effect which
gatekeeping might have on it and on physician integrity
generallyu I bring together elements of the previous chapters
and show why the conflict between obligations to patient care
and to medical gatekeeping is chiefly an internal conflict
which principally affects only certain kinds of physicians.
I discuss the ways in which this conflict raises important
questions of professional and social integrity for physicians,
and how that integrity is viewed differently by physicians and
their patients. I argue that this conflict is ineliminable
under the current system of health care in the U.S. and that
it has certain implications for defining "good" doctors in the

future.

In the final chapter I lay out a compromise proposal for
easing the move toward integrity-preserving gatekeeping by
physicians through adoption of a national health insurance
program, and argue that among the principal architects of such
a program at the macro and.mid-level allocation levels must be
representative physicians, especially those involved in
primary care medicine. In addition, I argue that the bedside
rationing function (micro-allocation) must be carried out by
physicians. I explain why this dual role is required by

physicians' professional and. political dimensions of

47
integrity, and why their service in making macro, mid and
micro-level.decisions is, all things considered, the best hope
for a national health insurance policy that is "just enough"
for both beneficiaries and physicians. Finally, I argue that
a conception of morality’ which does not contain as an
essential element the quality of social justice is an
unacceptable conception of morality, one which precludes the
possibility of understanding in a useful way the notions of

personal, professional or political integrity.

CHAPTER TWO: INTEGRITY

It is widely recognized that the practice of medicine in
the U.S. is in a state of flux and both the roles of
physicians and the expectations of patients are changing in
several important ways. The result of these changes is an
emerging threat to the professional integrity of physicians as
traditionally understood. Integrity is a complex notion in
any context but none more so than with respect to the
professional and social obligations and responsibilities of
physicians, both as individuals and.as members of a particular
profession. In order to determine whether physicians have
integrity either as individual medical practitioners (what I
will call professional integrity) or as members of a group the
actions of which are subject to moral evaluation (what I call
their collective integrity) it.is necessary to understand‘what
it means to be a physician in contemporary society. However,
what it means to be a physician is undergoing a kind of
metamorphosis and the ultimate meaning which will emerge is

still uncertain in many respects [Burchell et al, 1988].

In this chapter I discuss the concept of integrity in
five different but related dimensions or, perhaps more
accurately, with respect to five subjects to which.it applies:
personal integrity; individual professional integrity;
collective professional integrity; political integrity; and
biographical integrity. I then show how professional

48

49
integrity for physicians may be partially understood as a
commitment to what Fried has called personal care [Fried,
1974]. chistinguish between internal (subject.dependent) and
external (observer dependent) perspectives of professional
integrity, and then discuss some connections between both
professional and political integrity and the problem of health
care resource allocation. I conclude by expanding on the idea
of biographical integrity and argue that it is the
biographical integrity of individual physicians which is most
threatened by the conflict between access to care and cost

containment.

While the literature on integrity is not large, several
notable characteristics appear regularly in the discussions,
and we may use them to gain a foothold on the concept. One
intuitively attractive idea is that of making an identifiable
and substantive commitment to specific values and principles
and acting in accord with them, especially in response to
challenges [Benjamin, 1990a; Blasi, 1983; Halfon, 1989].
Aristotle argued that.the ability to make such commitments and
then, in light of maturing understanding, to adjust the
specific ends at which they are aimed requires a kind of
excellence in the formation of the right sort of habits; in
the greek it is arete, or virtue [Aristotle, Nichomachean

Ethics].

50

Space limitations preclude making a full case here for
‘understanding integrity as a virtue, but if that conclusion is
provisionally granted on the grounds of plausibility, several
interesting features become clear. As a virtue, integrity is
not easily dislodged or dismissed, as Aristotle says. It is
a characteristic which is acquired through successfully
withstanding repeated temptations and challenges to one's
commitments rather than simply awarded or bestowed following
a single act [Aristotle, 1941; Halfon, 1989]. Over time,
integrity increasingly serves as a defining characteristic of
certain individuals. The loss of their integrity would
seriously diminish their identity as persons, both as
internally perceived by them and as externally perceived by

others.

Using Aristotle's account of moral virtues in the
Nichomachean Ethics as a guideline, integrity has to do with
voluntary acts, involves choice, is guided by a rational
principle and aims at honorable ends [Aristotle, 1941]. Like
other moral virtues concerned with the practical life (as
contrasted with intellectual virtues which are concerned with
the theoretical life) integrity issues from a certain state of
character that does not come by nature but must be learned by
habit. As an acquired feature of one's personal character,

integrity is not assumed to apply to all individuals.

51

A.second intuitive idea about integrity connectswwith.the
etymologic origin of the term, the Latin integer, which means
wholeness, completeness or unimpaired unity. Considering the
nature of persons with integrity in this regard we might
understand that all aspects of the individual's character, and
in particular the commitments one makes, are related, or of a
piece [Blasi, 1984; Kekes, 1983]. Being a whole person and
making identifiable, substantive and internally consistent
commitments exemplifies integrity inasmuch as such persons
both reflect their current natures and strive to improve them
at the same time. In a sense, persons with integrity are two
selves; the one they actually are in the present and the one
they hope to become in the future. As John Kekes has
remarked, "The two selves may coincide, but they are unlikely
to do so since few men have achieved the better self they want

to." [Kekes, 1983:500].

This commitment to improve oneself by actively pursuing
what are subjectively perceived to be worthy ends is both
difficult and complex. It is difficult because it requires a
confidence of moral correctness about one's chosen ends that
is strong enough to move one to action along a particular
path. This confidence in one's moral correctness takes time
to strengthen and mature and requires considerable courage to
become operative. In discussing difficulties for adolescent

females in making moral choices, Lyn Brown has observed that

52

acting raises questions about herself as a knower

and accurate perceiver. To act in ways that one

feels are good or right is to bring one's

perspective into the world; it is to claim a public
space, a "moral identity" [Brown, 1990:105, quoting

a term used by Blasi, 1983].

Such action-supported claims of moral identity, if
consistent and reasonably comprehensive are what constitute
individual moral maturity [Pellegrino, 1982]. However,
comprehensive consistency is not always possible. Persons
live their lives in different ways at different times, and
often assume various roles in so doing, e.g., parent, spouse,
sibling, child, teacher, citizen, neighbor, physician, etc..
Multiple claims of moral identity which arise from the pursuit
of different ends can create very complex internal moral
tensions. These tensions can threaten the integrity of the
individual by stressing his.or her ability to remain committed
to pursuing the multiple worthy ends. Such tension can
readily be seen manifested in the different reactions to

professional, civic and personal challenges facing physicians

in the United States.

On the one hand physicians hold both a professionally
inherited obligation and a personal commitment to the
principle of patient advocacy in medical decision making. On
the other hand there is an inescapable pressure from multiple
sources to economize in medical resource expenditures, the
vast majority of which are physician selected. Since some of

those pressures come from their own ranks and, more

53
importantly, their own reflections, physicians feel an
internal tension pulling them in seemingly incompatible
directions: patient advocacy on the one hand, and the demands
of gatekeeper on the other [Abrams, 1986; Cassell, 1981;

Hilfiker, 1987].

This is not an entirely new problem for physicians
however, as medical researchers involved in therapeutic
research historically have faced divided loyalties. As a
conscientious doctor, the physician/ researcher feels compelled
to place the interests and well-being of her patients at the
forefront of her professional responsibilities. But as a
competent scientist, she also feels obligated to conduct
careful and thorough research protocols, the requirements of
which may occasionally conflict with the patient/subject's

best interests, or certainly at least his or her preferences.

There are, however, significant differences between the
kind of conflict physicians face as researchers and the
conflict they would face as gatekeepers. Medical research
scientists who are also physicians constitute a minority of
all physicians and traditionally have been located in academic
institutions. The research patients/subjects should and
typically do understand that the medical care they receive is
part of a research program, that their participation is

voluntary and that they may withdraw from the research without

54
affecting their relationship with their physician. As
research subjects they understand that the tradeoff they face
is participation in a therapeutic research protocol in order
to receive a medical treatment which may not be otherwise
available. The protocol may involve additional tests,
examinations, costs or other inconveniences as well as some
estimated but unknown risks to the patient/subject. In
addition, many research patient/subjects will have already
failed to respond adequately to the standard treatment(s) and
are willing to accept the explicit tradeoff, as evidenced
(however thinly) by their willingness to sign a document
indicating they have given their informed consent. Finally,
the requirements of consent for patient/subject participation
in research are more detailed and thorough than the

requirements for standard medical treatments.

Of far greater importance however, is the fact that as a
result of both federal requirements and those of Institutional
Review Boards, patient/subjects are explicitly informed about
the objectives of the research, the nature of their medical
care, and the availability of alternative methods of treatment
if any exist. This last point is where the conflict facing
physicians as researchers and as gatekeepers diverge in a
morally important way. Patient/subjects must be given the
information they need to make an informed decision concerning

their participation in research and the expected consequences

55
of that participation as well as the consequences to them if
they do not participate. In contrast, the tradeoffs in
medical care access that'are.requiredflby.rationing mechanisms
will not be optional for patients if rationing becomes the
standard of practice. If physicians function as gatekeepers
they will have both.the authority and.the social obligation to
assure that the required tradeoffs are made. One interesting
moral question is how a physician can simultaneously embody
commitments to both patient advocacy and cost containment and
avoid moral schizophrenia, to say nothing of maintaining
professional integrity. Indeed, the interactions and
relationships which physicians have with their patients
partially define their professional identities. As Brown has
noted, "The moral reasoning, moral feelings and moral action
in which these [physicians] engage are given coherence by a
moral identity achieved through and defined by

relationship[s]" [Brown, 1990:107]

T e Concept of Physician Integritv
Integrity without knowledge is weak and useless,
and knowledge without integrity is dangerous and
dreadful.
-- Samuel Johnson (Rasselas,1759)
Physicians, perhaps more than any other professionals,
have a wide range of choices in terms of whether and in what

areas to specialize, when and where to practice, under what

conditions of employment, and so forth. The concept of

56

physician integrity must be applicable to all varieties of
physicians' choices in these and related matters so that its
presence or absence will be readily recognizable to
individual physicians, their professional colleagues and most
importantly perhaps, to their patients. Benjamin builds on
the general idea of integrity introduced above and identifies
more specific elements as it applies to individual persons:

What emerges is a conception of the person as an

integrated triad consisting of: (1) a reasonably

coherent and relatively stable set of highly
cherished values and principles; (2) verbal
behavior expressing these values and principles;

and (3) conduct embodying one's values and

principles and consistent with what one says.

These are the elements of integrity. Taken

together they constitute the formal structure of

one's identity as a person. [Benjamin, 1990a:51]

If the profession-specific values and principles for
physicians can be filled in, this conception of integrity can
be used to describe physicians' professional integrity. If the
concept of physician integrity is to have a meaningful and
useful content, its embodiment in the professional lives of
individual practitioners must be recognizable to their
colleagues and to their patients. What emerges should be a
recognizable and widely applicable concept that is useful in
assessing and comparing the professional strengths and

weaknesses of particular medical practitioners insofar as they

relate to professional integrity.

57

The Prgfessiogal Integrity of Physicians

If we combine the three ideas from Kekes, Benjamin and

 

Aristotle, and apply them to physicians in the professional
practice of medicine, a clearer picture begins to emerge.
Using this combination of complementary views, the
professional integrity of physicians can be understood as a
characteristic of individuals which consists of three formal
ingredients. Physicians with integrity:

(1) make substantive commitments to benefit patients and
contribute to advancing medical science. They act according to
those commitments within a whole and integrated professional
practice;

(2) select specific commitments because they embody certain
values and principles which the individual physician holds
especially dear in his or her professional practice;

(3) respond to challenges to these personal commitments by
using reasoned choices which reflect the physician's maturing

sense of commitment and consistency of professional character.

So far this is only a formal notion of integrity and does
not contain any specific articulation of the "reasonably
coherent and relatively stable set of highly cherished values
and principles" to which Benjamin refers. Not surprisingly,
this is rather difficult to do. When first entering medical
school students typically are in their early twenties, single,

and highly motivated to do financially well by doing moral

58
good through the practice of medicine. As their education
proceeds through clinical clerkships and residency, however,
there too often occurs a kind of brutalization of the students
as a result of the pressures and demands placed on them by
their teachers and.preceptors, all in.the name of patient care
(Silver and Glicken, 1990; Sheehan et al, 1990; Kay, 1990).
The personal values and principles the students articulated in
writing the required essay for admission to medical school are
severely challenged in the process of acquiring the skills and
"clinical detachment" of the modern physician. One
graduating medical student captured the entire experience
succinctly when she remarked at a meeting with some high
school students who were hoping to be admitted to medical

school, "Medical school changes your values."9

Given this transformation of personal values which
medical education too often occasions, it is difficult, if not
impossible, to specify the exact values and principles which
physicians.or:medical students with integrity'will.manifest in
speech and behavior. But this does not mean we ought give up
hope of ever finding or graduating physicians with

professional integrity. Rather than try to articulate a

 

9The medical student was a woman I met when I served as
an advisor to a medical Explorer post at the University of
Kansas Medical Center in Kansas City in 1983. The comment was
made at a meeting with some high school students who were
thinking about careers in medicine. Unfortunately, I do not
recall the medical student's name.

59
finite listing of specific values and principles tO‘WhiCh most
physicians with integrity would assent, I will suggest that
there are four general elements or components to professional
integrity that must "fit together" or cohere in physicians
with integrity. These four components are identified not in
terms of specific principles or values but in terms of
distinguishable but interrelated roles; attentive student,

competent clinician, caring attendant, and patient advocate.

With nearly 600,000 licensed physicians in the U.S., it
is unrealistic to expect that all will be equally good at what
they do. But those who are good physicians, good in both the
sense of technically competent and the sense of morally
reflective and responsible, will acknowledge the fundamental
need to exhibit these specific characteristics as indicative
of their professional integrity. Moreover, these
characteristics indicate not only their professional values,
principles and priorities but provide insight to their
personal values as well and, when embodied in a single

individual, are components of a whole and integrated life.

Each of these roles implicitly reflects the embodiment of
specific values and principles in terms of which.the roles are
performed, even if ‘they are .not explicitly* articulated.
Together they provide the minimum content of the formal notion

of integrity with respect to the complex professional role of

60
physicians. Furthermore, they are applicable to the
characterization of a person who has integrity as a physician
regardless of the individual's specialty or particular form of
employment”. It should be clear from the labels that these
are also all characteristics of some activity or other; that
is, the physician with professional integrity will connect her
beliefs about the specific values and principles of good
medical care with the way she actually manages her patients'

medical care.

It is important to keep in.mind that integrity is largely
a formal concept and the four substantive elements of it that
I am discussing will be present in greater and lesser degrees
and states of balance in different physicians. It is not the
case that every physician or every group of physicians will
develop and maintain the same degree of professional
integrity. The moral requirement is only that they each make
a genuine and sustained effort to achieve and maintain their
own balance of the four component roles. I will now say more

about each of these components individually.

 

m Whether such an individual has integrity as a whole
person, what I describe below as biographical integrity,
remains an open question at this point.

61
The Elenente ef Physician Integnity
Attentive Student
First, all physicians must be students of human health,
illness and medical treatment. Whatever area of medicine and
in whatever employment arrangement they finally select, the
need to remain abreast of current developments is universally
recognized as an essential part of good medical practice. In
an address to the Indiana University medical school faculty,
Richard J. Reitemeier, Professor of Medicine at Mayo Medical
School and past president of the American College of
Physicians advised,
Far and away our most critical need is to
understand clearly what the public expects of us.
Foremost is the application of what is best in
science and technology. This is primary and is the
underpinning of all else expected of us. Let me
repeat: the application of what is best in science

and technology [Reitemeier, 1988:162].
(author's emphasis)

To remain abreast of the many and varied developments in
these fields, it is essential that physicians remain.committed
to the study of medical science throughout their careers. In
an effort to meet this critical need, continuing education
units are offered in every specialty as well as family
practice and many hospitals and states periodically require
that physicians accumulate a minimum number to remain in good

standing.

Beyond this there is also the requirement that physicians

62
make sustained efforts to keep up with developments in the
social and behavioral sciences and in ethics, insofar as work
in those fields pertains to the care of patients. Clearly
this will not be easy to do, as many physicians find it overly
taxing to stay abreast of the technical and therapeutic
advancements in even their own area of specialization. 'To add
to this a requirement that they also keep abreast in other
fields may appear unreasonable. But two important points
should be kept in mind. First, the requirement is not that
physicians be conversant in every aspect of their own and
related fields, but only that they not allow their formal
study to end with their graduation from medical school or
residency programs. Physicians with professional integrity
will make a genuine and sustained effort throughout their
careers to attend conferences, read professional journals and
in other ways actively participate with the continuous

evolution of medical science and practice.

Competent Clinician

Physicians with integrity who are involved with patient
care will be competent clinicians where competency is
determined by those practitioners who are well respected by
their peers in their respective fields. In addition,
competency can be determined by the evidence of a treatment
outcome track record that is commensurate with their

professional colleagues and the reported medical literature.

63
This is not to be understood as making the nearly vacuous
claim that everyone should do as well as everyone else.
Physicians in every specialty and in general medicine
generally know about the other physicians in their institution
or community who treat patients with similar kinds of
problems. They can identify those practitioners who provide
exceptionally good care, as well as those whose patients seem
to have more than the usual amount of complications and poor
outcomes. There was recently formed an organization which
sought to do just this sort of identification, that is,
identify especially good physicians in a variety of medical
specialties throughout the United States and many major cities
in the world who are regarded by their peers as especially

competent professionals (Phoenix Alliance, 1991).

This professional competency is demonstrated chiefly in
two ways. Physicians must be able to make accurate diagnoses
and appropriate treatment decisions in a timely manner so as
to minimize the burdens and maximize the benefits for each of
their patients. But they must also recognize when the nature
of the patient's condition does not lend itself to medical or
surgical intervention. One of the most difficult lessons to
learn in the study of medicine is when not to intervene, and
it is a lesson which dates back to the writings of Hippocrates
(though it is not part of the famous oath) in the admonition

Primum Non Nocere (First Do No Harm).

64

Physicians are party to a great temptation as well as
tradition of intervening in a patient's course of illness and
suffering, but it must be tempered with a thoroughgoing
clinical-- and not merely theoretical--understanding of the
limits of one's professional expertise and abilities. In
their roles as clinicians, physicians with integrity recognize
that good medical care does not always mean actively
intervening in some medicinal or surgical way even if the
patient requests it. At various times in the course of
patient care every physician faces the decision to act or to
refrain from acting. Physicians with integrity will draw on
their experience both from personal practice and from their
continued professional study to correctly make that decision
so that the outcome to their patients is the best possible.
This is where the art and science aspects of clinical judgment
become indistinguishable, and where the third role of caring

attendant naturally arises.

Alternatively, or perhaps parallel to this, is the need
to recognize appropriate disclosure of individual professional
uncertainty regarding a particular patient's medical care.
Physicians are trained, socialized, expected and come to
expect of themselves a treamendous intellectual command of
medical science and its limits. In many cases these internal
and external expectations combine to the extent that

uncertainty rarely impinges on clinical decision making, and

65
leads the physician to speak and act as if she in fact knew
more than she actually did. This behavior occurs despite the
same physicians' candid admissions of professional
uncertainty, at least "at the level of scientific theory"
[Benjamin, 1985:120; Katz, 1984]. Physicians with integrity
will carefully guard against this form of professional hubris,
and conscientiously disclose to patients and colleagues the

limits of their own expertise and confidences.

Caring Attendant

When active intervention is not effective or perhaps
indicated, physicians with integrity will continue to attend
to their patients by providing comfort and support to them in
their illness. lNorman Cousins, in the Journal of the Anenieen
Medica; Association, noted this point in the following way:

There are qualities beyond pure medical competence
that patients need and look for in their
physicians. They want reassurance. They want to
be looked after and not just looked over. They
want to be listened to. They want to feel that it
makes a difference to the physician, a very big
difference, whether they live or die. They want to
feel they are in the physician's thoughts... I pray
that even as he attaches the highest value to his
science the physician will never forget that it
works best when combined with his art, and indeed
that ‘the art. is ‘what. is :most. enduring' in ‘the
profession. For ultimately it is the physician's
respect for the human soul that determines the
worth of his science [Cousins, 1982].

Similarlyy Francis Peabody, in a:now famous essay published in
the same journal in 1927 wrote,

The essence of the practice of medicine is that it
is an intensely personal matter--the treatment of a
disease may be entirely impersonal; the care of a

66

patient must be completely personal. The

significance of the intimate personal relationship

between the physician and patient cannot be too
strongly emphasized for in an extraordinarily large
number of cases both diagnosis and treatment are

directly dependent on it [Peabody, 1927].

These comments refer to that aspect of professional
behavior that has been called the physician's "bedside manner"
though it occurs as much in the clinic or office as at the
hospital bedside. Physicians with integrity are not, and must
not.allOW'themselves to become, mere repair technicians to the
human organism. To view patients as collections of organ
systems in various states of improper functioning and need of
adjustment is to lose the essential connection with humanness
that has distinguished medical care from all other kinds of
repair. Indeed, the term medical "care" is indicative of the
kind of expected interaction which patients bring to their
encounter with their physicians. Quoting Peabody's essay
again, "One of the essential qualities of the clinician is
interest in humanity, for the secret of the care of the
patient is in caring for the patient" [Peabody, 1927].
Physicians with professional integrity will be especially
cognizant of the need for "care" in those cases where they are
not able to offer curative or compensatory interventions as

well as when they are able to effect cure or compensate for

disability.

67

Patient Advocate

Finally, the fourth element or component of integrity as
it applies to the professional practice of medicine is that of
patient advocacy as discussed in Chapter One. It is the most
comprehensive of the four roles in terms of the ways in which
it is manifested and what counts as its reasonable limitations
is the least clearly defined. Nonetheless, it is of central

importance to the notion of physician integrity.

William May has warned that the role of patient advocate
may be unjustly'manipulated by individuals.or‘corporationS‘who
are more interested in low cost or high profit items and
services than in the best interests of patients (May, 1986).
Recent examples include physicians who make personal financial
investments in pharmacies, physical therapy centers, radiology
groups, etc. and then refer their patients exclusively to
these centers at a higher rate of usage then they did before
investing in the businesses [New York Times, August 9, 1991,
section A;p1]. May's solution is to encourage physicians to
take a controlling part in the growing corporatization of
health care and thereby preserve and protect their role as
patient advocate lest it fall into the hands of those with
goals other than the maximization of patient welfare. Siegler
has also argued that

The physician-patient relationship is the moral and

clinical center of medicine, and decision-making

within this accommodation is the central event of
the medical enterprise...a principal physician

68
should also serve as his patient's friend, advisor
and advocate within the health care system. This
latter responsibility includes guiding the patient

through the maze of hospitals, laboratory services
and consultants [Siegler, 1986:150-51].

In short, the professional integrity of physicians as
evidenced through their role as patient advocates includes
joining with their patients in battling illness and
disability--and sometimes the health care system itself--in
order to maximize the benefits to individual patients. This
function includes marshalling the resources necessary to
secure competent, effective treatment when possible, and
compassionate support when curative treatment is not possible.
In some cases it may also include securing access to medical
care for patients who are unable to do so on their own. This
latter situation is one of the ways in which the moral
obligations of patient advocacy as a component of professional
integrity run into conflict with the social obligations of
cost containment by involving physicians in controlling access
to medical care. As such, patient advocacy warrants more

detailed discussion here.

