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A Moral Approach to a Healthcare Mandate: Good Citizenship

If polls are to be believed, perhaps half or more of the people in this country do not consider “health care for all” a collective good, claiming that a “mandate” violates the American ideal of individual liberty. One American physician argues that this Tea Party talking point violates a fundamental, moral mandate of American citizenship.

In last week’s Viewpoint in JAMA, the Journal of the American Medical Association, Dr. Zeke Emmanuel proposed an alternative way of thinking about a citizen’s responsibility to obtain health insurance.  He asserted that there is a mandate, a civic duty to buy insurance based on the moral duty each of us has to decrease certain burdens that we pose upon others in society.

A law called the Emergency Medical Treatment and Active Labor Act (EMTALA) states that emergency personnel, including physicians, have a duty to rescue those in need of medical assistance, even when the burdens to the emergency care provider are more than minimal.

A doctor, nurse, or EMT that finds you injured or incapacitated in an emergency has a legal and moral obligation to help you.

This law extends to hospitals that must provide emergency medical care to everyone, regardless of insurance status.

“Indeed, EMTALA can be accurately said to have established universal health care in America—with nary a whimper from conservative activists,” says Forbes contributor Avik Roy.[1]

If physicians and hospitals have this duty, Dr. Emmanuel reasons that “Individuals have a corresponding duty to purchase insurance to cover the costs of this care.”

He interprets this to mean individuals, at minimum, should buy catastrophic policies, not necessarily more comprehensive ones. This requirement, he says, is “consistent with respect for individual liberty.”

In terms of the cost to the individual, catastrophic policies, especially those with some deductibles, should be affordable and would mitigate the burden on the general public who end up paying higher medical costs and insurance premiums because those completely uninsured fail to meet this obligation.

The recent mass shooting in Aurora, Colorado provides a real world demonstration as to what happens when injured individuals without health insurance are taken to hospitals for treatment. The most seriously injured of the 58 people shot continue to require round the clock hospital care that could easily cost hundreds of thousands, if not millions, of dollars per person.

Among them is 23-year-old Caleb Medley who was shot in the eye and is now in an induced coma in the ICU. He has no health insurance. Adding to the burden on society in terms of health care costs is the fact that his 21-year-old wife Katie is also uninsured and has just had a baby. In both Caleb’s case and his wife’s, hospitals cannot turn patients away when they are in need of acute care (i.e. Caleb’s injury and Katie’s delivery).

There is no information as to whether Katie received any prenatal care, but if she did not because of lack of health insurance, there could have been potentially serious risks to her baby’s life as well as her own during and even well after the pregnancy.

According to a 2011 survey by the Colorado Trust, more than 1.5 million people in the state are uninsured; 20 percent of whom are able to pay for health insurance, but said they were not willing to pay. As many as 28 percent of 19 to 34 year olds in Colorado are uninsured, the highest among any age group.

One of the reasons that young people refuse to buy health insurance even when they are employed is that they consider themselves healthy and see little risk of getting sick.

Unfortunately, that assessment is (obviously) not always accurate. Besides specific conditions that are more prevalent in young people, like Hodgkin’s lymphoma and testicular cancer, accidents – the most common cause of death in this age group – are all unforeseen. Then there is the second leading cause of death for ages 15-24 – homicides.  Gunshot and knife wounds are the kind of unexpected health emergencies for which all too often young people do not insure themselves.

The media’s response to the Medleys’ uninsured status was to advertise the website where we could all go to donate money for their medical bills. Denver Health set up charity funds to take donations to help defray the cost of all the victims’ care.

Even if enough millions are raised for these particular patients, is online “crowd funding” and hospital charity really the way we, as a country, want to deal with the issue of access to and costs of healthcare in the US today?  If they don’t raise enough money, the hospital will pass on the costs of their care to insured people, and insurance costs will rise as a result.

Instead, why not use the Aurora tragedy with the resultant dilemma of the victims’ enormous uninsured medical bills as a teachable moment to finally have a serious discussion about the need for everyone to buy health insurance?

The notion of the “common good”, of pulling together as a society, needs to return to the place of honor it held for so many decades before the Neoconservatives and then the Tea Party demonized it.

