The contemporary health care in the United States of America, as well as all around the world, is filled with multiple problems such as scarcity of resources, the need for more practical management, skills shortages, and various ethical dilemmas concerning the relationships and interactions between the patients and their doctors, financial matters, and the provision of care. A lot of studies and researches are directed at the search for solutions to these issues. Many countries employ special medical programs and policies designed to minimize the problem and address some of the outcomes. One of such actions implemented in the United States is Obamacare, which is another name for Affordable Care Act (ACA). The purposes of the ACA are to maximize the number of patients covered by the medical services, to improve the quality of the delivered services, and to take the control of the growing health care costs in the state (Summary of the Affordable Care Act, 2013). Even though Affordable Care Act is intended as a health reform beneficial for the American population and the healthcare system, it had brought up a number of ethical dilemmas and issues that will be discussed and explored below. This paper provides a discussion of such ethical problems facilitated by the ACA as the issue of bundled payments, patient insurance, the involvement of the government in health care, the sorting of medical practices and procedures, and the effect of the reform on doctor – patient ratio.
Ethics in Health Care and Medicine
Healthcare ethics relies on four major principles that are beneficence, non-maleficence, autonomy and justice (Summers, 2014). These principles lie at the base of medical decision-making and assure that the medical professionals achieve their goals and accomplish their tasks in the most ethical way possible.
Non-Maleficence
The principle of non-maleficence assumes that no harm should be done to the patient and that a medical professional is to be oriented only to the benefit for the client (Summers, 2014). The understanding of the principle is complicated by the fact that “harm” is a relative and multidimensional concept that can be defined in a variety of ways according to the aspects of life it affects. For instance, in the contemporary health care the doctors may save the life of a patient, but the cost of the provided medical procedures and services may exceed the paying capacity and the insurance cover of the patient so much that this person could end up in financial debt for many years. In this situation, it is difficult to determine whether the doctors created a benefit or hard to the patient’s life in the long-term. This is a meta-ethical question that is based on the determinants of moral actions and whether or not they are the same for every patient and doctor (Stanford & Connor, 2014). In clinical settings, harm is mainly viewed as physical damage or medical error that makes the patient’s state worse (Summers, 2014). Another way to harm a patient is negligence or the failure to act on a situation and deliver the required care.
Autonomy
The principle of autonomy is the patient’s right to decide whether or not they should receive treatment (Summers, 2014). That way if medical procedures and practices are imposed on a patient who chose not to receive care the actions of medical professionals would be considered unethical and viewed as the breach of a client’s autonomy. This principle serves to expand the principles of beneficence and non-maleficence adding the patient to the medical decision-making process and making it less totalitarian and controlled by the doctors solely.
Beneficence
Beneficence is another complex side of health care ethics. The principle of beneficence requires the medical workers to withdraw from their ethical egoism and focus on the benefits for the patient only (Summers, 2014). For instance, a medical professional has no right to refuse helping a person they dislike based on any reasons (it can be an individual rivalry – a patient is a doctor’s enemy, or universal notion – a patient is a criminal). Personal judgment of the clients is unethical in health care.
Justice
Finally, the principle of justice stands out because it affects the relations between medical workers and the patients, as well as those within the staff itself (Summers, 2014). In other words, justice should apply to the provision of care for the patients (no one should be prioritized without a valid medical reason), and to the procedures and operations within the medical facilities (the employees should be managed equitably and treated without any person bias).
Affordable Care Act (Obamacare)
Affordable Care Act became effective since March of 2010 when President Obama signed the health reform that went by the title the Patient Protection and Affordable Care Act (Summary of the Affordable Care Act, 2013).