Patient Advocacy Through Personal Care

Patient advocacy is a major constituent of what Fried has
termed the personal care model of medical practice [Fried,
1974]. His central notion is that personal care extends beyond

direct medical care interventions and includes "unqualified

69
fidelity to that patient's health". In support of this claim
Fried.cites the Hippocratic Oath, the Declaration of the World
Medical Association and the International Code of Medical

Ethics [Fried, 1974:50].

As discussed in Chapter One, the idea here is not to be
understood as an unqualified sense of advocacy. Fried
recognizes that physicians have always had to manage their
time and efforts carefully to assure each patient that he or
she received proper professional attention while still
attending to emergency cases and other urgent needs“ But that
speaks only to trading off individual patients' needs against
each other when they occur at the same time and some immediate
decision is required. That is not likely to be the kind of
conflict which arises through rationing of care. In
rationing, it is more likely that a particular person
presently seeking medical care will be judged less medically
needy than some other person who will need the same resources,
though at a later time. This sort of tradeoff requires
placing a higher priority and more compelling claim on an
unidentified but statistically real person's needs than that
of a presently real person's needs. Thus, when this model of
personal care is examined under the need to ration medical
care, Fried, Levinsky and others have dug in their heels and
flatly denied that any doctor with professional integrity

could serve two masters, that of patient advocate/caregiver,

70

and that of rationer or gatekeeper to medical resources.

Abrams [1986], Angell [1985], Fried [1975], Levinsky
[1984] and Pellegrino [1988], have all argued that physicians
ought not allow their professional standing and integrity to
be compromised by the need to ration, and have insisted that
patient advocacy is the primary duty of all physicians.
Abrams puts it this way:

If the physician fails to maintain the primacy of
patient advocacy, he has failed his profession and
his patient... Physicians must practice on behalf
of their patients. They cannot divide their
loyalty, and I am concerned that this basic loyalty
is threatened A physician cannot serve two
masters. Conflicts of interest between individuals
and society will arise. Society ought to insist
that the individual physician's role for the
individual patient is as patient-advocate, not as
disguised financial gatekeeper or fiscal agent for
whomever is paying the bill... Physicians should
not become agents of the state (or any other
employer) for rationing or any other purpose.
Their social role as patient advocate is too
valuable to sully with deception and consequent
mistrust (my emphasis)[Abrams, 1986:18].

Marcia Angell insists,

The involvement of physicians in rationing is not
only premature; it is also inconsistent with our
role as advocates for the health of our patients.
... As individual physicians, we must do the very
best we can for each patient. The patient rightly
expects his physician to act single mindedly in his
best interests. If very expensive care is
indicated, then the physician should do his utmost
to obtain it for the patient If society is
spending more than it can afford on medical care
(and this has yet to be demonstrated), then that is
all the more reason for the physician to abide by
his commitment to be an uncompromising advocate for
the patient '5 needs (my emphasis) [Angell, 1985:19].

71
Fried maintains:

One is entitled to be treated decently, humanely,
personally and honestly in the course of medical
care. ... the physician who withholds care that it
is in his power to give because he judges it is
wasteful to provide it to a particular person
breaks faith with his patient [Fried, 1975:242].

Levinsky writes,

Physicians are required to do everything that they
believe may benefit each patient without regard to
costs or other social considerations. In caring
for an individual patient, the doctor must act
solely as that patient's advocate, against the
apparent interests of society as a whole, if
necessary .. . they should decide how much to do
according to what they believe best for that
patient, without regard for what is best for
society or what it costs. The doctor's master must
be the patient (my emphasis) [Levinsky, 1984:1573].

Finally Pellegrino argues,

It is in the interest of society to preserve the
integrity of the physician's primary responsibility

to his or her patient, ... rationing may not be as
inevitable as generally supposed ... [Pellegrino,
1988:261].

From these remarks one might conclude that for physicians
to preserve and promote their professional integrity they must
do far more than pass board exams and deliver reasonably
effective medical care; they must remain uncompromising
patient advocates even in the face of efforts to ration
medical care through treatment reduction or outright denial.
I will argue that these views represent an overly narrow
perspective from which physicians ought examine the need to
ration medical resources, including their own professional

time and services.

72

Qiffenent §ubject§ 9f integrity
To think of physicians as only physicians, divorced from
the rest of their lives in their many other roles is to deny
them full membership in the human community. No physician, no
matter how dedicated and virtuous, is only and always a
physician. Each is also part of a family, a neighbor, and a
citizen member of the local human community in which he or she
has chosen to pmectice. Physicians' experiences, concerns,
desires and projects from each of these different roles
comprise what Williams calls their full character [Williams,
1981], and it is in and through their characters that
physicians qua persons develop and manifest individual and

collective applications or subjects of integrity.

For present purposes I wish to restrict the focus of the
term "integrity" to what can be understood as the moral domain
of its applicability. While we may sensibly speak, for
example, of one's physical integrity being disrupted by injury
or illness, or one's emotional integrity becoming unbalanced
by extreme grief, I wish to put aside these meanings and
concentrate on the sense of wholeness and connectedness of the
moral character or fabric of an individual's life» Given that
restricted use of the term, it is important to understand the
distinctions among different applications of moral integrity

regarding the various roles in individual's lives.

73
As these distinctions will show, while it is possible for
individuals to have a partial range of integrity, that is,
integrity within some roles and not others, it is only by
having integrity'which encompasses all the roles in one's life
that an individual be properly said to have what I call

biographical integrity.

The various roles one occupies in the course of living a
life each require their own sense of :moral identity’ as
discussed by Blasi and Brown above» ‘While the different roles
will sometimes.make conflicting demands, each role is occupied
by a single individual who must be able to manifest a coherent
and sustained wholeness to his or her character. This is
possible only to the degree the individual can integrate the
commitments to the principles and values which serve as the
motivating infrastructure of the various roles and projects
the individual pursues. It is this sense of integration that
I mean to capture by the term biographical integrity; Lacking
biographical integrity is not merely lacking a desirable
trait; such a deficiency risks significant psychological and

emotional burdens arising from a kind of moral schizophrenia.

Personal Integrity

As I shall use the term, personal integrity refers to the
behavior of the individual in his or her private (i.e.,

nonprofessional, nonpolitical) life. On Benjamin's model, the

74

presence or absence of personal integrity is determined by the
connection between what an individual believes and claims
about certain highly cherished values and principles and how
they are used to guide the actions in his or her private life.
These beliefs, statements and behaviors cohere or fail to
cohere in the roles individuals play as spouse, parent,
sibling, son or daughter, neighbor, and friend. In short,
personal integrity concerns the behavior of individuals as
members of their non-employment related personal alliances,
both chosen (friends, elective social groups) and unchosen
(family members). Serious illness disrupts various
components of one's personal integrity insofar'as.it‘encumbers
the ability to rationally consider and evaluate personal
values and projects and to make decisions concerning them.
Pellegrino and Thomasma have argued that

The fact of illness is an insult to those aspects

of existence most integral to being human.

...illness deprives the patient of his distinctly

human freedoms--to act, to make his own decisions,

to be independent of the power of others. The

integrity of the patient's self-image as a human is

shattered, or at the very least, threatened

[Pellegrino and Thomasma, 1981:252].
In discussing the psychological integrity of persons
Pellegrino has further noted that

serious illness confronts us with the

possibility of a substantially altered self-image

or even non-existence. A new image, new points of

balance, and a new definition of what constitutes

health must be established if we are to become
"whole" again [Pellegrino, 1990:366].

75

Our highly cherished values and principles which
partially define who we are and serve as springboards to our
decisions and actions may be significantly but not necessarily
permanently affected by serious illness. Our ability to
remain committed to these ‘values and. principles may be
directly challenged by illness, and our personal integrity
will be reflected in our reactions to changes in our sense of
physical, emotional, psychological and spiritual well-being.

...restoration of the integrity of the person is

the moral basis of the physician-patient

relationship. That is why any morally authentic

doctor-patient relationship must by definition be
"holistic" [Pellegrino, 1990:367].

Ingividuai Professional Integrity

As discussed in the second section of this chapter,
professional integrity can be understood relative to the
behavior of individuals when acting in their professional
capacities. Considered as individuals, I have suggested that
comparative degrees of professional integrity for physicians
can be evidenced through the four roles of attentive student,
competent clinician, caring attendant and patient advocate.
But the practice of medicine is a collective enterprise as
well as an individual one in terms of its origin, educational
structure, delivery, financing and transferability, and
therefore the physician's role as professional patient
advocate also carries with it a significant collective

dimension. In that regard, the professional integrity of

76
individual physicians must cohere with a third subject of

integrity, that of collective integrity.

geiiective Profeesional Integrity

Collective integrity in this context includes the shared
beliefs, claims and behavior of physicians when acting
collectively in organized professional capacities for various
purposes. This subject of integrity includes the knowing and
intentional acceptance of the social consequences to persons
who are not patients of physicians but who are directly
affected by the collective decisions of those physicians. ZFor
example, the collective integrity of different groups of
physicians may be evidenced, to the degree they have control
over them, by the established abortion policies at their
health care institutions; the criteria for patient admission
such as ability-to-pay, or HIV status; the practices of
restricting admitting privileges to certain specialists in an

effort to maintain income levels, etc..

Collective integrity exists when the members of a
profession (or other collective) share beliefs in certain
values and.principles which relate to the nature and effect of
their collective actions and act accordingly. In order for
the profession to have collective integrity the individual
members must act so as to assure those defining collective

values and. principles are promoted and. preservedl For

77

physicians these include at a minimum, a self-policing
function to identify and correct the professional behavior of
unethical or impaired physicians, and a careful attention to
the nature and operations of physician organizations to avoid
an unjust manipulation of patients, other physicians, or other
members of society. As Blasi has argued, "A morality that
actually works, not only in this or that action, but also in
one's life in. general, must be rooted in some form. of
identity" [Blasi, 1984:136, quoted in Brown, 1990:105]. But
the collective identity of physicians is notably absent from
the public's perception and understanding of the medical
profession viewed as a whole. For such an identity to emerge
public statements supported by consistent and widely ranging
behaviors will be required.

Rarely do our government or institutional leaders

speak convincingly, as the founders of our country

did, of the moral purposes of their enterprise.

The inescapable challenge for all our institutions

in the next century, the one upon which the

revitalization of our national life depends, is to

recapture the sense of moral purpose transcending

self-interest.and self-preservation [Pellegrino and
Thomasma, 1981:2451.

Agreement on statements such as these and consistency in
professional behavior supporting them will be difficult to
secure in many cases. Each member of a collective decision
making group has separate obligations to his or her patients,
professional colleagues and to his or her personal values and

principles, and conflicts will emerge among these conflicts.

78
What will be required is a reflection on and judgment about
the individual's commitment to each set of obligations,
especially those understood to be professional in nature, and
those deemed social or political in nature, i.e., as a member
of a particular community. It is in this latter regard that
perhaps physicians' most serious and difficult conflicts
arise, the tensions between what he or she feels as a
professional is indicated in a given case, and what he or she
feels is socially justified, all things considered. Social
justice by its very nature extends beyond the individual
physician-patient relationship to include all members of the
community directly and indirectly affected by a particular
decision or action. The operative values and principles in
this context are the focus of what I call one's political

integrity, discussed in the next section.

Good and responsible professional judgments within an
individual's private practice are not sufficient to preserve
the collective integrity of the medical profession as a whole,
or even within various sub-groups. Individual surgeons who
are "knife happy", psychiatrists who strive to "keep their bed
census up" and others who take unfair advantage of the trust
which patients hold in their decisions are often known to
other physicians. Similarly, physicians, residents or medical
students who tolerate immoral behavior by their colleagues,

whether it be in the form of cheating in school or research,

79
intentional abuse of selected colleagues or impaired
professional functioning from drugs, alcohol, or mental
illness, all endanger the integrity of the medical profession

as a whole.

Insofar as these.other’physicians.or students allow, and
thereby enable such behavior to occur, they contribute to the
diminishment of the integrity of the profession, their own
collective integrity. The conception of integrity which
applies to the collective actions of the profession is similar
to that of individual integrity to the extent that individual
members publicaly identify with the collective, and personally
embrace statements of commitment to certain values and

principles that are made by the leadership of the collective.

Thus, whenever the actions of one member is contrary to
the publicaly professed values of the collective generally,
there is a sense among the other members that they (understood
collectively) are behaving inconsistently and.in some sense at
moral odds internally, that is, within the collective. If
such behavior of any minority negatively affects the way the
collective is viewed generally, either from within the
collective or by nonmembers, then the ‘majority have an
interest in either correcting the behavior of the minority or
removing them from its membership, and that interest is

motivated by a desire to maintain collective integrity. To

80
fail to do so is to endanger and perhaps even to lose their
collective integrity; Once lost, the integrity of the
individual or the collective is extraordinarily difficult to

reestablish.

Consider, for example, the diminishment in the eyes of
the public of the collective integrity of American politicians
in recent years due to the scandalous actions of a few.
Whereas members of Congress publically take an oath to uphold
the laws of the country upon inauguration into office, and
furthermore make public affirmations of commitment to
principles and values while campaigning for office, when
illegal or immoral behavior is publicly identified by the
media the integrity of the individual suffers impuration.
When such behavior occurs by multiple members, by extension
the integrity of the collective is questioned; though the
collective's commitment to principles and values are often
publically restated, the behavior of a few render the public

perception of those statements empty and insincere.

Other examples include the serious weakening of the
public's perception of the collective integrity of television
evangelists because: of sexual and financial impropriety;
savings and loan and Wall Street investment officers because
of irresponsible investments and embezzelments; and members of

the media for failing to verify accuracy of reports in order

81
to maintain truthtelling and respect for privacy; The
dedicated and honorable actions of even the most virtuous
members of these various collectives will be unable to reverse
the public's perception that professional integrity is a
claimed, but inaccurate characteristic of the collective
generally. For all the good that some individuals may do, the
public does not have the sense that as a collective whole they
are honorable, or just, or morally respectable in their
professional behaviors. When we try to conceive of what will
be required to reestablish collective integrity among such
groups we find it to be a monumental task. Only the
consistent efforts of a significant majority toward
reestablishing that integrity, combined with the absence of
further wrongdoing, will be able to reverse the public's

perception of the integrity of the collective.

Our society is already worried that "in deferring to the
expert in technical matters, it has lost control of the value
and purposes of that technology" [Pellegrino and Thomasma,
1981:2551. There is ample evidence for this concern as
evidenced by recent court battles and media attention to
conflicts among physicians and family members concerning the
appropriate medical care of patients, e.g., the well known
cases of Karen Ann Quinlan, Earl Spring, Brother Fox, Joseph
Saikecwicz, Nancy Cruzan, Janet Adkins, Helen Wanglie, etc..

As a result of this concern the Patient Self-Determination Act

82
was.passed in.Congress, mandating that patients be provided.an
opportunity to execute an advance directive on admission to
any federally funded health care institution. This law is
witness to a general distrust by the public of some of the
professional decisions and actions of physicians in general
and small groups in particular who take a stand contrary to
the expressed wishes of the patient and/or patient's family.
There is a very serious possibility that this same loss of
collective integrity is currently threatening American medical
professionals, especially physicians, in terms of its
collective approach to the problems of access to care and cost
containment. The intersection between one's professional and
community life is where the political values and principles

one holds as a member of a community emerge.

Political Integrity

Physicians who are sensitive to the effects which they
have both socially and professionally in the course of living
in.a community, and.who try to be sensitive to and incorporate
knowledge of the supposed effects in their social and
professional decision making, demonstrate a subject matter of
integrity that may be termed political integrity. Political
integrity here comes from the original greek polis, and is
meant to indicate not a particular ideological set.of beliefs,
but recognition of living in a polis or community. Political

integrity refers to the interrelated coherence of an

83
individual's verbal and physical behavior with the values and
principles he or she claims to use in making decisions about
how they will interact with other members of their community
in all relevant social and professional aspects of their
lives. It is a recognition and acceptance of social
responsibility to what one knows about the needs and
expectations of others in the community, especially concerning
one's moral--as contrasted with clearly defined legal--
obligations. It is "a responsible actualization of what one
knows to be right and true" concerning our fundamental social
connectedness [Blasi, 1983:206, quoted in Brown, 1990:106].
Just as the entrepreneur "threatens the [economic] integrity
of society when he despoils the environment" [Pellegrino,
1990:368], so too does he rend his own political integrity in

so doing.

Biographical Integrity

Given these four roles in life to which the concept of
integrity may be applied: personal; individual professional;
collective professional; and political, what is now needed is
a way to view that life as a single whole, the completeness of
which includes those multiple dimensions and still is capable
of having holistic integrity. To describe this overarching

subject of integrity I will use the term biographical

84

integritynu

If we consider a biography as the story of a person's
life as a whole, it covers, insofar as the life is reasonably
unified, all of that person's various roles (e.g., as
physician, son or daughter, spouse, parent, friend, neighbor,
citizen, etc.). One could possibly have professional
integrity as a physician but not biographical integrity, if
one's uncompromising commitment to patient advocacy totally
distorted or obliterated one's identity as a‘citizen or member
of society. Perhaps it is more accurate to say that one's
commitments as a patient advocate might be inconsistent with
the principles of justice to which one is emotionally or
intellectually committed as a citizen or social being. Such
a person would lack biographical integrity. The price one
would pay for surrendering or foregoing biographical integrity
in such a situation would be a sort of fanatical or unbalanced
singlemindedness if one ‘were to abandon just. principles
(supporting, among other things, fair'equality'of opportunity)

in favor of patient advocacy.

By focusing’ only' on. one Ikind. of integrity such. as
individual professional integrity, or even more narrowly on

the patient advocacy aspect of professional integrity, and.not

 

“ This term was suggested to me by Martin Benjamin on an
earlier draft of this chapter.

85

considering the further political dimensions of the effects of
those actions, a physician's life viewed as a whole life, will
be defective. MacIntyre puts it well when he writes: "It
would not be the kind of life which someone would describe in
trying to answer the question 'What is the best kind of life
for this kind of man or woman to live?'" [MacIntyre,
1984:201]. Nor would it be the kind of life we would want our
physicians to live, for it would be a life which lacked
biographical integrity. Even if our personal physician was a
brilliant diagnostician and therapist, if she lacked any
appreciation for the larger impact.her personal, political and
professional decisions had on the welfare of the community as
a whole, we would think her shallow and unconnected to the
larger stage on which our lives are played out. Indeed, we
would likely consider her life lacking in the richness of
meaning that her patients enjoyed in their lives by
integrating the different roles they each play despite their
medical ailments” Though she may be wholly dedicated to being
the best physician she possibly can, she would not be, in this
sense, a full participant in the human community and her life
would to that extent lack coherent meaning. Williams has
argued this point in the following way:

In general a man does not. have one separable

project which plays this ground role [i.e.,

provides a motive force which propels him into the

future, and gives him a reason for living]: rather

there is a nexus of projects, related to his

conditions of life, and it would be the loss of all

or most of them that would remove meaning
[Williams, 1981:13].

86

There must be, and. in jphysicians with. biographical
integrity there is, a broader awareness of the role medical
care plays in the general health and political stability of a
community as a whole. This awareness is not restricted to
physicians however, for one of the concerns all socially
responsible individuals have is what sort of community they
will live in and that concern necessarily includes the
availability of medical care generally. Furthermore, socially
connected, morally responsible persons will be genuinely and
actively concerned with the overall welfare of others in their
community. They will seek ways to assure adequate housing,
food, education and employment as well as health care for the
population as a whole. Though we may never achieve a
completely satisfactory balance in society with.respect to the
general distribution. of 'wealth and. resources, given ‘the
'universal need for medical care, those who value human.dignity
and respect will strive to provide some decent minimum level
of care to all genuinely needy persons [Arras, 1984]. By
acting on these concerns in a socially constructive way,
individuals' efforts enable them.to leave a mark on the social
world, the goodness of which will outlast their own temporal

presence in it.

Using Benjamin's conceptual model, integrity is a formal
structure of the interrelationship and coherence of the values

and principles individuals hold dear, and the way in which

87
they become manifest in speech and action. Taken together,
these concepts and behaviors constitute one's identity as a
person. Personal, professional, collective, political and
biographical integrity then can be distinguished in terms of
the specific 'values and. principles involved” Physician
integrity (considered both individually and collectively) is
only one part of an optimally integrated life of a (whole)

person.

The set of values and principles claimed by individual
physicians as the moral grounding of and guidelines for
personal behavior will be personal and may vary widely.
Nonetheless such values and principles must be consistent with
those of their professed professional and collective
integrity. To fail in this latter regard is to attempt to
carve out a piece of one's life wherein integrity will reside,
and allow the other aspects to be integrity free. But such an
attempt, though perhaps logically possibLe, is nonetheless
psychologically dubious, for it creates the conditions for

moral and behavioral schizophrenia.

It is the conclusion of this thesis (fully expressed in
Chapter Five) that in pulling all these aspects of the self
together so as to lead an integrated and unified life,
physicians, in the interest of integrating their roles as

physician and citizen, have both to take the lead in the

88
design and support of a system of health care rationing and to

occupy the role of gatekeeper in it.

e a and Extern l Pe s e t'v s o n t

In addition to distinguishing between the five subjects
of integrity discussed above, it is important to note the
difference between a physician's internal perspective of her
own integrity and the more external perspective of it
available to her patients and colleagues. These two
perspectives will differ with respect to each physician, some
to a considerable degree. Moreover, though at different times
one perspective may be more accurate than the other, there is
no single, objectively correct perspective which is fully
accurate. The reason for this is that no single perspective
can contain all of the relevant information from all of the
affected parties to the appropriate relationship(s), and this
is an ineliminable incompleteness“ That being the case, it is
apparent that any particular person's view concerning the
integrity of a given physician will necessarily be an
incomplete view, including that of the individual physician.
This incompleteness in perspective may partially explain why
Levinsky and others who reject.physician involvement.in micro-
allocation object to it so strenuously; They may be trying to
impartially and objectively assess physicians' professional
obligations and associated professional integrity. Their

arguments appear to insist that physicians' professional

89
obligations to patient advocacy ought "trump" their other
obligations, most.notably'the political ones, some versions of
which.might lead to physician involvement in micro-allocation

of health care resources.

But such a narrowly defined viewpoint will necessarily
lack the richness and connectedness that a more broadminded
and biographical perspective would include. Each physician
has his or her own character and personal interests, family
relationships, religious and social activities, all of which
contribute to unique personal--and professional-—conceptions
of the good. Individuals' personal conceptions of their
professional obligations, liberties and interdependencies.may
find sympathetic colleagues in some regards, but there is no
single conception of their social or political obligations
that is universally shared. Indeed, there is some evidence
that physicians do not possess even a shared understanding of

the moral underpinnings of their own profession”.

The medical profession is at a crossroads concerning its
public image and moral respectability in The U.S. In a 1985

address to the Governors of the American College of Physicians

 

12 Contrast the following sentiments of two leading voices
among contemporary physicians: Howard Lang, Chairman of the
IHospital Medical Staff section of the AMA who argued "The time
has. come to diminish. pno nono activities." and Richard
Reitemeier, past President of the American College of
Physicians who suggested it is "[t]ime to provide care to
those who cannot pay."[Lang, 1990; Reitemeier, 1985].

