Ethics of the individual mandate

by Raymond Raad, MD, MPH

There is a remarkable inconsistency between the ethics of medical practice and the discussion about the health care reform law passed this past March, especially the individual mandate.

In medicine, it is considered unethical to force a patient to do something against his will.  Patients are allowed to disagree with their doctors and to decide for themselves whether they want to heed their advice.  Patients are even allowed to refuse medical care when doing so would threaten their lives.  A patient is allowed to refuse warfarin if he has atrial fibrillation or a deep vein thrombosis.  He is allowed to refuse surgery for a resectable tumor – provided he understands the consequences.

Many of us would disagree – sometimes quite strongly – with such decisions.  But few would advocate forcing patients to do such things, even if it were for their own good.  Instead, because respect for autonomy is a major principle of bioethics, we favor trying to convince them.  The only exception is when a given patient does not understand the nature and effect of the decision he is making – which only applies to a small minority of patients.

When it comes to health care reform, however, these standards are thrown out the window – few people seem to consider it a violation of respect for autonomy to force people to buy health insurance.  I did a search for articles discussing the ethics of the individual mandate, and my most striking finding was that there were so few of them! There are a few that focus on whether the mandate is constitutional, which is important, but is not the same question.  There are also a few articles that argue that the mandate is ethical because it is “necessary” to insure everyone.  These articles implicitly focus on another principle of bioethics – distributive justice – but they barely even mention autonomy.

Yet, it is hard to understand how the individual mandate is compatible with respect for autonomy.  If it is unethical to force a competent person take antibiotics even if it might save his life, how can it be perfectly ethical to require him to buy a product that might be to his benefit?

I am aware of two possible answers to this question.  The first is that respect for autonomy must be balanced against other principles.  That may be so, but then we should be explicit that the individual mandate does violate respect for autonomy and those who are pro-mandate should have to justify that violation.  Instead, there is almost no mention of autonomy surrounding this issue.

The second is that a patient who refuses medical treatment is hurting only himself, but one who refuses to buy health insurance imposes costs on the rest of us by using the emergency room.  That is a fair objection, but it has a simple solution – abolish EMTALA.  This would be politically unpopular (to say the least), but since when does politics constrain ethics? Shouldn’t it be the other way around? If old laws are leading to significant violations of a major principle of ethics, then conscientious healthcare thinkers should be willing to consider abolishing them.

Raymond Raad is a psychiatry resident.

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