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The moral price of the profit motive in medicine John Sobieski

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Recommended Citation Sobieski, John, "The moral price of the profit motive in medicine" (2016). Honors Theses. Paper 952.

The Moral Price of the Profit Motive in Medicine

by

John Sobieski

Honors Thesis

in

Jepson School of Leadership Studies University of Richmond

Richmond, VA

April 25, 2014

Advisor: Dr. Jessica Flanigan

1

Abstract

The Moral Price of the Profit Motive in Medicine

John Sobieski Committee members: Dr. Jessica Flanigan, Dr. Terry Price, Dr. Javier Hidalgo My thesis argues that a medical profit motive is immoral because medical care influenced by a

profit motive can undermine the value of patient health. In Chapter I, I develop a moral critique

of the medical profit motive while arguing that doctors have a moral obligation to promote

patient health and well-being. Additionally, I demonstrate that a medical profit motive can

theoretically exist in medical decision-making and be permissible. In Chapter II, I explore the

medical profit motive on the organizational level. I argue that the structure of modern medical

care allows for a profit motive to regularly be introduced into medical decision-making. I also

demonstrate that an organizational medical profit motive is more morally impermissible at the

administrative level. I will offer suggestions on how to better align modern medical care with

moral medical care—both on an individual level and a structural level; in addition, I then offer

suggestions on how health care systems and medical groups can change current practices to

either diffuse a medical profit motive or align pecuniary profit motives with proper medical care.

In Chapter III, I focus on the application of my argument into health care policy, and from this

application, I forward a theory of values-centered health care.

2

Acknowledgements

First and foremost, I would like to thank my thesis advisor, Dr. Jessica Flanigan, for being the

best philosophical resource and provoker of independent thought that a senior thesis student could ask for.

Without Dr. Flanigan, none of this would have been possible. Dr. Flanigan’s entrance into the Jepson

School and my initial journey through the honors thesis track coincided at precisely the right time, and as

soon as I heard her defense of uniform drug legalization, not only was I impressed, but I knew that I

needed to have this professor advise my medical ethics thesis. After the fact, I can safely say that one

would be hard pressed to find a more intellectual, challenging, and extremely intelligent professor that is

equally patient, funny, and approachable. Her belief in my abilities and dedication to my project were

instrumental in transforming my passion into applied ethics.

The other members of my committee, Dr. Javier Hidalgo and Dr. Terry Price, have also been

immensely helpful throughout this process. Without their thoughtful input, my thesis would not have been

even half as properly defensible. I would like to recognize Esme Hidalgo as an honorary member of my

committee for being present at a vast majority of my weekly meetings and being very patient throughout

all of them. Hopefully you see this one day!

For every individual over the past year that has been willing to engage in a conversation about the

value of health or the medical profit motive, I thank you. These conversations have challenged me to

uncover what I believe to be the moral facts behind medical care, and relics of every conversation can be

seen throughout this work. Specifically, I want to thank Sean Hickey for reading over a first draft of my

thesis and offering constructive and interesting input.

I could not have completed this thesis without the emotional support from my family, my friends,

and my girlfriend, Carmella. I am tremendously grateful to all those connected to this project.

3

Table of Contents

Introduction...............................................................................................................5

Chapter I: The Problem with the Medical Profit Motive...........................................6

Obligations in Medical Care................................................................................................8

The Unconditional Value of Health: Characterization and Obligation Generation...........24

The Medical Profit Motive is Inconsistent with Physician Obligations............................31

Profit Considerations in the Modern Doctor-Patient Relationship....................................35

Chapter II: The Medical Profit Motive in Medical Administration........................46

The Medical Profit Motive Revisited: Does The Agent Matter?.......................................49

Responsibility....................................................................................................................52

Excuses..............................................................................................................................58

Expertise............................................................................................................................65

Chapter III: Values-Centered Health Care……………………………..................75

The Sovereignty of the Medical Expert.............................................................................78 Reducing Conflicts-of-Interest...........................................................................................82

Goal-Mindedness Towards Patient Outcomes...................................................................86

“Wal-Mart” or “Southwest” Healthcare............................................................................90

A Values-Centered Response to the Pro-Market Position.................................................96

Conclusion……………………………...................................................................98

4

Introduction

The profit motive in medicine, which is the desire to maximize pecuniary profit as a

primary motivation in patient care, is unethical. Regardless of whether the functional body

outputting a medical profit motive is a physician, a group of physicians, or a large hospital,

proper medical care should not be undermined by a desire for monetary gain. To say that medical

care should not concern itself with money (i.e. costs, budgets) would be foolish; rather, I am

asserting that treating medicine like any other business is disrespectful to the core values that

predicate patient care. Human health is too important of a currency to be thrust into a system of

financial modeling and cost/benefit analyses that aim to yield maximal gains; medical

practitioners should be primarily motivated by maximizing patient health and wellness.

My thesis argues that a medical profit motive is immoral because medical care influenced

by a profit motive can undermine the value of patient health. In Chapter I, I develop a moral

critique of the medical profit motive while arguing that doctors have a moral obligation to

promote patient health and well-being. Additionally, I demonstrate that a medical profit motive

can theoretically exist in medical decision-making and be permissible. In Chapter II, I explore

the medical profit motive on the organizational level. I argue that the structure of modern

medical care allows for a profit motive to regularly be introduced into medical decision-making.

I also demonstrate that an organizational medical profit motive is more morally impermissible at

the administrative level. I will offer suggestions on how to better align modern medical care with

moral medical care—both on an individual level and a structural level; in addition, I then offer

suggestions on how health care systems and medical groups can change current practices to

either diffuse a medical profit motive or align pecuniary profit motives with proper medical care.

5

In Chapter III, I focus on the application of my argument into health care policy, and from this

application, I forward a theory of values-centered health care.

Chapter I: The Problem with the Medical Profit Motive

“Either perspective is by itself stubbornly one-sided in its view of physicians simply as self- interested economic accumulators or as devoted altruists. We favor a view which recognizes that these two perspectives are not incompatible and accepts the elements of truth in each of them.”1

The medical profit motive allows medical practitioners to privilege monetary profit over

human health and well-being. For this reason, the profit motive is immoral. My goal in this

chapter is to propose guidelines for how physicians can permissibly act on profit motivation in

clinical practice. Patients have certain justifiable expectations from their physicians, and those

expectations are part of what generates a physician’s obligations to their patient. Even absent

from expectations, there are ways that a doctor ought to treat their patient populations based on

the role they assume (a medical doctor), the value that is at stake in operating through their role

(human health), and the uniqueness of the physician-patient relationship (or, at least, what is at

stake within the relationship). Given that a physician truly has strong moral reasons—or an

obligation—to promote patient health and wellness, it is morally impermissible to bypass those

obligations through an ulterior motive. This is especially the case when the currency at stake—

the currency that could potentially be lost in a coercive transaction—is of value so supreme, that

it is morally abhorrent to disrespect.

The argument is as follows:

P1: Doctors have a moral obligation to promote patient health and well-being.

1 Brock, Dan W., and Allen E. Buchanan. "The Profit Motive in Medicine." The Journal of Medicine and Philosophy 12 (February 1987): 1-35. doi:10.1093/jmp/12.1.1.

6

P2: In some instances, a medical profit motive acts antagonistically against the moral obligations obtained by physicians. C1: Pro tanto, a medical profit motive is immoral. P3: Outcomes can outweigh morally impermissible motives. P4: When a medical profit motive is pursued to promote patient health and well-being in the most optimal manner, the outcomes of the medical profit motive align with the outcomes of moral medical care. C2: Beneficial health outcomes can outweigh an immoral profit motive, though the profit motive remains impermissible.

In Section I, I demonstrate why doctors have obligations to their patients, and why these

obligations amount to a medical doctor being required to promote patient health. Doctors have

general duties to several different parties that they encounter as well as obligations generated

through the physician-patient relationship. I will explore how these obligations are generated and

what importance they have relative to other obligations. Even if one does not subscribe to the

existence of special obligations in medical care, physicians still have strong moral reasons to

promote patient health and well-being. In Section II consider a particular reason that strong

obligations are generated in medical decision-making: the unconditional value of health. In

Section III, I then show that the obligations that physicians have to their patients are sometimes

violated when physicians consider profit obtainment during medical decision-making. Through

the discussion in Section II and III, I argue that human health has unconditional value whereas

monetary profit is only conditionally valuable. For this reason, a medical profit motive is pro

tanto immoral to uphold in medical decision-making. A medical profit motive can exist when the

motive is utilized to promote patient health in the most optimal way possible, but the moral

obligations of physicians must be considered over medical profit motives when the two conflict.

In Section IV, I apply these principles into the doctor-patient relationship as it exists in the

current medical environment. In Section V, I discuss the implications of this position and

consider relevant objections to my argument.

7

I. Obligations in Medical Practice

When a parent takes care of her child, there are obligations that the parent has to her

child. When someone signs a contract with you, that individual has an obligation to you to

uphold the terms of that contract. The existence of obligations is relatively uncontroversial; what

is more debatable is the basis of obligations, the kinds of obligations that can exist, and the

extent to which particular obligations matter over other obligations or other considerations. For

example, one might believe that a parent’s obligation to take care of their child would be

stronger than an obligation to pick up a friend from the airport. That plausible position must be

defended by claiming that the value of the parent-child relationship—or what is at stake when

violating that relationship—is more valuable than what is at stake in a particular friendship.

Through an analogous weighing of values, I will argue that medical doctors have an especially

strong moral obligation to their patients, and this obligation is to promote patient health. My

argument does not hinge on the existence of special obligations. Even if one were to claim that

unique obligations did not exist in medical care, I will still be able to demonstrate that doctors

have strong moral reasons to promote patient health and well-being before considering any non-

medical factors in medical decision-making.

To illustrate the basis of obligations, consider the following case:

The Basketball Game. 100 individuals are present at a basketball game and are currently occupying the bleachers. Suddenly, one person (C) collapses in the stands and is showing the signs of having a heart attack. Assume that only one individual may assist C before the paramedics arrive. You are also one of the individuals in the stands. This case illustrates that we all have moral obligations to assist people in need. If it were

true that obligations did not exist between human beings, there would be no binding reason that

any of the 99 other individuals would have to make an attempt to save C’s life. If no obligations

8

to assist existed, no one would be morally blameworthy for C’s negative medical outcome (or

failing to aid C). Without duties to assist, someone could still make an attempt to save C’s life

because it would align with their desires/ends or would be—for some reason—desirable to them.

But people should not just save C’s life because of their desires, but rather because a general

duty of beneficence exists in society. Under a general duty of beneficence, which stems from

multiple prominent moral theories, there are strong moral reasons to assist those in need when

assisting is possible.2 If we acknowledge a general duty of beneficence exists, then the obligation

to attempt to save C’s life stems from the fact that C is another person in need (so C should be

saved if it is possible and reasonable).

Given that C should be saved, who should save C? One plausible way of allocating the

obligation to save C is proximity. Imagine you are one of the individuals in the stands, so perhaps

you should make an attempt to save C. Unfortunately, you are on the absolute far left side of the

bleachers, and C collapsed on the absolute far right side of the bleachers. The person directly

next to C is G, and G happens to have the same medical knowledge as you. Moreover, C requires

immediate medical attention, and by the time you are able to reach C, his condition will

significantly worsen. If this were the case, G has a greater duty to save C’s life, especially if C

has a time-sensitive ailment. From this, we can see that there is sometimes a spatial component

to obligations. Still, this obligation is not supreme to all other considerations that G may hold; it

was simple chance that G was placed next to C. If G had some “special” or unique obligation to

C, G would also have a “special” obligation to every adjacent individual in the bleachers if they

2 Beauchamp, Tom, "The Principle of Beneficence in Applied Ethics", The Stanford Encyclopedia of Philosophy (Winter 2013 Edition), Edward N. Zalta (ed.), URL = <http://plato.stanford.edu/archives/win2013/entries/principle-beneficence/>.

9

happened to show signs of having a heart attack and nothing would oblige G to treat C before

any adjacent person.

Or, imagine that C happened to attend the basketball game with a spouse, S. We might

also think that S has a stronger obligation to save C’s life over saving your life or G’s life

because S has an established relationship with C. If this is true, S would have an obligation to

save C’s life before saving your life or G’s life, even if you or G happened to collapse in a

similar moment with a similar medical ailment. How can we explain that belief? S has a special

relationship with C, and S is uniquely positioned to recognize the needs of C. S has a legitimate

reason to favor the medical needs of C over adjacent persons when another individual may give

medical attention to C.

Or, imagine that G made a promise to act in the best medical interest of C, or let us even

say that G signed some sort of contract with C in similar terms. This seems to be the most

compelling case yet for which an individual has a particularly strong obligation to promote the

health of C. If there was a promise or contract involved, G would be especially at fault for not

attending to the medical needs of C compared to other bystanders.

Before G rushes to action, consider another case:

The Basketball Game, Part II. 100 individuals are present at a basketball game and are currently occupying the bleachers. Suddenly, one person (C) collapses in the stands and is showing the signs of having a heart attack. Assume that only one individual may assist C before the paramedics arrive. You are one of the individuals in the bleachers. The individuals in the bleachers include G (who has signed a contract with C to act in C’s best medical interest) and D, who is a medical doctor.

Regardless of where D is seated, whether D was familiar with C before this occurrence, or if G

signed some sort of contract with C with the terms mentioned above, D is the best positioned to

10

promote the medical needs of C. Therefore, D should be the individual to assist C. In general

terms, D has an obligation—as a medical doctor—to promote the medical needs of any

individual in close proximity and in an emergency situation.

Interestingly, a doctor’s obligations trump the general duties of beneficence that any

other individual may have towards C (I will further argue for this position later on). It does not

necessarily change the obligations that other individuals have towards C; it instead allows the

obligations that other individuals have towards C—the obligations to promote C’s health (or

life)—to be an obligation to allow D to perform some action of medical assistance. In cases of

human health, the role that a doctor assumes comes along with powerful obligations, obligations

that may even outweigh the obligations of other agents. These obligations apply equally to

anyone at the basketball game, and they could still hypothetically be subdued by a further, more

powerful obligation: a doctor’s unique obligation to one of their patients.

Thus, consider a third—and final—case:

The Basketball Game, Part III. 100 individuals are present at a basketball game and are currently occupying the bleachers. Suddenly, one person (C) collapses in the stands and is showing the signs of having a heart attack. Assume that only one individual may assist C before the paramedics arrive. You are one of the individuals in the bleachers. The individuals in the bleachers include D, who is a medical doctor. C also happens to be a patient of D.

Since C is D’s patient, D is indisputably the one who must act on C’s behalf. The doctor-

patient relationship generates obligations that the physician has towards the affected individual,

C. Not only do doctors have obligations towards members of society from duties of

beneficence—similar to other citizens—and obligations to care based on their role as a medical

doctor, they also have special relationships with their patients, which generate strong obligations.

These successively developing cases demonstrate that strong obligations relating to human

11

health exist in society, and further, these cases demonstrate that a medical doctor reliably incurs

these strong obligations in the same way that a spouse incurs obligations (or how proximity can

generate obligations).

These basketball cases may not have demonstrated the strength of a physician’s

obligations conclusively, but there are several other reasons to believe that the doctor-patient

relationship can generate obligations that carry great moral weight. Before I turn to the exact

nature of these obligations—what a medical doctor is obligated to do—I want to explain why

medical doctors possess strong obligations to their patients. Below, I will list and describe five

ways that an individual can gain obligations, and from the list, I will explain how each situation

applies to a medical doctor in the doctor-patient relationship. (Note: this list is not exhaustive,

but it is certainly a list of several conspicuous reasons.)

First, strong obligations can be generated when someone assumes a distinct role; we shall

call these obligations role obligations.3 Individuals in certain roles have obligations to persons,

groups of persons, or even society. When someone assumes a role—willingly or unwillingly—he

accepts that obligations come packaged with the role. At least when roles are assumed willingly,

so too are obligations. Even if one believes that obligations are only generated when an

individual assumes them voluntarily, some roles and their attending obligations are voluntary.