The act enforces a number of demands that the majority of the US citizens, as well as legal immigrants have medical insurance (Lachman, 2012). The individuals without coverage are to be penalized and pay a percentage of their taxable income and the income increases by the year (Summary of the Affordable Care Act, 2013). Of course, there are exceptions to this policy; they are the individuals who have been without coverage for a term of under three months, imprisoned persons, undocumented immigrants, and those who cannot afford the tax due to their low income (Summary of the Affordable Care Act, 2013). Besides, the employers (who have 50 or more employees) are required to offer coverage to the workers. Moreover, Affordable Care Act expands the other medical programs such as CHIP (health insurance program for children) and Medicaid making more individual eligible for the affordable and accessible health care services. The ACA works through premium credits (the opportunity for the individuals with various levels of income to obtain health insurance using the Exchanges), and cost-sharing subsidies (Summary of the Affordable Care Act, 2013).
The objectives of the ACA include the reduction of the costs of health care services for the population and the state, the provision of a list of benefits coming as an essential package that is to be offered by all the health covering programs. In addition, the availability of health care is maximized through the creation of a website where the potential patients can find all necessary information about the essential packages, their contents, costs, and coverage options (Summary of the Affordable Care Act, 2013). The website aims at informing both the users and the insurers about the rules and regulations enforced by the ACA.
Ethical Issues and Implications
The health care reform and Affordable Care Act brought a variety of ethical issues and implications to the public attention. The main question raised by the implementation of the Act is whether or not it is possible to deliver affordable health care of high quality to the population without violating the rights of separate groups of individuals (Sorrell, 2012). That way, regardless of all the positive potential the Act carries and all benefits it brings about, the public opinion is still divided into the supporters and the critics of this reform.
Cost-Utility
Before the implementation of the ACA, the evaluation of cost-efficiency of medical services and procedures was accomplished by means of the calculation of quality-adjusted life years also known as QALYs (Neumann & Weinstein, 2010). The ACA does not rely on this evaluation principle and uses a system of bundled payments instead. These payments assume the financing of the health care facilities and centers based on the standard costs assigned to each medical procedure and treatments for various diseases and conditions. For instance, if an individual is brought to a hospital with a heart attack, the medical workers are allowed to deliver the procedures within the standard cost of the treatment for heart attack. Besides, in case if the care given to a patient costs less than the standard value, the hospital gets to keep the remaining funds. Such approach, though practical and cost-effective, motivates under-treatment; and this is the first ethical question of the ACA. Does the affordable care assume lower quality? Will the hospitals be able to disconnect from the ethical egoism and practice the principle of benevolence under such circumstances? It is likely that motivated to deliver less costly services the medical professionals may start to prefer the equipment, materials, and medications from cheaper sources.
In addition, as the healthcare systems of other countries still rely on QALYs developing various treatments and procedures, there is a chance that the regulations of the Affordable Care Act will create cultural, professional, and practical disconnection between the American health care and those of other countries and limit its chances for development.
Mandatory Insurance Purchase
The Affordable Care Act demands that all the legal residents of the United States of America purchase medical coverage (Lachman, 2012). This is one of the most controversial aspects of the ACA that was predicted to cause a level of public dissatisfaction. This requirement is the major cause of the division of the American society into the opponents and the proponents of this reform. The article of Lachman (2012) presents the comparison of the points of view of the Liberal Egalitarians and Libertarians along with Free-Market Supporters. According to Lachman (2012), the Liberal Egalitarian view assumes that every legal resident has a right to health care, and this way all the barriers to the reception and provision of it should be removed. That way, making health care more accessible and affordable, the government supports a universal good. The Liberal Egalitarian view seems to see the actions behind the health care reform as an example of the utilitarian approach that ensures the highest amount of good for the largest number of individuals – the main principle of the utilitarian ethics (Stanford & Connor, 2014). At the same time, the actions of the government are seen as the intrusion in the freedom of the society and separate individuals and violating the right to choice and personal responsibility; this is the view supported by the proponents of Free Market and Libertarians (Lachman, 2012). This idea maintains that health care, as well as medical insurance, is a commodity that is purchased by the individuals based on their personal choice and desire. Forcing people of the United States to buy any goods is illegal and breaches the liberties of the free population that, due to such regulations, becomes limited in their choices.
