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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  • http://www.somebodyhealme.com Diana Lee

    Forcing someone to buy insurance isn’t the same as forcing someone to receive medical care.

    • Constantino

      Care to elaborate?

    • jsmith

      You are correct. See Brian’s post below.

  • pheski

    Quote: “it is hard to understand how the individual mandate is compatible with respect for autonomy”

    Wow. Let’s go the autonomy route and eliminate speed limits, bans on burning slash during a drought, hunting out of season, income taxes, required attendance at school, stopping at red lights, parking regulations, public nudity.

    Is it really so hard to see the difference between an **individual** physician not being allowed to impose her personal preferences on an **individual** patient and society enforcing (or prohibiting) certain behaviors?

    P

    • Raymond Raad

      Pheski, thanks for the comment. If I understand you correctly, you’re arguing against the principle of respect for autonomy, which is a different topic altogether. Respect for autonomy is already a widely held principle in medical ethics. I’m just arguing the individual mandate is not compatible with that principle.

      No I don’t see a difference between an individual physician imposing his views and “society” doing the same. “Society” is just a group of individuals. It doesn’t act. It is always a person or a group of people who impose their preferences in the NAME of society. Both violate autonomy.

    • Constantino

      @pheski, Would you mind telling me why you think it is ok for a group of people to “enforce (or prohibit) certain behaviors”? How exactly does it differ from an individual person imposing his or her views on another individual? I’m not sure I see the difference.

  • http://wellescent.com/health_blog Wellescent Wellness Blog

    The whole concept of “forcing” people to buy health insurance being equivalent to informed consent is a rather weak argument because it hinges on the basis of the implementation. Were we simply taxed for health care in the same way that we are taxed to spread the burden of education and road infrastructure costs, it would be hard to justify an argument of being “forced” because paying such a tax would simply be considered a responsibility of “carrying one’s own weight”. The real argument here is whether the healthy have some obligation to cover the medical costs of the those who are born or become ill.

    Most other countries have decided the issue as being one of equality where forcing undue financial hardship on those who are ill is unacceptable for a modern society. However, when the system is based on for-profit health insurance, the only real way to ensure access to health care for those with ongoing health issues is to ensure that insurers can offset the coverage costs by having a significant population that is generally healthy. The individual mandate accomplishes this within the a private system.

    • http://Www.twitter.com/alicearobertson Alice

      The UK had to allow the free market entry into their socialized system….it saved lives and saved their government money. But it was too late. Major cuts that will mean more old equipment with faulty results, more waiting lists…..blah, blah….

  • http://www.nallyfamilypractice.blogspot.com Adam Nally DO

    Thank you! Well stated.

  • Obedient Law Abiding Citizen

    Courageous post. Moral question: What should one do in response to a political mandate that one disagrees with in principle?

    Importantly, bear in mind the important distinction between spiritual law and political law.

    Spiritual law applies to universal beliefs about respecting other people’s rights, not hurting others, not taking stuff from others, not getting them to do your bidding by violent threats. These transcend different cultures regardless of religion or even lack of organized religion.

    Political laws are laws decreed by certain people ie “elected rulers” who have declared themselves as having authority over other people ie “common folks”. This can be decreed by an elected Title, a document of paper, a crown, a funny hat, a badge or more often than not, it can be decreed merely by being bigger, stronger or having more weapons.

    What is a person to do? Well one way of viewing it is that you should obey both types of laws. The spiritual laws are to be obeyed because it is the moral, right thing to do. The political laws are also to be obeyed, because if you don’t, you’re at great risk for some harm, either being locked in cage, having your belongings taken from you or being robbed of your life.

    So when asked if we should go along with mandates on our behavior, specifically mandates on how to spend our money, whom to give a percentage of our earnings to, what laws to obey, you can choose my strategy, which is to obediently follow the rules so as not to be harmed. If instead you instead decide to bravely stick with what’s morally right, bear in mind that this might be foolish from a practical point of view as long as the rulers have total control over you.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Let’s see… You find it perfectly ethical to refuse emergency treatment to people that cannot pay, thus letting them expire on your doorstep, but you have an ethical dilemma with fining those who refuse to chip in for their unplanned emergency care. Interesting perspective on ethics.

    • Brian

      Truly.

      The author seems to believe that the only truly ethical way to preserve autonomy is to abandon beneficence.

  • Chang She

    Great article. I like the distinction between whether something is constitutional vs whether it’s ethical.