For example, if someone chooses to become a firefighter, he has assumed the role of

“firefighter”. Normally, we do not have an obligation to run into a burning building and save

people and possessions, but we do have a duty to save someone’s life (if possible). But, we could

not reasonably be expected to run into a burning building without training or equipment. Luckily,

3 Jeske, Diane. "Special Obligations." Stanford University. October 17, 2002. Accessed March 27, 2014. http://plato.stanford.edu/entries/special-obligations/#4.

12

the person who has assumed the role of firefighter is required to uphold his obligation to fight

fires, and in doing so, he is upholding the general duties of beneficence for the rest of society (a

sort of division of moral labor).4

The division of labor for society’s general duties is morally relevant, and this idea also

demonstrates the true importance of a division of moral labor in other situations. When someone

willingly assumes a role that generates unique or necessary obligations, she is accountable for

upholding those obligations. If someone chooses to become a teacher, she must be in the

business of promoting the rational capacities of the people she is instructing; that is one of the

obligations that teachers must have. The obligations stemming from being a teacher are directly

linked to the act carried out from her role as teacher. If a teacher does not uphold the obligation

to educate, it cannot be said that she is a morally sound teacher.

The role of a doctor also generates strong obligations—obligations that are directly linked

to the doctoral identity. When someone becomes a doctor, he obtains special responsibilities and

obligations that normal citizens would not have based on their medical training, access to

relevant information and technology, and the other features of a career in medicine. Doctors

willingly assume that role, and in doing so, consent to upholding certain principles of proper

patient care. It is clear that doctors consent to their role and the obligations that go with it

because they pledge to act in their patient’s best medical interest.5 Whenever people voluntarily

enter into the role of medical doctor, they are fully aware that being a doctor means having

special responsibilities within patient care.

4 For more on the concept of “Division of Moral Labour”, please see: Scheffler, Samuel, and Véronique Munoz-Dardé. "The Division of Moral Labour."Proceedings of the Aristotelian Society, Supplementary Volumes 79 (2005): 229-53. http://www.jstor.org/stable/4106941. 5 Orr, R. D., N. Pang, E. D. Pellegrino, and M. Siegler. "Use of the Hippocratic Oath: A Review of Twentieth Century Practice and a Content Analysis of Oaths Administered in Medical Schools in the U.S. and Canada in 1993." Journal of Clinical Ethics 8.4 (1997): 377-88. Print.

13

Similar to the fireman scenario, the role obligations of medical doctors are important

because they uphold society’s intrinsic duty to promote health and livelihood, the most concrete

and essential realization of a duty of beneficence. Just like you or I would not be expected to run

into the burning building, we cannot be expected to pick up a scalpel and perform surgery. Does

that mean we are not obligated to promote health? No, but non-physicians certainly do not have a

strong obligation to promote health based solely from our role in society.6

Second, role obligations are particularly strong when they are premised on providing

public goods, as opposed to a role that is premised on providing instrumental goods, private

goods, or conditional goods. A firefighter has strong obligations to fight fires, but one can also

imagine that, for example, a landscaping company has a unique obligation to maintain your

external property if you are a customer of their company. Apart from considerations of the

impact from not upholding these sets of obligations, maintaining the aesthetics of a property is

not a public good—it is an instrumental good. By “public good”, I mean a good that is shared by

the largest set possible of individuals in a community with the largest net benefit to the

community.7 Public goods are provided by a subset of individuals within a community, and I

further define a public good as some good that is owed to a community based on the intrinsic

rights of the people within that community. Within this definition of a public good, landscaping

services are not a public good. Certainly, it is good that the company upholds their obligations to

you, but that is merely contractual. One may claim that a landscaping company has an obligation

not to destroy your property or harm any person on your property, but individuals are already

6 Other patient care professionals may have a similar strong obligation, but I am not concerned with that idea in this thesis. Here, I am looking at the moral significance of profit motivation forwarded by doctors in the doctor-patient relationship. Future work may explore profit motivation on a variety of levels in patient care, but this argument will not. 7 Shue, Henry. Basic Rights: Subsistence, Affluence, and U.S. Foreign Policy. Princeton, NJ: Princeton UP, 1980. Print.

14

owed this level of respect, protection, and consideration from every individual member of

society. Within the realm of public good-promoting obligations, one can imagine that even this

set of obligations can be graded based on importance—and thus some can be morally worse for

failing to uphold. As mentioned above, everyone cannot be expected to fight fires (even if

everyone ought to promote safety and well-being in society through a duty of beneficence), so

providing for this public good is a necessary condition of being in a civilized society.

Given this distinction, doctors are more like firefighters than landscapers because they

provide for public goods rather than instrumental goods or private goods. Medical doctors are

responsible for promoting the health of the human population, which is a necessary precondition

to satisfy almost any other public good.8 To further illustrate the distinction between public

goods and instrumental goods, examine the following case:

The King’s Dilemma. King Arthur has a finite amount of gold pieces that he must spend on his castle, and his advisors assure him that the gold can only be spent in one of two ways. One way that King Arthur can spend his gold is to build a state-of-the-art educational institution that will develop the rational capacities of his citizens. On the other hand, King Arthur can also choose to spend the gold on a combination of sanitation, hygienic, and medicinal purposes. The kingdom can noticeably benefit from additional education. In addition, severe health issues already exist within the castle walls, but can be cured through the implementation of purposes listed above.

This thought experiment is introduced to show that some public goods are more morally urgent

than others, and therefore they should have priority over other goods when considering how to

allocate resources in order to promote such goods. Knowledge development is a non-excludable

public good that everyone benefits from, and for that fact, we have reasons to uphold or promote

8 Shue, Henry. Basic Rights: Subsistence, Affluence, and U.S. Foreign Policy. Princeton, NJ: Princeton UP, 1980. Print.

15

that good in society.9 What is proper education without adequate human health among an

educated population? Citizens can still be educated, but if a population is not healthy and is

lacking a particular quality to life, it is hard to justify spending a majority of resources on

developing rational capacities when a majority of resources can be allocated to combat active

health threats to the population. This is not to suggest that promoting rational capacity should be

forfeited in health crises, but in essence, promoting health and well-being is instrumental to—or

a necessary condition of—promoting any other public good, including education.

Even if one does not believe that human health and well-being is a public good that

everyone is obligated to promote, they can at least see how health can be instrumental to

maintaining other public goods. Klosko introduced a theory of political obligation towards lesser

discretionary goods that stems from a society benefitting from presumably beneficial public

goods. In his argument, if a scheme of government X provides a non-excludable public good A

(along with a set of other goods that may not be presumably beneficial in the same way), as long

as the cost to maintain A with discretionary goods does not come at the same cost as failing to be

provided A, one can have an obligation to promote those discretionary goods.10 In this way, if

we have obligations to promote non-excludable public goods that we benefit from, we may have

obligations to promote public goods that are preconditions of those certain non-excludable public

goods being maintained or promoted. I assert that health and well-being count as public goods

that are necessary to promote in order to preserve other non-excludable public goods in our

society.

9 Klosko, George. "Presumptive Benefit, Fairness, and Political Obligation." Philosophy and Public Affairs 16.3 (1987): 241-59. Print. 10 Ibid., 241-59.

16

However, as it has been demonstrated already, we cannot all be expected to directly

promote human health (even though we all have that obligation in some form or another).

Consider this: just like we have obligations not to interfere with national defense, we do not

necessarily have to actively promote or maintain national defense—even if we benefit from it.

This might not change our obligations to promoting or maintaining the public good of national

defense, but regardless, I believe that it is still obligation-inducing. To examine this in a different

light, we have obligations of not interfering with non-excludable public goods that juxtaposes

with our obligation to promote non-excludable public goods. We may not have obligations to

directly promote national defense (but we have obligations to refrain from internally threatening

public safety), so too citizens may not have obligations to promote health directly while still

having obligations not to degrade health (I will soon argue for this in more detail).

Fortunately, some individuals can directly fulfill their societal obligations to promote

public goods. Just as the soldiers in our military actively incur the public good-promoting role

obligation related to national defense, so too, doctors are the guardians against the threats

towards society’s health and well-being. If it is not the most important public good to promote,

the right to be healthy—to a reasonable degree—is one of the most important public goods to

promote. Since doctors, from their role, are charged with this task, they are given strong

obligations to promote well-being in their communities. This set of obligations is not necessarily

stronger when the individual being treated is the patient of the doctor, but the public good-

promoting obligations are definitely more salient.

Third, as the basketball case illustrated, strong obligations may be generated when we are

well positioned to provide some form of a good. Physicians therefore have especially strong

obligations to promote health because they are well placed to do so. Peter Singer’s classic

17

example of a baby drowning in a pond illustrates this intuition. If a baby is drowning and you are

standing right next to the pond where it is drowning in, your obligation to help the child is

especially strong because you are well positioned to provide a good that is essential to the child’s

existence.11 I simultaneously agree and disagree with the position that Singer has presented. I

think that distance (from the pond, from a patient, etc.) must be normatively relevant; the fact

that you are standing beside the pond does not change your general obligation to save the child’s

life, it just makes that obligation more prominent. In other words, the fact that you happen to be

standing next to the pond does not spontaneously create a new obligation to save the child’s life

when it comes as a minimal cost or risk to you. Nevertheless, you may be less blameworthy for

allowing a similar child located 300 miles away to drown in a similar pond. Proximity does not

change one’s obligations, but it does alert us to those obligations. Singer would contend with this

belief, but where I agree with Singer is the idea of someone being well-positioned to provide a

certain good or beneficial action. Being well-positioned can be translated through different

media. In Singer’s case, being well-positioned can mean having the ability (assuming little risk is

undertaken by the acting agent) to aid the drowning child, which is a more literal interpretation

of “well-positioned”. Well-positioned can also be interpreted to mean having a knowledge base

or a skill set that can allow one to aid—with minimal risk obtainment—someone in need.

In this way, like the bystander near a drowning child, physicians are well-positioned to

provide a good that is essential to human existence. Having a library of medical knowledge and

knowing how to treat an array of human ailments, the medical doctor possesses a number of

obligations towards human health promotion that other individuals without that knowledge

cannot be at fault for not upholding. As in the basketball case (II), the fact that D, the doctor, had

11 Singer, Peter. "Famine, Affluence, and Morality." Philosophy and Public Affairs 1.3 (1972): 229-43. Print.

18

the knowledge and skill necessary to properly treat C was the true reason that D was morally

required to treat C, not just because D was the “doctor” present. Having the proper medical

knowledge and skill set to treat medical ailments is an intrinsic component of being a doctor, but

we can also separate it to show that even without the title, the same set of abilities generates a set

of strong obligations. For example, consider a scenario where D is an individual who is present

and is not a medical doctor. While he is not in this role, he has studied heart attacks for years and

happens to have the proper knowledge and skills necessary to effectively treat C. By having that

knowledge—without being a physician—D still has an obligation to treat C. Taking this further,

when a person with an exceptional knowledge of proper human health is engaged in a

relationship with someone who is seeking counsel on proper human health, it would be morally

reprehensible for the expert to not utilize, to their fullest capacity, their medical knowledge or

skill; increased responsibility—and therefore moral accountability—can be assigned when an

agent with medical expertise is willingly engaging with an agent who is forfeiting a portion of

their agency (in medical decision-making) to the individual with medical expertise.

Fourth, obligations can be generated when individuals willingly enter into an obligation-

generating relationship, which would bestow particular voluntary obligations upon the respective

agents in the relationship. As mentioned before, it is easy to see how one can incur strong

obligations when he knowingly consents to having them; assuming that an agent is fully

informed about what obligations will come along with entering into an obligation-generating

relationship (and he agrees to enter into the relationship), he is culpable if he does not uphold

those obligations. Thus, this form of obligation generation is important because it is widely

agreed as being true, even by the non-voluntarist school of thought on obligations.

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A classic example of this type of obligation generation is when an individual signs a

contract to uphold certain obligations to another individual (or a group of individuals). For

example, if I sign up for a cellular phone service, I agree to pay a cellular phone company every

month to provide me various instrumental goods related to having a cellular phone; this

agreement is in the form of a contract that I sign. If I no longer wish to have an obligation to pay

the cellular phone company, I can opt out of the contract (and forfeit my ability to receive

services from that particular company), but while I am bound by the contract, I must uphold my

obligation to pay the company. Assuming that I have read the terms of the contract and

understand their implications, there is no reason that I should be surprised that I have an

obligation to uphold the contractual terms.12

Employment relationships are another example of how voluntary agreements can

generate obligations. When one agrees to be an employee in an organization or for another

person, there are unique obligations that the employee has towards their employer. Similar to the

contractual argument, if the employee is not coerced into an employment relationship (it is truly

voluntary), then the employee has obligations to her employers. This principle applies as long as

the agreement and nature of work are morally permissible (i.e. an employee is not coerced into

employment and voluntarily accepts employment terms that they are aware of, or a hit man

would not be morally obligated to murder just because the hit man was under a contract).13

Like customers or employees, doctors are fully aware what obligations come along with

agreeing to be a medical doctor, and therefore they implicitly consent to these obligations

(otherwise, they should not participate in patient care). Consent-based obligations are strong,

12 Fried, Charles. Contract as Promise: A Theory of Contractual Obligation. Cambridge, MA: Harvard University Press, 1981. 13 Macleod, Alistair. "Moral Permissibility Constraints on Voluntary Obligations." Journal of Social Philosophy 43.2 (2012): 125-39. Print.

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voluntary obligations when the values and obligations at stake within the voluntary relationship

are clear and well-known upon engaging in such a relationship.14 When someone is graduating

medical school, he has an understanding of the ethical implications of being a medical doctor. To

affirm this belief, graduating medical students often take some sort of oath (whether it be the

Hippocratic Oath or the Oath of Maimonides) to not harm patients and to operate in the patient’s

best medical interest.15

One may object that consent-based obligations are established through knowledge of the

profession, knowledge of the values at stake in medical care, and knowledge that primary

motivator for medical decision-making ought to be patient health and well-being. Yet there is

strong evidence that any reasonable knowledge conditions are met because new medical doctors

experience a period of residency after their academic medical education, a period of observation

and understanding of the true medical profession that compliments years of clinical observation,

medical ethics education, and interactions with other physicians. Therefore, a medical doctor is

fully aware of what obligations he will be incurring in a medical career and the value of patient

health that is at stake in medical decision-making. From this, it would be unreasonable for a

physician to claim that he did not voluntarily consent to promoting patient health and well-being.

That is like saying a police officer does not consent to upholding the law when she becomes a

police officer. The voluntary obligations of physicians are fundamental to their profession, and if

14 A view on consent to obligations based on consent and knowledge can be seen in “Pacuit, Eric, Rohit Parikh, and Eva Cogan. "The Logic of Knowledge Based Obligation."Synthese 149.2 (2006): 311-41. Print.” Here, the authors support a model of knowledge and consent based obligation generation—with particular emphasis on (1) the existence of knowledge as a necessary condition for a primary obligation to be generated, and (2) a secondary obligation on the recipient of the primary obligation to ensure the knowledge necessary for obligation generation is in place. 15 Orr, R. D., N. Pang, E. D. Pellegrino, and M. Siegler. "Use of the Hippocratic Oath: A Review of Twentieth Century Practice and a Content Analysis of Oaths Administered in Medical Schools in the U.S. and Canada in 1993." Journal of Clinical Ethics 8.4 (1997): 377-88. Print.

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a physician acts outside of obligations he knowingly consented to, he is not acting as a morally

sound doctor ought to act.

