Health Disparities: Just and Unjust Robert M. Veatch Professor of Medical Ethics Kennedy Institute of Ethics Georgetown University
Mar 30, 2015
Health Disparities:Just and Unjust
Robert M. Veatch
Professor of Medical Ethics
Kennedy Institute of Ethics
Georgetown University
Deamonte Driver (deceased)
Cause of death: No dentist
Medicaid Pediatric Dental Access Disparity
• Maryland: Medicaid children– less than one in three receive dental service– 16% had access to restorative services
• D.C.: 29%
• Virginia: 23%
Primary Care Access Disparity
• Gentleman without primary care–Calls 911 whenever he feels sick–Knows EMS service must respond and
transport him to a hospital–Knows ER will look at his sore throat
Unjust disparities and Universal Basic Healthcare Access
• Unconscionable lack of basic healthcare coverage in the United States
• Cost not necessarily the limit– Better dental care for Deamonte would have
been cheaper and more humane– The ER is not the cost-efficient way to deliver
primary care
• Universal access to just basic care is a right
Unjust and Just Disparities
• Funding universal basic care requires setting limits
• Rationing of care is a logical necessity–Rationing by wallet–Cf. rational rationing
Rational Rationing Exclusions
• Treatments not established to be effective• Treatments for trivial problems
– Cosmetic surgery– Minor aches and pains
• Morally controversial interventions• Voluntarily assumed risks (the problem of
justified health disparities)
Just (Justified) Health Disparities
• Some health risks are voluntarily and intentionally undertaken
• Ethically suspect to impose the resulting health costs on the basic health plans of other people
• We have to confront the rationality of voluntarily choosing less than maximal health
Arizona Governor Jan Brewer
The Irrationality of Maximizing One’s Health
• The goal of maximizing health conflicts with the goal of maximizing well-being• Implication: People are voluntarily less
healthy than they might be• Intentionally• Rationally
• Different people deviate from maximal health by different amounts• Health disparity that is not unjust
Implications for Health Insurance
• Unfair for insurance to pay indiscriminately for both just and unjust health disparities
• To have the resources to pay for Deamonte Driver’s tooth ache, we need to separate the costs of voluntarily (fairly) chosen health risks
• Need to separate two kinds of fair health disparities
Monitorable Health Disparity Costs
• Smoking– Monitorable– Behavior in the public nexus (purchasing)– Linear dose-response correlation– Clearly not worthy of public subsidy (cf. fire-
fighting)
• Health fee calculated to reimburse insurance system
Monitorable Health Disparities
• Smoking• Alcohol (?)• Public skiing• Professional sports
Nonmonitorable Health Disparity Costs
• Obesity and hypercholesterolemia– High cholesterol medically bad and costly– Two plausible approaches:
• Diet and exercise• Statins
– Standard recommendation: diet and exercise first– Statins as a backup
Statins
• 25 million Americans take a statin• Cost: $11/month or more• Aggregate cost: $26-34 billion/year• “Diet and exercise first” can be questioned• Some people don’t try diet and exercise first
or don’t try it seriously enough• Is it “just” that insurers pay for these
statins?
Problems in expecting people to pay for their own statins
• Diet and exercise are not monitorable• Relation of cholesterol to diet and exercise
not linear• No reason why it is rational to expect
maximum use of diet and exercise before statins
• Statin use may be rational alternative• = a “just disparity”
Statins and Just Disparities
• Those with high cholesterol who have not adequately tried diet and exercise are different from those who have
• Many statin users are free-riders• They have a health disparity that is not
unjust
The Problem of Just Disparities
• Those with high cholesterol who have not maximized diet and exercise have “just disparities”
• In theory they should pay their own way
• Impossible to enforce• Must resort to ethical appeal
Ethical appeal and just disparity
• Some with high cholesterol have not tried diet and exercise
• No one should be expected to eliminate all voluntary health risk
• Rational people will not have ideal cholersterol level without statins
• Resulting disparities not “unjust”
Ethical appeal and just disparity
• People should make a “reasonable” effort• Insurance should not pay to treat voluntary
(just) disparities– Place health fees on monitorable risks (tobacco)– Try to transfer nonmonitorable health costs– At least appeal to ethical duty– Attempt to develop valid monitoring
• Such policies necessary to be able to pay to cover Deamonte Driver and others with unjust disparities
Thank you