In the meantime, for those only motivated by self-interest, Dr. Emmanuel’s argument that there is a moral obligation for everyone to buy health insurance  should be persuasive.

About Deborah Shlian

Deborah Shlian is a physician, medical consultant and author of numerous non-fiction articles and books as well as three published novels co-authored with her husband Joel (Double Illusion, Wednesday’s Child and Rabbit in the Moon). Rabbit in the Moon, an international thriller, won the 2008 Gold Medal, Florida Book Award, ForeWord Magazine's Silver Award for best mystery, the Royal Palm Literary Award and Honorable Mention for best Audiobook for the San Francisco Book Festival. Deborah is co-author with Dr. Linda Reid, of the Sammy Greene thriller series. Dead Air, the first in the series won the 2010 Royal Palm Literary Award for Best Thriller. Devil Wind, the second in the series, won the Hollywood Book Award for best Audiobook and the 2011 Royal Palm Literary Award for Best Thriller. Her latest nonfiction book, "Lessons Learned: Stories from Women in Medical Management" will be released in March, 2013. After 25 years in Los Angeles, Deborah and her husband now reside in Boca Raton, Florida.

14 comments on “A Moral Approach to a Healthcare Mandate: Good Citizenship

  1. thedrpete
    August 13, 2012

    “The notion of the “common good”, of pulling together as a society, needs to return to the place of honor it held for so many decades before the Neoconservatives and then the Tea Party demonized it.”

    That notion is progressive ideology, contradicts both the U.S. Constitution and its predicate, the Declaration of Independenjce, as well as being contrary to natural law. In other words, it does not, and cannot, make rational sense. By definition, Ms. Shlian, you are advocating slavery.

    • Brian Ross
      August 14, 2012

      Dr Pete:

      “promote the general Welfare” refers to the GENERAL welfare, not the stand-alone interests of the extremely selfish and self-centered, such as yourself. That notion of commonwealth is as old as the document, and a key belief of the Founding Fathers that is perhaps the most unique centerpiece of the American system of government. We are not a monarchy, or an oligarchy serving your rich friends like the Kochs. We are a republic, a commonwealth where we have exceptional freedoms, but we also come together, by way of our common interest via the government, to do things like roads and schools and sewers and bridges and tunnels and keeping rivers from catching on fire that serve that common good. It’s a shame that Fox News and idiots like you demonize what is best about this country: We are here to be the best we can be, but we are also here for our fellow man, our neighbor, the guy who lost his house in a tornado, the man with two kids whose job was cut to give his CEO a $14M target bonus. The world is unfair. In the richest nation in the world, though, we set minimum threshold standards for how our least able, our elderly, and our working poor are treated. We can do far better than countries that have far less and do far more. Not that in that self-centered haze that you live in you’d get any of this. Hopefully someone else won’t slip into that dark hole with you.

  2. thedrpete
    August 14, 2012

    What about the Founders’ assertion — based on natural law — that each human being is sovereign and subject to no other without permission do you not get? What about the unalienable right from the Creator to life, to liberty, and to property (from whence comes the pursuit of happiness) do you not get?

    Liberty is the right to do whatever the heck you want . . . just as long as you don’t infringe on another’s rights in the process. “[C]ommonwealth” doesn’t exist in either the Declaration of Independence or the U.S. Constitution, either as word or idea.

    The phrase “provide for the common Defence and general Welfare of the United States” is not carte blanche. It’s a statement of purpose and is followed by the 18 enumerated powers. The one and only reach that a rational adult can make to say that the federal government has authority to be involved in medicine and pharmaceuticals in any way, shape, or form is in its management of the military.

    The duty of the U.S. Government is to protect and defend collectively the unalienable rights of Americans, a right (self-defense) that each of us retains individually . . . no more and no less. Note that your and my unalienable rights don’t place any obligation whatsoever on anyone else. Cars, boats, houses, groceries, a job, a minimum wage, a “living wage”, “healthcare” are stuff, commodities and no one — not a sole soul — has a right to them.