Fifth, a fiduciary relationship can generate obligations.16 A fiduciary relationship is one

that is established based on a differential of influence and agency capacities; in the relationship,

one agent has weak agency, or when “an agent who is either ignorant of the consequences of his

actions or is not directly involved in the transaction [and] relies on another person to transact on

his behalf (for example, children in child labour agreements, citizens in agreements between

countries).”17 In a relationship based upon dispensation of decision-making action to an agent in

a better position to make decisions, the agent on the top of the power differential is called the

“fiduciary”. A classic example of a fiduciary relationship is when someone hires a stockbroker to

invest a set amount of money. When you give a stockbroker your confidence (in the form of a

large sum of money), you are forfeiting your ability to have complete control over your assets in

the hope that your stockbroker will make decisions with the given amount of assets in your best

financial interest. In this relationship, the stockbroker possesses not only a significant portion of

your property, but also a great deal of trust from you, his client. This concession of trust

generates strong obligations on the fiduciary’s behalf.18 If I believed that my stockbroker would

be self-interested during a time period when they made investments with my money, I would not

give them my money in the first place. Placing the needs of the non-fiduciary agent first and

foremost in a fiduciary relationship is a necessary requirement for that relationship to justly

remain intact. If the fiduciary does not place the needs and concerns of the affected agent before

16 Easterbrook, Frank H., and Daniel R. Fischel. "Contract and Fiduciary Duty." The Journal of Law and Economics 36.1 (1993): 425. Print. 17 Satz, Debra. "XIV-The Moral Limits of Markets: The Case of Human Kidneys." Proceedings of the Aristotelian Society (Hardback) 108, no. 3 (2008): 269-88. doi:10.1111/j.1467-9264.2008.00246.x. 18 For more on trust-based obligations, specifically in medicine, see: Miller, P. B. "Trust Based Obligations of the State and Physician-researchers to Patient-subjects." Journal of Medical Ethics 32.9 (2006): 542-47. Print.

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his own needs, substitutes the needs of the affected agent for less important or beneficial needs,

or just disregards those needs, the fiduciary is taking advantage of the special relationship—and

thus the fiduciary loses credibility (and should lose influence).

The doctor-patient relationship is also a fiduciary relationship, which is yet another

reason that doctors have strong obligations to act in the best medical interest of their patients.

When it comes to medical decision-making, individuals are naturally weak agents. A vast

majority of individuals do not have the medical knowledge or expertise to make informed

decisions about their health care.19 When someone seeks counsel from a medical doctor, they are

doing so under a set of implicit assumptions about the doctor’s intentions. Operating under

implicit assumptions in a fiduciary relationship comes along with obligations to act in

accordance with those assumptions, so long as those assumptions are reasonable, moderately

uniform across similar relationships, and the fiduciary is aware—going into the fiduciary role

assumption—of the responsibilities they possess that generate these assumptions.

For example, if I visit my doctor with knee pain under the assumption that he will avoid

touching my knee during his clinical assessment, I cannot reasonably expect this. Therefore, my

physician would not be at fault for conducting a physical examination of my knee. In contrast, if

I visit my doctor with knee pain and expect the physician to treat my (potential) injury in my best

medical interest, this is a very reasonable expectation. Another reason to believe that fiduciary

duties are formed within the doctor-patient relationship is because a patient consents to medical

19 This is why the role of the physician, or the “healer”, has persisted throughout history. Being able to adequately take care of oneself requires an extensive knowledge of human health and physiology that an average person cannot reasonably be expected to hold. I am not claiming that human beings “should not” have the ability to take care of themselves; I am claiming that with all thing considered in the modern world, this is not a reasonable principle to maintain. Medical doctors and medical facilities are typically well-equipped to promote human health, and if it were somehow the case that an individual could (1) diagnose, (2) plan a treatment discourse, and (3) evaluate treatment effectiveness themselves, I would hastily withdraw this assertion.

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care from the doctor, thereby forfeiting a significant portion of their agency in the medical

decision-making process. However, when consenting to medical care and forfeiting this agency,

it is vital that individuals consent to this process willingly. Assuming this occurs, individuals can

reasonably expect a medical doctor to be making medical decisions with their best medical

interest in mind, just like a client can expect a lawyer to be making legal decisions for them in

the best interest of the client. If a physician does not act out of those intentions, he is acting

coercively. If a patient forfeits agency in the medical decision-making process and is naturally a

weak agent in the field of medical decision-making, it can be said that a medical doctor—

responsible for their care—gains fiduciary duties.

The foregoing arguments all support the claim that physicians can have obligations to

their patients. Role obligations, public good-promoting role obligations, favorable positions,

voluntary obligations, and fiduciary relationships relating to medical care all generate

obligations, and medical doctors have obligations to patients for these five reasons. I now turn to

the question of why health promotion is so important. Why are the obligations of physicians

premised on human health promotion before all other considerations? To answer this question,

and to explain how this answer is foundational to our understanding of proper medical care, I

will now address the value of human health, a value that is so resilient, it has been able to bolster

my arguments for doctoral obligations—and even prima facie generate obligations for

physicians.

II. The Unconditional Value of Health: Characterization and Obligation Generation

To say something is unconditionally valuable means that it is valuable regardless of

whether or not an agent subjectively values that item. For example, regardless of whether

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someone values my autonomy, it can be said that my autonomy is valuable—irrespective of what

moral theory informs that value assignment. The mere fact that my autonomy exists makes it

valuable, and without my autonomy, I am not able to access and pursue personal projects.20 The

counter to something being unconditionally valuable is for that something to be instrumentally

valuable; when an item is instrumentally valuable, the value of that item depends on the

individual assessing the value of that item. Even if the individual may place a high value on an

instrumentally valuable item, it does not mean that it must be uniformly respected and not

interfered with (and vice versa). For example, if you happen to value a slice of pizza, it is

valuable to you, but a slice of pizza is still just instrumentally valuable. There is nothing

unconditionally valuable about pizza, and it is completely reasonable for someone to not value

pizza.

This distinction is morally significant because it illustrates the reasons in favor of

respecting certain things. If I do not value a slice of pizza, I cannot prevent you from eating

pizza, but not because of the value of pizza. Rather, in doing so, I would not be valuing (read:

would be disrespecting) your unconditionally valuable autonomy, and as long as you eating pizza

does not interfere with the unconditional values of others, you are free to respect that

instrumental value. Still, we needn’t respect all autonomous choices. Imagine you want to

murder a pizza vendor in order to gain a free slice of pizza. This is not permissible; you may

value pizza and see a net positive in personal value from having the slice of pizza, but this cannot

be valued the same as ending the pizza vendor’s life—it can’t be equated, and therefore can’t be

considered a moral decision. This case illustrates that values must be balanced, and that

20 Korsgaard, Christine M., and Onora O'Neill. The Sources of Normativity. Cambridge: Cambridge University Press, 1996.

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unconditionally valuable things like autonomy should generally outweigh instrumentally

valuable things.

Now, suppose that you happened to be starving so badly that you were on the brink of

death and the only food that you had access to—before your impending death—was a slice of

pizza. Even if you did not subjectively value that slice of pizza, the slice would become more

valuable within the moment that it had the immediate potential to save your life. Lifesaving pizza

is still instrumentally valuable, but it becomes instrumental to promoting a higher order value

(something unconditionally valuable): your health and well-being. Your situation changed the

value of the aforementioned pizza because the slice of pizza is necessary to preserve other values

within your life (and the essence of your life); something instrumentally valuable like a slice of

pizza is able to become at least more objectively valuable because it is promoting value of a

higher order.

It may be ironic that I am discussing pizza in a section about human health and life, but

these cases illustrate how values like autonomy or human health should not be weighed against

other conditionally valuable things. As a baseline argument from the lifesaving slice of pizza

example, if one maintains that health is an instrumental value, there are still reasons to think that

health promotion can still matter. Beyond that, I believe that health promotion is instrumentally

valuable to promoting the unconditional value of health.

My claim is that health is unconditionally valuable. This idea is informed by a Kantian

moral theory: human health is unconditionally valuable because it is a necessary condition for

one’s rational will to exist (and to be properly maintained and fostered, for that matter). Without

proper health, one cannot fully pursue personal projects—and cannot fully exercise their rational

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capacities. For that reason, human health is a value that exists within each human being, and that

value exists regardless of the individual perspective on that value. David Velleman, in his paper

entitled A Right of Self-Termination? explores this idea. Velleman supports the notion that

human health—in the form of human life—is valuable regardless of subjective opinion. He

rejects the idea that human life can never be ended, but he supports the idea that human life

cannot be ended based upon one’s own valuation of a life (or, in other words, a substitution of an

instrumental value for an unconditional value). Velleman introduces that idea here:

“That’s what I miss in so many discussions of euthanasia and assisted suicide: a sense of something in each of us that is larger than any of us, something that makes human life more than just an exchange of costs for benefits, more than just a job or a trip to the mall. I miss the sense of a value in us that makes a claim on us—a value that we must live up to.”21

Velleman is speaking about the inherent value within us that exists objective to our individuality,

something that not only we must “live up to,” but—as he further explores—that we must respect.

When I say respect, I mean not only in the sense of non-interference (our negative duties in

regards to the value in others), but also in the sense of aid and value promotion (our positive

duties in regards to the value in others).

This value that we must respect is our rational will and livelihood. When we are in a state

where our rational will and livelihood are above a reasonable, baseline level that does not hinder

our essential activities or projects, it may be said that we are healthy.22 Surely, one may have a

definition of healthy that includes the necessity of proper diet, consistent exercise, and maybe

even a certain degree of mental stimulation, but the exact definition of human health is not what I

21 Velleman, J. David. "A Right of Self‐Termination?" Ethics 109, no. 3 (April 1999): 606-28. doi:10.1086/233924. 22 Murphy, Dominic, "Concepts of Disease and Health", The Stanford Encyclopedia of Philosophy (Summer 2009 Edition), Edward N. Zalta (ed.), URL = <http://plato.stanford.edu/archives/sum2009/entries/health-disease/>.

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am trying to clarify in this argument. However minimally a definition of human health may be

structured, my only claim about health is that it is better to be healthy.

Some parameters of human health are uncontroversial. For instance, simply maintaining

basic organ functioning does not mean you are healthy; I would not consider someone in a

persistent vegetative state to be healthy. On the opposite side of the spectrum, I do not think it is

fair to include something like a particular amount of muscle mass or a cosmetic feature to be

included in a definition of health. For the sake of the argumentation, the definition of health that

I will be using is as follows: If someone is free of disease and illness, is not living a life that will

inevitably lead to preventable disease or illness, and can carry out normal species functioning on

a day-to-day basis without aid, I will consider that individual “healthy”.23 Thus, when I am

speaking about health promotion, I am referring to aiding a return to the conditions mentioned

above (or, in cases where that may not be possible, the best effort possible in order to attempt to

return an individual to the conditions mentioned above).

With that established, I want to reintroduce the point made prior to the preceding

paragraph. As Velleman has explored in his argument on self-termination (and something

explored by many philosophers writing on Kantian ethics), we have value intrinsic to our

humanity that cannot be interfered with for something of lesser value (i.e. happiness, money) to

be promoted. Further, we have a duty—as fellow human beings—to respect the rational will and

existence of other human beings, with the idea of “respect” being actualized in two forms.

Taking that idea to the arena of human health and well-being, according to a deontological

affirmation that we must respect—in more than one way—the rational will and livelihood of

23 I want to emphasize that I must take a definition of health to further my argument. I am not trying to argue for a particular definition of health, I am simply taking a definition that I believe is the least controversial and will be easiest to include within my main argument.

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others, from the previous argument, it then follows that we have an obligation to “respect”

human health and well-being.

This fact is much easier to comprehend from the perspective of negative duties; surely, I

have an obligation to not interfere with the health or livelihood of some other individual. It is

more difficult to assert that we have a positive duty to promote—or maintain—the health and

well-being of other human beings. To see why both are true, consider re-stating this principle as

an obligation to promote human health and well-being through non-interference and positive

provisions. This argument is another way of approaching the topic of a general duty of

beneficence; from this line of reasoning, we have additional moral reasons to promote societal

well-being. If someone standing next to me has a heart attack (like in the case of The Basketball

Game), I have an obligation to promote their health. That does not change, even if I do not have

the skills necessary to effectively carry out that health promotion. But, as explored when talking

about obligations in the basketball game case, this shortcoming can be mitigated by another

individual—the aforementioned “division of moral labor” facilitated by medical doctors.24

Thus, we arrive at what I believe to be the strongest case for strong obligation generation

in medical care: the fact that medical doctors are responsible for promoting an unconditional

value embodied in human health, well-being, and livelihood. Medical doctors are the individuals

responsible for maintaining and promoting the essence of human life: human health. That, I

24 There is no normative difference between an individual’s positive and negative duties related to human health promotion, but I do not maintain that no difference exists between positive and negative duties in all of ethics; it is easier to see how someone’s positive or negative duties in the subject of health promotion both tell in favor of a division of moral labor. To not interfere with human health promotion is only half of what is morally at stake in medicine, and apart from an ability to actively promote health and well-being, there are reasons to believe that health promotion is an obligation that society inherently maintains.

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believe, generates strong obligations that must hold doctors accountable for not making efforts to

maintain or promote human health.

Sam Scheffler has argued that unconditionally valuable goods generate obligations to

promote or advance those goods.25 Take, for example, a non-instrumental relationship (like a

close friendship). The relationship is not maintained “solely as a means to some independently

specified end,” so there are reasons to believe that my friend makes non-instrumental claims on

me that would otherwise be unreasonable for a miscellaneous person to make on me. This is

permissible because of the nature of the relationship; for something to be able to non-voluntarily

formulate responsibilities for me, it must be of a higher-order, unconditional value. Further, there

would be something wrong with turning my non-instrumental relationship into something

instrumental (or having it be formulated on an instrumental basis). Now, let us assume that my

close friend was assigned to me through giving money to an agency that leases out close

friendships. There seems to be something inherently wrong with commodifying something of

non-instrumental value.

Health is an unconditionally valuable good, and from Scheffler’s argumentation, it

follows that medical doctors are therefore obligated to provide for human health promotion. One

advantage of an unconditional value approach to justifying obligations in medical care is that it is

informed and supported by the preceding arguments for obligations while simultaneously

providing justification for those obligations. From Scheffler’s argument, there are also reasons to

believe that commodifying patient health—based on its non-instrumental nature—is wrong. To

gain something of instrumental value from a relationship of a non-instrumental nature is like

25 Scheffler, Samuel. "Relationships and Responsibilities." Philosophy and Public Affairs 26, no. 3 (Summer 1997): 189-209. doi:10.1111/j.1088-4963.1997.tb00053.x.

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paying for a close friendship or taking advantage of a spouse for profit: there seems to be

something non-instrumental undergoing degradation in these transactions.

A doctor is the individual responsible for human health promotion, a role that they willingly

assume. Doctors are the embodiment of a “division of moral labor” in human health promotion

(also an idea also explored by Samuel Scheffler).26 Further, human health is not only a necessary

public good, but a value that is fundamental and unconditionally valuable. And, if nothing else,

doctors are well-positioned to promote the unconditional value of human health.

III. The Medical Profit Motive is Inconsistent with Physician Obligations

Recall the discussion about the value of pizza. At one point, I introduced a hypothetical

situation where you wanted to kill a pizza vendor to obtain a free slice of pizza, which may have

seemed like an absurd situation to propose. Yet it is not so absurd when we acknowledge that

physicians consider monetary profit over human health promotion. These practices are both

morally unsound for a similar set of reasons. After all, in both cases, a rational agent would be

disrespecting an unconditional value for their own pursuit of an instrumental value like pizza or

money. Both of these cases are therefore impermissible ways of responding to unconditional

values. Doctors, especially with their set of strong obligations towards patients to promote

health, are morally blameworthy for not considering patient health over monetary gains (when

the two values are pitted against one another). Thus, physician obligations are pro tanto

incompatible with a medical profit motive, and thus, a medical profit motive is pro tanto

immoral.

26 Scheffler, Samuel, and Véronique Munoz-Dardé. "The Division of Moral Labour."Proceedings of the Aristotelian Society, Supplementary Volumes 79 (2005): 229-53. http://www.jstor.org/stable/4106941.