90
the President of the College said:

I submit that the future of our profession is at

great risk ... our activities do not derive from

any right we have to practice--such a right does

not exist. Rather, we hold a franchise given us by

society, by the public--our patients--and it is a

franchise that society can alter or even

withdraw... The public trusts us technically and
personally, but it does not trust us economically

nor does it trust us to represent its best

interests. Paradoxically, despite medicine's

scientific advances, we are in deep trouble... We

have no common voice as a profession (my emphasis)

[Reitemeier, 1985].

What then might be the basis for physicians' duties to
society as a whole, if indeed there are any duties beyond
those expected of all citizens? Radovsky has argued that the
duties are limited to those indicated by the actions of
government and medical regulatory bodies; there is no
obligation to the public at large that is grounded in the
nature of the professional work itself [Radovsky, 1990].
However, there is reason to believe that this view is neither
shared nor endorsed by the majority of the public. To the
contrary, many believe that contemporary medical practitioners
lack the important moral sensitivity and idealism that has
traditionally been part of their professional heritage. There
is widespread and growing mistrust of physicians' motivations
and general commitment to humanism in the practice of medicine
[Daniels, 1991]. Two-thirds of Americans think doctors are
too interested in making money while close to sixty percent

think.doctors do not care about people as much as they used.to

[Harvey and Shubat, 1989].

91

It seems reasonable to conclude here that despite some
physicians' sincere commitments to maintaining individual
professional integrity, the collective integrity of the
profession is perceived by the public to be quite low. The
reason may be that while the public considers most individual
physicians to have adequate individual professional integrity
as evidenced by the four roles identified above, they are at
the same time seriously lacking in individual and collective
political integrity. That is, while physicians are good
patient advocates when viewed narrowly and.in the first person
("my" doctor's care of me), physicians' general failure to
perceive the larger political ramifications of single-minded
patient advocacy significantly contributes to the high costs
and restricted access to care suffered by everyone. If
something like that interpretation is close to the truth, it
becomes understandable that the public perception of
Physicians' collective professional integrity is sadly

lacking .

The five subjects of integrity discussed above must be
"fleshed out" by specifying the values and principles which
give each application its embodied instantiation and
ViSibility in the world. What I have termed biographical
integrity is most closely associated with typical usage of the
term; this is the idea that the principles and values

Operating' in. and ‘through. one's ‘various. roles are fully

92
integrated into a life that is a complete whole. Physicians
with biographical integrity will practice medicine in a way
that can be integrated with their personal and political
convictions and not only the more narrow conception of their
profession. Such a broad, mature perception or understanding
of one's life is more philosophical than technical (in the
narrow sense) and as such it is not the sort of thing that can
be directly "taught" like the metabolism of ethanol in the
liver can be taught. It requires the ability not only to
identify the different roles one must play, but to perceive
and appreciate the often subtle relationships and mutual
influences they have on each other and in one's life as a
whole. This understanding can only be acquired over time and
as the result of living through personally engaging
experiences which challenge the different subjects of
integrity aligned with the various roles one plays. As
suggested earlier, integrity can be understood as a concept
properly residing in virtue ethics, and biographical integrity
perhaps is, in Aristotle's terms, both an intellectual and

moral virtue.

The question for present purposes is whether the
conceptions of integrity outlined here can be reasonably
expected of physicians generally, and in particular of
Physicians involved in the primary care of patients. One

thing is clear from the foregoing discussion. Individual

93
physicians will have biographical integrity in greater and
lesser degrees depending on their level of understanding and
personal commitment to developing and manifesting that

integrity.

Justice

One of the key components of a wholly integrated life--
this applies universally and not only to physicians--is an
intuitive sense of and passion for social justice which arises
out of an individual's political integrity. That is, the
individual recognizes that each role occupied influences and
is influenced by the decisions and actions made in the other
roles. Justice is the sense of a interrelated and coherent
sense of oneness which communicates through our individual
emotional and psychological singularity. Without this sense
of justice there is no common thread of understanding, no
particular vantage point from which to view the different
social and political choices with which we are faced as an

ineliminable part of social living.

It follows from my account of the component structure of
integrity that some physicians will require more careful
attentiveness to professional integrity than others by the
nature of their interactions with patients. Physicians in
psychiatry and primary care, for example, typically have

longer standing and more intimate knowledge of their patients'

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94
lives than do more technique-oriented specialists, emergency
medicine physicians or those engaged exclusively in research
rather than patient care. Psychiatrists and primary care
physicians may therefore be expected to be held to higher
standards of wisdom in dealing with their patients' medical
needs [Pellegrino, 1985] but all physicians share obligations
to understand and pursue the components of political and

collective integrity.

Integrity is a character trait we desire and expect of
all physicians regardless of their degree of personal
familiarity with us or the likelihood of future interactions.
Professional integrity is not just something we would like to
see present, but a reflection of the minimum characteristics
that are expected.of relatively few professionals, notably the
clergy, military and police officers, politicians, teachers
and attorneys, in addition to physicians. However, the
substance of what is integrated in terms of specific values
and principles may differ somewhat from profession to
profession, though all include a fundamental need for trust in
the professional integrity of each.kind.of professional" That
is why ‘when 'moral wrongdoing by ‘these professionals is
uncovered we sense a greater feeling of outrage and violation
than if the same errors were committed by individuals whose
activities do not include the same public trust and

confidence. These professionals are in positions to do us

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95
much greater harm than others with whom we interact by virtue
of either their responsibility for our safety (military,
police or politicians), or their knowledge of our private
hopes, aspirations, weaknesses, fears and vulnerabilities
(clergy, teachers, attorneys, physicians). We rely on their
professional integrity to warrant and safeguard our trust and
confidence in them as individuals, and we further rely on
their collective integrity' to identify' and remove 'those
members who lack individual professional integrity. Finally,
we rely on their political integrity to put into proper
perspective and make judgments about the effect their
professional actions have on the welfare of our community as
a whole, all things considered, and to act both individually
and collectively in a just and fair manner for the benefit of

that community.

For physicians treating patients there will sometimes
occur medical problems which have their origin in nonmedical
(i.e. non-biologic) aspects of the patient's life» The origin
of these problems can be traced to prior social and political
changes which make gaining access to health care very
difficult for the patient and therefore often delayed, e.g.,
patients whose residence is in a toxic environment caused by
industrial waste, or who lose their medical insurance when
changing employers. Such delays can significantly complicate

patients' medical conditions and diminish prospects for

96
successful treatment when they do manage to gain proper
professional attention. Thus, concerns with medical care
access arise for physicians both in terms of their
professional integrity as competent clinicians and patient
advocates, and in terms of their political integrity as

members of a just society.

The kind of person one is--and hence the presence or
absence of one's biographical integrity--will be reflected in
and.perhaps even be constituted by the orderings manifested in
these sorts of decisions, decisions which bring together
professional (both individual and collective) and political
concerns into a dynamic and ongoing engagement of the
individual as person in a community. The first four subject
areas of integrity of physicians discussed in this chapter,
personal, individual professional, collective professional,
and political each flow into and partially shape the other.
They reinforce or diminish a physician's overall biographical
integrity as they are individually strengthened or weakened

through the individual's response to challenges.

To refuse categorically to participate in the social and
political events and issues which affect us all is to fail to
fully engage the world, to hide from our responsibilities as
participating members of the human community and as a result

to live less than a full life. Moreover, to insist that one's

97
professional obligations trump one's political obligations is
to be both excessively narrow in one's perception of
professional integrity, and to attempt to divorce oneself from
that community in times of moral conflict. It is to try to
appear perhaps to be living apart from the community and the
obligations to it which non-physician members clearly share.
Yet no one can live outside his or her community. Indeed, it
is from our social experiences that we develop, embrace and
eventually define ourselves in terms of certain values and
principles. Just as no physicians can practice medicine in
isolation (patients, after all, are required) so too no
professional values or obligations--and hence no conception of

professional integrity--can arise in a political vacuum.

In The Plegue Camus captured the sense of internal
conflict which can arise when a physician strives to maintain
an operational sense of both individual professional integrity
and political integrity in times of widespread social
upheaval”. In that story Dr. Rieux at one point is asked by
the journalist Rambert to certify him as free of the plaque in
the hope that he could then leave Oran. Rieux refused,
stating that he did not know whether Rambert had the plague,
and that he could not make an exception to the established

policy of quarantine; even with the certificate Rambert would

 

13I am grateful to Martin Benjamin for suggesting the
analogy of Dr. Rieux to me.

98
not be able to leave. To this Rambert made the following
reply.

"No," Rambert said bitterly, "you can't understand.

You're using the language of reason, not of the

heart; you live in a world of abstractions...I

approached you because I'd been told you played a

large part in drawing up the orders that had been

issued. So I thought that in one case anyhow you
could unmake what you'd helped to make. But you
don't care; you never gave a thought to anybody,

you didn't take the case of people who are

separated into account...You'll soon be talking

about the interests of the general public. But
public welfare is merely the sum total of the

private welfares of each of us" [Camus, 1972:82-

83].

The tension in this situation is between a professional
political obligation (establishing and maintaining the
quarantine) and the desire to help someone whose plight one
understands and with which one identifies. From the foregoing
discussion of physician integrity and its characteristic
elements, including the way it develops over time in response
to challenges, two points are clear. First, the care of
patients by physicians with integrity extends beyond mere
direct medical intervention and assumes an ongoing
faithfulness to the person who is the patient even when
curative care is not possible to provide. Second, physicians,
like everyone else, are also members of a social and political
community with connections to and interests in the various
projects and interconnections which community life entails.
As such, they have multiple bases of interests in those

concerns which have precipitated discussion about the need to

ration medical care. These interests arise from several

99
perspectives in addition to that of being a provider of
medical care. Physicians are also at times recipients of
care; members of families whose other members will require
care; neighbors and friends to others who will require care
and perhaps most importantly, members of communities which

need to decide how best to assure fair access to that care.

Thus, in discussing rationing medical care generally, it
is philosophically inadequate and ethically unfair to
physicians to dismiss their involvement on the grounds that
such rationing decisions will taint their professional
integrityu Their professional integrity is only one component
of their biographical integrity and cannot, in these
circumstances, be usefully examined or assessed in isolation
from their collective integrity as members of a community of
physicians and.their political integrity'as part.of the larger
public community in which they live. To attempt to do so is
to compartmentalize their lives and to distort their
characters, resulting in conclusions which fail to fully grasp
the moral and political complexity of the problem of physician
integrity and the role of gatekeeper. Insofar as biographical
integrity and virtue may mutually indicate the presence of the
other, physicians cannot. Ihave ibiographical integrity
selectively, that is, in only part of their lives. To have
biographical integrity is to integrate the multiple values and

principles which one embraces in the different roles one

100

occupies, and ultimately to be of a single piece.

The dynamic nature of the relationship between the
professional integrity' of jphysicians and. their’ political
integrity as members of a community will require periodic
adjustments in elements of the former. What it means to be a
physician in the U.S. is different in 1990 than it was in
1950, mostly for reasons of complex social change and
evolution, but due also in part to the technical developments
in medical care itself. Since social change is inevitable and
has recently come to include the clear need for medical care
rationing (see Chapter Three), physicians cannot hope to
escape personal involvement in medical care allocation. How
they approach this challenge will affect and be affected by

their professional, collective and political integrity.

More importantly, I want to suggest that the collective
and political obligations of physicians as members of their
local communities extend beyond those professional obligations
voluntarily undertaken.with respect to particular individuals
[Ozar, 1988] and include the duty to provide some of the
needed leadership in finding a solution to the problem of
securing universal access to medical care. Both as private
community residents who are affected by the ultimate outcomes
of these deliberations and as professionals especially well

suited to understand the nature and scope of the problem, as

101
well as key players in whatever rationing program is
developed, individual physicians have a duty to help solve
these problems. This duty arises out of the common roots of

collective and political integrity.

gees Political Integrity Threaten Patient Adyeeeey?
If a thorough analysis of the problems facing medical

care in the U.S. concludes that rationing is the ‘most
preferable solution, all things considered, and that
physicians are the most appropriate persons to conduct that
rationing by serving both as individual gatekeepers and as
crucial advisors at the macro and mid-levels of allocation, a
political requirement for them to do so may appear to run
contrary' to ‘the jphysicians' traditional professional
obligation of patient advocacy. Since the requirements of
professional integrity (which include the duty of patient
advocacy) as well as the duties of good citizenship (which
include participation in health care rationing) are both moral
goods, the conflict between them is a moral conflict. And

moral conflicts are almost always messy affairs.

My goal is to search for a way to understand this
requirement of political integrity that manages to preserve
both the individual and collective.applications of the concept
of professional integrity for physicians. A middle ground

will be sought which may end up being a synthesis of the two

102
duties of patient advocacy and citizenship arising from the
respective desires to maintain both professional and political
integrity. Alternatively, it may be a compromise, a kind of
patchwork splitting the difference between them [Benjamin,
1990]. In either case, insofar as physicians are required to
make and implement specific rationing judgments and patients
are expected to abide by them, for there to be continued
social harmony and cooperation there must be a way to view and
understand the physicians' new gatekeeper role such that both
physicians and their patients can live with it with moral

integrity if not always with total comfort.

CHAPTER THREE: FAIR AND UNIVERSAL ACCESS TO RATIONED CARE

Some commentators have suggested the need for medical
care rationing is not yet present [Angell, 1985] or at least
not yet a crisis [Pellegrino, 1986]. Others argue that even if
rationing does become necessary, physicians ought be exempt
from making rationing decisions and are morally and
professionally obligated only to employ the guidelines for
rationing which others set forth [Fuchs, 1984; Levinsky, 1984;

Veatch, 1985, 1987, 1988].

While not providing complete arguments for the need to
ration here and relying on others to make that case fully
[Aaron and Schwartz, 1990; Bailey, 1986; Callahan, 1987;
Daniels, 1985; Fleck, 1990a; Friedman, 1986; Menzel, 1990;
Ozar, 1983; Schelling, 1979; Schwartz, 1987] in this chapter
I will argue for two main points. First, I will show that
there are persuasive moral and political arguments for
establishing a system of universal access to a basic package
of health care services for all citizens residing in the
United States (and possibly all residents) and second, I will
argue that rationing of medical services is required to make
universal access possible. Finally, I will suggest that in a
morally justified rationing procedure physicians must play a

major and direct role.

103

104

Heeith Care and Equality of Opportunity

Arguments to secure universal, equitable access to a
basic package of health care services involve both individual
rights.and.societal.responsibility [Arras, 1984; Fried, 1976].
It is a matter of individual rights in the same way that
entitlements to the material resources of food, clothing,
shelter, legal representation and (for somewhat different
reasons) public education are matters of rights. An adequate
minimum of each kind of resource is required for any
individual to have fair equality of opportunity with everyone
else to pursue his or her own conception of the good. In the
United States one of the fundamental principles of justice is
that such an equality of opportunity is a primary good in
Rawls' sense and as such, each citizen is entitled to it as a
right [Rawls, 1971]. The entitlement and distribution
programs for the essential goods of food, clothing, shelter
and legal representation as well as education are
legislatively constructed and administered through a
combination of federal and state government oversight bodies

and arrangements.

In this chapter I will argue that a minimum adequate
level of health care ought also be included in that list of
basic resources needed to pursue one's conception of the good.
To lack adequate health care is to be disadvantaged in society

in the same way that one is disadvantaged if lacking any of

105
the other basic resources. Yet there is aidistinctive feature
about health care needs that is not part of the other kinds of
needs. The other needs can be roughly quantified in.a more or
less standardized way, thereby enabling a specification of the

type and amount of resources necessary to meet those needs.

Standardized categories and minimum quantities of food,
clothing, shelter and education have been established and used
to place a limit on the social obligation to provide those
goods to individual members of society as a matter of social
justice. Thus, not only is everyone entitled to fair and
equal access to these same basic goods, but the same minimum
amount of these goods. If access to that minimum amount is
provided, the recipients are on roughly equal ground in terms
of their ability to pursue their individual life projects and
conceptions of the‘good; they share an equality'of opportunity
with respect to their basic needs and resources. The same
cannot be said for health care, however. The range of health
care needs, both among different individuals and for a single
individual at different periods in his or her life span is so
great that quantifying the health care resources required to
meet those needs is extremely complex. Indeed, depending on
how widely the concept of medical "need" can be interpreted,
medical consumerism could absorb all existing resources and
still not meet all the public's medical "needs" [Callahan,

1988; Frankel, 1991; Wiggins, 1987]. In spite of ‘this

106
uncertainty, legitimate concerns about national fiscal
solvency require that we be able to agree on a just and fair
upper limit to the medical services which society is required
to provide to any one individual as a matter of social

justice.

In an effort to address this problem Norman Daniels has
developed a theory of health care needs in order to "provide
a basis for distinguishing the more or less important among
the many kinds of things health care does for us" [Daniels,
1981:81]. In trying to find a lexical ordering among the
various health care needs, Daniels favors a distinction
suggested by David Braybrooke between course-of—life needs and
adventitious needs [Braybrooke, 1968]. Course-of—life needs
are such that

a deficiency with respect to them endangers the

normal functioning of the subject of need

considered as a member of a natural species...

Personal medical services...count.as{course-of-life

needs in that deficiency with respect to them may
endanger normal functioning [Daniels, 1981:88].

Daniels' general argument can be briefly summarized in
the following way. To achieve personal satisfaction or
happiness individuals must be able to construct a range of
life plans and conceptions of the good as goals which they
have a reasonable chance of attaining, given certain normal
Opportunities and resources. These goals will be relative to

particular economic and political circumstances of a given

107

society and hence tied to "its stage of historical
development, its level of material wealth and technological
development, and even important cultural facts about it"
[Daniels, 1981:93]. The resources necessary to achieve those
goals include a minimum level of physical and mental
functioning, aspects of which may be impaired by disease.
Daniels concludes that "We can therefore use impairment.of the
normal opportunity range as a fairly crude measure of the
relative importance of health care needs at the macro level"
[Daniels, 1981:94]. Individuals' health care needs are thus
conceived on this theory as things we need "to maintain,
restore or compensate for the loss of, normal species
functioning" [Daniels, 1981:93,95]. Daniels goes on to argue
that

if’ an acceptable theory of justice includes a

principle providing for fair equality of

opportunity, then health care institutions should

be among those governed by it. (author's emphasis)

[Daniels, 1981:95-6].
The reasoning behind this claim contains two points. First,
meeting health care needs as defined above has an important
effect on the distribution of opportunity, which is (at least
one of) the primary social goods. Since no one deserves the
advantages or disadvantages conferred by the accidents of
birth (they are morally arbitrary), positive steps need to be
taken to provide fair equality of opportunity. Health care

has a limited contribution to make in this regard as its goal

of normal functioning concentrates on a specific class of more

108
or less obvious disadvantages that are responsive to medical
interventions and tries to prevent, eliminate or ameliorate
them. 'The second point is that individuals are free to revise
their goals over the course of their lives, and therefore have
an interest in maintaining a normal range of functioning in

order to achieve their revised goals [Daniels, 1981:101-2].

From here Daniels is able to argue that effective health
care is the kind of material social resource that can.restore,
maintain or compensate for normal opportunity range, thereby
providing individuals with equal opportunity to pursue
satisfaction and happiness. However, the requirement to
repair, restore or compensate for all forms of structural or
physiologic deficiencies in individuals is clearly an
impossible and therefore unreasonable obligation. By
recognizing this we have a rational basis for limiting the
general social obligation. to devote common resources to
providing all forms of health care to all persons. Moreover,
it is important to recognize that this limitation applies not
only to resources to treat deficiencies in normal species
functioning, but includes understanding an individual's normal
opportunity range as relative to his or her chronologic age.
On this construction, the assessment of the importance of
treating an individual's health condition will vary according
to, among other considerations, the age of the individual

relative to some broad divisions of age, e.g., young, middle

109
aged, elderly, very elderly. In using this approach Daniels
hopes to avoid the most serious objections about age-bias in
allocating health care services since the rights claim to
those resources will apply equally to all persons at every
stage of their lives, though they may apply differently at

each stage.

Daniels recognizes that this theory of health care needs
does not provide a way to answer all the questions about
distribution of resources, and that the rights and
entitlements to have certain health care needs met are only
indirectly specified. Moreover, both the resolution of hard
medical cases as well as determining the relative ranking of
providing health care resources and other social goods will
require careful moral judgment [Daniels, 1981:108].
Furthermore, despite his focus on assuring fair and universal
access to a minimum equality of opportunity, Daniels' account
is nonetheless compatible with a multi-tiered system of health
care delivery. What it does show, however, is that if a
society desires to provide for a fair equality of opportunity
for its citizens, there is a very strong argument for
requiring the provision of at least a minimum level of
effective health care to all persons. That minimum is to be
determined by the conception of species typical functioning
and the normal range of opportunities which exist for

individuals in that society at that time, relative to the age

110

of the individual.

neeess to Care A Society-Wide Responsibility

In addition to being required by the social justice
objective of equality of opportunity, there are three other
reasons why providing a basic level of health care to all
members of a society like the contemporary United States is a
societal obligation. First, medical services are a social
product both in terms of trained personnel and physical
resources. Medical, nursing and allied health students pay
through their tuition only a fraction of the actual costs of
their education with the balance coming from state and federal
taxes [Crowley, 1987]. Taxes are paid by the general public
who at various times in their lives also comprise the patient
population. In addition, the physical resources necessary to
conduct the research and experimentation which provides
medicine with its effectiveness and grounds its scientific and
public respectability are supported chiefly through tax

revenues .

Some have argued that medical expertise is an "owned"
skill, and the individuals with those skills ought be allowed
to choose to whom and under what conditions (including fee
schedules) they wish to make them available [Sade, 1971].
However, in order to become a licensed health care

practitioner the vast majority of persons must pass through

111
the health care education system which owes the bulk of its
existence to the tax paying public“. Thus, the
opportunities to develop the very skills and knowledge
necessary for the practice of medicine are provided. to
practitioners by the people who hope to benefit from those
skills and that knowledge. In this sense of tax-based
financial support, patients enable health care providers to
become health care providers. In the sense that a right is
more than just an interest or preference but also invokes
entitlements, the tax-paying public has a right to at least
some health care services even if they do not have the ability

to pay all the usual and customary fees [Fried, 1976].

Second, the poor, the completely disabled, the
underemployed, the unemployed and the imprisoned, though they
provide disproportionately small or no contributions to the
general tax base are typically not life long members of these
groups. The majority spend only a small fraction of their
lives as social welfare recipients with the balance spent as
tax paying contributors in the same way as the rest of

society. On average, there is a 25-35% annual turnover of

 

1". The two exceptions to this general educational pattern
are those who were educated in medical centers outside the
U.S. (typically identified as foreign medical school graduates)
and those who obtained their entire health care education in
private institutions and received no tax based support
including student educational loans. Together they comprise
a small percentage of practicing health care professionals,
however.

112
individuals who qualify as poor [Fleck, 1990b] . Thus, many of
the poor are only temporarily poor and to deny them a basic
good that is necessary for equality of opportunity because
they are poor is to unjustly discriminate against them during
what may well be a transient and highly vulnerable period of
their lives. .As a society we provide the other basic goods to
the poor, and for the same reasons are similarly obligated to
provide at least a basic package of health care services as

well.