    The genius that was America before progressives whittled away at it is based on each human being acting in his or her own enlightened self-interest. That fits human nature as it is, if not how you wish it were. A potato farmer in Idaho works long and hard to benefit his family. That results in someone else seeing an opportunity, and he becomes a trucker. Same with wholesalers and grocers. The farmer doesn’t know me and I don’t know the farmer, but I get to eat potatoes, and from Idaho to East Tennessee many benefit. Each player acts in his own self-interest and can dictate to none of the others.

    If Ms. Shlian sees me walking down the sidewalk, approached me, points a gun at me, and demands my money, a rational person would see that as armed robbery, a crime. .If Ms. Shlian sees an elderly woman on a curb with an apparent broken ankle, and she comes across the street, points a gun at me, and demands $100 to pay for treatment for the woman, a rational person would see that as armed robbery, a crime. If Ms. Shian approaches a crowd in the square, holds her gun, and demands a buck each to pay for the woman’s care, a rational person would see that as armed robbery, a crime.

    What, Mr. Ross, do you not get about persuading government to do the stick-up for you also being armed robbery and a crime? The government’s sole job is to protect and defend my life, my liberty, and my property, not to plunder them.

    • Brian Ross
      August 14, 2012

      First, Dr. Pete, one of the cornerstones of American democracy was espoused by Jean Jacques Rousseau, the French political philosopher who said that “Man is free, but everywhere he is in chains…” He points out that, at all times, we give up some freedoms, like the ability to choke the life out of you if I find you annoying, or urinating in someone’s soup in a restaurant, because the trade off is that we get certain benefits from being part of a group or civilization. No one is completely “free.”

      You say: “The duty of the U.S. Government is to protect and defend collectively the unalienable rights of Americans.” Finally, something we agree upon.

      First, it’s inalienable; Second, while you trolls always think this means national defense, you just granted that the government should protect and defend my rights to life liberty, and the pursuit of happiness.

      To do that, the government not only defends you from foreign invaders, it makes sure that you have roads and schools and that someone keeps you from bleeding to death when they find you dying on a sidewalk.

      That is also how the government defends us “collectively.” That collectivism is social and shhhh… Socialism.

      Let’s look at your scenario:

      “A potato farmer in Idaho works long and hard to benefit his family. That results in someone else seeing an opportunity, and he becomes a trucker. Same with wholesalers and grocers. The farmer doesn’t know me and I don’t know the farmer, but I get to eat potatoes, and from Idaho to East Tennessee many benefit. Each player acts in his own self-interest and can dictate to none of the others.”

      First, the potato farmer isn’t out there by themselves. To keep someone from taking their land, and their potatoes, he has a deed (government) that spells out where his land stops and starts. He has the sheriff (government) to protect him and his family if someone comes out to steal his potatoes. He has a court (government) to protect his land if you or the Koch brothers come and want to take it from him without paying for it, or failing to pay. The same court (government) can also help him sue if someone tries to cheat him on his potatoes.

      Someone becomes a trucker to get his potatoes. The trucker has to get a license (government) to haul the potatoes that says that he’s qualified to drive a vehicle of that size and type. The state Department of Transportation (government) will make sure that his truck is safe so he doesn’t have an accident and kill you on your way to the potato store, or that his truck is so heavy that it breaks down the roadbed of the highway (government) that you and I paid to carry the potatoes to the potato store near your house. Or are you saying that you don’t believe that the government has a right to tell people who can drive, or protect your inalienable right to not be crushed by a ton of spilled potatoes on I-40.

      The wholesaler actually can dictate to the farmer and/or the trucker what they can do by how he’ll pay them, or when he will require delivery. He probably bought the potatoes on the commodities market, which is regulated (government) so people can’t hoarde or cheat the system and drive food prices to the point that you would lose all the Internet money that you pay to whine here at our website to one $200 potato. The wholesaler will probably have to store the potatoes for a time. They will have a local or national inspector (government) make sure that your potatoes are stored in a sanitary place that isn’t crawling with rats and bugs. They too have access to police to keep their goods safe (government), firemen to keep them from being prematurely baked (government), and courts (government) should someone on either end of the deal try to screw them over, or set up camp inside their warehouse.