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I have established that health has unconditional value, but I would like to speak briefly

about the “profit motive” as mentioned in this paper. Philosophers, including Buchanan and

Brock, have also addressed this topic and their analyses will be discussed later in this

argument.27 To reiterate, I define a medical profit motive as the desire to maximize pecuniary

profit from patient care as a primary motivation in patient care. A medical profit motive is not

the same as medical cost considerations; I am asserting that the former is unethical and the latter

is responsible (when taken in isolation from one another). If a medical doctor is considering costs

to patients, costs to other patients, and costs to society when making medical decisions, this can

more easily be morally permissible. The situation changes when for-profit medical providers,

including doctors, go beyond cost considerations to consider their own monetary gains.28

When profit motivated reasoning is injected into patient care, a medical provider is

objectifying the patient and performing a commodification of that patient’s health and well-

being. To “objectify” a patient is to reduce the patient to something instrumental, like a

commodity. Patients are human beings, and their humanity should disallow a commodification

process to take place towards something fundamental to their humanity. The doctor-patient

relationship is a non-instrumental relationship that generates strong obligations, and it is wrong

to take advantage of it to produce instrumental goods. Patient health must exist outside the realm

of commodification; it is of a higher-order, unconditional value.

Throughout this discussion, I have assumed that whenever something is of unconditional

value, it carries significant moral weight. If two things of value are pitted against one another

27 Brock, Dan W., and Allen E. Buchanan. "The Profit Motive in Medicine." The Journal of Medicine and Philosophy 12 (February 1987): 1-35. doi:10.1093/jmp/12.1.1. 28 I define “for-profit” healthcare organizations to be for-profit organizations (in the traditional sense) and non-profit healthcare organizations with a Board of Trustees. Essentially, I am excluding charitable healthcare organizations and community healthcare organizations.

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(meaning that promoting one value will disrespect or undermine the other value), the thing of

higher value must be promoted. I realize that sounds nebulous, so allow me to clarify this

determination. Even if, all things considered, item A is of a higher value than item B, does that

necessarily justify promoting item A over item B? Fortunately, human health can escape from

this tenuousness when being pitted against a medical profit motive because a medical profit

motive is something of instrumental value. No matter which way it is dissected, the desire for

medical providers to gain additional revenue is a relative, conditional value. Hardly anything

about our moral intuitions or any predominant moral theory would justify a model of the medical

profit motive being unconditionally valuable.29

In other words, when something of unconditional value is weighed against something of

conditional value (and one must be promoted over the other), we should preserve the thing of

unconditional value. For example, slavery is immoral because slavery substitutes something of

conditional value (free labor) with something of unconditional value (autonomy, respect). This is

even true in cases where the “things” of unconditional value are weighted heavily in number

against the “things” of conditional value. Consider the case where a building is up in flames, and

in this building, the human race has managed to gather all of the greatest artistic achievements

over the last century. However, there is something else within the inflagration: a human baby.30

You must choose to save the body of art that has been collected in the building or the human

baby, and you cannot save both. What would you save? There is no question that the art is

valuable, but I believe that most would agree that we would be morally required to save the

29 Velleman, J. David. "Beyond Price*." Ethics 118.2 (2008): 191-212. Print. 30 Buss, Sarah. "Needs (Someone Else's), Projects (My Own), and Reasons." The Journal of Philosophy 103, no. 8 (August 01, 2006): 373-402. Accessed April 16, 2014. http://www.jstor.org/stable/10.2307/20619955?ref=search- gateway:5a573eb9f71faa9025c10bd36400855a.

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child’s life.31 Here, we can see that what must be at stake in value considerations—and choices

within those considerations—are not just considerations about the quantity of competing values,

but the types of values that are at stake. Applying this into the health vs. profit debate, it would

not be appropriate to consider the amount of profit at stake in medical decision-making when

unconditional values like health are in jeopardy of being undermined.32

One may justify a medical profit motive in patient care, insofar as it does not undermine

proper patient care—which is the essence of a physician’s obligations. Yet I have argued that if a

doctor acts on a medical profit motive, and that motive is antagonistic towards the health of the

patient, in every case, the profit motive is morally impermissible. An unconditional value (like

patient health) cannot be valued over a conditional value (like profit). Even if a medical profit

motive is in accordance with promoting patient health, it is still immoral in this case because it is

pro tanto immoral to consider monetary profit in medical decision-making, but that immoral

characteristic can be overcome by beneficial patient outcomes. The fact that a profit motive is

prevalent in patient care is morally permissible so long as the medical doctor responsible for

patient care is promoting patient health to the fullest extent possible (again, independent of a

profit motive). In the negative interference cases, if doctors decide to undermine proper patient

care, they are not only acting against what is morally required from them, but they also are

31 A view that supports this intuition can be found in: Singer, Peter. "Famine, Affluence, and Morality." Philosophy and Public Affairs 1.3 (1972): 229-43. Print. 32 Some would argue (such as Judy Thompson in her work “A Moral Defense of Abortion”) that just because one can prevent a wrongdoing or benefit someone with minimal effort does not necessarily lead to an obligation to prevent that wrongdoing or benefit that individual. While acknowledging her position, I believe this is an overgeneralization and misguided. I think that the circumstances do matter when considering moral blame for not benefitting someone; if the values at stake are unconditional and the effort required to prevent wrong/benefit are miniscule, one can be held morally accountable for failing to act with beneficence. To use Thompson’s examples while applying my own beliefs, Henry Fonda can be held morally accountable for not touching the feverish brow when he is a walking distance from the ill patient (and a patient could be conceived as having a right to his cool hand). I do not believe that the same right would be generated when Henry Fonda is a plane ride away from that same patient; it would be more unreasonable to claim this.

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undermining the fundamental, implied mechanisms predicating medical care. If a medical doctor

does not act in accordance with the fundamental obligations that predicate moral patient care, it

cannot be said that they are an ethical doctor. The cases where a medical profit motive interferes

with and undermines the value of human health are enough to suggest that a medical profit

motive should not exist in medical decision-making, but some situations may permit such a

motive.

IV. Profit Considerations in the Modern Doctor-Patient Relationship

I have developed a theory of value assignment and assessment in medical care related to

pecuniary profits. I will now show how this theory applies in real-world medical decision-

making. Aspects of the modern medical field are sometimes driven by profit motive

considerations over considerations of patient health, and profit motive-driven care undermines

patient health more than is often perceived. A medical profit motive undermines patient health in

three ways: a medical profit motive—maintained by a medical doctor—compromises the health

of that doctor’s patient, compromises the health of other potential patients, and undermines the

standard of care that particular patient groups morally ought to receive.

First, a medical profit motive can compromise the health of individual patients. For

example, a physician or for-profit health system could benefit greatly (in the economic sense)

from over-treating particular medical ailments or conditions (another name for this case being

polypharmacy).33,34 In some cases, physicians are driven to keep patients on sustained treatment

33 A formal definition of “polypharmacy” is “when an older adult patient, often over the age of 65, is prescribed—and is taking—five or more medicines or treatments at one time.” Although this definition exists, there is no exact medical definition of the term “polypharmacy”. Thus, when I refer to polypharmacy in this argument, I am referring to the instance where a patient is prescribed—and is taking—more than one pharmaceutical at a time. Additionally, I will use the term “polypharmacy” and

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plans because they receive higher profits from having their patients stay on these treatment plans.

Jerome Schofferman addresses this issue in the field of Interventional Pain Medicine. As a pain

doctor, Schofferman makes the claim that “profit is an incentive to provide the best care

possible…[but] it is when profit becomes unreasonable that there is a problem;” Schofferman

goes on to say:

“Pain specialists may limit their practice to the most profitable patients—those who require interventions such as injections or neuromodulation. They might decline to see those patients who need only pharmacological management, counseling, rehabilitation, or just support and advice. They may rationalize this practice style by thinking, “it’s what I do best,” “it’s what I like to do,” or “it’s what I was trained to do.” More disturbing might be, “I’ve got a lot of overhead,” or “I’ve got to make a living.”35

To prefer certain patients over others on an economic basis (even assuming that all patients being

considered are insured and can pay) is the ugly realization of the medical profit motive: choice

medical care that affects the livelihood of patient populations.

Within these cases, there are instances where physicians have the same motivations, but

they come at a higher additional cost to the patient: their health. Physicians may have an

economic interest to not only treat patients on a continual basis, but also to recommend treatment

plans or pharmaceuticals that they will receive a higher profit from prescribing. Profit-motivated

physicians could prescribe drugs even if the drugs are not the most effective defenses against

patient ailments, or even if some sustained treatment plans have additional health costs to a

patient (such as known or unknown negative health side effects). In these cases, side effects

“overprescription” to refer to the increased use of prescription medicine to treat medical ailments (so the term may also be used to refer to a systemic issue). 34 A great article that introduces the concept, problem, and scale associated with polypharmacy is: “Gorard, D.a. "Escalating Polypharmacy." Qjm 99.11 (2006): 797-800. Print.” 35 Schofferman, Jerome, MD. "Interventional Pain Medicine: Financial Success and Ethical Practice: An Oxymoron?" Pain Medicine 7, no. 5 (2006): 457-59. Accessed November 21, 2013. American Academy of Pain Medicine.

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alone should be enough to caution medical doctors from over-treating their patients, because to

do so is harmful.36 Several more focused studies confirm that polypharmacy negatively impacts

patient health.37,38 When a medical profit motive starts to negatively impact patient health on a

direct level, the medical doctor facilitating the impact is at fault. In these cases, a medical profit

motive cannot justify over-treatment when patient health is at stake.

Second, a medical profit motive can compromise the health of larger patient populations

or other patients that a medical doctor might not have direct contact with. Consider the following

case to demonstrate the concept of a medical doctor imposing social costs:

The Prodigal Physician. A medical doctor M works for a hospital, so Dr. M does not directly bear the costs associated with medical decision-making. Dr. M is especially wasteful in medical decision-making, always keeping his patients within the hospital as long as possible, prescribing the most expensive treatment plans for his patients, taking the longest amount of time to see patients as possible, and performing other tasks associated with medical care with no regard for costs. Dr. M receives increased profit from increased medical cost.

When a medical doctor is imposing social costs on a system or on society as a result of a medical

profit motive, that profit motive should not be present in patient care. The idea of a social cost is

relatively simple: a social cost is a cost that is borne by a community, a system, or society rather

than a private cost, which is borne by an individual.39 Certain medical decisions affect more than

just a single patient or the medical doctor making the decision. For instance, if a doctor were to

see a patient continually if it is not clinically indicated that a patient needs constantly renewing

visits, a doctor may monetarily benefit from that constant stream of visit costs. The monetary

36 Hsiao, W. C. "When Incentives And Professionalism Collide." Health Affairs 27.4 (2008): 949-51. Print. 37 Unsworth, D. J. "Controversy: Adrenaline Syringes Are Vastly over Prescribed." Archives of Disease in Childhood 84.5 (2001): 410-11. Print. 38 Zarowitz, Barbara J. "Anticoagulant Polypharmacy." Geriatric Nursing 32.3 (2011): 198- 202. ScienceDirect. Web. 11 Mar. 2014. 39 Coase, Ronald H. “The Problem of Social Cost.” Law & Economics 3, October 1960. Print.

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costs of continual patient visits are not the only costs to be considered in this situation; we must

also consider the time lost for the doctor to see other patients, patients who may require medical

attention. In other words, this example highlights that the profit motive can compromise overall

patient care if doctors allocate their time on the basis of monetary considerations rather than

good patient care.

Although doctors legally have the right to decide which patients to see, patients who have

the proper insurance have the right to see a physician if they so choose, and physicians can only

work a certain amount of hours within the day, I deny that these considerations are appropriate

enough to defend a profit-motivated model of patient care. Doctors—along with patients—need

to be more responsible and consider costs to the health of others as a result of prolonged (and

unnecessary) medical care.

The medical profit motive leads to additional negative health effects, some that may

materialize in more indirect ways (but are nonetheless caused by a physician being profit-

motivated). Medical doctors have a monetary interest in becoming highly specialized within the

medical field, which has led to a shortage of primary care physicians.40,41 In the United States,

the population is aging rapidly, which will require an increased number of primary care

physicians to address in the future. The United States is also expecting a huge increase in the

need for primary care physicians when the Affordable Care Act comes into full fruition.42 Along

with the aging population and patient populations increasing, the country is experiencing a

40 Cross, MargaretAnn. "What the Primary Care Physician Shortage Means for Health Plans."Managed Care Magazine Online, June 2007. http://www.managedcaremag.com/archives/0706/0706.shortage.html. 41 Giang, Vivian. "There Is A Serious Shortage Of Primary Care Doctors And It's Only Getting Worse." Business Insider. September 10, 2013. http://www.businessinsider.com/there-is-a-serious-shortage-of- primary-care-doctors-and-its-only-getting-worse-2013-9. 42 Peckham, Carol, and Perry A. Pugno, MD, MPh. "The Impending PCP Shortage: How Bad Is It?" Medscape. N.p., 17 Sept. 2013. Web. 12 Mar. 2014.

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decrease of primary care physicians available and a decrease in the number of medically trained

individuals entering into primary care.43 Here also, profit motivation affects the entire health care

system. As Arnold Reiman writes, the economic incentives of specialty practice “are attracting

the great majority of physicians into specialty practice, and these incentives, combined with the

continued introduction of new and more expensive technology, are a major factor in causing

inflation of medical expenditures.”44 Again, medical doctors should have the autonomy to decide

what specialties within the medical field to focus their attentions towards, but that decision

cannot be irresponsible and void of societal considerations. A lucrative occupational choice is

not always the most moral choice even if it is morally permissible. No matter what field a

medical doctor decides to focus in, he must examine the condition of the medical field—and thus

the needs that the medical field displays. If there will be a deficiency of primary care doctors

moving forward with health care reform, there will be a large social cost associated with that

deficiency.45 The responsibility to address this shortage falls—at least in the short-term—on the

doctors within the medical field. It is necessary that some doctors suspend their medical profit

motive for the social costs that may be resultant from increased medical specialization.

Third, a medical profit motive negatively impacts the entire medical field because a profit

motive can detract from—or sometimes can prevent—considerations about alternative treatment

plans or a focus on preventative medicine. Thus, some medically preferred treatment plans can

be overridden by monetarily preferred treatment plans. Based on our current medical incentive

structures, preventative medicine does not provide for increased profits, even though a focus on

43 Mercer, Marsha. "How to Beat the Doctor Shortage." AARP. N.p., Mar. 2013. Web. 12 Mar. 2014. 44 Relman, Arnold S. "Eliminate the Profit Motive in Health Care." Physicians for a National Health Program. September 28, 2011. http://www.pnhp.org/news/2011/september/eliminate-the-profit-motive-in- health-care. 45 Cross, MargaretAnn. "What the Primary Care Physician Shortage Means for Health Plans." Managed Care Magazine Online. N.p., June 2007. Web. 12 Mar. 2014.

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preventative medicine is undoubtedly in the best medical interest of most patients. Here, you can

see a situation where the interests of for-profit medical providers are in direct tension with the

obligations that medical providers have to promote patient health.

To see how this tension pans out in real-world medical care, consider treatment regimes

for Celiac disease (and its resultant gluten intolerance) that are premised on the idea that

preventative medicine is not as profitable as lifelong treatment, and therefore lifelong treatment

should be the governing model of patient care. According to The Celiac Disease Center at the

University of Chicago, Celiac disease afflicts “an estimated 3 million Americans,” yet only three

percent of the people afflicted by it are aware of the nature (and cure) of their illness.46 If Celiac

disease is correctly diagnosed, the effective treatment is simply a gluten-free diet.47 Doctors

theoretically have a monetary interest in treating the symptoms of Celiac disease, though,

because they do not see a monetary gain from advising gluten-free diets or championing

awareness of Celiac disease within relevant patient populations.