Third, since at least the end of the Second World War
the public as well as elected politicians have demonstrated an
increasing awareness of the need for and, more importantly, a
willingness to assure if not universal access, at least
greatly increased access to health care, regardless of the
individual's ability to pay for that care. Through their
taxes and political representatives the nonmedical public
provides the resources to enable the care of the needy who
cannot pay for it. This commitment to improving social
equality of opportunity in health care is what led to the
creation of the Social Security program in the 19303, the
Indian Health Service in 1955, Medicare and Medicaid programs
in the mid-19605 and, for reasons of compensation in addition
to social equity, the Veterans Administration health care
system for military veterans in 1930. These health care

financing programs are certainly not without significant

113
problems and have proven to be much more difficult to manage
and control than was anticipated. Nonetheless, the public's
commitment to maintaining these programs remains strong,
though various reforms have been attempted [Fein, 1986]. To
sum up, because health care resources and personnel are
dependent on tax support and because it is unjust to deny
health care to the poor and because the public willingly
supports programs to provide that care, some minimum level of
health services must be made accessible to all residents of

the U.S. as a matter of social justice.

From a philosophic perspective this is important, for the
public's moral and political support of the health care
industry serves as a non-utilitarian grounding for requiring
a just system of allocation of resources and services. Since
the public makes possible the existence of the health care
industry through its tax revenues, access to (at least) a
basic package of health care services can be viewed as an
individual entitlement that is derived from both the right to
equality of opportunity and a partial return on assessed
taxation. If universal access is fiscally possible only
through some capitation scheme and that scheme includes
rationing, then rationing itself can be grounded in equity and
justice as well as utility, thereby providing both utilitarian
and nonutilitarian arguments for its development and

implementation .

114

Given the current costs of providing medical services and
the fact that at least 30 million residents do not.have access
to services because of their inability to pay for it and
ineligibility for existing tax supported medical care
programs, the next question is how'to honor that right without
running up a medical bill so large that no other social or
other programs can also be provided. It will do little good
to guarantee universal access to medical care if in order to
do so it is necessary to eliminate all other social programs

which help enrich the community environment.

Alternatives to Rationing

Several commentators have suggested that rationing is
premature in the U.S. at the present time, since there are
effective methodological alternatives to the delivery of care
which have not been tried, or not tried with sufficient
duration or scope to effect the desired results. Chief among
these suggestions is to reduce the current amount of waste in
medical care. As noted in Chapter Two, Angell has suggested
that more prudent utilization of medical resources may
generate sufficient savings to enable wider distribution of
medical services and.meet the aggregate needs of the nation as
a whole. She prefers this to weakening physicians' commitment
to patient advocacy by forcing them ‘to become directly
involved in rationing: "Identifying and curtailing such

unnecessary medical care, rather than rationing beneficial

115
technologies, should be the thrust of cost-containment

efforts" [Angell, 1985].

In addition to eliminating clear instances of waste,
other reductions have been suggested including reducing
general administrative which costs currently one-fifth to one-
fourth of the total costs of health care [Woolhandler and
Himmelstein, 1991] reducing pharmaceutical company
advertising, profit margins and exclusive authority to
dispense medications, and reducing physician and administrator
salaries to better approximate salaries of other professionals
in the work force. While it is undoubtedly true that these
efforts would slow the rise of health care costs generally,
their implementation will not be sufficient to solve the
current inflationary crisis in health care financing and
delivery [Coddington et al, 1990]. It has been shown
repeatedly that the upward slope of the overall cost curve is
largely due to increasingly sophisticated and expensive
technology and, to a lesser extent, to the aging of the
population [Coddington et al, 1990; Schwartz, 1987].
Therefore, even if we eliminate all waste and reduce general
overhead costs, it would only delay but not alter the rising
slope of the curve. Indeed, Reinhardt has argued that at the
current difference between the rate of the rise in health care
costs over the annual inflation rate it will take only 82

years for health care to swallow 100% of the GNP (Reinhardt,

116

1990].

Setting Service Limits Not a New idea

The suggestion of setting limits to the types or amounts
or conditions under which medical services will be provided
has been approached incrementally since at least the early
19808 beginning with the private development of Health
Maintenance Organizations (HMOs) and other managed care plans
and the federal government's move to adopt the Diagnosis
Related Groups (DRG) payment plan for Medicare service
providers. While the DRG system was explicitly not intended
to be a capitation of service program but only a capitation of
payment, it nonetheless has functioned as a capitation of
service in many instances. The development of HMOs is closer
to the capitation of service program in design. HMOs aim at
providing medical services for their membership, but operate
under expenditure targets which total less than the combined
income from member premiums and.corporate investments.in.order

to assure a profit.

One of the ways to assure that physicians comply'with.the
established goals and purposes of the HMO is to contract with
the physicians directly. In exchange for an assured minimum
patient enrollment, the HMO may require contracted physicians
to accept annual expenditure targets. That way if a physician

overextends the expenditure target she can be required to pay

117
the excess expenditure in the form of reduced compensation or
even be dismissed from the HMO contract agreement. In
addition to placing physicians in an adversarial role with
respect to patients who request additional diagnostic testing
or more expensive treatment modalities, such arrangements can
place physicians in.a similar adversarial role with respect to
other physicians contracted with the HMO (recall the case of
the HMO psychiatry patient with episodic amnesia from Chapter

One).

In discussing the private, for-profit corporate sector,
Blank has cautioned that with the recent and growing control
of American hospitals by corporations,

control continues to shift from local institutions

to regional and national ones. Standardized

decisions are made at corporate headquarters and

applied at the local level without an appreciation

of the possible uniqueness of local values and

needs [Blank, 1988a:17].

Despite the unsavory nature of these approaches, from a cost
control perspective the opposite extreme is equally
unsatisfactory; writing vague and open-ended guidelines for
medical treatment expenditures which are to be "filled in" at
the discretion of individual physicians in making particular
patient treatment/rationing decisions. Such a proposal
defeats the entire thrust of cost control and allows
individual physicians to continue to practice medicine as if

the financing of medical care was wholly separate from its

provision.

118

Perhaps the most radical suggestion, and the one most
earnestly resisted by several (but not all) physician
organizations, is to establish a national health service which
would educate the medical care professionals as well as
administer, finance and deliver the entire spectrum of health
care services for the nation as a whole. To accomplish that
would require a huge effort by Congress which would have to
make decisions about what health care services would be
provided, under what conditions and according to what
mechanisms of financing and delivery. In effect it would
require the creation of something like the National Health
Service in Great Britain. Though universal access to health
care could thereby be achieved, the costs of doing so both in
financial terms and the necessary loss of freedom.of choice in
selecting providers and services may well prove to be

unacceptable to the American public [Daniels, 1986].

Furthermore, there is a very real danger of allowing
serious social injustice to occur if we rely solely on the
perspectives of elected but only minimally informed political
officials to determine the appropriate range and type of
medical care "packages" to which the public will be entitled
under a national health service. In a country of nearly a
quarter billion persons governed by a few hundred federal
lawmakers comprising 0.0002 (two ten-thousandths) percent of

the population, there is a very dangerous potential of a small

119
minority imposing rationing mechanisms on the less powerful
groups in a politically unfair way. Though this is an
inescapable feature of all such wide ranging decisions in a
representative democracy, the moral good of health care is so
fundamental to equality of opportunity and the ability to
pursue one's own conception of the good that we cannot afford
to risk its general availability to the vagaries of the
political system alone. The task of specifying the nature of
normal species functioning' and identifying' the. resources
required to assure an adequate level of health care properly
falls to the biomedical sciences [Daniels, 1981]. But this
speaks only to identifying which medical care resources are
required to achieve the objective of a universal minimum
equality of opportunity. The decisions of how best to
prioritize, finance and deliver those same services is an
entirely different matter, and one not properly suited to the

members of the medical profession.

Though entrusting the rationing decisions to the 500,000
physicians in the U.S. is better by a thousand fold compared
to the federal politicians (0.2 percent of the population), it
is still a very small representation. Moreover, since the
profits of medical care delivery accrue to providers, such an
arrangement could be compared.to entrusting the‘welfare.of the
chickens to the care of the foxes. There is currently little

reason to believe physicians generally will be any more

120
selfless and altruistic in considering the health care needs
of the patient public than would the legislators. Indeed,
there is a significant risk that the decisions made by
physicians will be as self-serving to their personal and
collective interests as many of the decisions made by members

of Congress are to theirs.

Historically, physicians have not behaved in the most
just or morally defensible way when given significant control
over health care allocation and treatment decisions.
Historical examples of medical paternalism provide ample
evidence of the risks of harm which such a narrowly conceived
approach to health care engenders. Even with the very best
intentions, American medical-political history is replete with
unjust and insidious programs that were publicly claimed--and
believed--to be aimed at serving the best interests of the
affected.groups, e.g., the mental health programs of the 19308
and 1940s, the Tuskegee syphilis study, the study of
gammaglobulin for treatment of hepatitis at Women's Hospital,
etc. [Rothman, 1990:Appendix A; Beecher, 1966]. That part of
their professional history as keepers of "a sacred trust" is
what has led to the creation of oversight and regulatory
bodies like the national organ procurement and transplantation
network, Institutional Review Boards, Professional Review
Organizations, Utilization Review Committees, and other

groups, many of which include non-physician community members

121

by design [Beecher, 1966; Harris, 1966].

So there must be a third option, one that does not rely
for the just allocation of medical services on the decisions
of a few persons ‘whose individual and collective self-
interests may color their perceptions of justice in health
care distribution. The obvious place to turn for such a
perspective is the patient-public themselves whose tax
revenues will be used to finance the health services, and
whose health care needs will be served by the allocation
system that is established. Moreover, public involvement is
needed to establish the claim that rationing would be accepted
by the public who will be affected by it. This is required to
assure that its implementation is feasible, i.e., will not be
met with great resistance by patients and physicians. At the
same time, its implementation must be acceptable to physicians
if it is ever to be given a fair trial in practice. If there
is no clear consumer based desire for rationing to drive the
implementation of such a program, a philosophic-cum-moral case

will need to be made even more persuasively to policy makers.

Medical Rationing: Responsible Denial of Desired Qere

Arguments for rationing as a method of securing fair,
universal access to medical services arise from three
perspectives, each of which begins with the recognition that

there are limits to the resources which can be devoted to

122
medical care. The first perspective is based on an
understanding of a need to significantly increase the current
levels of access to medical care. The second perspective is
characterized by a general unwillingness to allow the rate of
medical cost increases to continue. Finally, there is a
growing appreciation that less drastic methods to curtail

costs than rationing have universally failed.

The first perspective, a recognition of the need for
increased access, will unquestionably add to the costs
problem. If we can show that rationing is needed by virtue of
being the only solution likely to be successful in meeting the
two main objectives of assuring universal access to health
care and controlling its rising costs, then it stands a much
better chance of being perceived by the relevant policy makers
as necessary, even if it is not (yet) explicitly preferred by
the general public. Unfortunately, there is such deep seated
resistance within the medical community to considering
rationing as a possible solution that the word seldom arises
in the medical literature except as an evil to be avoided
[Qonrnei of the American Medical Association, Special Issue on
Caring for the Uninsured and Underinsured, 1991;265:2437-
2624]. But the mere efficiency of rationing will not satisfy
those who object to viewing the moral obligation of providing
universal access as resting on the shoulders of a simple

utilitarian calculus. As briefly mentioned in Chapter One and

123
more fully discussed in this chapter above, health care
rationing must include elements of equity. That requirement
will ShOW’ that. a purely utilitarian justification of a

rationing system is inadequate.

As already mentioned, cogent arguments for the
inevitability of the need to ration beneficial medical
services have been made by several authors [Aaron and
Schwartz, 1990; Bailey, 1986; Callahan, 1990; Daniels, 1985;
Fleck, 1990a; Friedman, 1986; Menzel, 1990; Ozar, 1983;
Schelling, 1979; Schwartz, 1987]. That same conclusion is
intuitively obvious if 'we accept two reasonable initial
assumptions. First, there are financial limits to what we as
a society can and ought spend on health care services at the
macro level of allocation» Clearly we cannot spend the entire
national budget on health care, so some choices will have to
be made about how health services ought be ranked among other
social needs. That by itself does not precipitate rationing
however, for it is logically possible that society could
decide to provide all the needed.health care services and tend
to other needs with what remains. The second perspective

shows why this approach will not work.

The second perspective is shaped by the realization that
society's health care needs will continue to expand both in

range and in cost. The reason for this double expansion is

124
that we currently have no widely accepted method of
distinguishing health care needs from health care wants or
desires [Callahan, 1987, 1988, 1990]. The notion of what is
a medical need is formed at the frontiers of medical
technology and research; if anything better can be done,
patients typically want it. And as medical technology
advances, the total costs of providing the latest.in.care‘will
continue to rise accordinglyu Unless individuals cease
seeking the best and latest in medical treatments, we shall

have to ration medical care.

Daunting though it may seem, this goal of changing the
public's desire for medical care does have its supporters.
Fried terms the employment of "elaborate ruses" to pretend
that illness, old age and death do not exist "part of the
neurosis.of our age" [Fried, 1976:33]. Callahan‘describeS‘the
area of poor medical outcomes (measured in terms of patient
health status) which result from using the newest technical
innovations in marginally indicated circumstances, as the
"ragged edge" of medical treatment and progress, e.g.,
intensive care for the very premature and low birth weight
newborns, bypass surgery for the very old, and AZT
(Zidovudine) therapy for AIDS patients.

No matter how far we push the frontiers of medical

progress we are always left with a ragged edge--

with poor outcomes, with cases as bad as those we

have succeeded in curing, with the inexorable

decline of the body, however much we seem to have
arrested the process...the eventual outcome will

125

not likely be good; and when, eventually, those

problems are solved there will be others to take

their place. That is the ragged edge of medical
progress, as much a part of that progress as its

success [Callahan, 1990:63].

One of the most frustrating and perplexing features of
this phenomenon is that not all treatment outcomes at the
ragged edge are bad; there are some remarkable successes. In
utilizing highly technical and expensive measures we are
sometimes capable of producing extraordinary benefits for some
patients. However, questions of appropriateness quickly arise
concerning the use of new medical technologies for multiply
compromised patients. It is these limited successes together
with the progress we have not yet achieved which "galvanizes

the research and clinical community, ever pulling us

onward" [Callahan, 1990:64].

Callahan argues that as a nation we ought accept the
technical level of health care we have already achieved, at
least for the time being, and reprioritize our' medical
expenditures away from the frontiers of scientific progress
and toward concerns of social justice and efficiency, i.e.,
assuring universal access to medical treatment. Arguing from
the perspective of distributive justice, he claims that the
advantages which accrue from sustained, aggressive medical
research come at too high a price. Though patient survival
and functioning outcomes will likely improve as more

experience at the "ragged edge" is gained, he argues that we

126
cannot continue to pursue costly advances in this frontier
research while simultaneously denying access to even basic
health care to millions of persons because of their inability
to pay. He suggests, in effect, that we trade off pursuit of
maximization of life expectancy (i.e., survival) for that of

maximization of equity.

Callahan's suggestion, while perhaps initially appealing
from a purely conceptual perspective, is pragmatically
unmanageable, at least at the present time. His goal of
redistributing resources in order to increase public access to
treatment would likely include changing and redistributing
many specialized medical practices in urban centers toward
more primary care in rural areas. We have seen for several
years a trend among medical students which indicates this is
unlikely to occur. Despite the stated objective by many
medical school applicants of a career in primary care in rural
areas, the selection of residency programs and practices by
medical school graduates has steadily moved away from primary
care toward specialization over the last twenty years [ Brooks,

1991; Babbott et al, 1989].

Second, a significant amount of health care expenditures
are directed at research at many levels and in many
directions. To reorient the personnel and resources devoted

to research at the "ragged edge" toward primary and secondary

127
care, will require disturbing many individual's career plans
and professional interests. Moreover, not all researchers are
physicians. Many are scientists who are not interested,
qualified or licensed to practice medicine. In addition, the
American public has voiced a long standing desire, sometimes
escalating to a demand, for the latest and best medical care
that is available anywhere [Coddington et al, 1990].
Callahan's suggestion to stop pushing back the frontiers of
medical research and redirect those efforts toward increasing
access to health care, though motivated by deep concerns for
social justice, is a much more ambitious and complicated

suggestion than may first appear.

flny Rationing Has Not Been Requested

There has been little public outcry for rationing of
medical services until recently for three reasons. First,
most persons employed full time are provided. a medical
insurance package:as a part of the total benefits they receive
from their employer. If they do need medical care few ever
see their medical bill and therefore have little knowledge of
the price of their treatment. Even if they did know the
price, it is paid by their employer's insurance company and
does not directly affect the employee. Mereover, very few
people have an adequate understanding of their health care
insurance coverage even.if they have copies of their insurance

policies. To think that this pattern of general public

128

ignorance will change by itself is unrealistic.

Second, persons at the greatest risk of being denied care
for lack of ability to pay are neither politically unified nor
(until very recently) actually' abandoned. by the :medical
establishment. Most needy persons eventually get the medical
treatment they require and the costs of their care are simply
shifted to the medical bills of the wealthy and the insured.
The medically uninsured have a fluid and dispersed membership,
are unorganized and typically below average income earners.
The majority are unemployed or underemployed and consequently
do not contribute significantly to the general tax revenues.
As a result, they are politically invisible and therefore
ineffective. Thus, the medical needs of the poor are easier
to pass over without action since the political and fiscal
repercussions from doing so are not likely to be very risky to
politicians. The harm which occurs through non-treatment of
the poor does not result in a notable loss to the national
economic infrastructure, nor is it reflected in dramatic
differences at the election. polls, despite the tens of

millions of persons affected.

Third, until recently the public has been ignorant of the
general plight of the medically uninsured and underinsured.
Since most of the poor eventually get medical care there is

little public attention drawn to their often significant

129
difficulties in getting that care. Without graphic displays
of pain, suffering, bleeding and death, the media find other
stories to tell on the evening news. Though there have been
more such stories in the recent press, for the most part the
number and type of instances where medical treatment is
actually denied to persons seeking it is simply not yet
alarming to the rest of the public [Levy and Hill, 1989]. But
this situation is rapidly changing. There has been both a
rising public mistrust of physicians and an increasing number
of medical treatment review committees and associated denials

of treatment over the past two decades [Kilner, 1990].

Thus, despite the general public's inaction about
inequalities in access to health care, many groups are showing
great interest and have begun forming plans to combat the
rising costs and inequities in access. Insurance companies,
physician associations, hospital associations, the federal and
state governments, etc. each have their own task forces and
study groups dedicated to finding a way out of the twin
problems of access to care and cost containment. Indeed, the
Hospital Insurance Association of America recently reported
that over six hundred separate proposals to reform health care
eligibility, delivery and payment systems have been introduced
in state and federal legislatures throughout the United States

[HIAA, 1991].

130

The reasons for these changes can be directly linked to
the rising prices of the medical treatments delivered to
patients. As the expenses have escalated, especially over the
past two decades, the third party payers (chiefly the federal
government, private insurance companies and large self-insured
employers) began to take very close looks at the charges for
the services rendered.and.the justifications of the providers'
decisions to provide those services. What they found was
little evidence of reflection by physicians about either the
cost (actual operating expense incurred by the provider) or
the price (charges assessed to the payor) of the medical
services in making decisions about providing it. The
investigators also grew suspicious that some physicians'
diagnostic and treatment decisions were not consistent
throughout the community of providers, and more importantly,
the indications for expensive diagnostic and therapeutic
interventions were not supported by published medical
literature. These preliminary conclusions seem to support the
position taken by some [Angell, 1985] that the problem.of cost
containment can be solved chiefly by elimination of waste and

inappropriate decisions in treatment expenditures.

Third party payers began to institute various contract
control mechanisms with health care providers to protect the
payer's financial resources from being unwisely or unfairly

consumed, e.g. requiring precertification of need before

131
authorizing payment for hospitalization of non-emergency
patients. As a result, the ability of the hospitals and
physicians to shift the costs of providing medical treatment
for the poor to the bills of the insured patients has been
increasingly scrutinized by payment review committees. These
committees are under strict orders to contain costs, resulting
in. an. external financial restriction. of 'the jphysicians'
freedom and authority to do what they feel is medically
indicated in the treatment of individual patients. As the
treatment authorization power of external reviewers increases
and the power and autonomy of physicians decreases, payment
for medical treatment to persons at the margins of medical

"need" are increasingly denied.

Despite both the concern.about.costs and social and moral
obligations to assure access to needed health care, widespread
inequalities in access abound. In response to these
inequalities several plans to assure universal access have
emerged from both the medical and business communities
[Himmelstein and Woolhandler, 1989; American Academy of
Pediatrics Legislative Proposal, 1991; Enthoven and Kronick,
1989]. But whereas we may find agreement on the fact of
inequalities and injustices in the health care financing and
delivery systems, that is not the same as agreement on the

best resolution to those problems.

132

One problem lies with the constituency of the bodies
assembled to debate and draft the various approaches. This
point is well made in the recent reports and discussions
concerning the experience of participants in the Oregon Health
Decisions Movement [Crawshaw, 1985; Jennings, 1988]. In
Oregon, state and federal Medicaid funds are being examined
for possible internal reallocation. ‘The ultimate aim is to be
able to assure universal access to basic health care for all
by extending the eligibility for Medicaid benefits to 100% of
the federal poverty level from its current 58% [Hadorn, 1991].
Additional funding for this increased coverage will be
generated by internal shifting of expenditures; setting
extremely low priority--and therefore availability of funding-
-for certain kinds of care to any of the poor (e.g. liver
transplants for alcoholics), and making much higher priority
the allocation of the remaining medical services. Seven
hundred and nine services have been identified and several
studies conducted to attempt to establish both an objective
(outcome measurements) and subjective (public valuation
surveys) weighting of the perceived relative importance and
value of the services [Dougherty, 1991; Oregon Health Services

Commission, 1991].

A significant difficulty that has arisen through this
process is that the persons whose access to health services

are most directly affected by the decisions, in this case the

133
poor, are seldom party to the discussions [Daniels, 1991b].
Many of the poor are unable to attend the public meetings for
lack of transportation, others cannot participate in telephone
surveys for lack.of telephone service, and still others cannot
be canvassed by pollsters for they are homeless and reside in
transient locations” ‘What results.is a collection.of opinions
from interested persons from the middle and upper middle
classes (a disproportionate representation of which are
medical professionals [Daniels, 1991b]) who respond to surveys
and assemble to discuss what should be included in and what
exempted from a "basic" health care service package for the
poor. The non-poor are attempting to decide how best to
ration medical service to the poor using the funds available
from their own selected tax revenues, but for the most part
without the informed input or consent of the poor themselves.
What is needed is a more representative system of input and
decision making which incorporates the views and preferences
of the majority of recipients of rationed care. There has
been a long standing truism in government that wherever there

are programs for the poor, there are poor programs.

ijections to Physician Gatekeepers

The position taken by Levinsky et al. to exclude
physicians from involvement in medical care micro-allocation
is purportedly based on the Hippocratic tradition of patient

advocacy, but is more accurately an excessive romanticization

134
the history of medical practice. The principled ideals of
medical care reflected in the Hippocratic Oath have never been
embodied in the actual practice of medicine; there has always
been a gap between the rhetoric and the reality [Priester,
1989]. That is not to say that the principles and ideals
reflected in the Hippocratic Oath have not served to guide
medical practice over the past two and a half millennia.
Clearly they have been the touchstone of good medical
practice. Indeed, Pellegrino has claimed that the Doctor of
Medicine degree (M.D.) only signifies passing the required
courses; it is the publicly taken Hippocratic Oath which
commits the physician to her way of life and special
obligations [Pellegrino, 1988]. Yet Pellegrino also insists
that attempts to turn physicians into gatekeepers are morally
unsound and pragmatically suspect [Pellegrino, 1986]. He and
others favor a broad based public discussion and resolution to
the problem of access to health care for all Americans, and
urge physicians to wash their hands of individual decision

making.