  • Jeff Taylor

    This is a distraction. As pheski says, we already have many things we have to do. The choice is whether we want to actually have a decent functioning and productive society, we being social animals after all. Or not.

    • Constantino

      I’m not sure “we already have many things we have to do” is enough of a justification. Legality is not the same thing as morality. Could it be there is already a number of laws in our books which lack a moral justification? I agree with the author. If you wish to violate a person’s right to choose on a particular matter, the burden of proof is on you–the one who wishes to take away that choice.

      • Brian

        Yes, but proof of what? Proof that establishing a moral (or just) system requires some diminished individual freedom?

  • Alex Voldman

    Great post Ray. I’m with you. I believe the government has a role in providing subsidies, coupons, promoting affordable options for the purchase of private health care (all from taxes that I am mandated to pay), but forcing me to buy insurance is too much.

  • Daniel Bernstein

    “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.”

    Which “major principle of ethics” are you arguing EMTALA violates? The post you reference argues that EMTALA is unconstitutional, stating that “EMTALA requires private citizens, largely physicians, to provide the fruits of their labor without compensation or due process, and as such represents an unconstitutional ‘taking’ of private property.” Please forgive my lack of understanding, but I fail to understand how performing one’s job at one’s place of work is can be considered an ethical principle at all. According to the Declaration of Geneva, a physician shall “not allow his/her judgment to be influenced by personal profit or unfair discrimination” (see http://www.wma.net/en/30publications/10policies/c8/index.html). Ethically, compensation for provided care should not be dictating whether or not a physician cares for a specific patient.

    What EMTALA does do is that it “imposes specific obligations on Medicare-participating hospitals [not physicians themselves] that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay” (see http://www.cms.gov/EMTALA/).

    In effect, EMTALA makes law what, again, the Declaration of Geneva has already made principle, that a physician shall “give emergency care as a humanitarian duty unless he/she is assured that others are willing and able to give such care” (see link above). If a physician does not see his or her primary duty as attending to the care of his or her patients, then I believe that a “major principle of ethics” actually has been violated.

    As to the issue of the Individual Mandate, I agree with Pheski. There may be laws that any one individual is unhappy with, however, laws (in their intent) are written for the benefit of society as a whole. Requiring everyone to obtain healthcare benefits the society in the long run because individuals requiring care will not need to pay huge monetary sums out of pocket and hospitals will not be required to provide care (emergency or otherwise) without some form of compensation (i.e. repayment by insurance companies).

    • Raymond Raad

      Dan, I’m not arguing that EMTALA is definitely unethical. That would be a bigger claim that would require more support. Here is my argument: EMTALA creates a free-rider problem whereby those who don’t have health insurance can free ride on those who do. This free-rider problem is then used to justify an individual mandate, and that mandate violates respect for autonomy. In this sense, EMTALA leads to something (the mandate) that violates a principle of ethics (respect for autonomy).

      • Brian

        Sorry, not buying it.

        First of all, I disagree that the individual mandate violates the principle of respect for autonomy as a medical ethics principle. Personally, I view it as existing outside of the realm of medical ethics; this is an issue of public policy, not medical treatment per se. So I believe you’re misguided there.

        But even were we to accept your proposition that it is at odds with the principle of respect for autonomy, you present a simplistic view of medical ethics by avoiding the very legitimate question of whether the values of beneficence and/or justice apply from a societal standpoint.

        • jsmith

          You are right that the insurance mandate does not violate pt autonomy. The law states you have to have insurance, not that you have to use it.

  • X

    My problem with posts like this is authors like to gloss over the unsavory part of their plan. I actually think your viewpoint is valid; I am all about personal responsibility. But please have the testicular fortitude to, rather than say “abolish EMTALA,” say something like “Patients who choose not to buy insurance but then find themselves in need of medical treatment should not receive said medical treatment, even if death is the likely outcome without treatment, if they cannot pay for it.”

    • pcp

      aka “The Jan Brewer philosophy of health care”

    • Raymond Raad

      X, fair enough, people who have views like this do tend to gloss over some things. But it’s much more complicated than both “end EMTALA” and “those who can’t afford care not getting any”. People are motivated by more than just money. Judging by the views of many of the physicians on this site, there are lots of docs out there would would offer charitable care rather than watch people die on the street. But yes, autonomy would likely entail at least some people not getting the care they need.

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        You mean die?
        …because they don’t have cash and you are just fresh out of charity….or just in a bad mood today…. or they didn’t beg persuasively enough… in the United States of America….
        It’s not personal, of course. It’s business.