This is just one example of a problem with the medical profit motive in treatment of

medical ailments; treatment correlates with profit, regardless if it is clinically indicated that

treatment is needed or not. Alternative or less burdensome treatment plans (such as a diet

change) do not produce a profit, so the incentive to pursue such plans is not concrete. The

incentive, truly, should be a moral one, not one based on profit. This is not only an issue because

the commodification of human health—by placing health against monetary profit—is immoral in

the sense that disrespecting an unconditional value by promoting an instrumental value is pro

46 Celica Disease Center. “Celiac Disease Facts and Figures.” The University of Chicago Celiac Disease Center. August 2005. www.uchohospitals.edu/pdf/uch_007937.pdf. 47 Briani, Chiara, Diana Samaroo, and Armin Alaedini. "Celiac Disease: From Gluten to Autoimmunity." Autoimmunity Reviews 7.8 (2008): 644-50. Web.

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tanto wrong, but the profit motive often leads to worse patient health outcomes. This situation is

absolutely impermissible.

V. Some Objections to my Argument

In this section, I will address some arguments in opposition to my thesis. First, one may

argue that a doctor is merely a businessman. On such a view, if a doctor wishes to maintain a

medical profit motive and consider costs associated with medical care, that motive is not in

tension with his obligations. Proponents of this view may argue that for a medical doctor to be

fully autonomous and provide excellent patient care, he must be able to maintain a profit motive.

This objection prompts a clarification. When I claim that a medical doctor should not

consider monetary profit in patient care, I am not trying to suggest that he should not consider

the costs associated with medical care; that would be an inaccurate extension of my thesis. I fully

believe that cost considerations can exist within patient care because I believe that cost

consideration is one of the obligations that doctors have to patients and the health care system. A

fully responsible physician will be able to weigh cost considerations against treatment

effectiveness and patient health without compromising an ethical principle outlining patient care.

I argued above that a doctor is not foremost a businessman because he has especially

powerful obligations to promote patient health. Even if doctors are somehow businessmen within

the medical field, it does not necessarily follow that doctors gain the right to maintain a medical

profit motive—as demonstrated by the potential for a medical profit motive to undermine the

value of patient health. Medicine should not be considered a business. It is still morally not ideal

for a profit motive to exist in patient care, as evidence of a pro tanto wrongdoing that is

associated with any medical profit motive. When a doctor incurs professional obligations, he

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forfeits some of his autonomy (to make any medical decision, regardless of patient outcomes) in

exchange for patient trust and the power to make medical decisions for a patient.48

As I have indirectly mentioned throughout this argument, there are still situations where a

profit motive can exist in patient care. My argument does not seek to prevent all cases of profit

motivation in individual medical care (or, in other words, within the doctor-patient relationship).

The following case illustrates a scenario when the profit motive may be morally acceptable all

things considered:

The Greedy Neurosurgeon. Dr. Cash is the top neurosurgeon in the world, so when a relevant patient is treated by Dr. Cash, they receive the best possible medical care. However, Dr. Cash is not motivated by promoting patient health and well-being; Dr. Cash happens to charge large sums of money for his services, and he is driven to provide excellent patient care solely based on large profits.

Based on the foregoing arguments, there is still something wrong with medical care being driven

by profits, but The Greedy Neurosurgeon case illustrates that medical outcomes can overcome

the wrongness of commodifying health. If a medical doctor avoids profit considerations in

medical decision making, it would be morally ideal; this scenario, of course, should be weighed

against the scenario where profit considerations are abolished along with optimal patient health

outcomes.

I acknowledge that completely removing the potential for a medical profit motive in

patient care would remove a significant portion of motivation for physicians to provide excellent

health care services, even though this is not morally ideal. In the case of The Greedy

Neurosurgeon, a profit motive can exist because it is utilized to promote the most optimal health

48 No need for this point to be ethically troubling. If someone voluntarily forfeits their autonomy to you, it is permissible to violate that portion of autonomy they conceded. This exists in medical care through the autonomy forfeiting that results from informed consent to medical treatment.

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outcomes for his patients. But insofar as a medical profit motive exists and acts antagonistically

towards promoting optimal patient health outcomes the profit motive is morally impermissible.

One may also object that medical doctor is simply a health consultant for a patient. If so,

then doctors do not have a responsibility to promote patient health in all situations. One may ask,

“Doesn’t patient satisfaction and happiness matter too?” Proponents of this position assert that an

individual’s well-being is their own value to selectively maintain, and it would be a violation of

preventions towards medical paternalism to try and claim that patient happiness should not be the

motivating factor in medical decision-making. In this argumentation, it would be unethical to

make a claim on the value of another individual’s health.

Patient happiness and satisfaction is significant, but it would matter more if it were not

for the fact that patients are often “weak agents” in the medical decision-making process. Debra

Satz, in a paper discussing the moral considerations behind organ markets, defines “weak agency”

as the situation where “an agent who is either ignorant of the consequences of his actions or is

not directly involved in the transaction…relies on another person to transact on his behalf.”49 In

this definition, patients seeing a medical doctor are weak agents over medical decision-making

relating to their own health. A patient may desire a particular treatment plan, but since they—on

balance—have limited knowledge about human medicine, they cannot make a fully informed

and appropriate decision about their treatment, albeit they cannot carry out most treatment plans

without the counsel or action from a medical doctor.

Since it has been shown that patient health is of unconditional value, if a medical doctor

operated with a primary motivation being patient happiness and satisfaction, it could be possible

49 Satz, Debra. "XIV-The Moral Limits of Markets: The Case of Human Kidneys." Proceedings of the Aristotelian Society (Hardback) 108, no. 3 (2008): 269-88. doi:10.1111/j.1467-9264.2008.00246.x.

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that they would be acting impermissibly because they could allow patient health to be

compromised for something else of conditional, instrumental value: happiness.50 For this reason,

if patient happiness is something of instrumental value, then the argument that I have developed

throughout this chapter applies, and patient happiness then cannot be promoted over patient

health. This does not mean that a medical doctor should disregard patient happiness and

satisfaction completely; there is still an element of respecting patient happiness that comes along

with moral patient care. Something of instrumental value is still something valuable to an agent.

It is when this instrumental value could potentially undermine the value of something

unconditionally valuable, like human health, that a problem arises.

VI. Conclusion

In this chapter, I have demonstrated that a medical profit motive is incompatible with

ethical patient care, but may be able to still exist when considering patient health outcomes. I

first outlined the ways in which a medical doctor has strong obligations towards his patients, and

from that discussion, I showed that these obligations are premised on promoting patient health

and livelihood. Due to the nature of these strong obligations, medical doctors cannot

simultaneously maintain a medical profit motive and consider patient health; patient health

should be their primary consideration.

50 This position may be interpreted to be at odds with a prevention of medical paternalism, and I am endorsing medically paternalistic action. First, consider that I am simply discussing this idea in the context of patient happiness being a primary motivation. I firmly believe that patient happiness matters in medical decision-making, but it cannot be what drives physicians to treat ailments and choose patient discourses. If that were the case, medical decision-making would lose effectiveness. If patient happiness was the ultimate barometer to guide physician decision-making (i.e. the happiest patient was the one that was treated most effectively), doctors would become glorified drug dealers: prescribing patients nothing but morphine to combat their medical ailments would produce the happiest patients. Clearly, our intuitions tell us that there is something wrong with this situation. In addition, this position should not be interpreted to mean that patient happiness—materialized into medical decisions—should not be factored into treatment plans; my argument considers that refusal to care is a legitimate and important check on paternalistic decision-making in medicine.

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From this discussion, it may seem as though I am being very critical towards medical

doctors. Despite the foregoing ethical argument against a medical profit motive, I acknowledge

that medical doctors operate in a complex field driven by a large number of considerations and

responsibilities. I do not believe that the existence of a medical profit motive is entirely the fault

of the medical doctor, so in the next chapter I will explore the existence and unfortunate

fostering of the medical profit motive by agents other than the medical doctor. There, I argue

that physician incentive structures are ethically flawed, and they ought to change to act in

accordance with relevant moral principles in patient care. On a systemic level, new issues arise

that further suggest that a medical profit motive is immoral to maintain when administering over

patient care.

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Chapter II: The Medical Profit Motive in Medical Administration

“It is undeniable that for-profit health care involves potential conflicts between the interests of providers (physicians, managers, administrators, and stock-holders) and those of patients. In the most general terms, the conflict is simply this: an institution with a strong, if not an overriding, commitment to maximizing profit may sometimes find that the best way to do this is not to act in its patients’ best interests.”51

In the previous chapter, I discussed cases where a medical profit motive is carried out by

a singular medical doctor. There, I suggested that the negative outcomes that result from certain

medical profit motives are enough to tell against the existence of a medical profit motive in all

medical care. The elimination of profit motives would be an ideal scenario if we, as a society,

could uphold all moral principles strictly (that is, if we could be moral saints).52 However, even

though a medical profit motive commodifies patient health and is pro tanto wrong, we cannot

halt these motivations or criticize any singular medical doctor for operating within our current

medical system so long as they are optimally promoting patient health with a profit motive.

The same logic does not apply to bodies of medical doctors or to administrators of large

medical organizations with direct patient impact. For these agents, maintaining a medical profit

motive on a meta-patient, organizational level introduces new levels of moral concern that afford

them fewer excuses to commit the wrongdoings associated with a medical profit motive.

My thesis in this chapter is that a medical profit motive—pursued by organizations or

maintained on an organizational level—is morally worse than a medical profit motive maintained

within a patient-doctor relationship. A medical profit motive on an administrative level is

51 Brock, D. W., and A. E. Buchanan. "The Profit Motive in Medicine." Journal of Medicine and Philosophy 12, no. 1 (1987): 1-35. doi:10.1093/jmp/12.1.1. 52 Wolf, Susan. "Moral Saints." The Journal of Philosophy 79.8 (1982): 419-39. JSTOR. Web. 25 Feb. 2014. <http://www.jstor.org/stable/2026228>.

46

especially morally wrong because it fosters and facilitates further systemic wrongdoing. When a

medical organization maintains a profit motive, they not only commodify patient health, they

coerce medical practitioners into committing a similar commodification and pressure one another

into considering monetary gain over optimal patient health promotion. This profit motive is

especially wrong when the individuals maintaining the medical profit motive are not medical

professionals, thereby rendering them almost entirely unable to properly value human health and

well-being in medical decision-making.

The medical organization operates in two separate “firms”—the medical staff and the

administrative staff. Each face different challenges, require different criteria for performance,

and are normatively different.53 The leadership structure of medical organizations do not face the

same type of pressures that medical practitioners face, so it is harder to justify operating in an

immoral system when changes could feasibly be made to align profit-driven practices with

medically optimal practices.

Some may reply that this position would be an impossible business model to uphold or

would be overzealously attacking the issue of business considerations within medical care. This

thesis is not directly concerned with business considerations; the moral travesties that result from

a systemic medical profit motive defeat any considerations of profit. I am engaging in ideal

theory in this chapter, which intends to lay out the moral facts behind administrators’ medical

profit motives.54 These moral facts can—and will be—engaged and interpreted differently, and I

am not attempting to outline the exact ways that a moral medical organization ought to weigh

53 Harris, Jeffrey E. "The Internal Organization of Hospitals: Some Economic Implications."The Bell Journal of Economics 8.2 (1977): 467-82. JSTOR. Web. 13 Mar. 2014. <http://www.jstor.org/stable/10.2307/3003297?ref=search- gateway:056ba3079cdac1571a6495bf9e702c88>. 54 This concept was introduced by John Rawls. See: Wenar, Leif. "John Rawls." Stanford University. March 25, 2008. Accessed March 24, 2014. http://plato.stanford.edu/entries/rawls/#IdeNonIdeThe.

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pecuniary considerations against patient care decisions. I will offer some suggestions for medical

organizations, but my mission here is to tease out the moral facts within an administrative

medical profit motive so that they can be prepared for real-world application.

To clarify the role of ideal theory in our moral reasoning, consider the following thought

experiment from David Estlund. Imagine the morally ideal reality of a situation (M) as a “picnic

spot” on a distant—yet visible—hill. If we desired to find the best picnic spot to have a picnic,

we would surely want to reach the best picnic spot, M. Now, suppose that the M picnic spot was

unreachable because the hill was surrounded by a terribly lethal fog that instantly killed any

morally imperfect individual who passed through it. Since we could not reach M or it would not

make sense to try to reach M, that does not mean we should deny the fact that M is the best

picnic spot. Knowing about M also has value because we can still find and analyze other picnic

spots based on the qualities that we see in M.55 In the same way, determining how the morally

ideal medical organization should be organized does not call for a medical organization to

completely overhaul their existing structure. This analysis is pursued so that the moral facts of

their operation can inform future action, invoke self-reflection, and create an ideal for moral

reference.

In Section I, I further explore the case of The Greedy Neurosurgeon from Chapter I. I

then compare it to a new case that intends to introduce an organizational medical profit motive in

order to uncover what truly separates the profit motives of these different agents. From this

analysis, I delineate what I believe to be the most compelling reasons that an organizationally

maintained medical profit motive (which I will abbreviate as an “OM medical profit motive”) is

55 Julius, A. J.. “David Estlund, Democratic Authority: A Philosophical Approach.” Philosophical Review 119, issue 2 (2010). 256-58.

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more morally wrong than an individually maintained medical profit motive (which I will

abbreviate as an “IM medical profit motive”). In Section II, I demonstrate how the wrongdoing

of a profit-motivated medical administrator is heightened due to the leadership position (and

resultant agency) that the administrator holds. Leaders of a medical organization are more

morally blameworthy due to their responsibility for collective wrongdoings. In contrast, doctors

are coerced by leaders—directly or indirectly—into wrongdoing.

In Section III, I argue that medical administrators are afforded fewer excuses for

wrongdoing and can more reasonably be expected to change a system predicating immoral

medical decision-making, rather than simply operating within it and accepting some moral

blameworthiness in order to come out with optimal patient health and well-being. For this

reason, an administrator’s maintaining of a profit motive is especially wrong. In Section IV, I

argue that besides the patient, medical decisions (or decisions impacting patient health and well-

being) should be made by medical experts, and when non-medical experts commodify human

health and well-being in order to compare patient outcomes against a profit motive, they are

especially susceptible to wrongdoing. In Section V, I consider two objections to my position that

challenge the obligations within medical administration and the practicality of my position. In

Section VI, I offer suggestions on how medical administration can be revised—and can

commit—to promote ethical medical practices and decision-making processes.

I. The Medical Profit Motive Revisited: Does The Agent Matter?

In Chapter I, I argued that The Greedy Neurosurgeon’s profit motivations are pro tanto

morally wrong, but the wrongness of the situation is outweighed by the value of good medical

outcomes for Dr. Cash’s patients. While cases where a medical profit motive positively

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correlates with patient health and well-being allow for moral excuses in particular cases, the

same cannot be said for the systemic issues that are presented from a medical profit motive.

Consider a similar case:

The Greedy Administration. Cash for Health Hospital is the top hospital in the world for cardiac surgery, so when a relevant patient is treated in Cash for Health Hospital, they receive the best possible medical care. However, Cash for Health Hospital is not motivated by promoting patient health and well-being; Cash for Health Hospital happens to charge large sums of money for their services, and the administration is driven to provide excellent patient care solely based on large profits.

Obviously, this scenario is a bit unrealistic considering hospital administrators must be

concerned with at least a baseline of patient health and safety (in order to exist and function as

an organization, let alone a hospital). Nevertheless, the administrators of Cash for Health

Hospital are an instructive caricature of some modern healthcare institutions.

In contrast to The Greedy Neurosurgeon, The Greedy Administration is more culpable for

the moral penalties associated with a medical profit motive. In Chapter I, I established that

medical doctors have a strong obligation to promote patient health and well-being based on non-

profit motives. This idea was challenged by the case of The Greedy Neurosurgeon. On one hand,

profit-motivated medical doctors are morally blameworthy for commodifying patient health and

valuing it against profit, and on the other hand, medical doctors are morally blameworthy if they

do not optimally promote patient health and well-being. Thus, The Greedy Neurosurgeon forces

one to concede that, aside from the pro tanto wrongness that is associated with health

commodification, physician profit-motivation can be justified only when it is maintained in order

to uphold the strong obligation to promote patient health. Even then, it is not as though a profit-

motivated physician is praised for being self-aware of their ability to on-balance justify a profit

motivation; there is still a component of wrongness to health commodification that is undesirable.