As argued above, clearly there must be public discussion,
but the enormous and intricate complexity of the problem
precludes the likelihood of a general public referendum
precipitating a workable solution. The many delays and cost
overruns in.the.Oregon.Health Decisions Project are witness to

the magnitude of this difficulty. Although a fundamental

135
alteration in the general kinds of medical treatment
expectations of patients has been called for by several
authors [Blank, 1988; Callahan, 1990; Fried, 1976] most
commentators agree that any policy will ultimately have to be
produced by the political institutions. While this is
undoubtedly true from a purely legislative standpoint it does
not mean that the substantive rationing decisions must be made
in committee rooms in the nation's capitol. It is my
contention that if a rationing policy is to be both effective
and acceptable at the local level where it will have to be
implemented, then at least some patient-specific judgments for
rationing decisions must also be made locally, constrained
within nationally mandated guidelines and restrictions. It is
unworkable to attempt. to design. a :national health. care
rationing plan which includes cost containment efforts
expressed in terms of specific indicators for treatment access
and denial except perhaps at the uncontroversial extremes of
the range of possible indicators; for example, all otherwise
healthy trauma victims ought to receive limb-saving emergency
care and all persons with simple tension headaches should be
denied computerized axial tomography (CAT scans) to rule out
extremely improbable brain tumors. Beyond these extreme sorts
of indicators however, there are too many variations in
environmental, behavioral and cultural-sociologic conditions
as well as the perceived needs of particular patients for a

fully articulated national rationing policy to achieve its

136

intended goals.

It may well be asked why a national problem of access to
care and cost containment is any more difficult to work out
than that being attempted by the state of Oregon. Oregon
citizens certainly are not homogeneous, but the OHDP is
designed to address the health care access problems of only
the poor, not the entire population. ‘The poor in Oregon, like
those in any state, are much less heterogeneous than the
national population viewed as a whole. As those differences
increase with larger inclusion criteria for eligible persons,
finding a single solution that works equally well in
Appalachia, Beverly Hills, the Bronx, Houston and Missoula
will be virtually impossible to construct. A single example
will help illustrate the.differences.among caretakers in their
perceived needs for family members with objectively similar

medical conditions.

One of the health care expenditures that will have to be
rationed under a comprehensive national rationing program is
long term care of the elderly. These expenses account for
significant portions of the overall health care budgets and
are projected to consume even larger amounts in the future.
In a 1986 study, health care expenditures in the last 12
months of life for patients aged 65 and older averaged

$21,000, compared to $23,000 for a similar group who were

137
relatively unimpaired until just before death [Scitovsky and
Capron, 1986]. But whereas 96% of the expenses for the latter
group were for hospital and physician services, only 25% of
the expenses of the former group were for these services, and
the rest were mainly for supportive care such as home and
nursing home care. In fact, the bulk of Medicare
reimbursement for all elderly patients who expire is accounted
for by supportive care for patients other than those who
receive intensive medical care in the last year of life. It
appears unlikely that more than a relatively small part of the
high medical expenses at the end of life, and of the elderly
in general, are due to aggressive, hospital based and high-
tech care of terminally ill patients. Most of these expenses
seem to be for care of the very ill but not necessarily dying
patients; care that especially in the case of the very old and
chronically ill, is relatively conservative, yet expensive.

[Scitovsky and Capron, 1986; Lubitz and Prihoda, 1984].

Such care, given over many months and years is expensive
in several ways beyond pure economic costs, a fact not
revealed by studies of Medicare expenditures alone (which do
not cover most supportive or nursing home care). The
attendant medical care is provided in varying ways in
different ethnic and socio-economic environments and the
associated costs cannot be fully expressed.or accounted for in

medical bills. For example, in many Hispanic and Asian-

138
American communities more so than Black and Caucasian ones,
adult.children often.care for their debilitated elderly family
members in their homes rather than use institutional care
facilities. Some of the reasons accounting for this
difference are economic, but others have to do with cultural
traditions and most are a combination of both factors. The
caretaker at home in these situations cannot usually also be
a wage earner, a fact which contributes to the overall costs
to families for medical care of the elderly member. In
contrast, in some large urban areas where both adults work
full time and many families reside in multi-unit apartment
complexes, caring for bedfast family members is not always
possible in the more limited apartment space, and
institutional care facilities are required despite the strong

wishes of family members to the contrary.

Given these differences, rationing health care
services to elderly patients must be done within the context
of a holistic package of medical services that is tied to the
relevant cultural and socio-economic realities of different
communities in the U.S. Only in this way can both the patient
and family anticipate and prepare appropriately for the level
of services provided when the elderly patient's physical
condition inevitably deteriorates. To write a single,
nationwide program for medical care of the elderly under these

widely differing support mechanisms and conditions is to fail

139
to understand the relevant cultural differences in the
perceptions of distributive justice by different members of

the American society.

Mere; and Political Requirements tor Rationing

Two conditions for any national rationing program must be
met for it to be both morally justifiable and politically
acceptable. First, the overall mechanisms of rationing must
be fair when viewed from the relevant perspectives, and
second, they' must apply ‘universally; If the rationing
decisions are made impartially with respect to each
individual's medical need and social role (e.g., employed,
disabled, prisoners, etc) and do not single out identifiable
groups.of individuals.as:medical rationing targets (e.g., AIDS
patients, prisoners, etc.) such rationing will be consistent
with the moral principle of securing fair and equal
opportunity for all members of society. It is the attention
to the particularizing aspects of individuals' medical needs
where all rationing program proposals run into complicating
trouble, since no population is truly homogeneous [Aaron and
Schwartz, 1990]. Thus, in designing a national health care
rationing program the diagnosis and/or treatment
classification system(s) will involve political, medical and
ethical considerations. While it may be appropriate for
experienced politicians and bureaucrats to make the final

necessary political tradeoffs, prior to those decisions are

140
the equally important moral and medical decisions about
rationing which politicians are not intended, empowered nor

sufficiently informed to make.

One of the chief political requirements is that the
health care financing system in the U.S. become "closed"
[Morreim, 1988] . A closed financing system refers to a global
financial budget which ranges over a comprehensive set of
expenditures in one area, e.g. health care. Such a budget is
constructed so that income revenues accrued in any'part of the
system by any means (fees, savings, investments, etc.) are
able to be transferred within that system to replenish or
expand resources in any other part of the budget for that
system. When the financing system is tightly closed, there is
no risk that the revenues generated.will be siphoned off to be
used for a separate and unrelated purpose in another system.
Even without specifying which services are to be rationed, it
is reasonable to anticipate the rationed services will all be
beneficial services, since there is no point in providing and
therefore rationing nonbeneficial services (see Chapter Five).
As a result there will be a significant.number of ineliminable
sacrifices entailed by instituting a rationing program. This
is a morally important concept in health care rationing since
the consequences of failing to secure a closed financing
system leave open the possibility that the rationing

sacrifices and tradeoffs made in one area, e.g. , discontinuing

141
organ transplantation, may be lost to non-health care

purposes, e.g. , increased resources for military expenditures.

Thus, a closed health care financing system is morally
required in order to justify the individual sacrifices and
tradeoffs that will have to be made according to the rationing
criteria. Since the bulk of health care financing currently
comes from private insurance and is not directly tied to the
overall federal health care budget (i.e., government
programs), savings generated in one part of the health care
sector will not automatically become available in other parts.
Whatever savings are realized by elimination of waste and
foregoing expensive, experimental research will be transferred
to the pockets of the payers who would otherwise have had to
assume those costs, and not to increasing access to services
by the poor. Those payers may decide to invest their savings
or to cover losses in other non-health related areas, or they

may elect to simply keep the savings as profits.

There is no requirement that these private institutions
and public agencies reinvest those savings in underfinanced
areas of health care, or even to reinvest them at all. That
is why even if we were able to reduce waste in health care to
zero (which is impossible) and secure broad public acceptance
of the need to forego expensive medical research (which is

unlikely), without a closed financing system the resulting

142
increases in efficiency will entail no concomitant increases
in access to health care, and hence, no increase in equity of
care. For the relevant political decisions concerning
tradeoffs and management to be possible and effective, the
ranges of concerns must be tightly limited.to health care, and

that requires closing the system of financing for it.

The moral decisions, on the other hand, must reflect an
understanding and incorporation of those principles of justice
and efficiency which are broadly embraced by both physicians
and the larger public. Given the long debate and wide
disagreement in the medical, religious and philosophic
literatures as to which.moral principles ought be used and how
they ought be ranked and allowed to mutually influence each
other, the proper identification of these principles can come
about only through concerted efforts to elicit overt public
demonstration of their acceptability. Though it has incurred
several notable difficulties already noted, the best known
attempt to do this on a large scale is the Oregon Health
Decisions Project. Similar projects have been attempted with
varying degrees of success in California, Hawaii, Maine,
Illinois, Indiana, Washington, Colorado, Vermont, Idaho, Iowa,

and New Jersey [Jennings, 1988].

Finally, the medical decisions are the proper focus of

health care practitioners who are knowledgeable about specific

143
categories of illness and treatment and, to a more limited
extent, the social and psychological aspects of illness. A
consensual and coherent "medical perspective" has not yet
emerged from the ranks of the professional bodies, but it is
the catalyzing force which I suggest most needs initiation.
If a strong and united professional medical voice can be
generated to address the specific medical considerations in
the design of a rationing system, and can suggest substantive
components to it, such a voice is likely to serve as the most
effective catalyst for the broader’ public discourse and
decision making. In order to represent a professional
consensus about the medical features of a rationing system,
such a voice will have to reflect an understanding of the wide
variations among' patients who seek. medical care. 'That
understanding can only arise from individual health care
practitioners who reflect on their own professional
experiences and find ways to articulate that experience and

the lessons learned from it collectively.

Given the enormous range of imperfections and individual
differences among patients, the experience of treating the
same patients over time is necessary for an understanding of
that person in all his or her distinctiveness and individual
characteristics [Gorovitz and MacIntyre, 1976]. This is why
a single, "recipe" approach to medical care rationing cannot

hope to be adequate to the task of meeting the medical needs

144
of the population of individuals. There is an ineliminable
need for limited authority and autonomy of health care
providers to make individualized treatment decisions about
particular patients. Under ideal circumstances these
decisions will be made by physicians who have known and cared
for their patients professionally for an extended period of
time and can place that holistic health care over the course
of their lifetimes into proper perspective, a perspective that

is embraced by the reasonable and responsible patient as well.

The individuating features of particular patient's
medical needs notwithstanding, it is also true that certain
kinds of general treatment decisions can be made for patients
within broad classifications of medical conditions. If we
consider these two approaches as placed at opposite ends of a
continuum, certain general classifications for admission and
denial of care will work at the extreme ends where there is
wide concurrence of the efficacy and justice of those
categorical decisions. As we approach the middle, however,
individual physician's decisions about particular patients and
their comparative need for medical attention will be required.
Furthermore, these decisions cannot be justly or efficiently
made unless physicians are allowed sufficient latitude in
using their professional judgments concerning admission,
denial, continuation and termination of care as well as a

range of decisions concerning the selection of particular

145

interventions.

While we may chose to empower physicians to make a range
of medical judgments about patient care within the National
Health Insurance Program (NHIP) fiscal constraints of
rationing, we cannot hold them to unrealistic standards of in
making these decisions. There will always be both the
possibility and actuality of error in diagnosis, prognosis,
and selection of specific treatment modalities. Error is
unavoidable in medical care not merely because it involves
imperfect human knowledge and tools, but because it is a
science of particulars with enormously wide ranging
manifestations. Given the ineliminable and tragic consequences
that will often accompany inculpable error in medical decision
making, the decisions pertaining to medical care rationing
must be minimized as much as possible. To accomplish this,
some degree of individual autonomy in making rationing
decisions ought be allowed the particular human beings
(patient and physician) who‘will live‘with.the consequences of
those decisions. The reason why a "customary standard" of
medical practice is so difficult to identify and assess is
because in the truly personal care:of patients, physicians are
not generally fungible. Different physicians may treat
patients with similar illness differently as a function of
both the overall medical needs of the individual patient as

understood by the physician who knows the patient.well [Blank,

146
1988b] and the influences of the predominant practices of

other physicians in the community.

Thus, to attempt to construct a national health care
rationing program on the basis of a national "standard of
care" that cannot be adjusted for local cultural and socio-
economic variations is to produce overly rigid standards that
will likely fail to serve the interests of a large number of
patients and their physicians. Blank has also noted this
point and joins Comroe and Kaplan in suggesting that the
solution is to turn to the public itself for "resolving the
questions of human values raised by biomedical technology"

[Blank, 1988a:174; Comroe, 1978: Kaplan, 1975].

However, it may not be the whole public that needs to be
involved. Blank favors subdividing the public into "more or
less specialized, attentive publics" for purposes of
soliciting input to the program design. The suggestion is
that we will likely gain nothing constructive and risk losing
valuable time and resources by throwing too widely our net of
questions toward the public at large» Weiner appears to agree
when he suggests that we view'the various professional experts
as crucial initiators.of public discussions for they have "the
capacity to anticipate problems related to their work at an
early stage and participate with other groups to make choices

consistent with more inclusive public value systems." [Weiner,

147

1982].

The importance of Ueinq the Right Proceee

While there is an undeniable efficiency and
attractiveness in focusing on the views and arguments arising
from educated and informed experts, there is also a danger in
thinking that the uneducated or uninformed public has little
or nothing constructive to contribute to programmatic
proposals for health care access or cost containment. As I
explain more fully in Chapter Five, no matter how conceptually
clear and logically reasoned a specific policy may be, if it
"won't play in Peoria" it will be functionally useless in
practice. We will not all agree on what is to be done, but
then we never have in the past. To insist on a wide consensus
of public support as the minimum requirement for a morally
defensible health care access program is effectively to assure
that no such program will ever be proposed. We are much more
likely to succeed if instead of focusing on the substantive
elements of the rationing plan itself we concentrate first on
the process by which the plan will be generated. If we can
accept that the process is fair and reasonable, and further
understand that we are all bound by the limits we impose on
ourselves through it, specific denials of treatment generated
from the rationing program may be perceived as unfortunate but

not unfair [Blank, 1988a].

148

This point is especially difficult to effectively
communicate to :many individuals. There has been. a firm
reluctance by the various specialized publics to look beyond
their own self interest to the needs of the country's
population as a whole. Labor unions invariably object to
employee cost-sharing, the American Association of Retired
Persons consistently objects to means testing, small
businesses object to paying for health insurance for their
employees, the health insurance industry objects to losing its
market to a national insurance program or special tax
revenues, the Congress and state governments all claim they
have already overtaxed and overspent. But this is a
ubiquitous problem for the U.S. generally; we have always had
a difficult time distinguishing between what might be called
the them-us and the us-us. Health care rationing under a
national program may well prove to be the single greatest
unifying project which helps to collapse the different senses
of them-us into just one us. On the other hand, a continued
failure to solve the problems of access to care and rising
costs in the U.S. will drive us further toward.a perception of
a.highly fragmented them-us. It will also continue the heart-
rending consequences of being denied medical care that are
disproportionately and.unjustly faced by the poor, the elderly

and the uninsured.

As the two pressing needs for gatekeeping in the face of

149
fiscal restraint and patient advocacy in the face of
gatekeeping become clearer, and the likelihood that physicians
will have to fill both roles at least some of the time becomes
greater, the result is almost certain to pull physicians with
professional integrity apart, and thereby risks destroying any
semblance of collective integrity for the profession. The
appropriateness of applying the concept of integrity to these
two professional roles is in.danger of being undermined.by the
crisis in health care, yet may also be the best place to turn
for both the solution to the crisis, and their individual

preservation.

If physicians come to understand both the scope and
severity of the harm to persons who are denied care and the
seriousness of the threat to their own individual and
collective professional integrity as well as their political
integrity as.a result of those denials, some physicians may be
motivated to try to effect the necessary changes. Whether
there will be enough support from such physicians in every
state or region to provide the needed leadership to developing
a well reasoned program of rationed care will depend in part
on what the rest of the profession decides to do. If
physicians in general do not properly grasp the need for their
leadership role in helping solve this national problem of
social justice and medical service, or if they choose to

ignore the threat it brings to their professional and

150
political integrity, the consequences to the profession may

well be dramatic and irreversible.

Solutions to the problems of access to care and cost
containment will undoubtedly then be authored and administered
by non-physicians who will likely ignore physicians'
objections to those solutions, especially if those objections
arise from claimed concerns about damage to the integrity of
the medical profession. If physicians do not assemble a
united and coherent effort to help solve the problems posed by
inequalities in access to care and uncontrolled cost
containment and instead insist on promoting their own
interests ahead of the medically needy, few'patients will feel
any need to become concerned with physicians lamenting the
loss of their professional autonomy and diminished social
respectability. The fiscal challenge and moral inequities are
clear. The emerging role of the physician as a politically
connected and socially integrated member of the community is
becoming clearer. What remains to be made clear is the
specific nature of this new role of gatekeeper to the medical

resources .

CHAPTER FOUR: MEDICAL GATEKEEPING

By connecting the discussions of professional and
political integrity in Chapter Two with the need for health
care rationing in Chapter Three, I now move on to discuss the
role of gatekeeper in rationing health care resources. This
role is crucial to whatever programmatic form the rationing
eventually assumes, for the process of rationing begins with
the premise that not every need will be met. Thus, the
relationship between the medical gatekeeper and those
requesting medical services will be difficult, though it does
not have to be.adversarial. Fleck.has argued that philosophers
must serve as "facilitators and guardians of the integrity of
a certain kind of socio-moral conversation to [help]
resolve social problems fairly" [Fleck, 1990a:248]. In this
chapter I will focus on the nature and costs of the conflicts
facing physicians who serve as public gatekeepers to medical
resources while trying to maintain "a commitment to
undominated. equality’ among’ all jparticipants "[Fleck,

1990a:249].

Not every rationing decision can be made at a distance;
some require the perspective of the bedside to properly frame
the choices that need to be made and evaluate the relative
advantages which different options provide. The gatekeeper, if
adequately informed of both the chronic demands placed on the

medical resources generally and the particular episodic

151

152
demands of individual patients, can serve both.sets.of demands
responsibly by making clear to the respective parties two
points. First, the payer(s) must understand the scope of the
resources needed to provide adequate amounts of the needed
services, and second, the patients must understand.the need to
conserve resources wherever possible, including some instances
of foregoing personally beneficial care. It is one thing to
require medical care gatekeepers to mention these points in
the context of discussions about health care in general. It
is quite another to require of the gatekeeper that the payers
and patients be made to understand and accept those limits in

the relevant contexts.

As the social world both changes and is changed by the
events which comprise it, including those of professional
medicine, there usually follows a change in the way physicians
perceive themselves and are perceived by the members of
society, both individually and collectively [Starr, 1982]. It
is not surprising then that the relationship between doctors
and their' patients as 'well as the relationship between
organized medicine and the public each evolves over time in
response to changes which occur in various relevant domains,
e.g., medical research, national economy, social politics,

medical jurisprudence, etc.

153

ine Qeiinition of Medical Gatekeeping

As briefly discussed in Chapter One, the only way a
rationing mechanism for medical care can work effectively is
if someone at the direct patient care level makes one of
several crucial decisions: not to admit a particular person
seeking medical attention; to admit a person conditionally,
depending on the results of one or more tests; or to admit a
person unconditionally and to direct him or her along one
particular treatment path rather than another. In the event
the initial decision is not to admit the person seeking
treatment, the denial of treatment, if made by a physician,
will significantly affect that particular physician-patient
relationship regardless of the nature or length of its
historyx A couple of examples will help illustrate the nature
of some of the problems associated. with this difficult

situation.

In some managed care plans a physician is not authorized
to refer a patient to specialty clinics for weight management,
pain control, alcoholism, etc. and must utilize hospital
outpatient clinics staffed by social workers because they are
considerably less expensive. If the physician believes that
only the more experienced care available at the specialty
clinic is likely to be effective for a particular patient her
only option is to share that belief with her patient and

explain that the patient's medical coverage does not include

154
such treatment. This forces the physician to admit that, in
effect, effective treatment is available locally but our
(i.e., the patient's and physician's) medical care program
does not include it as a benefit. If you want it, you will
have to pay for it with discretionary, after tax dollars. For
many persons among the middle class and for all of the poor,
this effectively precludes the patient from receiving the
treatment”. Recall also the example from Chapter One of the
physicians who play off the "hot potato" of rationing among
each other in a managed care program. Such a situation puts
the tensions between gatekeeping and patient advocacy in a
slightly different domain, but the moral tension remains

essentially the same.

These sorts of cases are by no means unusual and they may
occur under some rigid rationing mechanisms, leaving physician
gatekeepers saddled with their internal conflicts between
patient advocacy and social justice. Such cases will likely
occur unless one of three alternatives is adopted: (1) we
refuse to explicitly and visibly ration medical care and
continue the status quo; (ii) we redefine physicians'
professional obligations--away from patient advocacy--in light
of the need to ration, or; (iii) we come to understand and
accept the need to ration generally, and to insist on

effective and compassionate gatekeepers. If we as a society

 

” I owe this example to Jeffrey Sussman, M.D.

155
believe the third option is morally preferable, bringing it
about will require a recasting of what many believe is the

proper role of physicians in contemporary society.

The need for physicians to function as gatekeepers is a
relatively new development, and many physicians are having a
hard time accepting this role, believing it to‘be.antithetical
to their traditional self-image as caregivers to patients.
Other physicians, particularly the most recently trained, are
more accepting of this role, perhaps out of recognition that
in increasing numbers physicians are becoming employees—~and
therefore secondary players rather than directors or managers-
-of the nearly seven hundred billion dollar business of
medical care. By perceiving their professional positions more
as those of employees than independent operators or directors,
more recently trained (and therefore typically younger)
physicians may be better insulated psychologically from the
tensions and trauma associated.with the need.to»deny access to
care in some cases. They are, in acting as keepers of the
gate, only doing what they are told, and trying to keep their

jobs.

The.belief that.physicians have heretofore not faced.this
ethical choice, not had to ration medical care in the sense of
trading off meeting patients' needs with justly and

efficiently allocating' medical resources. is a :naive and

156
erroneous belief. The past decade and more has witnessed a
clear shift in the structure, process and outcome of medical
care away from individual physician control to that of
organizational control [Relman, 1980] and it is alarming to
many' physicians [Shortell, 1986; Relman, 1987; Burchell,

1988].