  • Anonymous

    If EMTALA is abolished, would any emergency room actually refuse care to a patient brought in without proof of money or insurance on him/her and either unconscious or without ability to communicate ability to pay? If such emergency care is refused, how big will the lawsuit be if the patient dies or suffers greater harm due to the refused care?

  • http://fertilityfile.com IVF-MD

    What is the value of charity? No, not just to the recipient but also to the giver? Here’s some food for thought.

    I can speak from personal experience that there is something positive and good that comes from voluntary charity work. For example, last year, according to my records, I logged over 70 hours of pro-bono work, done in indigent clinics and teaching institutions outside of my own practice. I did not earn a single dollar (well as a full disclaimer, I did have one patient end up coming to my practice because of lack of equipment to do treatment in the indigent clinic and pay me maybe a discounted $700 for $2000 worth of services) and in fact, with parking, gas and occasional other expenses in addition to the great amount of time expended, it was quite a burden. However, get this. I got so much out of it. Why? Simple. As you can probably guess, I got the emotional satisfaction of helping out of my own volition and that greatly adds to my life purpose. Now, let’s change the story. Pretend that instead of being allowed to do this voluntarily, I spent the exact same time and energy but now I’m being FORCED to do the same charity work. What then? What a loss would that be? Not only do I feel violated and manipulated, but it also takes away the entire feeling of good will. I would argue that a large part of beneficence come from it being a gift from the heart with no outside coercion. When you put a law to someone’s head and force him to do something, it robs him of the act of charity.

    I would argue that many many many of the compassionate ER doctors I know would gladly give and/or have already given charitable acts of kindness even without a coercive law.

    I certainly agree with all of you that kindness is a great thing to have, especially if I labor and sweat and take from my own pocket to help others. However, would you not consider me a hypocrite if I talked and talked about helping, but all this supposed helping that I was talking about consisted of YOUR labor and sweat and taking from YOUR pocket to help others? Or would you forgive me as long as my intentions were good? :)

    • http://Www.twitter.com/alicearobertson Alice

      If all the altruists would unite and actually do something we would not be having this conversation. We can do these charitable works far better than a government program. We need more action verbs that are not just on paper. The historical movements that were started privately like The Red Cross, etc. Have changed history….but it takes people not bureaucrats.

      After natural disasters we see Christian organizations move in and serve so selflessly they are very productive (there maybe other organizations too, but I read Christian news, so therefore, I can report on that aspect).

    • Brian

      IVF-MD, while I certainly respect you, as you might imagine, I disagree with you once again. First let me thank you for your charitable work; if more people were similarly motivated, I think the positive effect would be much greater than the sum of its parts.

      That said, I believe that any cogent discussion of medical ethics, and further whether the individual mandate somehow runs counter to the values and principles of medical ethics, must consider those values and principles together.

      As an example, even if we grant the author that the individual mandate somehow runs counter to the value of autonomy (a sentiment with which, by the way, I don’t agree), his work is not done. He seems to treat medical ethics as though it is an all-or-nothing proposition: “Oops, this individual mandate seems to violate respect for autonomy, therefore it must be unethical.” But this is an overly simplistic analysis, a charge that I have leveled here three times already, but to which the author has yet to reply.

      Any cogent ethical analysis must consider a given ethical problem against all of the values of medical ethics. Those regulations, procedures, practices, etc. that we think of as ethical are often a trade-off between ethical values. Perhaps the satisfaction of non-maleficence and/or beneficence in this or that case justify some degree of encroachment on respect for autonomy. As an example, implied consent to treat suicidal patients is a practice that justifies an encroachment on autonomy because of its concomitant satisfaction of beneficence and non-maleficence.

      We may disagree about the ethics of the individual mandate, and that’s fine. But whether you agree with the author’s conclusions or not, you must at least recognize that his reasoning to get there is incomplete at best. That the mandate, in the author’s opinion, violates respect for autonomy, is not an a priori sufficient reason to conclude that it is unethical on its face.

      This, of course, sets aside the very real question of whether the author is correct that it violates respect for autonomy in the first place.

    • Brian

      Oh, and one other thing, if you’ll indulge me.

      There is another value in medical ethics that seems to have fallen by the wayside in this discussion, and that is justice.

      I interpret it as referring to distributive justice, namely, what is the most just way of distributing finite health care resources? Personally, I think it should be done from John Rawls’ “original position”, and as a consequence, I think that every person should have access to quality basic health care. If we accept that government should not be in the business of eliminating the insurance market, then the only solution remaining is to ensure that that market is at least set up with an eye toward distributive justice. The individual mandate is but one solution to that problem.