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This component is teased out and amplified in cases such as The Greedy Administration

because health commodification on a systemic level comes at a higher moral price. The

obligation to promote patient health and well-being is shared among medical practitioners and

medical administrators, but the role obligations that develop from these respective positions are

also inherently different. Administrators in medicine segment their attention between providing

excellence in patient care with running a business. I am not suggesting that medical doctors who

practice on an individual level are not concerned with running a business; I am simply claiming

that administrators in medical organizations have a unique, impersonal obligation to sustain their

business. An adminsitrator’s obligation is unique because it is further removed from direct

patient care and is a crucial aspect of his role and function in medical care. If medical doctors or

groups of medical doctors maintain a business, they have no obligation (per se) to run a

profitable enterprise. They might maintain a profit motive, but their strongest obligations are to

promote patient health and well-being. Medical administrators have obligations, based on their

position, to maintain a profitable enterprise. These obligations do not reflect the moral facts of

patient care, however. Obligations from an administrative role cannot be confused with

obligations that stem from the unconditional value of patient health (and the unconditional value

of the doctor-patient relationship). Unfortunately, this is what links their role with the wrongness

of a systemic profit motive: the agents that lead the business of medicine—the immoral aspect of

medical practice—are absolutely more culpable for the wrongdoing which stems from

commodifying and improperly valuing patient health.

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In the following three sections, I will introduce the main reasons that I believe an OM

medical profit motive by a medical administrator is more wrong to maintain than an IM medical

profit motive by a medical doctor.56

II. Responsibility

The first aspect of an OM medical profit motive that distinguishes itself morally from an

IM medical profit motive is the idea that there can be a hierarchy of culpability when a leader is

overseeing a collective wrongdoing. When considering acts of wrongdoing, it is not always

adequate to conduct an examination under the lens of individual actions. Sometimes, actions

carried out from groups or organizations are immoral, but it is not always immediately obvious

when we look at individual effort/action that each member of the group takes an equal (or any)

share of moral blame for the immoral action.57

Take, for example, a case where three individuals (A, B and C) work together in order to

stab another individual, D, to death.58 The individual contribution from A, B, or C would not, in

isolation, be enough to actually murder D. In a way, we cannot morally accuse A, B, or C with

murdering D because assuming other contributions were not made to the murderous action, not

one of the attackers would be considered a murderer. This example challenges our idea of

individual responsibility in wrongdoing because we intuitively know that all of the three

participants should be morally responsible for murder, but no single individual’s action killed

56 I will disregard arguments supporting leaders in a medical organization with an IM medical profit motive because I do not believe that any argument supporting this position could be a sufficient moral defense; an IM medical profit motive held as a medical administrator is the product of individual greed and desire towards commodifying patient well-being (without any rational basis), and this immoral motive should not be confused with the desire for a medical administrator to have an OM profit motive. 57 Pettit, Philip. "Responsibility Incorporated." Ethics 117.2 (2007): 171-201. Print. 58 Lawson, Brian. "Individual Complicity in Collective Wrongdoing." Ethical Theory and Moral Practice 16.2 (2013): 227-43. Print.

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D.59 To account for this shortcoming, we must analyze individual responsibility within collective

action.

In Individual Complicity in Collective Wrongdoing, Brian Lawson addresses the

responsibility of individuals for collective wrongs.60 Lawson’s position is that any contributor,

no matter the degree, is accountable for the wrongdoing of a group if they knowingly contribute

to a harmful outcome that stems from the group participation. This position, Lawson

acknowledges, is met with some hostility. His “Modified Complicity Principle” seems to assign

equal blame to wrongdoing that stems from participation among active group leadership and

minimally participative group members alike.61 To counter this objection, Lawson replies that a

causal approach to harm assessment does not fully capture what is important when assigning

moral blame for contributions within a collective action.

I agree with this general analysis, but I do not agree with the final position adopted by

Lawson. A minimalist model of individual responsibility within organizational action cannot

properly account for external factors that have influence over the agency within collective action

schemes. On Lawson’s view, if a company is accused of deceiving their shareholders, the

executive council, the managers within the company, the human resources department, and the

individuals working in the mailroom (who ultimately send and receive postage relating to this

wrongdoing) share the same share of wrongdoing. For this reason, I reject the notion that the

59 Parfit, Derek. “Five Mistakes in Moral Mathematics.” Reasons and Persons. Oxford: Clarendon, 1984. N. pag. Print. 60 Lawson, Brian. "Individual Complicity in Collective Wrongdoing." Ethical Theory and Moral Practice 16.2 (2013): 227-43. Print. 61 The “Modified Complicity Principle” is as follows: (Basis) I am accountable for what others do when I knowingly contribute to a harmful outcome that results from our collective contributions. (Object) I am accountable for the harm or wrong we do together, independently of the actual difference I make.

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characteristics of a particular collective of individuals have no influence on the method of which

we should assign individual moral blame.

There must be a division of responsibility in collective wrongdoing, but it need not be

equal. On my view, group leadership ultimately must accept a larger portion of moral blame for

collective wrongdoing in most scenarios. This position is similar to Kutz’s model of individual

responsibility within collective action, which separates agents within collective action schemes

into those with executive intentions and those with subsidiary intentions.62 Agents who fall into

the category of having executive intentions ultimately drive collective action by setting collective

goals and determining individual actions, while those with subsidiary intentions “rationalize their

activity with reference to the executive intentions.”63 I will not argue that those with executive

intentions, whom I am calling leaders, are the only ones who can accept blame for collective

wrongdoings. I do believe that leaders must be held more accountable for the moral penalties

associated with collective action.

As a modification of the above thought experiment, let us take the same three individuals

with murderous intentions (A, B, and C) and assume that, within their collective, A is the leader.

A has determined and directed that the three will stab D at the same time, and because B and C

are subsidiaries to A (for whatever the reason may be; we can assume that they are employees),

they follow direction from A. It is unreasonable to assume that B and C do not accept any moral

blame just because they are following direction from A, but at the same time, it is reasonable to

place more moral blame on the one who directs the efforts of the two stabbers, or in general, the

one who directs the efforts that collectively result in wrongdoing. Lawson tries to accommodate

62 Kutz, Christopher. Complicity: Ethics and Law for a Collective Age. Cambridge: Cambridge UP, 2000. Print. 63 Ibid.

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this intuition in his Modified Complicity Principle, but I believe that he falls short—at least in

the fact that his principle lacks practical application. The earlier case about the deceitful

company displays not only that Lawson’s account does not align with our intuitions, but that it is

an unreasonable position to maintain when trying to apply a theory of wrongdoing in collective

action. Applying Kutz’s account into this case, the wrongdoing would be reasonably split

between the vastly different agents in the scheme of wrongdoing: the executives and the

subsidiaries.

Lawson also argues that accountability in collective wrongdoing can only be assigned to

agents who knowingly contribute to collective wrongdoing. This is also a misguided position

because it also falls short in application to theoretical cases (so staying within ideal theory). In

theory, if stabbers B and C have no idea that murder is immoral or do not realize that their

stabbing action can murder someone, some might be ready to state that they are not culpable for

the murderous action. This situation happens to be premised around a wrongdoing that hardly

any moral theory would agree is morally reprehensible: murder. When the wrongdoing becomes

less clear if it is morally reprehensible (or it is not generally known that a collective action is

morally wrong), individuals within those collective action schemes can still be held morally

responsible. For instance, if a hunter believes that a deer does not have a moral status (because it

lacks a rational capacity) and proceeds to hunt it for food, if we discovered that the deer had a

moral status similar to human beings, it would not let the hunter off the hook morally. This is a

similar claim to stating that the slave owners of the past were still morally accountable for

enslaving other human beings, even though the popular held view was that those subject to

becoming enslaved peoples lacked the inherent right to autonomy.

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Lawson believes agents in collective action are separated into the ignorant and the

informed related to the moral facts predicating a certain collective action scheme. Even though

ignorance towards wrongdoing is more complex than Lawson argues for, it cannot be a

justification for wrongdoing. This is the wrong way of approaching the situation, especially

because ignorance is not morally ideal if it can be overcome. In administration of medical

services, administrators may not know that maintaining a profit motive is immoral, but it does

not necessarily let them off the hook morally. Individuals with an IM profit motive and an OM

profit motive are both morally required to not commodify patient health and well-being by

pitting those values against something of conditional value like money. When dealing with

unconditionally valuable things in a morally risky environment, there is an obligation to inform

oneself about the moral facts of action in that environment. This is especially true when an

individual is responsible for directing organizational action (in the medical field, when an

individual has an OM medical profit motive) and has access to information conveying the

relevant moral facts is accessible.

When one leads others with a conflicting motivation to obtain pecuniary profits, a

motivation that results in an expectation of medical practitioners to pursue a similar

commodification process, it is far more immoral because of the scope and moral risk involved in

this motivation. Leaders are especially responsible for collective wrongdoing in part because

they oversee many different agents who potentially act wrongly. Similar to the case of the three

stabbers, medical administrators with an OM medical profit motive are responsible for directing

the efforts of their subsidiaries to create a collective wrongdoing. Yet, administrators may even

be worse than the stabbers because with an OM medical profit motive, collective action does not

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produce one singular wrongdoing. Rather, repeated wrongdoings are the consequence of

leadership actions towards directing profit-influenced patient care.

This difference in attribution of moral wrongdoing is especially true when considering

collective wrongdoing in large organizations where things of great value, such as health, are

harmed within broader schemes. While the stabber case is not directly analogous to pro tanto

wrongdoing within patient-doctor relationships being overseen by medical administration, it is

sufficient for us to imagine in this way. Leaders are uniquely responsible because even if pro

tanto wrongdoing by individuals is justified when considering all relevant factors that are

inputted into a decision, if that pro tanto wrongdoing can be avoided by a leader, then it is not all

things considered justified for the leader to encourage behavior that is pro tanto wrong.

In sum, collective wrongdoing in medical organizations is actually an aggregate of

several wrongdoings that is overseen by leaders who have leadership obligations acting

antagonistically to values that should be upheld. It is not enough to suggest that culpability can

be assigned to those who are aware of collective wrongdoing. Profit-driven medicine is

inherently immoral, and agents acting within this scheme of medical administration should be

mindful of their responsibility to optimally promote patient health (or avoid harming patient

health), even if it is in tension with their role as business leaders. Medical administrators are

responsible for wrongdoings within organizational medical care, even if individual doctors are

only guilty of pro tanto wrongdoings. Additionally, as the agents responsible for cultivating the

structure of immoral practices in patient care, administrators are more morally accountable for

wrongdoing than individual medical practitioners.

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Leadership is premised on accepting greater responsibility for collective action. Leaders

must expect a heightened attention to morality when engaging in acts of leadership.64 The moral

stakes are higher for collective actions, whether it is morally beneficial or morally reprehensible.

In medicine and other areas that involve tremendously valuable and essential objects, this is

especially the case. The livelihood and well-being of human beings are at stake in medical

decision-making, and when someone leads an organization that oversees these decision-making

processes, they must accept more moral accountability, even if their direct actions do not produce

the morally reprehensible outcomes. That is the moral price paid for leading a medical

organization: less justification for wrongdoing and more responsibility in maintaining—through

a profit motive—the wrongdoing that results from medical practice influenced by financial

considerations.

III. Excuses

The second reason that those with an OM medical profit motive are more morally

blameworthy for allowing a medical profit motive to influence decision-making is the fact that

these individuals have fewer excuses for acting wrongly (in the context of the profit motive). It

goes without saying that medical practitioners are not victims or helpless in schemes of

wrongdoing. As I delineated in Chapter I, there are moral standards that must be upheld when

engaging in the doctor-patient relationship. Nevertheless, doctors and administrators operate

under different pressures and are afforded moral excuses in different ways. In the environment of

the medical organization, a medical administrator does not have the same ability to justify

maintaining a profit motive as a physician.

64 Ciulla, Joanne B. "Ethics and leadership effectiveness." The nature of leadership(2004): 302-327.

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There are several ways to think about excuses within schemes of wrongdoing. I intend to

demonstrate that those with IM medical profit motives have more excuses for their wrongdoings.

Agents within collective action schemes are more or less excused for wrongdoing insofar as

those with heightened agency in organizations can influence action. More specifically, coercion

can influence collective action, and if a collective action—or an individual action—is coercively

forwarded, it influences where blame should be assigned for wrongdoing.

The concept of coercion exists in many different contexts, so I will introduce what I

believe to be the conditions necessary for when coercion exists:

Values-centered coercion: An action A is coercive if it forces an agent to choose between two things of morally disproportionate value.

On this account, a coercive act forces an agent to choose between something of conditional value

and something of unconditional value, which is wrong because of its lack of fairness and respect

towards unconditional values, such as the affected individual’s agency. If a mugger points a gun

at you and exclaims, “Your money or your life,” the mugger is coercing you because he is pitting

the unconditional value of your life against the conditional value of money, something that is

immoral for him to do.65 If two things of unconditional value are being pitted against one another

in a coercive act (something such as a mugger proposing “your agency or your life”) is also a

form of values-centered coercion; forcing a choice even between two unconditionally valuable

things—things that ought not to be given value so as to weigh them against other values—is

coercive in nature. If two things of conditional value are being pitted against one another, on my

account, I do not believe there is coercion taking place.66

65 This case is taken from: Pallikkathayil, Japa. "Your Money or Your Life Coercion in Personal and Political Contexts." Diss., Harvard University, 2008. 66 There may be something wrong taken place (like the improper use of force), but in this scenario, I would not introduce the concept of “coercion”. For instance, if one were to approach you and say, “give

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In the stabbers case, without considering the nature of leadership that exists between A

and his followers, we can recognize wrongdoing that is shared by all the stabbers. We have not

even at this point considered why B and C were acting antagonistically or how they came to act

in such a way. Suppose that A threatens B and C with the potential of ending their lives if they

do not stab D. This case is clearly a form of coercion; B and C, without any other choices, are

faced with a difficult decision that seems to free them of at least some portion of moral blame. B

or C must choose between two unconditional values to disrespect, and because A is forcing that

choice, they are utilizing values-centered coercion. It cannot entirely justify B or C’s decision to

stab D, but knowing that B and C were coerced into acting in this manner helps us understand

that the normative nature of leadership can have influence on the culpability for wrongdoing in

collective action—especially in the light of unconditional and conditional values. Thus, we can

see how B and C could have some form of moral excuse for operating under coercive leadership.

This idea is applicable to an argument on responsibility for wrongdoing in organizations

introduced by Philip Pettit in which Pettit identifies three conditions that must be in place to

consider an agent fully responsible for wrongdoing: value relevance, value judgment, and value

sensitivity.67 Pettit then explains that upon one or more of the conditions for responsibility not

being met, one can begin to assign “partial responsibility,” a concept that is tied to moral excuse

in the proper context.

The concept behind an agent needing value reference is relevant because that means

something of moral importance must be at stake within a wrongdoing for this argument to apply;

I have established that this is the case when discussing the profit motive in medicine (health is

unconditionally valuable), so I will not further discuss the value reference condition. Next, value

me $100 or I will break your car windows,” it may be a wrongful use of force, but on the values-centered account, that would not be considered a coercive action. 67 Pettit, Philip. "Responsibility Incorporated." Ethics 117.2 (2007): 171-201. Print.

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judgment is the idea that an agent has the capacity to make value assessments for decisions that

are under moral assessment. I will discuss this condition later. The condition that I am concerned

with in relation to the aforementioned case of coercion is the condition of value sensitivity, which

states that an agent “has the control necessary for being able to choose between options on the

basis of judgments about their value.”68 This is related to coercion because coercion, by

definition, “diminishes [a] targeted agent's freedom and responsibility.”69 This definition

comports with the account of coercion I defended above. On both accounts, value assessment is

at the heart of coercive action, and if this assessment is hindered by an action or an action creates

an inappropriate comparison between values, that action is coercive in nature.