But this challenge to individual physician's professional
ethics and sense of autonomy has in some ways always been a
part of medical decision making. When a patient (or his
family) requests. a costly' treatment of debatable or no
utility, ethical concerns arise in the minds of morally
reflective physicians concerning the fair distribution of
resources. These concerns cannot remain detached from the
ethics of individual.patient care [Danis and.Churchill, 1991].
Whenever a physician refuses to provide or authorize futile
medical treatment to a patient, her actions reflect a decision
to make certain tradeoffs and to accept the consequences of
that decision. The defense that providing futile or debatably
beneficial treatment is unprofessional because it is
inappropriate is motivated by the belief that one of the
requirements of professional medical care is to refrain from
wasting resources, even if the person(s) requesting them can
afford to pay for them. The appeal here is to a sense of
social responsibility which serves as one of the constraints

on patient advocacy and always has [Jecker, 1990]. In

157
accepting a professional obligation to treat the ill,
physicians do not specify who they are willing to have as
their patients in advance. In that respect they--and society
in general--understand their professional commitments are to
society at large, though they also recognize that all their
patients will be individuals. "[This implicit] professional
promise literally alters the moral landscape" [Jecker,

1990:1351.

Eddy has described the conflict which leads to
psychological stresses associated with making the tradeoff
decisions required by rationing in the following way.

The subject of the real debate is defined by six

elements: (1) explicitly, as a matter of policy,

(2) having payers (3) withhold payment (4) from

people who otherwise have coverage (5) from

standard services that have demonstrated benefit

(6) because of their cost [Eddy, 1991:106].

The implicit dimensions of justice or fairness in Eddy's
remark concern the authority of the policy makers to deny
payment for beneficial services and the endorsement of the
providers and recipients for that policy. From the brief
quote we cannot tell whether the authority is legitimate or

the endorsements universal and sincere, but the implication

that they are could reasonably be construed to be doubtful.

In his book Stron Medic‘ne, Menzel has also discussed
this issue and argues that of all the proposed resolutions he

favors what he terms "prior consent" [Menzel, 1990]. The idea

158
is that as part of being guaranteed access to an adequate
minimum of health care, each person will be given an
opportunity (once a year and before they become ill) to choose
the nature of their fair "ration" of health care coverage.
The choice is to accept coverage either as a contractual
guarantee of direct medical treatment for a predetermined
basic level of health services if he or she becomes ill, or as
a cash payment of an equivalent amount in dollars (of
insurance coverage, not actual treatment expenditures) to be

used for other purposes as determined by the individual.

As a general approach to the problem, Menzel's analysis
is helpful and his suggestion for contractual prior consent is
to a certain degree compelling. When the details get fleshed
out more fully however, it is apparent that Menzel puts a
rather strong and particular libertarian twist on the reasons
supporting prior consent. His basis for supporting this
option is the hesitation he feels about presuming to know'what
is in the best interests of all persons; some of the poor may
well judge that from their perspective the cash equivalent of
medical treatment can.be better spent meeting costs other than
health care coverage. Menzel rejects seeking social
egalitarianism in medical care through rationing since he
believes that ‘whatever level of rationed care might be
selected democratically (i.e., by the numerically larger and

politically active middle class) will likely be deemed to be

159
excessive by the poor; The rational poor person would be more
likely to prefer a leaner health care package if they could

get the difference in cash.

However, if individual persons do»select the:cash.option,
there is a risk to them of not having sufficient resources to
pay for their medical care in the event of (future) health
care need. Depending on the relative rigidity of the
rationing mechanisms operating, the medically needy poor may
well be denied care as a result. On Menzel's view such a
denial of treatment may be justified at the level of macro-
allocation.by referring to the individual's "prior consent" to
be denied treatment as evidenced by their free decision to
take the cash equivalent rather than the insurance coverage
for later medical care. He writes,

Of all the proposed resolutions of the original

conflict, [access to care ye cost containment]

prior consent by far gives us the greatest
confidence and ability to stick to our rationing
guns in this kind of "public patient" situation.

If we understand its selective justification of

hard efficiency, we should be able to look patients

in the eye with little moral hesitation. It will

be hard but hardly disloyal. Rationing is always

distasteful medicine to swallow, but it may be just

what we, as well as the doctor ordered [Menzel,
1990:18].

This perspective, though perhaps baldly rational in its
detached, programmatic approach, is nonetheless coldly
unfeeling toward the unlucky poor persons who, after

deliberating responsibly, decide to take the cash equivalent

160
of the medical treatment coverage for use in some other way,
perhaps to augment a family member's medical coverage during
the course of a particular illness. Moreover, this approach
to rationing decisions ignores the morally important personal
relationships which often exist between patients and their
physicians. .Adherence to such. a jpurely' mechanical and
bureaucratically administered rationing method fails to
account for the real life tensions and mutual desires for
effective medical care that are a substantive part of

individual physician-patient relationships.

Menzel's approach requires that physicians stand idly by
and refrain from providing materially available medical care
to some persons seeking treatment. Such a system of universal
health care "coverage" will require a huge change in the way
we think about what constitutes morally acceptable medical
care [Callahan, 1990; Eddy, 1991; Fried, 1976] . British
physicians have faced this problem for many years under the
economic limitations imposed by the National Health Service.
In response to facing these choices, Aaron and Schwartz note
that

Wherever possible, British doctors recast a problem

of resource scarcity into medical terms. They have

developed standards of care that incorporate

economic reality into medical judgments ...

[according to a British cancer expert] the key to

turning down the patient is not to get eyeball to

eyeball with him because if you do there is no way

you can actually say no [Aaron and Schwartz,
1984:54,56].

161

To be fair to Menzel, his discussion is conducted at the
level of macro-allocation and provides little attention to the
tough and complex emotional consequences of implementing macro
level decisions at the micro level. Menzel's perspective is
not without social or political precedent however. It is
similar to the perspectives of those who oppose other forms of
conscripted participation in programs of social assistance
such as Social Security, a required minimum wage and
fluoridation. Our society has decided these programs are
sufficiently basic and beneficial that we provide them with
conscripted tax revenues over the objections of the more

libertarian-minded objectors.

A good and just rationing system ought work effectively
at all three levels of care: macro, mid-level and micro-
allocation. Insofar as any rationing mechanism.has the micro-
level effect just identified it is unlikely to be embraced by
physicianS'who, in trying to remain faithful patient advocates
and avoid this outcome, may very well be tempted to "work" or
"game" the system; manipulation that. may’ be technically
allowable, yet undermines the procedural fairness of the
program's design by taking advantage of loopholes and other
exceptions out of the contexts in which they were intended to
operate. Consequently, such a rationing program is unlikely
to function effectively and therefore will not serve its

intended purpose of assuring social justice through

162

responsible and fair medical care gatekeeping.

The Personal Dimensions in Medical Care

The practice of medicine in contemporary American society

 

is markedly different in several ways from what many senior
physicians who are now approaching retirement initially
practiced, and that is to be expected over the course of four
and a half decades. But in many other ways the practice of
medicine is essentially unchanged. The personal dimension of
thejphysician-patient relationship has remained fundamentally
the same throughout the various transitions in the history of
health care. This has been and continues to be regarded as
the single most important aspect of the profession of
medicine. Evidence for this is apparent in the fact that the
personal interactions between physicians and their patients
have always been and continue to be taught as the fundamental
and primary locus of medical care. No matter how much our
social dynamics change it is reassuring to believe that when
you go to the doctor you.will be treated with respect, concern
and genuine personal care, as well as competence. We expect
nothing less from our physician in whom we entrust our most
private complaints, habits and fears. To do otherwise is to
engage not in personal medical care but in merely generic

physical repair.

We might ask how such.a personal dimension to health care

163
manages to find root and flourish in the complicated and
intertwined complex of medical consultation, referral,
diagnosis, treatment and care relationships. Medical students
in the beginning of their training learn pretty much the same
descriptive, factual information about human anatomy,
physiology and pathology, etc. and practice pretty much the
same techniques. But once they’ begin their individual
practices or advanced training in residencies their personal
abilities and individual styles increasingly influence the
kind of medical care they practice. Repeated interaction with
"their" patients over time molds and directs their
professional work and allows them to do the good of medical
care for which they trained. Though students from the same
medical school class are influenced by the same teachers, that
influence often affects them inrdifferent individual ways. .As
a result, no two medical practitioners function in exactly the
same way, with each developing his or her own professional

strengths and weaknesses.

Once engaged in a professional practice after completing
their formal training, physicians soon learn that the nature
of the interpersonal relationships they develop with their
patients will be often limited by external forces and
influences, at times in contrast to their personal desires.
Many of these influences will be economic in nature, e.g. high

co-pay and deductible charges or services outright excluded

164
from their patient's medical insurance coverage. While the
physician's personal and professional predilections may be
strongly oriented toward patient advocacy, they will
unavoidably conflict with the larger corporate perspective of
cost containment, a perspective that is embodied in formal
medical service rationing programs which depend on coverage

exclusions.

The reason the perspectives of patient advocacy and
rationing come into conflict are easily identified. First,
arguments favoring cost containment which are persuasive at
the aggregate, national level tend to fail when applied at the
individual patient care level [Blank, 1988a]. Factors such as
differences in patient demographics, local practice patterns
and community resources vary with sufficient range to render
a national standard of personal care unattainable. Second,
attempts to respond appropriately to patients' virtually
unlimited claims to health care must be tempered by the
physician's knowledge of limited medical resources. This pits
the individual physician against society whenever she utilizes
resources locally, and against her individual patients when
she is required to deny care in order to save resources for
some other patients, under some other physician's care, or her

own future patients (patients requiring care in the future).

When examined this way it is apparent that while the

165
typical physician-patient relationship is founded on mutual
trust and promise-keeping, what Fried calls fidelity [Fried,
1974], but is forced to exist.within a fiscally driven impetus
toward resource conservation. 'The result is two 'moral
frameworks operating simultaneously; a narrowly conceived
duty-based ethics which emphasizes the patient advocacy aspect
of the physician-patient relationship, and a broader based
conception of social justice with roots in both utilitarianism
and equity and which provides fiscal priority to medical
service rationing. Though these frameworks are mutually
compatible in many instances they come int0>direct conflict in
the areas of marginally beneficial care, and clearly
beneficial but costly care for comparatively rare illnesses.
Physicians who serve as gatekeepers are therefore faced with
having to appeal to one or the other in trying to justify the

decisions they make.

The Rationing of Patient Advoeacy

Angell and the others who oppose physicians' rationing
medical care services fail to recognize the various competing
values which are inherent in the delivery of good health care
by physicians. In particular they fail to recognize the need
to ration their own professional time among different
patients, and their non-professional time among the other
aspects of their personal and political lives [Morreim, 1989;

Reitemeier and Brody, 1988]. Levinsky takes a different tack

166
from Angell in arguing for the same emphasis on patient
advocacy when he suggests " (i)t is society, not the individual
practitioner, that must make the decision to limit the
availability of effective but expensive types of medical care"
[Levinsky, 1984:1574] . Pellegrino has similarly argued, "Are
not the criteria for when and how to ration the responsibility
of all of us?... The criteria for rationing and the principle
of justice to be followed should rest with society, not with

physicians" [Pellegrino, 1988:261].

There is some degree of cogency to each of these
positions but a closer analysis reveals that these suggestions
are either short-sighted or unrealistic. The attempts by
Levinsky, Pellegrino and others to pass on to the larger
society the responsibility of sometimes saying "No" to
patients seeking medical care are short-sighted in the sense
that they fail to adequately perceive the complex
interconnections which access to care problems have with
medical decision making generally. A brief reflection shows
that for a physician to deny medical treatment to a patient at
one point in time may well result in that patient's developing
a more complicated and serious condition at a later time.
Because of the number of patient-specific variables which
contribute to the overall medical condition of a patient, it
is not possible for an impersonal set of criteria administered

from a bureaucratic distance to adequately take account of

167
this problem. There must be some room made for patient-
specific and individualized professional medical judgments as
to whether the otherwise relevant rationing criteria ought be

waived, given that patient's current condition.

To prohibit such judgments and rely instead on rigid
rationing rules will result in two significant kinds of harms.
Patients who do not initially meet the rationing criteria for
access to care but later develop sufficient severity in
symptoms and dysfunction to qualify will be harmed by the
delay in getting care and the associated suffering they were
forced to endure. Physicians caring for patients initially
turned away and later admitted when their conditions worsened
also will be harmed by the internal moral tension arising from
being forced to act in that way, especially if their
professional judgments are that early treatment will minimize
the suffering to the patient, expenditures to the payer and

hardheartedness to the physician.

Physicians who make medical decisions that are both
politically and professionally responsible recognize the
larger context in which their actions have effects. Their
decisions to treat or not to treat a particular patient
encompass more than just the patient, the physician and a
single, momentary and intervention-specific decision. They

also include the future implications of that decision;

168
implications for the patient, the physician and the
expenditure of resources needed to properly care for the
patient, all things considered. Physicians must be empowered
to act with at least some professional autonomy concerning
access to care for their patients, recognizing that such
autonomy can only exist within carefully constructed
guidelines and restrictions. The difficulty will be
establishing guidelines such that the denials of access to
treatment are both fair, and minimally harmful. The harms to
be avoided include: paying for unnecessary or only minimally
beneficial treatment; denying patients significantly
beneficial treatment; and causing in physician gatekeepers
internal moral tensions as a result of making the denials,
especially when they are likely to see and be asked to treat

the same patients at a later time.

Society cannot reasonably be expected to anticipate all
the possible combinations of factors which play a part in
individual medical decisions. As a result, contra Pellegrino,
it is unreasonable to suggest that society, however
represented, is capable of writing a book with sufficiently
detailed, just and efficient rationing "recipes" which
individual practitioners need only consult and follow. While
some generalizations can certainly be made (e.g., all simple
bone fractures will be treated, and no CAT scans will be

provided for tension headaches), they often will

169
underdetermine the content of the necessary rationing

protocols and program as a whole.

In the provision of medical care, especially primary
care, both competence and efficiency often. require
individualized medical discriminations based on particular
patient differences. Each patient's medical needs occur as
the result of unique combinations of biopsychosocial
characteristics and can be best understood and evaluated over
repeated interactions with the same physician. Given the
complexity of the forms in which different patients experience
illness, to attempt to design of a :rationing' procedure
consisting of specific treatment provisions and denial
indicators that are universally effective and fair is
unrealistic and coldly unfeeling toward the persons who are

the patients and the physicians.

The denial of health care to medically needy patients is
more than a sensitive and difficult area. It touches on the
very essence of the moral obligations inherent in the
physician-patient relationship, and especially for those
practitioners who strive for professional integrity which has
significant purchase in their lives. A number of authors have
pointed to the unique and individualized dimensions of the
physician-patient relationship, especially as they emerge over

time and repeated interactions as the proper focus of the

170
moral obligations which apply to that relationship. Cassell
notes

The fundamental fact of individuals is not sameness
but particularity ... individual differences from
the subcellular level to the family have a profound
effect on the diagnosis, treatment and outcome of
an illness [Cassell, 1981:78].

Similarly Fried argues

The integrity of the person as the center of moral
choice and judgment requires that we find room for
the inescapably particular in personality, that we
avoid disintegrating universality...The special
involvement we bear for our projects is an
appropriate recognition of our special involvement
in those projects [Fried, 1980:34].

In discussing the individual physician-patient relationship as
narrative, Brody identifies two different ethics which may be
used to characterize two distinct sorts of medical care
settings.

Let us assume, for purposes of argument, that the
tertiary care setting is characterized more by a
decisional ethic, whereas the primary care setting
is characterized more by a relational ethic. This
means that the approach to ethics in the intensive
care unit tends to be that among people who have no
prior history with each other, who have to carry
out discrete and generally predictable actions over
a limited time span, and who then will part company
for the future. In contrast, the approach to
ethics in the office of the primary care physician
tends to be that of two or more parties who plan to
engage in a long-term relationship, the
possibilities of which for the future can only be
guessed at vaguely, and for whom the most
particular behaviors will be much less important
than the maintenance of that relationship [Brody,
1987:172].

Brody's insight here points to a real difference in how

‘medical-moral judgments are likely to be understood.in the two

171
environments. He continues,

Judgments of patient autonomy, within the

decisional ethic, are thus likely to assume an all-

or-none character. In the relational ethic,
diminished autonomy much more often represents one
point along a time continuum, and a number of
maneuvers on the physician's part may effectively

alter this state of affairs [Brody, 1987:173].

When examining policy proposals for specific medical
rationing programs, the informed perspectives of physicians
are necessary in order to understand and appreciate the full
range of possible and likely consequences of the rationing,
including those to patients, to physician-patient
relationships, and to medical research and development. If
physicians think of involvement.in the health.care of patients
as their professional "projects" in Fried's sense then the
respect owed to the dignity of their patients would seem to
require that individual physicians, motivated by requirements
of professional integrity, must resist having to provide
medical care solely according to a rigid rationing formula;
there must be some allowances made for individual professional
discretion in providing health care, and perhaps even more so
in its denial. This will especially be true if the instances
of denial are interspersed with instances of treatment, as

should be expected in those physician-patient relationships

that comprise a relational ethic in Brody's sense.

Any plausible rationing scheme will have to make room for

some range of individualized decisions concerning access to

172
treatment and the exercise of professional judgmentm Since‘we
have always allowed and expected this element of judgment in
other important areas16 it is by no means a foreign concept
to incorporate in designing a medical care rationing program.
There is only so much that a mechanical ranking of statistical
information about symptoms, laboratory results and treatment
outcome averages can do in determining who should be admitted
to the medical treatment and what specific path they ought to
follow. At a certain point there is no substitute for

informed, reasoned and individualized medical judgment.

Since there are over 600,000 physicians and 250 million
(potential) patients in the U.S., no rationing formula can
possibly be constructed which is capable of accommodating the
full set of considerations required by the moral principle of
individualized respect for persons, where "persons" is
understood to refer to individual human beings and not
theoretic instantiations of statistical collectives. I note
the large number of practicing physicians for another reason;
it illustrates the scope of the problem these conflicts
entail. The conflict between the two duties of promoting
respect for persons through patient advocacy and promoting
social justice through participating in rationing touches

virtually every' physician involved. in. patient care, but

 

1'5 For example, college admission committees, (see Chapter
One) and the U.S. judicial system.

173

especially those who work in primary care.

These conflicts will serve to further compoundalready
stressful aspects of the physician's profession. David
Hilfiker, a primary care physician reflects on the personal
psychological effects of trying to treat patients who are ill
amidst the uncontrollable interruptions of the daily schedule;

The. emotional distancing' that. may initially' be
necessary to medical evaluation comes to dominate
the physician-patient relationship. We allow
ourselves to accept certain standards of efficiency
and productivity which militate against caring for
our patients ... Like many practicing physicians, I
entered medicine out of a desire to be of service
to people. Whatever other motives I may have had,
my root ambition was to help, to respond to others'
needs. What I failed to realize, however, was that
the very nature of my work as a doctor would push
me continually into the position of limiting the
help I would give, of ignoring the needs of others.
One of the pressing realities of my job was that I
repeatedly found myself contradicting my own inner
desire to be of service, a conflict that created in
me a deep sense of guilt (my emphasis) [Hilfiker,
1987:14,32].

As Hilfiker points out, the effects of these stresses are
alarming: The U.S. loses the equivalent of seven medical
school graduating classes each year to drug addiction,
alcoholism and suicide [Hilfiker, 1987]. Add to that effect
the inestimable stress generated by the need and/or
requirement to ration medical care to one's patients for the
good of society and we begin to see the destructive potential
such a policy carries for physician-patient relationships. We
may well ask what sorts of individuals in the future would be

attracted to a profession which carried such conflicts and

174

stresses as an integral part of daily functioning.

The best way to find a resolution to this series of
conflicts both between physicians and their patients and
within physicians individually, is to seek. a system. of
interpreting medical treatment rationing limits (both in terms
of what is provided and what is denied) that is effective,
universally applicable, fair and further contributes to the
fairness of the overall medical treatment system. In
addition, there is a programmatic need for an accommodation of
individual gatekeeper judgments which avoids incentives for

serving the self interests of either physicians or patients.

One possible approach to finding such a rationing system
is to re-examine the meaning of patient advocacy in light of
the two concepts I have discussed throughout this
dissertation: physician integrity and medical gatekeeping.
The former is important for it brings to our understanding of
patient advocacy an awareness of multiple professional and
political obligations of physicians. The latter is important
for its focus on the need for individualized and clinically
informed medical care rationing decisions. If we can find and
manage to integrate the right arrangements of social, moral,
medical, economic and political values and principles in
making medical rationing decisions, the process of generating

a national rationing program that is both explicit and public

175
will be much less stressful and more readily accepted by the
public who will constitute its patients and by the physicians

who will be charged with its daily implementation.

Given the complexity of this challenge it is clear that
such an arrangement cannot be prescribed in advance. It must
emerge over time as the evolved product of a sustained attempt
to secure universal access to rationed medical services from
health care providers with professional (individual and
collective) and political integrity. Just as the Oregon
Health Decisions Movement is conceived by its participants as
only a first step in moving toward a more just system of
providing health care, we as a nation need to immediately
begin a public dialogue to move toward solving the problems of
distributive justice in providing medical services. In the
next chapter I outline a four step decision process for
beginning such a dialogue in a useful and well informed way.
It is by no means a recipe for solving the problems of access
and cost containment. It is to be understood instead as a
suggestion for generating the momentum of sustained public
dialogue, a first step on what will surely be a very long

journey toward greater justice in health care.

CHAPTER FIVE: A FOUR STEP COMPROHISE PROPOSAL

In this chapter I suggest a series of four steps aimed at
constructing a national health care insurance program (NHIP)
which is fair, guarantees universal access to a basic package
of services, is affordable to the public, and does not present
physicians with the starkly conflicting moral obligations of
the current system. Such a NHIP is motivated by the twin
goals of securing fair equality of opportunity through access
to an adequate minimum. package of medical services for
patients and what will be for many persons (both physicians
and patients) alternatively an integrity preserving compromise
or'a synthesis between the obligations of patient advocacy and

medical gatekeeping.

A NHIP will be a compromise rather than a synthesis for
those persons who, in agreeing to it, still do not feel the
matter is "fully settled; [for them] there is no closure, no
final harmony" [Benjamin, 1990;71. Some such individuals may
still prefer that physicians act as fully committed advocates
for their patients independent of considerations of macro,
mid-level and micro allocation which require rationing and
gatekeeping (e.g. Levinsky, Angell, Pellegrino, Veatch).
Alternatively, because of those same considerations other
persons may wish that social justice in health care be
promoted and maintained by physicians acting as gatekeepers

regardless of considerations of individual patient advocacy.

176

177

However, some persons holding these positions may
acknowledge that such physician--patient relationships are not
possible to sustain in a just society committed to patient
advocacy but constrained by limited medical resources, and
further acknowledge that a decision must soon be made to avoid
even greater injustice and suffering. They may then agree to
a middle position of fair and universal rationing and locally
directed gatekeeping which manages to split the difference
between pure individual patient advocacy and complete social
utility. Such an agreement is a compromise which, though it
may not fully be acceptable to them as the best solution under
ideal conditions, it is nonetheless.deemed.the best outcome to

the conflict, all things considered.

Alternatively, a NHIP might be considered a synthesis
rather than a compromise if the patients and/or physicians
affected felt that, all things considered, such a program is
truly preferable to their original position either of single-
minded patient advocacy or of strictly utilitarian health
care. As Benjamin uses the term synthesis is an outcome
characterized as a middle-of—the-road position that is
mutually preferred to the original positions by the
disagreeing parties.