      Another trucker will take the potatoes to the store, who is licensed by the state (government) and whose trucks are inspected by the Department of Transportation (government) for equipment safety and probably the county or state food authorities to make sure that they aren’t spreading disease everywhere (government). He is protected by the police and sheriffs (government) who keep robbers from attacking him on the way to the store with the potatoes, from drunks who might veer into his way and kill him, and from falling into the sink hole where the water main broke until the water utility guys (sometimes government) fix it.

      When it goes to the grocery store, they will have people advertise so you know that there are potatoes to buy there. They won’t be able to lie about them (10x the size of a normal potato) because the law prevents that (government). You’ll drive on city streets to get there that are paid for by your neighbors and you, past police who are making sure that you’re safe, and street sweepers who keep the verbal horse manure that spills out of your car as you spout off from being stepped on by passers-by.

      When you get to the store, it will have lights that are operating because you and the farmer and me all allow the utilities to put their power polls on public rights-of-way (Government). The storage and display bins will be subject to health inspections as well (government) to keep an eye on them being clean so you don’t die of an avoidable bacterial disease that will allow you to spend countless hours online being such a complete douchebag.

      Each player may act in their own self-interest, Dr. Pete, but, along the way they have a number of supporting players who help them act in their self-interest, and also keep other people’s self-interest from infringing on your self-interest.

      We call that: Civilized Society.

      Now, next, it’s Dr. Shlian. She’s a real doctor, Dr. Pete, not like you.

      Sadly, she’s not a proctologist, but then, I don’t think even House could think of a clever way to get your head out of your ass.

      • thedrpete
        August 18, 2012

        I think — and I’m trying to be civil here despite your lack of civility — that what you miss, Mr. Ross, is the difference between liberty (for which I argue) and freedom (for which I do not). Liberty is the unalienable right of each human being to do whatever the heck he wants . . . just as long as he doesn’t infringe on another’s like right in the process.

        My unalienable right from the Creator to liberty, then, certainly does not grant me the right to “choke the life out of you if I find you annoying, or urinating in someone’s soup in a restaurant . . . ” That would be license, not liberty, also known as freedom.

        Maybe 99.9% of federal regulations cannot pass the strict “necessary AND proper” test to legitimate a prior proscription by government on individual liberty. They exist because they were never subjected to the constitutionally-required test. That test dictated that yelling fire in a crowded theater could be criminalized a priori. It could not, however, dictate that yelling fire was criminal, or yelling fire in a theater was criminal, or yelling in a crowded theater was criminal.

        I think it was Ben Franklin who said something like those who give up liberty for security, deserve and will get neither.

  3. Elaine Forhman
    August 14, 2012

    I have been in the health and life insurance business in Fl since 1975. The industry has gone through many administrative programs designed to help people obtain health insurance at an affordable prices. To date, none of these programs worked. The situation gets worse with more and more uninsurable and uninsured persons needing care and going to emergency rooms as a means of obtaining care. These costs are all passed on to the consumers who have insurance. The program outlined above is the only option left to try.
    I am in favor of it.

  4. sandra ceren
    August 15, 2012

    Dr Shlian’s comments mirror my experiences with insurance corporations. The insurance industry through it’s lobbyists have disenfranchised many patients and their doctors. They sell contracts with their list of providers to other insurance companies who promptly lower the benefits without negative consequences. They fail to notify doctors of the changes. The “Blues” appear to be the worst oft them. This practice was unheard of until recently.

  5. Dennis Ackerman
    August 15, 2012

    One has to be saddened by the total lack of compassion by the “dr” pete’s of the world.  Thankfully Dr. Shlian and others like her understand that humanity does not begin with the word “I.”

    • thedrpete
      August 18, 2012

      You have no-nil-nada-zero-zip-zilch knowledge of my “compassion” or lack thereof, Mr. Ackerman. Your confusion, I think, is my abhorrence with slavery you see as a lack of compassion. I never talk about my charity. It’s no one’s business.

      “Humanaity” does not begin with the word “I”. Neither does muffin. Nonsequitur.