      I get the impression that you dislike regulation, that you’re the sort who believes that the best government is a small one with little or no regulatory role. I agree with you up to a point, but I do believe that prudent government regulation can be a powerful force for the protection of American citizens from the inevitable externalities of unregulated markets.

      • Raymond Raad

        Brian, you make a number of good points. It would take a lot of space to reply fully, but I’ll just say one thing:

        I acknowledged in my post that Autonomy must be balanced against other principles. My point is not that autonomy trumps everything, but that it should be considered seriously. In medical decisions we balance autonomy against beneficence. In health policy, we should also take autonomy seriously and balance it against other principles. But I don’t hear autonomy brought up AT ALL in discussions of the individual mandate.

        • Brian

          Raymond,
          Looking back, it appears I owe you an apology; upon my initial reading, I missed the part where you acknowledged the other values to be considered. Sorry to have misrepresented your argument.

          Nevertheless, as I’ve said before, I disagree with you that this runs counter to the value of autonomy unless you extend the penumbra of medical ethics to encompass even indirect aspects of medical care. I personally don’t, but that’s mostly because I think that to do so would lead the entire concept of medical ethics far afield of its intended purposes to begin with, into meta-health care, if you will.

          Either way, I understand your meaning, and it occurs to me that this is very similar to the unconstitutionality argument, but from a different perspective. Nothing wrong with it, but obviously I disagree.

      • http://fertilityfile.com IVF-MD

        Brian, thank you for your reply. Yours and the replies of others really make me think and scrutinize my existing views and I love that. By the way, if anybody knows of a good forum for real-time discussions as opposed to comment-section-chatting, please let me know.

        So Brian, I will agree with you that looking at The Mandate to purchase insurance from a viewpoint of justice, utility, beneficence is ultimately more important than looking at it in isolation from a viewpoint of autonomy alone. If we were to just cone down to autonomy alone, I can’t imagine any rational way to argue that it is NOT a violation of the rule of autonomy, but who cares? I will agree with you that it’s not as important as a debate on the big picture. To me, the big picture boils down to “How will this rule improve the quality of life of some people and / or hinder the quality of life of some people?”

        Well, my next argument is founded on the fact that in something so complex as human economics, there are almost always unintended consequences. What does that mean? Well….

        I am convinced that simplistic coercive approaches to social problems aren’t as good as they seem. In fact, they can do the opposite. Examples?

        Poverty is bad. Therefore, let’s take money from people who are not poor and give it to people who are poor. This should reduce the number of people who are poor. Has this worked or has the number of poor people actually gone up?

        Alcohol is bad. Therefore, let’s make it illegal to possess alcohol. This should make alcohol and all its health-related negatives and socially-related negatives go away. Did this work or did it actually create more problems?

        So now we are thinking. Not having health insurance is bad. So let’s force everybody get health insurance. This should make thing OK. Will this work or will it result in a cascade of other events that will ultimately make life worse?

        These questions are not best solved by hypothetical debate nor thought experiments. Let’s just study it scientifically.

        In a FREE world, things can studied scientifically just by sitting back and watching. Concepts such as evolution and evolutionary psychology show us that things that tend to result in the desired outcome will eventually propagate while things that don’t result in the desired outcome will die out. Such is the power of innovation and of the free market.

        So how does this apply here? Well, I’ve resigned myself to the fact that we can never solve this question by simply debating, so why not solve it by reality? Suppose we have have pilot programs where certain groups of people are subject to a mandate and other groups are allowed the freedom to find their own best solution. The validity of the results will not be perfect, granted, because in order to be perfect, the two groups have to be relatively isolated in their interaction. But for the sake of argument, let’s accept that and say pick a state on the far East Coast of the US and put in the strictest version of government healthcare that you can think of with mandated insurance purchase, high taxation, strict rules on insurance company terms, heavy-handed control of what businesses must submit to etc etc. Then on the far West Coast pick a state and let the free market run with emphasis on autonomy. No Mandate. Low taxes. No EMTALA. No regulation of insurance other than what the market will bear.

        Then sit back, grab some popcorn and watch the game play out for 4 years. Even before these 4 years is over, by halftime, let’s say, I trust we will learn some pretty insightful things.

        This will give time for the side with the “wrong strategy” to move on over to the other side’s strategy. If the East Coast method results in a happier place with people getting better quality health care and better quality of life, then we all win because now the West Coast can learn and shift over to that way. Vice versa if the West Coast turns out better.