An outcome is not a compromise when each of the

parties comes to regard its initial position as

mistaken, abandons it, and embraces the same third
position, which both now believe to be superior

[Benjamin, 1990;35].

178

Such an event can come about if persons develop or find
"new information, insights, arguments or understanding"
[Benjamin, 1990;33] sufficient to convince them to revise or
abandon their previously held position concerning the most
just system of health care financing and delivery. If that
new information, etc. draws on aspects of their own and
opponent's original positions but is mutually deemed superior
to either, the new outcome will be a synthesis. Thus, a NHIP
such as I describe below will be understood as either a
compromise or a synthesis, depending on how deeply committed
one is to the cogency of one's original position under ideal
conditions, and on reflection, how persuasive the arguments
supporting the middle position of fair and universal access to
locally rationed medical care are deemed to be, all things

considered.

A National Health Insurance Program

A national health insurance program is a system of
securing access to and financing for health care services for
all residents of the United States. For purposes of this
discussion the details of such a program need not be spelled
out as those details will vary with different conceptions of
it, e.g. Menzel's and Englehardt's libertarian approaches,
Daniels' Rawlsian approach, etc., [Englehardt, 1984; Menzel,
1983, 1990; Daniels', 1981, 1985]. The best conception will be

hammered out during the fourth step process described below.

179
For these purposes all that is needed is to be clear on the
general concept of a national health insurance program and
that the program will include at a minimum the following

features.

(a) A public and explicit specification of covered health care
services.

Services not covered by the NHIP would be available only by
private arrangements, though additional supplemental insurance
programs may be available for some services. Federal
legislation would be needed prohibiting insurance programs
offering duplicate coverage of services provided under the
NHIP. This is necessary to avoid allowing a "buy out" of the
NHIP, and creating a two-tiered system of health care for the

same services.

(b) A public and explicit criteria for eligibility in the
program. Eligibility for coverage may be limited to any one
or combination of several groups: resident citizens;
nonresident citizens (health care received in other countries
would be reciprocally paid by the U.S. payer); permanent
resident aliens; foreign students enrolled in U.S.
institutions; foreign nationals employed in the U.S., foreign
visitors, etc. My suggestion is to cover at least all
resident U.S. citizens and I would support expanding that

group to include foreign visitors, provided a reciprocal

180
coverage was provided to ‘visiting U.S. citizens by ‘the

respective countries.

(c) A requirement that service providers accept all NHIP
enrollees and NHIP schedules as payment in full for all
covered services.

These two requirements make the benefits of the NHIP equally
accessible to all eligible persons. "Provider shopping" by
consumers would be based on quality of service rather than

costs, leading to an overall increase in quality of services.

(d) An explicit fee collection system to finance program
expenditures. Premium payments for NHIP services may be
collected directly through general tax revenues. Additional
funds may include fees charged to non-taxpaying beneficiaries
of health care services, e.g. foreign nationals. There are
many methods which may be used to set the tax and fee
schedules, but a means-tested, off-budget system would
probably be the most fair and fiscally secure system, as well

as the most politically feasible.

Adoption of a NHIP system with these minimum features is
designed to assure equal access to specified health care
services for all eligible persons, while providing a mechanism
for controlling global expenditures by restricting the type of

services covered. The chief difficulties with designing and

181
implementing such a program reside in the process and outcome
of controlling expenditures through limiting services.
Whatever operational form the details of the NHIP finally
take, there must be public and explicit criteria for saying
"No" to some requests for medical services. Furthermore,
gatekeepers must be empowered to judge the appropriateness of
denials of medical treatment and/or attention, and to enforce

them.

Setting Conditions of Operation

Before determining which services are to be provided
and which excluded from the NHIP, several hard conditions of
operation must be established. The first condition is an
annual, off-budget global expenditure resource. This total
resource amount will have to be somewhat arbitrary, at least
initially, since the relevant concept of "need" in'the'context
of health care is vague and open to interpretation. As the
NHIP program managers gain operational experience they will be
better prepared to specify'what this expenditure total.must.be

to meet the nation's aggregate medical needs.

Since the transition to a NHIP will take some time while
costs continue to rise and will involve the addition of tens
of millions of persons into the total number of eligible
beneficiaries, it is reasonable to project an initial global

expenditure budget somewhat higher than the current total of

182
between eleven and twelve percent of the gross national
product. Most projections for the year 2000 place total
health care expenditures around fifteen percent of the GNP,
and that seems a reasonable initial capitation for the NHIP's
first years of operation. Adjustments to the global budget
can. be :made: as additional empirical evidence concerning

unforseen expenses and savings become available.

The second hard condition is the political structure and
mechanism for adjusting the NHIP in the future. There can be
no doubt that the initial NHIP will require ongoing
adjustments to better meet the emerging medical care needs of
the beneficiaries. Given that fact, a plan for what control
physician-gatekeepers, the public, and state and federal
politicians will have in the future must be specified to
enable appropriate long range planning. Parties to the
political negotiation of which services ought be included in
the initial NHIP will be aided by the knowledge of how future

negotiations and decisions will be structured and timed.

A Four Step Propoeei

My proposal can be described in four broad steps. The
first is for individual physicians to initiate discussions
within their own specialties and local medical societies
concerning the various medical service components of the NHIP,

given the initial global budget parameters specified. The

183
second step is the formation of a multi-disciplinary
Commission which will review the suggested service component
arrangements arising from different medical specialties and
societies and then draft an initial NHIP proposal. This
proposal will include the basic package of goods and services
to be provided to all eligible beneficiaries. The third step
is to conduct public community discussions of the Commission's
proposal and, through a process of referendums and public
meetings, collect general suggestions about how to adjust the
proposed program to better reflect the values, desires and
perceived needs of the general public» At the fourth step the
Commission's recommendations are forwarded to Congress along
with summary narrative comments reflecting the public's
considered opinions of the Commission's proposal. In
Washington D.C. the information will be considered for
discussion and debate until a final NHIPjproduct emerges*which
contains and reflects the considered judgments of the
principal players; practitioners, observers and analysts of
medical care systems, the public, and Congress. The final
version of the NHIP should be ratified by the public, and the
best way to do that may be left to the elected politicians to

determine.

Once the basic package of services is established and
universal access to those services guaranteed, the conflict

between the professional and political obligations facing

184
physicians can be expressed in the form of the following
question. How can a physician serve as the principal advocate
for her individual patient's medical needs while also serving
as the gatekeeper, which may include denying access to medical
resources for those same patients? ‘To answer this question we
must first return to the issue raised in Chapter Two

concerning the multiple and complex roles of physicians.

Physicians as Citizens

Physicians as persons occupy several roles in the course
of their daily activities only one of which is involved with
patient care. Other roles include that of family member,
neighbor and citizen and consist.of the activities.we normally
associate with those role descriptions. My analysis of
integrity in Chapter Two shows why persons can never possess
integrity in only part of their lives; to have integrity an
individual must have an integrated life, the parts of which
are connected by common values and principles; professional,
personal, and political. In Chapter Three I further argued
that neither an exclusively duty-based focus on individual
patient advocacy nor an exclusively egalitarian-utilitarian
focus on equitable access and cost containment through
rationing are adequate to integrate the multiple roles
physicians must play in the provision of medical care. Some
middle ground between these moral perspectives must be found

that can preserve the possibility of adherence to professional

185
values in medical practice, and still enable practitioners to
lead personally, professionally and politically coherent,
integrated lives. Without the former, medicine will be unable
to sustain the principled sense of its professional identity
and without the latter, a physician's life viewed as a whole

life will be defective.

A third moral perspective is needed from which physicians
and others can view and understand in a more comprehensive way
the conflicts between the obligations of being a patient
advocate and a member of a just society. One plausible
candidate has been evolving in the literature over the past
two decades; the non-utilitarian theory of justice developed
by Rawls [Rawls, 1971] and more fully articulated in the
context of health care by Daniels [Daniels, 1985] and, with a
more libertarian twist, Menzel [Menzel, 1990]. These
theoretic suggestions are significant improvements in our
understanding of justice generally (Rawls) and for the
purposes of health care rationing (Daniels and Menzel), over
either the utilitarian or duty based conceptions. Daniels and
Menzel each sketch paths toward the general.goals of providing
health care by developing a sense of how distributive justice
ought to function under conditions of both relative and
absolute scarcity and increasing demands for the scarce

resources .

186

Justice is a word with so many meanings in so many
contexts that when.considered in the abstract it easily eludes
our understanding. A recent book by Robert Solomon has
focused on this difficulty and his thesis is that

Justice is first of all a function of personal

character, a matter of ordinary, everyday feeling

rather than grand theory... justice is not a

utopian plan for the perfect society but a personal

sense of individual and collective fellow-feeling

and responsibility. It is not an abstract

theoretical ideal but a constellation of feelings

and a perfectly ordinary virtue of character ... We

are participants in the social world, not just

observers of it, and the emotions that make up our

sense of justice cannot be just the sensibilities

of the benign spectator. Justice also involves

envy, resentment and vengeance, and all the other

passions that we feel when we are deprived or
cheated. In other words, true human justice
involves real human passions, not just a special

saintly distillation of them [Solomon, 1990:3-4].

I believe Solomon is basically correct and will add that
the political integrity I have described is very similar to
the sense of justice Solomon notes in the passage quoted. It
would do little good to urge physicians to shoulder the
responsibility of generating the initial discussions aimed at
producing a first draft design for a NHIP if the standard of
measurement by which their efforts would be evaluated is that
of perfect justice. Rather, I think there is much greater
promise of success that is both fair enough for all
beneficiaries and acceptable enough for all physicians if we
aim instead for a sense of justice that is perhaps not
perfectly just in the sense that all conflicts can be resolved

without remainder, but rather one that is "just enough"

187

[Fleck, 1990b].

Social justice, which essentially functions in this
context as distributive justice, presupposes scarcity or
limits. Just resolutions to issues of distribution of goods
and services always involve loss of some sort or other. If
there were enough of everything for everyone there would be no
need for a concept of justice in this sense. The question
from a moral point of view is how best to apportion the
losses. But health services are not the only scarce things of
value that ought be more justly distributed in the United
States. So also are public education, housing, transportation
and a host of other goods and services. Given these other
needs or spheres for distributive justice, perhaps a single,
comprehensive system of justice is beyond our current
collective political and social capabilities. We may be able,
however, to carve out enough of a sense of justice to work
satisfactorily in the area of health care while we continue to

seek justice in those other areas as well.

Michael Walzer writes of individual "spheres of justice"
where related but somewhat different senses of justice can be
used with respect to different sorts of relationships and
their associated conflicts in different kinds of situations
[Walzer, 1983]. We need not have or even search for a single,

overarching and thoroughgoing conception of justice which

188
applies to all situations and forms of conflict resolution
equally. Given the complexity of the personal relationships
and.their conflicts in.the pluralistic democracy of the United
States, it is appropriate to envision something like a sphere
of justice which is intended to function only within the
limits of a NHIP, though that by its scope will be

significantly large in its own right.

Such a conception of justice will allow a NHIP to emerge
that may not reflect, for instance, the same commitment to
absolute equality which figures so prominently in the United
States Constitution. It may instead favor newborns or the
mentally and physically handicapped members of society,
allowing them greater access to health care resources than is
generally available to the rest of the population. At the
same time, though such a distributive scheme diverges from
absolute equality it may be more just in so doing by achieving
a greater balance of compensatory functioning than any

alternative rationing mechanism, all things considered.

Consistent with this literal inequality of treatment
however, can be an equal respect and concern for all patients
who seek access to the health care system. As discussed in
Chapter Three, age-related criteria for allocating health care
resources is not ageist because it applies to everyone equally

over the course of a life. So, too, equal respect and concern

189
must apply to all who seek medical attention, including those

who are denied access by the gatekeepers.

An Integrity-Preserving Compromise Betyeen Patient Advocacy

 

and Social Justice

If physicians provide a collective leadership role in
generating discussions of and preliminary constructs for a
NHIP, patient advocacy could occur at two levels; the bedside
where physicians could pursue the best treatment available
within the guidelines of the developed NHIP system, and the
level of macro-allocation where the initial design of the NHIP
system as a whole is developed. Since the design of the NHIP
is.conceived.as dynamic and.responsive to evolving perceptions
of social and medical needs, the conflict between the
physician's obligations of patient advocacy and social justice
would remain but would be attenuated somewhat by virtue of
both obligations being at least partially fulfilled.
Undiluted, uncompromising, individual. patient. advocacy' by
physician gatekeepers would be impossible due to the need to
construct a national program with its ineliminable fiscal
constraints and medical service tradeoffs. The patient
advocate role would remain a professional obligation of
physicians however, and they would to be expected to continue
to fulfill its Similarly, the physicians' individual and
collective political obligations to promote social justice

through enabling universal access to health care will be

190
accomplished principally through adherence to the NHIP rules
and using prudential judgment with respect to its guidelines

for individual treatment decisions.

This proposal may not be entirely satisfactory to many
physicians, and in that case some of the moral conflict would
remain. This sort of unease is typical of compromise
generally and of being fully connected humans with different
roles in different contexts [Benjamin, 1990]. Since neither
duty, viewed in a pure sense, can be met without betraying the
other, some compromise between them is necessary; The
attractiveness and moral cogency of such a compromise arises
from recognizing the practical impossibility of fulfilling the
moral duty to promote equality of opportunity through access

to health care alongside the obligation of patient advocacy.

If physicians in local and specialty medical societies
engage in honest and patient-centered discussions about the
component elements of a NHIP, internal medico-political
infighting will have to be resolved for useful and sensible
programmatic proposals to emerge. Failure to find a
professional and collegial consensus 'will serve only' to
alienate physicians from each other once the NHIP is finally
in place, much as what happens in some managed care plans (see
Chapters One pp. 30-31 and Three p. 107). If the public

erceives the h sicians' recommendations as servin the
P

191
physicians' own financial interests ahead of those of the
patient population as a whole, the public will likely conclude
that physicians by and large do not adhere to the principles
embodied in their rhetoric and professional oaths, and may
feel little need to respond to physicians' (perhaps
legitimate) cries for relief from regulatory oversight,
educational financial debt, malpractice :premiums, or
inadequate compensation rates. The objective of a physician
consensus suggesting the initial NHIP service components is
not to try to get everything physicians want, but to be able
to live both professionally and as members of a just society
with everything they get. In short, the consensus goal is
conceived as a first step in enabling physicians to more fully
integrate their lives within the dramatically changed
professional and social contexts in which they live, and the

internal moral tensions which arise from those conflicts.

Whv Not Start With the Patient-Public?

Some may suggest that discussion of a NHIP ought begin
with open public forums and not with individual interest
groups' discussions, if indeed such discussions are needed at
all. I disagree with this suggestion because attempts to hold
public forums for generating allocation priorities lists risk
at least three significant sources of difficulty as evidenced

by the Oregon experience.

192

First, since attendance at public forums tend to consist
more of the active, vocal minority rather than a true sampling
of the larger resident population, the health care service
lists which emerge from such discussions are likely to be
"wish lists" reflecting individual or family medical needs and
not long range medical needs of the population as a whole,
considered as encompassing all medical needs over the course

of patients' lives.

Second, the public discussion forums of the type
envisioned are not currently functioning, and their design,
financing and evaluation will require significant expenditures
of human effort and fiscal resources. Since the desired final
outcome is a consensual public reaction to the multi-
disciplinary Commission's proposed medical service rationing
jpriorities, the<discussions may require several repetitions to
satisfactorily revise the program components. It is both more
sensible and cost effective if the public is asked to react to
and approve, rather than to create from scratch, a basic

package of medical care services.

Third, there is an intractable problem of hOW’tO evaluate
and incorporate significantly different public reactions
arising from different geographic and demographic areas of the
country, e.g., comparatively dense populations of the elderly

in the sun belt, the urban poor, the poorest poor in rural

193
mountain valleys of Appalachia and on Native American
reservations, etc. Compounding this problem is the increasing
mobility of the working population across geographic regions
together with the general aging of the population as a whole.
Each factor contains the potential for producing significant
fluctuations in the reported perceived needs of the vocal

public in different areas.

ine Role of Physicians in the NHIP

Given physicians' professional interests in and
familiarity with the range of medical care needs of the
general population, representative physicians, especially
those involved in primary care, will be indispensable members
of the special multi-disciplinary Commission charged, at the
second step, with producing a package of affordable health
care services for public reaction and approval. More
generally, physicians could serve the independently important
roles of initiating the discussions, urging Congressional
leaders to appoint the special Commission, and encouraging
their patients, friends and neighbors to participate in the

public forums to comment on the Commission's proposal.

Second, since the micro-allocation decisions of both
enabling and denying medical services to patients may fall to
primary care physicians more than any other type of

professional, the insights such physicians bring to these

194
deliberations could not be well approximated.by other kinds of
observers no matter how well intended they might be.
Therefore physicians should have the first pass at drafting
guidelines for how the bedside rationing program may be best
accomplished. This can be facilitated with special editions
of the.Journal of the.American Medical Association and.the.New
England Journal of Medicine devoted to this discussion
[Journal of the American Medical Association, 1991: May 15].
Commission members, the public and members of Congress would
then have a much clearer conception of a physician consensus
on an adequate NHIP and could use that consensus together with
its dissenting opinions to help focus further discussions
about health care allocation and rationing, including
restricting access to medical services. Under the NHIP
proposal I have suggested the beneficiaries will be all
resident U.S. citizens (at least), and unlike the Oregon
Health Decisions Project the commentators will not be talking
about which medical treatments should be provided and which
excluded for the health care needs of others; it. will
necessarily apply to the authors as well, and in an equally
comprehensive way. Though some persons may elect to purchase
supplementary medical insurance they will not be able to
purchase NHIP services separately, and will have equal but.not
advantaged access to those services. Indeed, in discussing
the "second tier" of health care service in Great Britain,

Aaron and Schwartz noted that

 

195

Until and unless shortages in the National Health

Service are pervasive enough to drive a substantial

portion of British patients to seek such services

outside the public sector, private medicine will be

unable to afford to offer high-quality tertiary

care [Aaron and Schwartz, 1984:55].

There are six reasons for suggesting that physicians
generally ought to initiate health care rationing discussions,
though they ought not to determine the final NHIP medical

service program content.

(a) Physicians as public gatekeepers.

For physicians to become involved in the initial planning
of a NHIP properly accords both macro and micro-level
allocation decisions to one of several important groups who
most directly and continually live with the consequences of
rationing decisions. In addition to physicians it is obvious
that nurses, allied health professionals, patients and their
families will all gain and lose from medical care rationing
(enabling and denying) according to the nature of their
particular needs and roles in an episodic way, sometimes
gaining the benefits of access to medical attention and
sometimes suffering harm from denial of the same. Some
persons will clearly face much higher stakes from those
consequences than will their physicians, but physicians will
also know this fact. Furthermore, individual physicians must
deal with all of their patients according to the gatekeeping
tradeoffs that they make, and do so over time under a variety

of situations. That fact should motivate physicians to at

 

196
least try to find some form of balance among the interests of
all of their patients with the interests of any particular

patient.

It.may be objected that physicians have a very poor track
record in terms of keeping patients' interests at the
forefront of their decisions". To entrust them now with
similar kinds of decisions at the level of macro-allocation
design is to invite a repetition of the past disasters and
injustices. The desperate fight waged by organized medicine
tijrevent (and when that became impossible, to forestall) the
public funding health legislation which generated the Medicare
and Medicaid programs in the mid-1960s has been widely
criticized and justly so [Harris, 1966; Fein, 1986].
Physicians as a group currently have both a poor track record
and a tainted reputation in the U.S. among those who study
their collective political operations, and, increasingly,
among the public. This difficulty, as I argued in Chapter
Two, arises principally from external perceptions of

inadequate collective integrity among practitioners.

 

17The New York Times July 26, 1991 on page A1 and August
11, 1991 on page E7 ran articles on the problems associated
with physicians who own their own medical clinics and
laboratories. Estimates place ten percent of all physicians
in such proprietary business relationships, leading the United
States Inspector General to regulate the practice and
instilling greater skepticism on the part of many concerning
physicians' public spiritedness and commitments to political
integrity.

 

197

There are mixed indications of how physicians in the
future are likely to be perceived. On one hand, stories of
physician greed and unjust manipulations of vulnerable patient
groups continue to reach the public. On the other hand, two
factors seem to indicate these concerns may not be as
warranted in the future as they have been in the past. The
first is that over the past two decades many colleges and
virtually every medical school in the U.S. have incorporated
medical ethics as a formal course of study somewhere in their
curriculum. Though the actual content and quality of that
curricular component varies among the schools, the point is
that the attention to the moral dimensions of medical
practice, including the social consequences of collective
professional decisions, has emerged as an important element in
the education of physicians both in medical school and as an
element in continuing education. This is reflected in the
establishment of regular features in leading medical journals
addressing problems in medical ethics and issues of social
justice in medical care. In addition, over the past twenty
years there has emerged a significant public and professional
awareness and concern about bioethics generally as evidenced
by the flourishing of institutes like the Hastings Center,
organizations such as the Society for Health and Human Values
and a half dozen highly regarded professional journals which
regularly feature articles on health care in the context of

social justice. In this respect physicians in the 1990s are

198

better educated than were their teachers in the 19508 and 608.

Whether these educational reforms have had any
perceptible impact on physicians' practice methods generally
is difficult to determine. Certainly some individual
physicians and their patients have benefitted greatly from
these efforts, while others may not.have been affected at all,
but it is unlikely that any physician or patient has been
harmed by them. Nonetheless, it seems reasonable to conclude
that there has been a general increase in physicians'
awareness of ethical problems in medicine and a need for
considerations of social justice to be part of any financing
or reform measures that will affect large segments of the

population.

Another response, a stronger and more important
consideration though at the same time perhaps a less cogent
one, is that both the public and physicians are aware of the
past self-interested collective behavior of physicians.
Initiating a discussion of how to structure a NHIP, making
their conclusions and recommendations public and inviting wide
scrutiny of them, is one way the members of the medical
profession might reassert themselves as a group with strong
commitments to collective and political integrity. To
generate a preliminary NHIP content for broader public

discussions aimed at designing a compassionate health care

199
rationing program would go a long way to redeeming their
reputation and reestablish physicians as the caring and
trustworthy professionals they once were so widely regarded.
Accordingly, to fail to do so, and to insist that rationing
health care is either an unnecessary or somehow unclean action
for physicians to undertake, is to allow their individual and
collective professional reputations to continue to deteriorate
and with them, their ability to determine the manner in which
medical care is practiced in the United States. Physicians
could wait for Congress to enact something like a NHIP, but
such a legal-based, bureaucratized and impersonal solution
would undoubtedly be ham-handed and only minimally effective.
Far better for physicians to voluntarily accept the mantle of
moral responsibility in this regard and assure the quality of
the human transactions which emerge from it, something of
which the law is utterly incapable: "Our nation will regain a
sense of its worth only if its institutions exhibit the
courage to pursue higher ideals than can be accomplished in a

lifetime" [Pellegrino and Thomasma, 1981:263].

(b) Informed decision makers.