  6. lovetennis60
    August 15, 2012

    Healthcare in the US and how to pay for it are huge problems. Unfortunately, both conservatives and liberals are so busy defending their ideologies that they are unable to discuss the necessary compromises needed to actually address the problem.

    As a cancer survivor, I can’t even imagine what it would be like to face this ordeal without health insurance. Without good healthcare, the right to “life” is severely compromised. This makes it every citizen’s duty to do what they can to pay for health insurance.

    I appreciate good, caring doctors like Dr. Emmanuel and Dr. Shlian , who have real life experience in the field, bringing these issues to our attention. Well done!

  7. Bonnie Cossrow
    August 15, 2012

    I read your op Ed and thought it was an excellent example of applying the reasoning for the healthcare mandate to the contract we citizens make with each other to create a functioning, intertwined, interdependent society that impacts all of us. If we do not understand the social contract that we are all a part of to fulfill the obligations of living together in a democratic society, then we will have a laisez-faire type of government as proposed by Romney, Ryan and their cohorts. And that will lead to anarchy, and this country will see the riots that I witnessed last summer in Madrid with 30,000 hungry, sick, out of work people gathered to form their own mini society just to survive. The enforcement of that compact is not slavery. It is the compact we make with each other to continue living together on this planet.

  8. Rose
    August 16, 2012

    Who is this Dr. Pete? Does he always respond contrary to every opinion posted? Does he forget the fact that in Massachusetts, you will pay a hefty state tax if you cannot prove your have insurance. He may have forgotten who was the governor of Mass when this law was forged. Rational? Talking about slavery is just inflammatory.

    It’s been many years since I’ve worked in an E.R., but during those years I saw people abuse the system, knowing they would be cared for by dedicated health professionals. Others legitimately could not afford premiums. Dr. Shlian is striving to pose possible solutions when people, through no fault of their own, require extensive medical treatment, e.g. After the Aurora shooting. She also mentions how a pregnant woman may have put her health and the health of her unborn child at risk by not seeking some medical care.

    I encourage more discussions of solutions to this healthcare problem, e.g. Mandatory comprehensive health insurance, one suggestion made by Dr. Shlian.

    • thedrpete
      August 18, 2012

      I am contrary, Rose to every opinion piece so far posted hereon. You infer incorrectly what I might imply when bringing up Massachusetts and Governor Romney. I’ve never indicated agreement with Mr. Romney.

      Slavery, by definition, is forcing someone to work for your benefit against his will. Dr. Shlian and Mr. Ross advocate that.

  9. John Ling
    August 21, 2012

    The Oxford English Dictionary defines slavery as follows: ‘A condition of having to work very hard without proper remuneration or appreciation.’

    To be fair, that’s a very broad definition. But it does cut to the heart of the matter. Practically speaking, it is slavery when a citizen contributes economically to a country and isn’t properly ‘remunerated’ or ‘appreciated’ with access to decent healthcare.

    This is certainly the conclusion that all OECD countries have arrived at. The United States, though, remains the sole hold-out. It appears that the American argument against ‘universal healthcare’ or ‘universal insurance’ tends to go like this:

    (1) A combination of enlightened self-interest and the free market will deliver an equitable outcome. No intervention is necessary.

    (2) Intervention necessarily leads to tyranny, and any good that might come out of intervention is inevitably outweighed by the bad.

    While I appreciate the historical reasons behind why so many Americans adhere so strongly to these views, I wonder if such arguments might actually be missing the point.

    Let’s take the issue of law enforcement as an example. Would it be better if we completely dismantled our police forces and relied on enlightened self-interest and the free market to provide us with an equitable outcome? After all, it might be less tyrannical than levying a tax on every citizen for the purposes of maintaining a police force. And those who desire security in their neighbourhood can, well, pay for it on an ad hoc basis.

    What I’ve observed, though, is that even the most ardent conservative balks at that line of logic. They find it extremely difficult to accept anything less than a fully professional police force answerable to the taxpayer.

    And that’s the crux of the matter: common sense. We need it more than we need ideology, especially in regards to such a crucial thing like healthcare.

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