        However, if we stick with the way we do it now and we guess wrong. Then EVERYBODY is stuck with the disastrous consequences.

        Everybody should be happy with this idea except for one group. Those who profit from a bad system would not want this type of experimentation because it would expose the truth, just as bootleggers would not have wanted people to ever learn that the lifting of Prohibition would have made society better overall, because while Prohibition was in place, they were getting enormously rich themselves from the way things were.

        So now if only we can discuss how we can execute this plan to try different ways out in different places and finally answer the question of which system is better — a coercive central planned system or a free market system?

        • Brian

          That’s a fair enough argument, but I think you may have inadvertently shifted the perspective a bit when you came to the insurance part.

          First, I think it’s worth noting that no one is being forced to purchase health insurance. Rather, buying health insurance is being incentivized by way of a fine levied on those who don’t buy it. If you think about it, this is not all that uncommon a scheme. As an example, I own a dog. We can agree that stray dogs, and dogs that carry rabies, are bad things. The city in which I live requires me to register my dog (including a dog registration fee), as well as provide evidence of vaccination (for which I have paid) or face a fine for not doing so.

          But second, it is not so much the fact that not having insurance is bad that has prompted this mandate, but the fact that not being able to afford or access health care is bad. Again, this goes to distributive justice for me; how do we ensure that finite health care services and dollars are distributed such that everyone has access to basic, quality care?

          In my opinion, the answer is relatively clear, if imperfect: Universal health care to provide for the fundamental health care needs of Americans. In addition, citizens would be free to purchase private insurance for additional health care (elective cosmetic procedures, etc.). Insurance companies would then be free to discriminate based upon pre-existing conditions, etc., because the safety net for those higher-risk patients would still be in place. Additionally, clinic overhead would decrease, because with fewer insurers to wrestle with, physicians wouldn’t have to hire an army of coders and billers.

          But I recognize that this remains an unpopular idea, because a belief in the power of free markets makes many very suspicious of the idea of universal, so-called “socialized medicine” (which, of course, it is, but now with scare quotes). The heartburn that I have is that even recognizing the ability of free markets to provide effective solutions, I cannot countenance the idea that we should trust in markets without guaranteeing that modicum of distributive justice.

          Therefore, I personally believe that government has a role in incentivizing markets to “do the right thing”, as it were. Orphan drug incentives are an example, and I believe that the individual mandate, though obviously an imperfect solution, is another example born of the harsh reality that is resistance to the idea of universal health care.

          In any event, it is always an honor and pleasure to exchange ideas with you. I’ll be on the lookout for forums such as you describe.

          • http://www.twitter.com/alicearobertson Alice

            First, I think it’s worth noting that no one is being forced to purchase health insurance. Rather, buying health insurance is being incentivized by way of a fine levied on those who don’t buy it. [end quote]

            Brian….this is a nice gussied way of succumbing to government control. It is a mandate that will be penalized and they are hiring over 16,000 IRS agents to make sure we appreciate the incentives!:)

          • pcp

            The 16,00 IRS agents is a lie that has been debunked countless times by non-partisan analysts, and by repeating it, you weaken all your arguments. This particular lie was chiefly promulgated by Newt Gingrich, who aggressively argued for an individual mandate until a Democrat moved into the White House.

          • Brian

            Brian….this is a nice gussied way of succumbing to government control.

            Surely you recognize that the federal government does have some regulatory role. I’m curious why you draw a distinction here. I’m not succumbing to government control so much as I am acknowledging its regulatory role, especially with regard to such a huge share of GDP.

            As for this:

            It is a mandate that will be penalized and they are hiring over 16,000 IRS agents to make sure we appreciate the incentives!:)

            The 16,000 figure has been debunked time and time again. I suggest you see http://factcheck.org/2010/03/irs-expansion/

  • IMDoc

    The insurance mandate does not exist because of EMTALA. It was placed in the bill to allow for the prohibition of pre-existing condition exclusions. The idea is simple: tax people who don’t purchase insurance so they are discouraged from waiting until they are sick, thus driving up insurance premiums for everyone. Insurance systems don’t work when there are no low-risk people paying into the system.

    • Anonymous

      Insurance systems don’t work when there are no low-risk people paying into the system.

      Actually, what is causing medical insurance to break down is that there is a relatively high degree of predictability of costs/losses for the individual, including when the costs/losses will occur. It is not like a high risk pool of 16-year-old car drivers where you do not know which one will have a crash when. But you do know that a person with cancer will need some type of expensive treatment in the near future, a person with type 1 diabetes will need insulin, etc..

