Tuesday, March 20, 2007

Dueling ethical views in Archives Internal Medicine re: "tiered" health care systems

In the March 12,2007 issue of the Archives of Internal Medicine, we find two differing views on the ethical status of a tiered medical care system. A one tiered system is exemplified by the Canadian system in which patients are forbidden to purchase care outside of the governmental sanctioned system. ( At least in Canada, they can still medically escape to the U.S.)In England, a private medical insurance scheme thrives, existing along side of the National Health Service.

Dr. Ezekiel Emanuel and Benjamin Krohmal argue in their article that a tiered system (i.e. one with more than one tier) is "just in principle and ..just in practice". They justify their position in part by reference to Rawls principles of justice, the first of which is that "all have the right to the greatest individual liberties compatible with the same liberties for others." Since some medical goods or services must go without public funding, justice protects the liberty of individuals to pay for medical options that the public (government) fails to provide.

In a companion editorial , Dr. Allan S. Brett takes a different point of view. He argues that a second tier may not be necessary and is problematic from an ethical point of view. He says that if we eliminated administrative waste and unnecessary medical interventions then people could then receive comprehensive medical care without a second back up , paid -by the-patient- tier. Since he also recommends a single payer system-i.e government-the "if" in eliminating administrative waste become a very big "if" and then we face the issue of who decides what is "unnecessary".

Further, he suggests that "effective evidence-based interventions should be included in the first tier, and ineffective or unproven interventions should not be provided in any tier."

His use of the term "should not be provided" glosses over what he is saying.What he is saying is that purchasing services not provided in the first tier will not be allowed, i.e will be made illegal. Phrasing this in the more candid way makes his claim that his view is not antithetical to American values empty.

Dr. Brett does not elaborate on what the process would be to decide which interventions are or are not effective but one can assume that would not be done by the individual physician in consultation with the individual patient.Those decisions would be made by committees appointed by the one party payer (which Dr. Brett favors) either directly or indirectly. Ironically, the egalitarian one tier patient system would establish a two tier physician system in which the higher tier would be the elite physicians who decide what should be "provided" and in the lower tier will be the rest of the physicians who will explain to patients what they will be not allowed to have.

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