Speaking in support of the Affordable Care Act, one may compare it to the mandatory vaccination practice that is a major preventive measure that ensures the minimization of the risk of various diseases in the society. Such comparison might allow one to see the preventative character of the ACA insurance regulations that help more individuals to access health care when needed which is extremely useful in both the short and long term. This point of view also can be supported by the fact that health care is a necessity good important for any individual regardless of their age, gender, social, and financial status. The mandatory insurance allows the government to bring this necessity good back from the price level of luxury goods for the population. At the same time, when compared to any other commodity such as fruits, for example, health care cannot and should not be imposed on the population regardless of how beneficial it is. In other words, eating fruits is very good for one’s health, but it would be unethical for the government to require that the citizens include a high amount of fruit in their diet by law.
The matter of insurance affects businesses, as well as the individuals. Under the ACA, the businesses with 50 or more employees are required to provide health insurance to the workers (Summary of the Affordable Care Act, 2013). This regulation may hurt many companies. In addition, it is still unclear whether or not the practices such as abortion and contraception should be insured as they clash with the moral beliefs of a large part of the American population. Besides, the companies may provide the sum of insurance to the workers in a form of wages, but for that the businesses will be fined (NCPA, 2013).
Procedures and Practices
The main objective of the Affordable Care Act is to take under control the costs of healthcare, and for that the government made sure to limit the health care professionals and organizations to avoid extremely costly procedures. In other words, working with the budgets assigned to each particular case, disease, or condition, the doctors will have to opt for cheaper practices and stay away from too expensive ones (Neumann & Weinstein, 2010). Practically, this regulation falls under the principles of the utilitarian ethics and allows the government and the organizations to save more costs and deliver care to more patients. At the same time, morally, when a doctor has a patient who requires expensive treatment to survive will be limited to only two basic options under the regulations of the ACA – to have the patient pay for the procedures (which will be impossible in many cases), or let the patient die.
The Profession of a Doctor
Having analyzed various ethical implications along with managerial and financial advantages and disadvantages of the Affordable Care Act, one may notice that the reform aims to increase the number of served patients making health care more accessible. At the same time, viewing this reform from the perspective of doctors, one will notice that few incentives are created for them – they are motivated to provide cheaper care, avoid costly practices, and are limited in financing (Neumann, 2012). That way, increasing the inflow of patients and creating more limitations for the doctors depersonalizes the care driving it away from the patient-centered approach. Besides, the larger number of patients will shift the doctor-patient ratio and create even heavier workloads for the medical staff. The potential long-term results of this phenomenon can be higher job dissatisfaction among doctors and nurses and increasing skills shortages.
Conclusion
The Affordable Care Act has been widely criticized ever since the very beginning of its implementation. The critics argue that health care is already affordable and accessible to the majority of the population, and the reform does not enhance any of these qualities (Neumann, 2012). The government is accused of meddling with the individual rights and freedoms of the populations forcing them to purchase a commodity in a form of health insurance. The proponents of the ACA maintain that health care should be viewed as a right that has to be included and ensured by the social contract. That way, the actions of the American government cannot be characterized as the breach of rights of the population. The other regulations of the ACA that consider the costs of the care delivered to the patients by the medical professionals puts the latter under a lot of pressure limiting them in choices of treatments. That way, the health care becomes cheaper but more limited and less personalized.
Reference List
Lachman, V. D. (2012). Ethical Challenges in the Era Of Health Care Reform. Medsurg Nursing, 21(4), 248-251.
NCPA. (2013). ObamaCare Creates Moral Dilemma. Web.
Neumann, P. J., & Weinstein, M. C. (2010). Legislating against Use of Cost-Effectiveness Information. N Engl J Med, 363, 1495-1497
Neumann, P. J. (2012). What We Talk about When We Talk about Health Care Costs. N Engl J Med, 366, 585-586
Stanford, C., & Connor, V (2014.) Ethics for Health Professionals. Burlington, MA: Jones and Bartlett Learning.
Summary of the Affordable Care Act. (2013). Web.
Summers, J. (2014). Principles of Healthcare Ethics. In E. Morrison, & B. Furlong (Eds), Healthcare Ethics (pp. 47-63). Burlington, MA: Jones and Bartlett Learning.