      So medical insurance has become more like prepaid medical care, though the costs are typically hidden from the patients. It also means that the true “insurance” component (i.e. coverage against unknown and unpredictable expensive costs/losses) is a relatively small portion of the medical insurance cost.

    • http://www.davisliumd.blogspot.com Davis Liu, MD

      Agree. The author of the post is trying to fit two very different issues together – patient autonomy versus individual mandate – which are unrelated.

      The issue of individual mandate is precisely to have an insurance system manage the health care system. As the author noted, “one who refuses to buy health insurance imposes costs on the rest of us by using the emergency room”, which is precisely why we are having the health care reform discussion.

      Unless of course, the author is advocating abolishing the insurance system and installing a single payer system, which is a completely different post and discussion.

  • pcp

    The individual mandate was a prominent feature of every important Republican health reform plan (Eisenhower, Nixon, Gingrich, et. al.) until January 20, 2009.

  • K

    I agree with a lot of the criticisms regarding the EMTALA – I don’t think a doctor can ethically refuse a patient in desperate need of care simply due to inability to pay and I do think that a certain degree healthcare is a right. Furthermore, I think a distinction needs to be made between the right of a patient not to follow a prescribed treatment – autonomy over body – and the right to property, which most of us agree can occasionally be compromised in the interest of the public good. This is why we pay taxes, and why services like firefighters and police are publicly funded. While I do think there are ethical issues in making someone purchase insurance from a private company, I don’t think requiring people to have insurance is, per say, unethical.

  • AA

    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.”

    I find it interesting that you as a psychiatry resident Dr. Raad said nothing about the fact that psychiatry constantly forces people into treatment against their will even when they are competent to say no.

    Sorry, I don’t mean to sound like I am picking on psychiatry but a case of someone receiving outpatient ECT against her will in Minnesota is still on my mind.

    In light of that fact, I don’t see a contradiction regarding those folks who favor the individual mandate.

    Also, aren’t single payer countries essentially mandating that people buy into the insurance system? The difference is that the costs are lower which I think is one reason why this law has people so upset.

  • http://www.twitter.com/alicearobertson Alice

    IVF-MD February 3, 2011 at 1:52 pm

    Brian, thank you for your reply. Yours and the replies of others really make me think and scrutinize my existing views and I love that. By the way, if anybody knows of a good forum for real-time discussions as opposed to comment-section-chatting, please let me know. [end quote]

    There are some good forums out there that do not delete and moderate (I like WSJ, love The New Republic…….especially love Reason magazine and their extremely well-thought out libertarian approach I don’t always agree with but feel enlightened after reading….for the pot smokers it’s a real oasis…..I think they will start posting start up medicinal hot spots with WiFi soon [remember Jon Steward said that after Colorado passed legislation on this they went from the healthiest state to the sickest:)]……The Atlantic has some great input…um….you can write to me and I will send you more…oh yes, Forbes Magazine is quite good and for the funky WIRED magazine is thought-provoking, but I definitely disagree with their evolutionary almost weird science. I subscribe to all these magazines…..of yes, RealClearPolitics…….and, of course, Free Republic is a hoot on some days…wicked sense of humor at times….there is always Newsweek and TIME…if I read an article I like I go to the blogs…..usually a yawn….same as The New York Times).

    This is such a good article to use as a sounding board about rights…..one on my heart is the freedom of speech. The internet gave us such a loud voice……it’s wonderful….when it isn’t suppressed. What I have found though is the more liberal the controller of a blog, the less they believe in freedom of speech…which means the thought police are controlling content that goes beyond personal offense, or slander, or libel…..it is just using your position to squelch a voice (agendas are at work…..whether it be sponsors or friends……it’s not truly freedom of speech when someone decides a poster’s voice shall not be heard on different levels even when the poster follows the guidelines). I may disagree with liberals….but I will go to the mat for their right to say what’s on their mind. It’s a vital right. I find Ann Coulter abrasive…yet funny at times……same with Olbermann….but they have the right to their opinions and should not be suppressed. Yet, the left is heavy handed at suppression which I find oddly fascinating, but inline with their tendencies to want more government mandates to protect their rights not realizing they are cutting off their nose to spite their face. This all ties in with the health care bill….liberals proclaiming they don’t mind giving up rights and money to help others not realizing they are ultimately hurting many more. No one should give up rights like that and we don’t need to give up rights to help other people……we need to give more of ourselves….and encourage more accountability for our personal lives and freedoms.