The second reason for asking physicians through their
collective organizations to provide the leadership for
discussing a NHIP proposal is that the likely consequences of
various medical care tradeoffs required by the limitations of

funding perhaps can initially be best estimated and understood

 

200
by those who actually practice medicine and medical research.
In the bureaucratic decision making within current federally
administered systems, (i.e., Medicare, Medicaid, Veterans and
Indian Health Services, Public Health Departments, etc)
arguments supporting particular allocation decisions sometimes
must sacrifice complexity in order to achieve cogency, but
risk seriously misrepresenting the medical care realities in
doing so. 'The reason for this is that the membership of these
oversight bodies is not made up principally of physicians,
though some physicians do serve on them. The nonphysicians
members (and perhaps the physicians) cannot be expected to
understand.all the relevant medical.consequences to individual
patients emanating from each policy decision. That risk may
be minimized if the initial debates and proposals are
conducted by the medical professionals themselves who can
better understand the complex natures of medical services and

treatment outcomes.

The kinds of tradeoffs among medical services required
under a NHIP will be justified only if it can be shown how
reductions in providing specific services will be both fair
and serve to maximize overall public welfare. It is clear
that maximizing public welfare presupposes understanding
certain important moral concepts in particular ways, among
them welfare, benefit, harm and fairness. Though physicians

have no advantage over others in understanding these terms and

201
how they ought to function, they are also perhaps no less
qualified to engage in these deliberations than other members

of society with the possible exception of philosophers.

Physicians have traditionally claimed both a professional
heritage and a moral obligation to dedicating their
professional loyalty first and foremost to their patients and
secondly to their professional colleagues”. Insofar as they
make further claims to collective and political integrity
their professional loyalties must be understood to operate
within the larger context of collective action aimed at
maximizing the social.welfare, at least insofar as that can.be
accomplished through good medical practice. Inf physicians
understand how making NHIP tradeoffs among specific services
will affect their collective professional and political
integrity both in terms of substance and in terms of public
image, then as individual members of the profession they will
acknowledge the need to do so for the good of their "own"
patients and the larger public, i.e., the patients of all
other physicians. Such understanding will reveal a perception
of the larger field on which individual physician's actions
and their consequences are played out. It will further

demonstrate that at least in the context of distributive

 

18It should be noted.that the Hippocratit:0ath.is directed
primarily to other physicians and only secondarily to
patients. Nonetheless, the professional moral obligation to
their patients is quite clearly stated.

202

justice, patient advocacy means to be faithful not only to the
needs of one's patients, but also to one's self as a physician
who practices in a social community. In other words, patient
advocacy cannot be properly or fully understood outside the
context of social justice. Robert Solomon has made some
important observations along these lines.

Loyalty is a kind of integrity, not within oneself

(conceived of as a self-sufficient, integral whole)

but rather with oneself conceived as a part of a

larger self, a group, a community, an organization

or an institution. ... Loyalty shifts the attention

from what we need and deserve from society (or any

institution) to what we should give and what we

owe. Loyalty forces us to reject (or at least

suspend indefinitely) the ideal of autonomy and

renders heteronomy not only respectable but

virtuous. ... Morality and justice are essentially

and first of all interpersonal but then become

intertribal as well. The problem is, perhaps, that

we are members of so many tribes at once [Solomon,

1990:288-91].
(c) Multiple perspectives

A third reason I suggest physicians assume this
leadership role is that despite their shared professional
functions, physicians in the U.S. number over half a million
and their professional interests range over a hundred
specialties and subspecialties. It is reasonable to suppose
that such depth and breadth will provide some degree of
understanding about different patients' perspectives in the
initial design of the NHIP. If the twenty five percent of the
public that have personal physicians know that the NHIP will

be implemented at the hands of their personal physician acting

in the role of gatekeeper, they are likely to inform him or

 

203
her of their views on the program's adequacy, at least as it

concerns their own care.

Traditionally, one of the chief obstacles to obtaining an
accurate representation of the public's perspective on any
issue of national importance is the belief by many people that
their individual viewpoint cannot possibly make any
significant difference. Since few private citizens have a
personal relationship with their congresspersons, most are
skeptical that any input they might offer would fall on deaf
ears, as they are only one of so many constituents. But the
situation is much different with patients and their
physicians. These relationships are more personal and the
individual constituencies much smaller. Unlike elected
politicians, physicians are not in medicine for an uncertain
few years but for the duration of their careers, usually
several decades. In addition, there undoubtedly will be many
opinion and editorial entries in newspapers and talk shows
reflecting the views of the vocal patient-public to help
inform physicians of the emerging public opinions in their

respective local communities.

It may turn out that physicians find private
conversations concerning a NHIP and its specific provisions
overly time-consuming to conduct with each.patienta But given

the importance of the conversations and the value of the

 

204
hoped-for suggestions, some limited compensation to physicians
for these conversations may be part of the envisioned NHIP
services [McIlrath, 1991]. In any event, finding a way to
satisfy the needs of both.physicians and patients under a NHIP

will be a profession-wide objective.

Since the initial NHIP proposals arising from the local
and national medical societies are not intended to serve as
blueprints for the final program, areas of professional
disagreement and uncertainty can be laid bare for the public
to see and discuss in the middle stages of the programs'
development. The purpose at this initial stage is to develop
a working model which will clearly expose and delineate the
perceived tradeoffs required by fiscal limitations and
preferred by physicians, and indicate in what ways those
tradeoffs will affect individuals with different health
service needs, i.e. which specific uses of specialized, high
tech medical care will have to be foregone in order to achieve

universal access to primary care.

(D) Designers and implementers

Fourth, by initiating these rationing discussions and
urging Congress to form a special Commission there will be
less of a perceived "us-them" conflict between those who make
macro-allocation decisions and those who make micro-allocation

decisions; the medical care gatekeepers will be helping draft

 

205
plans for the size and strength of the gate itself. As
Morreim. has noted, to allOW' nonphysicians to ‘make such
decisions in an uninformed way is in effect to allow them to
practice medicine, something which they are not qualified to
do [Morreim, 1988:21]. Fried has also noted in this regard "It
is monstrous if an individual doctor thinks like a budget
officer when he cares for his patient in need; but it is
chaotic and incoherent if budget officers and voters making
general policy think like doctors at the bedside" [Fried,
1974:34]. Moreover, making the final macro-allocation
decisions are appropriately the recognized expertise of no
particular professional group (medical, military, education,
etc.) and as such ought be made by the elected political
representatives after debate and assessment by the informed

medical practitioners and general public [Newton, 1982].

(E) Medical discussion forums already exist

Fifth, there already exist numerous well established
medical associations and societies ‘which. could serve as
initial vehicles for physicians' discussion forums to examine
and debate the kinds of health services tradeoffs which will
have to be made. Through the leadership such organizations
provide, initial proposals could be generated for the
Commission to consider which would include careful analysis of
how physicians collectively assess and rank order different

sorts of tradeoffs among medical services.

206

(F) Outcome feedback to medical education

Finally, a system of regularly updating and revising the
NHIP will provide opportunities to influence medical school
curricula to better suit the full range of responsibilities
which graduating physicians will face in their varying roles
within the NHIP. Physicians who do not have a clear conceptual
grasp of how contemporary health.care fits into the social and
political lives of U.S. residents as a whole will be ill
equipped to make responsible and workable NHIP gatekeeping
decisions or design suggestions. Medical school curriculum
components aimed at providing this understanding will help
enable graduates to better fill their roles as gatekeepers.
Just as the recent debates in the media concerning the
withdrawal of food and fluids from incompetent patients has
focused much attention on individual physicians' moral
perspectives on patient care, so too will discussion of
allocation of resources and access to care focus on
physicians' perspectives. If physicians' groups and
organizations initiate these discussions internally and
attempt to find a grounding for mutual accommodation and
compromise among their competing interests for providing
services, there will be an increased likelihood of finding
such recommendations persuasive both to the special commission
and the general public. On the other hand, if the medical
consensus recommendations are deemed unrealistic or

predominantly physician-serving, or if they never occur, then

207
the later comments by physicians on the NHIP will likely have
little more weight than the comments of other members of the

public.

ine.Speeial Commieeion

Since the basic NHIP plan is designed to provide
medical care coverage for the entire population, to specify
the component features of the basic package of ‘medical
services there needs to be broad based discussions by
individuals with well-informed perspectives. No single
profession or collection of individual experts working in
isolation is appropriate to design such a plan; many different
perspectives will be needed and representative spokespersons
for each perspective need to be well-informed about the
consensus views of members of their respective disciplines.
These discussions do not need to occur simultaneously, nor do
the individual groups have to operate independently and in
ignorance of each other's deliberations. Eventually, an
amalgam of representative perspectives, each embodied singly,
could be assembled into a single, multi-disciplinary
Commission. The goal of this special Commission would be to
issue a preliminary but substantive and cost estimate-specific
proposal which would serve as the second focal point in the
discussions about the NHIP. This Commission would need to be
small enough.to proceed relatively quickly (1-2 years) to some

preliminary recommendations which would have the fellowing

208

advantages.

First, the Commission's recommendations would emerge from
informed persons who have considered the ultimate goal of a
NHIP both as professionals and as members of their respective
communities, i.e., as citizens cognizant of their social
responsibilities when faced with a particular kind of a crisis
of distributive justice. This may sound like an idealized
collection of professionals and in some ways it is, but that
does not mean it would be impossible to find such individuals.
What it does mean is that selecting these individuals will
require empirical evidence of suitability for the task
envisioned. This will be difficult to do with absolute
fairness, but there have been many instances of recognizing
exemplary work in medicine”. The important point is not
that there are few such individuals in each professional
community, but that there are some in each community, and the
first challenge is to identify and recruit them to this

project. Since there are comparatively few such persons, the

 

19The Phoenix Alliance is a for-profit corporation which
keeps on retainer physicians throughout the Unites States and
the world.who have been identified by their peers as exemplary
practitioners. As an extra benefit "perk", large corporations
enroll highly valued employees with the Phoenix Alliance so
that prompt and competent medical attention is assured should
the enrollee or a family member become acutely ill while away
from home. As a second example, consider the Masterships in
the American College of Physicians and American College of
Surgeons. These are recognition awards exemplifying
outstanding and continued accomplishments in medical science
and dedication to the principles of service to patients.

209
task of selecting them once they have been identified is

thereby made somewhat easier.

Second, the recommendations would be provided from the
perspectives of professionally trained and experienced health
care providers as well as academic and
administrative/bureaucratic observers, scholars and
commentators on health care in the U.S. generally. As such,
the Commission's recommendations would reflect the negotiated
consensus of its members who are cognizant of and loyal to
their individual obligations of professional integrity. They
will have to be true to both their individual professional
principles as well as that of the Commission itself, much as
the work of the President's Commission for the Study of
Ethical Problems in Medicine and Biomedical and Behavioral
Research did in the early 19808. While such a charge is not

easy, it is manageable.

The goal of finding appropriate compromises and consensus
will not require that individual Commission members abandon.or
betray their professional integrity as specific kinds of
professionals, though this may well be a significant concern
for some, especially the representative physicians concerned
with obligations of patient advocacy. What it will require,
as Benjamin has pointed out, is that each member of such a

Commission

 

210

consider the extent to which the issue(s) admits of
reasonable differences of opinion, the need for a
singular policy on the matter, and the need for
virtual unanimity among members, if the
[Commission's] recommendation is to be credible and
persuasive ... [Each member must] value resolution
of the policy question on terms that pay equal
respect to the contending legitimate positions and
that stand. a reasonable chance of public
acceptability [Benjamin, 1990b:385].

Third, the recommendations of the Commission would
include the informed perspective of its members when
considering the NHIP as future recipients of medical care both
individually and as members of families receiving medical
care. It will not be the case that the programmatic
components of the NHIP will be designed by some individuals
for the benefit of others; the designers will also be the
recipients of the benefits and burdens of the system they
produce. The advantage of this arrangement is to provide an
additional motivation for fairness; when the person cutting
the cake is warned that he or she will receive the smallest

piece cut, great care is taken to be fair to all.

A final characteristic is that the Commission's
recommendations would emerge from a process of individual
members' deliberate reflections on the professional and
political interactions of the different aspects of their
individual lives. Such personal reflection and shared
examination will contribute to finding ways to facilitate the

integration of (at least some of) the conflicting roles in

 

211
their respective professional, political and personal lives.
Drawing on such reflection, the conflicts experienced by
others in similar roles may be more easily reconciled by

seeking balances among the multiple obligations they share.

For example, a representative neurosurgeon who is able to
draw on previous discussions among many other neurosurgeons
concerning the neurosurgical components of the basic package
of services could help put the perspective of the collective
of neurosurgeons into clearer focus. A similar process could
occur in each of the other medical specialties. If each
specialty group engaged in careful and directed discussions to
identify and provide clinical indications for the relevant
specialty-specific services, a specialty consensus could
eventually emerge for many interventions. While these
discussions and recommendations would be aimed at articulating
the various components of a minimum package of medical
services, some significant tradeoffs will undoubtedly have to

be made.

It may be objected that the medical specialties'
influence in these deliberations could be proportional to
their respective memberships, thereby stacking the deck in
favor of the status quo rather than contributing to an optimal
distribution of needed practitioners. Moreover, some

specialty groups may refuse to acknowledge that much of what

 

212
theprrovide ought be considered.elective services, all things
considered, and not included in the basic package of services
of the NHIP. In response, the special Commission would need
to address these concerns and some of its members might be
appointed from representative specialties. But the Commission
would need to focus principally on the larger concerns of the
patient public and not the needs of any particular medical

specialty.

In addition, primary' care physician 'members of the
Commission who have experience providing early treatment for
patients with.a variety of disorders over the courses of their
lives will be experientially positioned to comment on and
suggest priority rankings for some of the choices among
different medical services which. will have to be ‘made.
Furthermore, though. the input. of :medical specialists is
indispensable for acquiring an accurate understanding of the
range of medical care needs, specialists may well be
professionally disposed to favor allocations for treatment
protocols in their own areas of specialty, whereas primary
care physicians are more likely to have a reduced sense of
commitment to favoring of any particular set of treatments.
Thus, the "medical perspective" will need to be balanced
internally‘ among' the competing senses. of jpriority' which
different types of practitioners will articulate. This

balancing may be best accomplished through the discussions in

213
medical societies which already exist and through which the
physicians in local communities have already established

collegial as well as political organization and functioning.

Several additional discussants are appropriate to include
in the membership of the special Commission envisioned here.
The following is a list of some key perspectives that need to

be included, but it is not meant to be an exhaustive list.

A. Medical Economists. Medical economists will be
indispensable for explaining the estimated costs of including
various service and research components to the basic package,
as well as the economic interrelationships among the different
services and research efforts. Tradeoffs among the different
medical service options as well as between treatment and
research will have to be made since it is not feasible to
continue to finance medical treatments and.research.at current
rates of increase [Reinhardt, 1990, and Chapter Three of this
thesis]. Making those tradeoffs will require a clear
understanding of the way different economic areas of medical
care and research mutually influence and support each other.
This informed perspective is one which medical economists may
best be able to provide, and in so doing indicate ways in
which future adjustments to the basic package of services can

best be kept informed.

 

L301?" _'-_'_

214

B. Public Health. Public health officials including
epidemiologists will be needed to provide the larger
perspective of the health needs of the population as a whole
rather than ‘the isolated. needs of individual groups of
patients which practitioners typically see and serve. In
addition, public health professionals will be well suited to
offer supporting arguments for expenditures geared toward
preventive medicine and to draw comparisons to the effects of
specific environmental conditions on the general health of
identifiable subpopulations. Though environmental
expenditures for prevention and clean up efforts would not be
part of the health services budget envisioned in the NHIP,
evidence of their effectiveness in reducing health care needs
for specific disorders will likely contribute to increased

funding from the relevant non-NHIP budget lines.

C. Philosophers and Policy Analysts. Philosophers and
policy analysts will be needed to help identify and assess the
moral and political risks and conflicts that will inevitably
emerge as the issues of social justice and expenditure limits
within the overall national economy are debated and decided.
These professionals will be well suited for helping to keep
the discussions focused on the relevant issues and to assist
in distinguishing the areas of conflict that are moral,
political, procedural, and financial in nature. Such

clarification and focus will do much to expedite and enhance

 

215
the fairness of the conclusions which eventually emerge from

all these discussions.

D. Political Representatives. Bipartisan politicians
will be needed to keep the Commission's discussions and
debates about the basic package of services orientated toward
politically feasible and fiscally "sellable" conclusions.
This perspective is most likely to be found in those members
of Congress who have both knowledge of how the final debates
are likely to be played out, and established credibility with
their colleagues to find acceptable forms of compromise when

that is required.

The Role of the Patient-Public

Members of the business community and general public will
be needed to participate in a fundamental way. It will not be
sufficient to merely ask selected representatives of the
various professional groups to convene as a special
Commission, make preliminary outlines of the basic package of
health care goods and services, provide those recommendations
to the elected politicians who will hammer out a politically
and fiscally feasible program, and then expect the public to

simply accept whatever program structure and content results.

The general public must be both informed of and included

in the entire process as the key care recipients in whose

 

TFl-rz'jr l‘Y'I

216

interests and on whose behalf the various component features
of’the.NHIP are‘debated, balanced, compromised and synthesized
into a workable, affordable and acceptable national program.
This may be best accomplished in.a:manner similar to that used
in Oregon in its Health Decisions Project. In that process,
the local media regularly reported the preliminary progress
reports of the Health Services Commission as a whole. Those
reports were then discussed and evaluated by the public in
series of editorial correspondences (newspapers and
periodicals), television and radio talk shows and interviews,
and public meetings held at specified times in different
communities”. By allowing the general public multiple and
specific forms of participation in the decision making process
their perceptions of procedural justice will increase [Hughes
and Larson, 1991]. Danis and Churchill have argued that when
discussions turn to choices to forego marginally beneficial
care the result can be

[f]orces of social cohesion if they can draw at

least a part of their authority from public policy

which extends access to health care benefits to

all. Rights within health care can then be seen as

abiding in a context of rights to health care, with

each modifying the other. Both rights can be seen

as individual rights that are socially established,

rights of citizenship with reciprocal obligations.
Most important, there must be a vigorous public

 

2° It should be noted that the community meetings in

Oregon did not produce a hierarchy or lexical ordering of
medical services nor was that the intention. The meetings were
conceived and conducted to discover a general list of
community values as articulated by attenders, the majority of
whom turned out to be medical care professionals.[Daniels,
1991].

 

 

217

discussion about the health needs of the nation,

and of each state and region, to begin to establish

priorities. Without such discussion change will be

restricted to reactive, short-term fixes [Danis and

Churchill, 1991:28-9].
The philosophical underpinnings of this approach are
compatible with the position I have been advancing and the
reasons'given for justifying rationing health.care services in
Chapter Three. My argument for rationing parallels that of
Danis and Churchill in that both are consequentialist in
nature, arising from beliefs about the outcomes of resource
scarcity. But both arguments are also deontological in that
the chief motivating principle is the obligation to provide an
equality of opportunity. The two moral frameworks are not in
conflict, but rather complementary, each supporting the

other's programmatic conclusion but for different reasons

[Danis and Churchill, 1991:29].

These are not new ideas.in.a free and democratic society.
Just as the citizens in different states decide on issues such
as abortion, capital punishment, motorcycle helmet laws and
setting the age of majority as well as Medicaid eligibility
requirements, so too can that same citizenry express its views
on specific elements of the NHIP through the democratic
process and the modern. public square of the print and
electronic media. Indeed, rational choices leading to a NHIP
depend on the public's active involvement in the decisions

because it is precisely the values and principles of the

218
patient-public which will determine whether the choices are
generally acceptable, and therefore likely to be effective.
Wennberg has observed that "since the only way to find out
what the patients actually want is to ask them, practice
guidelines that take the form of prescriptive rules will not

work" [Wennberg, 1990:1202].

Dynamic Interplay with the Educational Structure ene Pnoeeee

A fourth feature of my proposal is to include ongoing
education and feedback mechanisms to continuously refine the
guidelines for gatekeeping (in both capacities of treatment
enabling and treatment denial) in the light of the evolving
perceptions and understanding of medical need, as well as
social justice. In addition to the Commission's work to
suggest specific medical service contents, it should also
include a plan for designing and implementing outcomes
measurements of the rationing program both as a whole (i.e.,
long term effects on the health status of the general
population) and in specific areas (e.g., regional infant
mortality and morbidity comparisons), in the light of which
the updating and future adjustments to the program can be
made. It will do little good to make the initial effort at
gathering multiple perspectives for what a package of services
ought to look like and then negotiate a working model for
implementation, if there is not a built-in system for an

accurate assessment. of its effectiveness in :meeting' the

 

219

perceived health care needs of the population.

An additional advantage of such educational feedback is
the opportunity to structure medical, nursing and allied
health educational programs to better fit the health service
needs of the public, rather than primarily the interests of
the faculty and students. These needs will include, in
addition to traditional courses in the structure and function
of the human body, curricular components aimed at increasing
students' understanding of the psychologic, sociologic and
moral dimensions of patients' lives. Such a curriculum would
more fully utilize the biopsychosocial model of health and

illness than has traditionally been the case.

 

 

Summary and Conclusions

As I have argued throughout this dissertation, integrity
is a difficult concept on which to become clear and the
professional integrity of physicians in the United States is
perhaps more difficult to clearly comprehend than ever before.
I have argued that only by operating as gatekeepers within a
properly designed NHIP can physicians enhance, safeguard and
preserve their professional and political integrity. The
compromise required for biographic integrity is between
obligations of professional integrity (which emphasize patient
advocacy) and of political integrity (which emphasize social
justice). Physicians can and should take part in designing
and implementing--as gatekeepers and care providers--a just
rationing scheme of health care resources. Not only is their
so doing compatible with preserving their integrity as
individuals and as members of a professional collective, it

is required in order to preserve that integrity.

However the NHIP is finally structured, insofar as
physicians sincerely seek to balance the duties of patient
advocacy with the obligations of social justice by providing
a leadership role in generating discussions for the
development of a NHIP, their lives will thereby become more
fully integrated and their individual professional and
collective political integrity will be enhanced. Insofar as

physicians qua members of their communities seek to complete

220

 

221
their lives, and in the process enrich and sustain the larger
and more socially connected morality which they have made
their own, they must acknowledge the political context of
their professional obligations. This will require they
recognize the need and accept the challenge to initiate the
work to construct a NHIP which provides to the medically needy
an adequate, if perhaps not everywhere completely

satisfactory, minimum package of medical services.

Difficult.gatekeeping choices will have to be made and it
will likely fall to physicians, especially those in primary
care, to make them as they occur. Of equal importance to the
ultimate success of the NHIP is the realization by the public
that this is not an easy or enjoyable task and requires many
tradeoffs, some with unhappy consequences for members of the
community, patients and physicians alike. I have argued that
if physicians wish to claim integrity in their professional
practices they must embrace with open eyes and.clear judgments
the role of gatekeeper to medical resources” 'That role cannot
be adequately fulfilled.by physicians merely in their capacity
as private individuals performing their duties of citizenship
by participating in public forums. It requires recognizing
the imminent need for and will to accept a significant
leadership role in the development of a NHIP which seeks
solutions to the problems of access to care and cost

containment. To do less is to remove the concept of social

222
justice from the conception of personal and professional
morality and integrity; And that would be to rob the concepts
of morality and integrity of their value and purpose in the

world of human intercourse and community life.

 

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