Medical practitioners are not coerced through a violation of their bodily integrity, but

they do face differing forms of values-centered coercion in medical organizations, forms of

coercion that medical administrators do not face. If a doctor approaches the doctor-patient

relationship while being observed or analyzed—through the medium of monetary value—by

organizational leadership, it creates an inorganic, morally risky environment for patient care.

Medical practitioners are in the best position to know what treatment plans are medically

necessary for patients, and within reason, administrators ought not to interfere with this process.

(This is assuming that we are also dealing with medical practitioners who are responsible and

socially conscious, factors that are vital for doctors to exhibit in order to strive for a more

morally sound medical organization.) When “greater control by management”—or more

actualized forms of coercion in verbal formats—begins to seep into a physician’s actions, it

makes it more difficult on the medical doctor to uphold his role obligations. In these cases, the

physician’s wrongdoing is in part the fault of medical administration.

68 Ibid., 171-201. 69 Anderson, Scott, "Coercion", The Stanford Encyclopedia of Philosophy (Spring 2014 Edition), Edward N. Zalta (ed.), forthcoming URL = <http://plato.stanford.edu/archives/spr2014/entries/coercion/>.

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To introduce some examples of this, one might imagine that an administrative order is

related to patient volumes in a certain clinical services sector of a hospital (i.e. the radiology

department, a pain treatment center, etc.). The administration realizes that the sector is not

receiving enough patient volume, so they try and competitively incentivize physicians to direct a

portion of their patient traffic—through a treatment plan—through this sector of the hospital,

even if may not have been medically necessary in isolation of a competitive incentive (especially

if that sector is normally profitable) and even if there is some health risk involved with treatment

from that sector of the hospital. Additionally, if an administrative body agrees to prescribe X

amount of pharmaceuticals or they have purchased a large number of a particular brand of

pharmaceuticals, there may be administrative actions in place that incentivize physicians to

utilize these medical resources, even if would on balance lead to worse health outcomes. In these

cases, if a medical doctor is a victim of values-centered coercion, he is relieved of some moral

blame. The classic case of the mugger can be related to patient care; a doctor may be forced to

choose between “your job/pay or patient health”, “your autonomy or your patient health”, etc.,

situations that are not morally favorable.70

In medical administration, leaders can act coercively to produce desired pecuniary

outcomes, so medical practitioners are coerced by administrators to perform morally

reprehensible actions.71 Theoretically, a medical organization is organized to try and separate the

70 These accounts of coercion can lead to decreased culpability in patient care, but the same cannot be said on the administrative level. On the administrative level, the decision that must be made—by the administrator—from external pressure could theoretically reduce down to “your job or profit,” which are two conditionally valuable things. Thus, my account of coercion does not apply to the medical administrator. 71 I will refer to a case based in economic theory: “If, for example, administrators find the hospital to be underutilized and losing potential revenues, then they would want doctors to admit more patients and increase their established margins over the scientific minimum. But such an improvement in "quality" may create pressure on capacity which the medical staff would find uncomfortable.”3 In this example, you

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costs borne and the profits made by medical practitioners and medical administrators, something

that is akin to “(making) doctors look like individual entrepreneurs who happen to conduct their

business on the hospital's premises.”72 In actual practice however, these two entities are

economically linked. Administrators do not have an influence in direct patient care, but they

indirectly have influence via external pressure on a practitioner to meet a standard or a

benchmark relating to patient care or the preemptive interference resulting from administrative

practices. This influence can be enough to raise moral alarm and force us to reconsider blame for

collective wrongdoing.

Intentions behind profit-motivated actions can also offer moral excuses to certain agents.

The intentions of those in The Greedy Administration are more inexcusable than those of doctors

for two reasons. First, a motive of this nature is sustained due to one thing (similar to the IM

profit motive): increased profit.73 Those with a profit motive—like the Greedy Neurosurgeon—

will never be fully justified, but the moral harm involved can be somewhat mitigated because the

neurosurgeon provides optimal patient care and acts on an individual basis. In contrast, at an

administrative or organizational level the profit motive more often than not negatively impacts

patient health and well-being and affects more people.

Second, the intention to make a profit is not enough to justify profit-motivated action

considering the moral risk involved in profit-motivated organizational decision-making in the

medical field. An OM profit motive is especially risky compared to an IM profit motive due to

can see how an organizationally-maintained desire for profit resultant from patient care conflicts with the obligations of physicians to promote the well-being of the patient 72 Harris, Jeffrey E. "The Internal Organization of Hospitals: Some Economic Implications."The Bell Journal of Economics 8.2 (1977): 467-82. JSTOR. Web. 13 Mar. 2014. 73 That is not a controversial claim; I am simply stating that the leaders of a medical business desire to make money for their business. To be fair and to place the overarching ethics behind the medical business aside, profits in a medical organization can be utilized to promote more advanced methods of patient care or to construct more optimal facilities for better patient care.

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the scale that an OM profit motive is maintained on. An OM profit motive involves countless

medical transactions and has the potential to harm patient health on a much larger scale. Thus, it

involves a degree of moral risk that is undesirable. As Dan Moller has argued, when something

involves moral risk and can be avoided, it ought to be avoided.74 An OM medical profit motive

has no morally sustentative defense that would tell in its favor, and the risks associated with

maintaining an OM medical profit motive are not worth the moral cost.

Another major difference between the administrator and the practitioner that allows the

latter the opportunity for moral excuse in medical decision-making is the amount of agency—or

the degree to which one can impact change.75 Medical practitioners are decision-makers, but

medical decisions are only made in the medical organization under the umbrella of

administrative practices. A doctor must be allowed to make what decisions he deems medically

necessary, so the patient-doctor relationship should be free from direct administrative control.

Even well-motivated doctors still cannot resist indirect controls on medical decision-making

(such as administrative policies, capacity issues, asset management) without being deemed as

“disobedient” or resisting administration. For indirect controls on patient care that produce

morally harmful outcomes, doctors have the excuse of decreased agency in the management of

the medical organization that denatures their portion of culpability for those wrongdoings.76

Those who set immoral policies in place or administer through the medium of immoral policy do

not have the excuse of being under immoral regulation; they have the ability to change policies

74 Moller, D. "Abortion and Moral Risk." Philosophy 86, no. 03 (July 2011): 425-43. doi:10.1017/S0031819111000222. 75 Ibid., 425-43. 76 There are areas in the medical organization that doctors have increased responsibility when compared to the administration, such as the responsibility associated with direct patient care and the responsibility of proper utilization. Utilization can be interpreted as the proper use of scarce medical resources, which can include physical resources or intangible resources (like time).

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in the medical organization. This ought to be the ultimate responsibility of medical

administrators.

IV. Expertise

The final reason I believe that an OM medical profit motive is more immoral than an IM

medical profit motive is because of the amount of medical expertise required for moral medical

decision-making. Under the current system, influence over medical practice does not correlate

with the amount of medical expertise one holds. Here, I am troubled by the fact that the

individuals with the most agency in medical organizations are largely not medically trained.

With medical training comes a particular ability to value human health, and if a role associated

with large-scale health commodification (an inherently immoral practice) does not require

medical training, that allows for a heightened degree of wrongdoing to be associated with that

role. An OM medical profit motive that is forwarded by a non-medical professional is a recipe

for exacerbated wrongdoing in patient care.

The role of the non-medical medical leader has developed within the healthcare

environment of hospitals. According to Alison Dwyer, medical administrators initially

functioned “as Medical Superintendents, who were often senior clinicians and statesmen within

the organization.” Initially, “these positions were usually well-defined, focussing on overseeing

clinical services of the hospital with the matron, and with little interaction with the finances of

the hospital.” Unfortunately, “in response to the increasingly complex healthcare system,

burgeoning new technologies and high cost of healthcare, the role and responsibilities of a

Medical Administrator have subsequently diversified” to encompass more business

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considerations.77 Today in the United States, the majority of hospitals are led by non-medical

professionals; a study in 2009 found that “of the 6500 hospitals in the US, only 235 are led by

physicians.”78

Given that this is a prevalent phenomenon, hospital administration is an important moral

issue. Imagine if a law firm was led by someone who has never attended law school and this

individual—along with a team of firm administrators with a similar skill set—was responsible

for determining best practices and policies for the firm and growing the business of the firm.

Something about this dynamic is unsettling. Although the firm is a business at its core, the idea

of a non-legal professional overseeing the operations of a legal group is counterintuitive.

I will not try and defend legal licensing as being unconditionally valuable, but imagine if

this same scenario involved decisions affecting unconditional values (which is where the analogy

to medicine and medical administration can then be drawn). Human health is unconditionally

valuable, and even though someone like myself—void of medical expertise—can recognize that

fact, without medical experts, the value of health cannot be properly recognized and cannot be

recognized on a case-to-case basis, a condition necessary for moral medical decision-making. A

medical expert is in a unique position to recognize the health state and health needs of a patient

because they have spent years understanding human physiology and the nature of human health.

This intimate knowledge of biological humanity allows someone to not only further appreciate

that humanity, but understand what is truly affected by a medical decision (on the physiological

level).

77 Dwyer, Alison J, MBBS, MBA, MHSM,F.R.A.C.M.A., F.C.H.S.M. "Roles, Attributes and Career Paths of Medical Administrators in Public Hospitals: Survey of Victorian Metropolitan Directors of Medical Services." Australian Health Review 34, no. 4 (11, 2010): 506-13. http://we4mf3mv5e.search.serialssolutions.com/docview/849563730?accountid=14731. 78 Gunderman, R., & Kanter, S. L. (2009). Educating physicians to lead hospitals. Academic Medicine, 84, 1348e1351.

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Considering the importance of expertise, it is even easier to see why The Greedy

Neurosurgeon permissibly operated despite his health commodification practices whereas The

Greedy Administration acted impermissibly. The administration is profit-driven without

reference to the scientific appreciation and knowledge of what drives their business functions. A

non-medical professional with an OM medical profit motive may try and supplant knowledge of

health administration for knowledge of human health, but that cannot succeed in a moral domain.

One might object that the fact of a medical administrator having little to no medical

expertise would lend itself to decreased culpability in medical profit-motivated wrongdoing.

This thought can be derived because one might link knowledge of wrongdoing with culpability

for wrongdoing. However, ignorance does not morally justify a non-medical professional

overseeing medical decision-making (as I have argued in the earlier section about responsibility).

Consider the following example, which illustrates the relationship between ignorance and

culpability. If a six-year-old child is placed into the driver’s seat of a car and is allowed to

operate the motor vehicle on a road, and if that child runs over someone, you cannot hold the

child culpable for that wrongdoing. This position seems to be at odds with the account of excuse

in wrongdoing I have previously argued for, but it is not. The child may be entirely non-culpable

not because of ignorance to the moral facts behind running other human beings over with a car,

but also because of incapacity to understand the wrongness of their initial position or role as car-

operator. There is no reliable reason why a child—lacking the capacity—could be expected to

exit a state of ignorance towards the moral facts of vehicle operation (i.e. you can end someone’s

life, and that life is unconditionally valuable). Yet the same cannot be said about a medical

administrator; they may be ignorant to the moral facts of medical care if they do not possess a

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certain degree of medical expertise, but they are not incapable of examining or changing their

role based on the moral facts they should become informed about.

Reversing this argument, one might claim that a medical doctor must accept increased

culpability for wrongdoing because of their unique position (their medical knowledge) to

recognize the degree of wrongdoing occurring in profit-motivated medical decision-making.

Medical knowledge is significant, which is why it would be better for medical doctors to be more

accountable in administrative roles. However, individual physician profit-motivation in a clinical,

individual context can often be excused, for the reasons stated above. On the other hand, once a

medical professional assumes an OM medical profit motive, they are not afforded the same

moral excuses and they are more accountable for upholding the values at stake in organizational

medical decision-making.

Another difference between a medical professional in this role and a non-medical

professional in this role is that the medical professional morally ought to be in the administrative

role. Doctors can assume the role and be morally justified while the non-experts cannot. Moral

ignorance cannot excuse the fact that the non-expert administrator ought not to be in that position

without adequate medical knowledge. In theory, to be a medical administrator without medical

expertise is like being a physician without a medical license. In the latter case, there is something

wrong with a physician who is not medically licensed; not only does it diminish (or abolish)

patient trust (if if is even established in the first place), it signifies that someone attempting to

assume the role of the medical professional is not qualified enough to earn a license to practice

medicine. Why do we not think about medical administration in a similar way? There should be

some component of medical expertise—similar to gaining a medical license—that ought to be

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required for a role that oversees multiple medical decision-making transactions and the larger

practice of medicine.

Given its prevalence in modern medical administration, and the moral significance

behind non-medical professionals overseeing patient care and medical organizations, there is

reason to think that serious revisions should be enacted in order to have hospitals and other large

medical organizations led by medical professionals. If it is the case that one with an OM medical

profit motive must be at the helm of a medical administration, it ought to be a medical expert.

This should not be a troubling idea. In fact, having a physician-leader of a hospital or a medical

organization improves quality-of-care and hospital rankings.79,80

One challenge to this idea is that clinicians and other medical experts may feel inclined to

stay in individual, autonomous practice and just engage in the doctor-patient relationship. But

these experts must also recognize that improved, moral medical care is dependent on medical

expertise in administrative practices. It may be the case that a poorly developed physician

management infrastructure (a lack of administrative accountability for physicians and the

responsibility of solely patients) is the cause of resistance to expert led care, so in order to move

forward, this infrastructure must be modified.81

In sum, it is far more immoral to maintain an OM profit motive when compared to

maintaining an IM medical profit motive because of administrators’ lack of medical expertise, in

79 Candace, I., & Giordano, R.W. (2009). Doctors as leaders. British Medical Journal, 338, b1555. 80 Goodall, Amanda H. "Physician-leaders and Hospital Performance: Is There an Association?"Social Science & Medicine 73 (2011): 535-39. doi:10.1016/j.socscimed.2011.06.025. 81 Pronovost, P. J., and J. A. Marsteller. "A Physician Management Infrastructure." JAMA: The Journal of the American Medical Association 305, no. 5 (2011): 500-01. doi:10.1001/jama.2011.71.

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combination with their heightened agency, increased responsibility in the medical organization,

and the absence of moral excuses.

V. Objections

I will now consider two relevant objections to my argument in this chapter. First, one

may argue that my discussion of the economic coercion and domination from medical

administrators towards those involved in patient care in the medical organization is unfair

because medical administrators—in for-profit health systems—face similar pressures from those

with even more agency in the medical organization (such as a shareholder or a trustee).

While I realize that medical administrators face similar pressures from stock-holders or

trustees in for-profit medical care, they are not afforded the same moral excuse because of

economic pressure. If stabber A is being forced by stabber A* to coerce B and C to act in

accordance with A*’s plan, and A*’s forcing of A is one of a purely economic nature, it doesn’t

provide the same moral excuse as B or C may be afforded if their health and livelihood are in

jeopardy. This is not to say that for-profit higher administration is not wrong, because an OM

profit motive at this level is still morally wrong. Rather, I don’t believe that the role obligations

of medical administrators (to maximize profit) can justify acting under economic (or other forms

of) pressure; medical administrators must be morally responsible through business practices by

acknowledging their influence on patient care and their ability to correct for moral wrongness in

medical operation, especially considering the level of agency a medical administrator holds in

the medical organization.

One may also object to my position by denying the plausibility of my argument when

applied into real-world medical administration. To claim that medical administrators ought to be

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medical experts and that an OM medical profit motive is morally risky is not the most “practical”

position, but being most practical and being most morally correct do not sometimes align. I

understand that administrators in healthcare organizations are valued because of their efficiency

and business knowledge (and medical organizations, in some ways, can benefit from that

mindset), but these assets should not conflict with an administrator’s ability to properly manage a

moral medical organization. Ethics should not be compromised for effectiveness. For example, if

it were the case that students with black hair were shown to perform significantly better

throughout college, it would not be the right decision to admit only students with black hair

because the moral decision would be to admit a diversity of students while considering factors

that—on balance—lead to success. Similarly, it is not necessarily the right decision to have the

most efficient medical administrators leading medical organizations. Business considerations

cannot justify the OM medical profit motive; as established in Chapter I, because these

considerations are conditionally valuable, and when compared to the unconditional value of

human health at risk, business and profit considerations are always less morally significant.