    Conservatives are usually strict Constitutionalists (and that word is subjective….with the Tea Party and their laminated copies of the Constitution and Bill of Rights as their Bible), to the liberal mindset that enjoys the freedom of speech clause until you disagree with them. I recently hopped over to the Huffington Post because I wanted the most radical opinions on health care I could find to make sure how I felt was covered on all bases…I wanted to be contested. There was a fantastic thread about health care with the big free marketers from the Heartland Institute wrapping up the debate really well. The journalist thought she had the goods, but she didn’t. I jumped in with little support. I loved it! It was wonderful to post without knowing a moderator could delete you (now that said on the immunization thread they have deleted a lot and when I was called a name [didn't bother me....you shouldn't be debating if you are hypersensitive] someone flagged it and it was deleted. They flag a lot because it’s a way to become a moderator]).

    I am the type who will go down in the flames over keeping our rights in tact. In truth……I am one who struggles with Wikileaks. My heart says he was a traitor….and yet, the repercussions of removing his right to do this has me a bit contorted. This has been done throughout history with wars, etc. and I can’t just say it is wrong because I fear it hurt Americans. If it helped Americans would I think it was right? That’s a poor litmus test for our rights. Just thinking aloud really.

    • Brian

      With all due respect, you decry liberal silencing of conservative viewpoints, and then put forward Free Republic? Freepers delete and ban even moderate posters all the time!

      Also, freedom of speech doesn’t necessarily mean you can post whatever you want, wherever you want. I take it as a given that the person hosting the comments has a right to allow or delete whichever comments they like (or don’t!).

  • Amy

    This is an excellent article. Raymond makes a great point that abolishing EMTALA would solve a lot of issues.

  • alice

    Hmm…..I thought I recommended Huffington Post to….is that fair enough?

    Freedom of speech is a constitutional right as I shared….I hate censorship….so. yes a moderator has the right to censor but it means they do not completely value freedom of speech and have a reason to supress thought. I differentiated this. That is the great thing about America…..if you do not like the way someone is censoring you can go elsewhere and yell it from the rooftops…it’s bloody well fantastic!

    • Chris

      Not really. The “both sides do it” belief obscures the real problems with both sides of various debates. It also substitutes “one of each” for actual balance. I’m not familiar with much in the way of how comments are run on the Huffington Post or Free Republic but I’m familiar with the articles on both and they’re not remotely equivalent.

      Freedom of speech exists only as regard the government silencing individuals and groups. It’s irrelevant to private individuals’ communications with and amongst each other. One may well “censor” or remove commentary for reasons other than not valuing freedom of speech. Indeed, many commenters attempt only to disrupt everyone else’s speech and communications…in that kind of case, removing the one commenter may preserve a discussion forum for dozens, hundreds or thousands of others.

      • http://Www.twitter.com/alicearobertson Alice

        But, Chris, you make the point why freedom of speech is important. If we silence critics we go back to a type of monarchy…which is played out on some blogs. Huffington was just purchased by AOL. I find that interesting because we know that ownership means expression of ideologies. Free Republic is only for those who like sardonic humor. I rarely go there, but when I do I go to the political cartoons. I recommend it only for those with a wicked sense of humor…..but I remain grateful I can still recommend it.

        Let me say for those who did not listen to PM Cameron on freedom of speech for all races this week…please do.

  • alice

    Still on cellphone…read factcheck…..I think Brian and pcp need to read a bit closer. There are a few play on words there.

    So how do you two think this mandate will be enforced in big government? What about families making over a quarter million? Maybe envelopes like church offerings? What about the new bureaucracy and the agencies created for enforcement? My imagination? Common sense dictates new laws need regulators to regulate.

  • http://www.twitter.com/alicearobertson Alice

    Surely you recognize that the federal government does have some regulatory role. I’m curious why you draw a distinction here. I’m not succumbing to government control so much as I am acknowledging its regulatory role, especially with regard to such a huge share of GDP.
    [end quote]

    So what happened to the incentives you discussed? Regulation via incentives?

    I ask a lot of questions in order to understand….are you saying you don’t mind giving up some rights for the good of others? Fines, mandates? How far do we go for the good? What would you define as the rights of man?

  • http://www.twitter.com/alicearobertson Alice

    I can’t find the non-partisan information on this (factcheck isn’t non-partisan..they say they are….but…they tend side with Obama. Have you read some of the exchanges with the editors that are online?)

    But for the sake of debate let’s take the 16,000 off the table. Let’s trash it. How will Obamacare be regulated or as you said incentive driven? Just how many new agencies that will employ people/agents will it take to regulate this law?

    I try to read both liberal and conservative magazines (why else would I continue my subscriptions of TIME, Newsweek and US News which is going under)? Huffington Post loves factcheck.

  • http://Www.twitter.com/alicearobertson Alice

    Okay I found the info on the IRS it was from the IRS Deputy Commissioner Steve Miller talking about the tools they will use to enforce (which could mean reducing you tax refund. Really interesting and backs up what I said and it is Congressional testimony about enforcement of Obamacare. I can share more about the non compliance fines and give the link about the 10 billion they can collect. Also, look up Steve King’s writings…which are Republican.

    • Brian

      Would this be the same Steve King who praised Republicans’ “mendacity”, and believes that the black farmer’s settlement was secretly reparations for slavery?

      Anyway, you haven’t provided a link to the IRS information, so I still have no reason to believe it’s not a lie.

  • http://Www.twitter.com/alicearobertson Alice

    I do not do well on a cellphone, so I grabbed the iPad and found this in about two seconds. Full testimonies at Congressional hearings should be widely available :

    http://www.michigancapitolconfidential.com/14020

    Snippet

    Since the bill was passed, more and more analysis is being done over just what impact the mandate will have.
    Michael Tanner, senior fellow at the Cato Institute, released his analysis of the mandate’s far-reaching effects.
    Tanner states that simply having insurance is not enough to escape the penalty. Plans will require such services as “ambulatory patient services, emergency services, hospitalization; maternity and newborn care, mental health and substance abuse treatment; prescription drugs; rehabilitative and habitative services; laboratory services; preventative services; wellness services; chronic disease management; pediatric services, and dental and vision care for children.”
    Failure to comply will result in a fine equal to 1 percent of income. The penalty increases to 2 percent in 2015, and finally to 2.5 percent in 2016.
    In 2016, the minimum penalty for an uninsured family of four (children count as half an adult) will be $2,085, according to Tanner.
    Those people who choose to go without health care could risk losing their income tax return if they don’t pay the fine. The IRS could withhold refunds to those who don’t pay, as was suggested by Steven Miller, an IRS Deputy Commissioner for Services and Enforcement.
    According to the Congressional Budget Office, four million people will face penalties in 2016. The federal government projects this will raise $17 billion from penalties by 2019.

  • Killroy71

    Why does no one question the ethics of forcing a private business to take actions that will result in losing money? You want to force insurers to take you, but you don’t want to take insurance until you are ready to start spending other people’s money on your health care. How ethical is that?

  • alice

    Killroy….asked a good question that is at the heart of Obamacare. The wonderful pre existing condition clause (again with two kids with cancer and a husband with two heart blockagesL) this seems wonderful…yet it would be like allowing me to have no auto insurance…get in an accident…then buying insurance to pay for what may or may not be my own negligence in having the accident or not being prepared with insurance. Why are the taxpayers and insurerers responsibile for other’s irresponsible behavior. That said some illnesses are not irresponsible…but I do not understand this widesweeping mandate that others pay for negligence.

    Yet, I struggle with more mandates…but would not be against true incentives (bonuses…not fines) to help us to help ourselves…like Progressive Insurance that offers discounts to tee totalers and those who do not smoke…less risk for them.

  • Chris

    The Principles of Biomedical Ethics were designed and formulated for medical care. Not insurance which is not medical care. It’s a product. Direct applications of the principles of biomedical ethics aren’t appropriate to other areas. Certainly one could formulate other ethical frameworks using some of the same concepts but a literal mapping doesn’t hold together.

    The economics of health care coverage are that we have to have everyone in the pool to distribute the costs enough. The individual mandate isn’t something i like. I don’t like injecting private companies (who are designed to make money) into this process. It’s going to prevent us really being able to get costs under control.

    But it’s not a question of medical ethics. It’s a fallacy to conflate medical insurance with medical care. The one really has nothing to do with the other in an ethical sense.

  • http://Www.twitter.com/alicearobertson Alice

    But it’s not a question of medical ethics. It’s a fallacy to conflate medical insurance with medical care. The one really has nothing to do with the other in an ethical sense. [end quote]

    I certainly did not mix ethics with mandates…it is a commerce problem. Medicine is commercial…insurance companies are commercial, and the government has taken control and mixed with commerce…that means a lot of medicine is profit driven and rarely is it privately funded. Medicine is dependent on politics, business, and government.

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