VI. Implications

There are several implications that can be drawn from my argument. I will offer two

major recommendations that I believe to be the most important interpretations of the above

analysis on the medical profit motive in the medical organization. Before I begin, I want to stress

that for any of my argument to have application into real-world medical administration,

administrative policy must change, and as I have mentioned above, this responsibility falls on the

shoulders of the medical administration. Thus, any digestion and application of my position

requires (1) self-reflection on the behalf of current (or rising) medical administrators, and (2)

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effort on the behalf of medical practitioners to utilize these arguments towards pursing a more

morally sound medical administration.

As I have stated before, I believe that medical experts would make for more morally

sound medical administrators; they would be able to properly value human health in the context

of decision-making. Medical experts as administrators could apply this trait into administrative

decision-making and would be able to make more morally sound health-cost tradeoff analyses. In

some instances, these analyses may provide for economically favorable outcomes, but in other

instances, a moral decision could be made based on the value of health assessed to be potentially

lost from an administrative decision.

Though still operating within an inherently immoral practice, expert-administrators

would provide for the most morally sound-yet-practical outcome: administrative practices in the

medical organization guided by those with the ability to adequately value human health. This

recommendation is stronger when also taking into account that research has demonstrated a

significant increase in the quality of a medical organization when being led by a physician.

If current administrators—or those with an OM medical profit motive—are to remain in

place, and assuming that profit motivations remain intact despite moral analyses, I recommend

that hospital and physician profits be aligned with quality-of-care directly. This is a similar

model to “accountable care” and “Accountable Care Organizations (ACOs)” that are being

implemented though the realization of the Affordable Care Act. ACOs are “collections of doctors

and hospitals that are paid to coordinate care, eliminate unnecessary tests and treatments, and

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keep people healthy and out of the hospital” through revised incentive and savings programs.82

At its core, the ACO model is able to succeed because it is able to “incentivize hospitals,

physicians, post-acute care facilities, and other providers involved to form linkages and facilitate

coordination of care delivery.”83 For example, within an ACO, a physician would be monetarily

incentivized to keep their patients out of the hospital or reduce the amount of days their patients

spend in the hospital. This is different than a fee-for-service model of medical reimbursement

that would incentivize physicians to maximize the amount of medical visits they carry out and

the amount of medical treatment they provide. Further, if a hospital is able to save money on

treatment plans while maintaining treatment effectiveness, they are able to share in a portion of

those savings with a government-sponsored health care program (like Medicare).

In theory, a shared savings/quality-of-care model of physician and hospital profit

derivation resolves—or at least mitigates—several of the moral issues mentioned above. On the

individual doctor-patient level, doctors are incentivized to provide the highest quality care

possible through monetary compensation (assuming that, all else not considered, they are like

The Greedy Neurosurgeon and only value money). On the administrative level, it is also morally

beneficial to align profit motivation and quality-of-care because medical administrators will

strive, based on their role obligations and collective motivations, to foster an environment where

patient health and well-being is on-balance being optimally promoted. If a hospital

administration were to adopt a shared savings/quality-of-care incentive model for medical

operations, they can enter into a similar state (morally) as The Greedy Neurosurgeon at the

82 Emanuel, Ezekiel J., M.D. "The Beginning of a Health Care Revolution." The New York Times. March 20, 2014. http%3A%2F%2Fwww.nytimes.com%2Froomfordebate%2F2014%2F03%2F20%2Fobamacares-four- year-checkup%2Fthe-beginning-of-a-health-care-revolution. 83 McClellan, Mark, et al. A National Strategy to put Accountable Care into Practice. Health Affairs. 29(5). 2010. 982-990.

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conclusion of Chapter I: pro tanto, health commodification through administrative practices is

still morally wrong, but while acknowledging that some practices must be place in order to

benefit patient health and well-being, the other remaining administrative policies and practices

ought to align profit motivation with quality-of-care. Indubitably, the promotion of patient health

and well-being is the intention behind the moral critique of the profit motive, so when keeping

that in mind, I support a solution that may include a portion of pro tanto wrongness but can

benefit patient care in the long run; thus, I assert that accountable care is the most morally

desirable model of medical profit derivation.

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Chapter III: Values-Centered Health Care

If I am right about the profit motive in medicine, what does that mean for health care

policy and health care reform?

In this chapter, I apply my thesis into the political and broader societal arena, looking at

morally-motivated medicine and how it can be applied throughout the overarching system of

health care in the United States. I have already examined clinical practice and administrative

practice through the medium of the profit motive, so to conclude this argument, I carry the

examination towards health care policy and discuss how policy may be shaped to help a moral

medical organization with reduced profit motivation to become a realistic benchmark.

Starting with a reflection on the previous chapters, I then introduce a theory values-based

health care. I then delineate several principles that I believe to be vital to moral health care

reform moving forward, principles that I further explore in the first three sections, respectively.

In Section IV, I address an objection to my position: a view on health care that is pro-market and

supports promoting quality-of-care through decreased economic regulation. In Section V, after

the explanation of a particular pro-market argument, I show how pro-market health care

discourse misses the moral facts at stake almost entirely. To be fair, I also discuss particular

aspects of a pro-market model for health care that approach areas of needed attention with reason

and legitimacy. In Section VI, I apply this debate into the sphere of health care policy. I address

areas of health care that are in particular need of moral examination either due to their inherently

morally risky nature or current immoral practices within the area. To conclude, I discuss the need

for reform within every tier of medicine.

Preface

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For-profit medical organization began to emerge as a prominent model for organization

in the mid 1950’s when conversations began to surface about the ethical implications of the

hospital, or other for-profit medical setting, acting simultaneously as a business.84 Dan Brock

and Allen Buchanan were among the first to discuss the medical profit motive in a negative

context in their work The Profit Motive in Medicine.85 The authors introduce the sheer

complexity of the ethics surrounding health care and the medical organization, a sentiment that is

shared by all parties within the anti-profit v. for-profit debate. They frame their argument around

two central criticisms against for-profit medical care that were voiced at the time:

(1) For-profit medical organizations did not do enough for the poor or did not provide

enough charitable service to warrant themselves being enumerated as a “hospital” or medical

organization.86

(2) A profit motive could be risky in a clinical context because of the inherent conflicts-of-

interest that could arise from “profit-seeking” practices.87

I agree with the essential dismissal of the Brock and Buchanan’s first concern; in their

argument, they state that a large portion of patients in the medical organization receive care

without paying, which acts in accordance with the relevant laws on hospitals treating patients

regardless of paying. Further, the authors state that a for-profit health care organization dismisses

their general obligations to provide for patient health and well-being because, like an individual,

they pay taxes (that fund physician care) and support health care. However, Brock and

84 Light, Donald W. "Corporate Medicine for Profit." Scientific American 255, no. 6 (1986): 38-45. doi:10.1038/scientificamerican1286-38. 85 Brock, D. W., and A. E. Buchanan. "The Profit Motive in Medicine." Journal of Medicine and Philosophy 12, no. 1 (1987): 1-35. doi:10.1093/jmp/12.1.1. 86 Ibid., 3-17. 87 Ibid., 17-33.

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Buchanan’s analysis of the second concern is circular and tenuous. They raise several valid

reasons why we should believe that for-profit medical care is damaging to clinical practice,

including the claim that the “consumer in health care…is in an especially vulnerable position,”

and the incentive of overutilization can introduce “serious and widespread health harms to

patients.”88

Even still, Brock and Buchanan fail to take a definitive stance on the issue. While they

started the battle, they hardly won the war against the medical profit motive. My pursuit builds

on their work. What ideals or principles would be of the utmost importance for those with power

in medical decision-making to consider throughout their functioning in health care? Brock and

Buchanan left a great deal to be answered in their initial analysis, and although the foundation

for sustained criticism is there, they chose to signpost the moral risk involved in medical profit

motivation rather than take a definitive stance.

Considering and expanding on Brock and Buchanan’s argument, I support the following

principles:

Principle 1: The sovereignty of the medical professional should remain intact.

Principle 2: Those with administrative privilege or systemic decision-making capacity

should make efforts to reduce pecuniary conflicts-of-interest in medicine, when possible.

Principle 3: Quality-of-care should be our guiding factor; patient health outcomes are

what truly matter.

88 Brock, D. W., and A. E. Buchanan. "The Profit Motive in Medicine." Journal of Medicine and Philosophy 12, no. 1 (1987): 1-35. doi:10.1093/jmp/12.1.1.

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These three principles prompt several medical reforms. Foremost, moral medical reform

should be values-centered. Thus, I take these three principles to be the guiding principles of

values-centered health care, a theory of how health care reform morally ought to be based on the

value of human health. In values-centered health care, health becomes a deontological constraint

on medical decision-making and policy formation; those with heightened agency in the medical

field must consider action through the lens of the unconditional value of health. Apart from

justice discussions in health care or market discussions in health care, values-centered health care

is concerned with disallowing profit considerations—or instrumental values—to govern effects

on the non-instrumental values at stake in patient care.

Values-centered health care exists in the realm of perfectionism when considering its

place in moral and political philosophy. Perfectionism means that one “advance[s] an objective

account of the good and then develop[s] an account of ethics and/or politics that is informed by

this account of the good.”89 That is exactly what I am doing here; values-centered health care is

premised on the moral facts that ought to make up the skeleton of the moral medical organization

or a portion of moral health care policy. The theory of values-centered health supports ethical

conclusions that should influence medical practitioners or current medical policies.

The following three sections will engage with values-centered health care in distinct ways,

with each engagement leading to important conclusions about moral patient care and the pursuit

of the moral medical organization.

I. The Sovereignty of the Medical Expert

89 Wall, Steven. "Perfectionism in Moral and Political Philosophy." Stanford University. February 13, 2007. Accessed April 03, 2014. http://plato.stanford.edu/entries/perfectionism-moral/.

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The first principle is derived from Brock and Buchanan’s attention to the patient-doctor

relationship and the degree to which patient trust generated strong obligations in medical. My

first principle to guide health care and medical reform is:

Principle 1: The sovereignty of the medical professional must remain intact.

Without the sovereignty of the medical professional being intact, a medical organization is

subject to unnecessary moral risk. As I have discussed, the medical professional is in a unique

position to recognize the values at stake in medical decision-making, especially in the clinical

setting. As soon as an act of reformation attempts to remove some portion of physician

sovereignty to account for increased costs or increased regulation, that act is removing what

makes moral medical care possible.

I am not, however, advocating for a complete removal of administrative privilege over

the medical professional. To allow for physician sovereignty is partly a function of what already

occurs in a standard medical organization; the “typical” hospital is comprised of “a nonprofit

corporation with a board of trustees as the ultimate authority…although the trustees delegate

operating responsibility to the hospital’s administration, there is also a second separate line of

authority emanating from the medical staff, which constitutes the hospital’s affiliated

physicians.”90 The classical medical organization intends to separate clinical care from

administrative work, something that is a necessary condition for physician sovereignty to begin

its establishment in the medical organization. If this were not the case, an administrator could

veto medical decisions (i.e. all prescriptions, procedures, and clinical treatment plans could be

90 Harris, Jeffrey E. "The Internal Organization of Hospitals: Some Economic Implications."The Bell Journal of Economics 8.2 (1977): 467-82. JSTOR. Web. 13 Mar. 2014. <http://www.jstor.org/stable/10.2307/3003297?ref=search- gateway:056ba3079cdac1571a6495bf9e702c88>.

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passed through to an objective medical administrator who only gives approval to means of

treatment that are monetarily desirable); there would be something fundamentally wrong with

that. It may seem redundant to mention that this aspect of physician sovereignty must be in place,

but keep in mind that these principles of values-based health care are not only retroactively

analyzing health care, they are in place for future reform to base action off of. In some future

policy decision, the line between administrative sectors and patient care sectors could blur, and

this principle would tell against such a decision.

Unfortunately, the line is blurring as health care organizations sift through reform and

increased mindedness towards pecuniary matters. There is only partial truth within the classical

organization of the hospital because direct clinical effect should not be the only measure of

practitioner sovereignty. As previously discussed, administrative decisions can also have

significant effects on patient care, an idea that extends to medical policy. A policy decision can

be viewed as restricting physician sovereignty, although to a lesser degree; I would be more

willing to claim that policy decisions end up affecting medical administration (which, in turn,

ends up affecting medical practitioners, but the connection is less direct). Due to this reality,

attention towards maintaining physician sovereignty must increase in health care. This idea tells

in favor of a previous argument for medical professionals to assume administrative roles in the

medical organization; if this were possible, physician sovereignty would inherently be promoted

because physicians would assume the roles that might otherwise be suppressing medical

decision-making. With or without a physician in an administrative role, medical expertise is an

indispensably valuable item in the medical organization. The same is true in medical policy

decision-making; health care policy must not overlook or stampede upon the moral uniqueness

of the medical professional.

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This principle will not be effective if physicians are not responsible; an indispensable

characteristic of the moral physician is responsibility (which includes awareness of the complex

organization that they operate within, accountability for wrongdoing, and the respective

sovereignty of the patient population in medical decision-making). Assuming the moral

physician is able to operate within a medical organization, efforts should be made to increase

physician sovereignty, even if that does not translate to overhauling current administrative bodies

for replacement. This should especially be a guiding principle when framing health care reform

around erroneous characteristics of clinical care through modern health care organizations.

In policy decisions, this principle can materialize in a number of ways. In essence, I

believe that the same arguments for medical expertise in administration should hold true for

medical policy makers:

P1: Hospital administration should require a certain degree of medical expertise. P2: There is no morally relevant difference between hospital administrators and certain public policy administrators. C: Some policy administrators should require medical expertise. When making decisions that will significantly impact systemic medical decision-making,

fundamentally understanding the value of human health is a necessary consideration for a policy

maker. From this argument, there are several revisions to current health care policy formation

that should be made. It may be ludicrous to claim that all health care policy makers should have

a medical degree or be medically trained, but those are the moral facts within values-centered

health care. This does not mean that this should be carried out towards full realization, but it does

tell in favor of moving the structure of policy making towards valuing medical expertise. This

can be achieved by having independent agencies comprised of medical professionals aiding in

policy formation, having medical policy be filtered through a similar agency before being passed

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into law, or even having the AMA (American Medical Association) appoint medical

professionals to particular roles that are responsible—in portion—for the creation and fostering

of health care policy.

II. Reducing Conflicts-of-Interest

The second principle (distilled from my medical profit motive discussion) is related to the

profit motivation itself:

Principle 2: Those with administrative privilege or systemic decision-making capacity

should make efforts to reduce pecuniary conflicts-of-interest in medicine, when possible.

This principle applies to all agents in the medical organization; as I have demonstrated, an

amalgamation of responsibilities in the medical organization is undesirable. With increased

external pressures—from society, from government regulation, and from other factors—on the

modern health care organization can lead to an increased willingness to implement regulatory

practices, some which may be detrimental to patient care or the patient-doctor relationship. This

principle is—in some ways—analogous to a principle that permeates clinical research ethics; in

clinical research ethics, conflicts-of-interest are undesirable, especially those of a financial nature.

Conflicts of interest in clinical research “point to a tension between relying on profits to motivate

business versus insulating drug development and testing from the profit motive as a way of

protecting research subjects and future patients.”91 Because of this, profit-motivated conflicts of

interest “may not be amenable to the commonly pursued remedy of addressing ethical concerns

91 Psaty, B.M., and R.A. Kronmal, 2008. “Reporting mortality findings in trials of rofecoxib for Alzheimer disease or cognitive impairment: A case study based on documents from rofecoxib litigation,” Journal of the American Medical Association, 299: 1813–7.

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in clinical research by promulgating a few new guidelines.”92 I believe the same concern arises

in standard patient care, and a similar motivating principle should be applied in order to protect

not only patient populations, but the medical doctor in the medical organization.

Of course, patient populations are the primary reason that this motivating principle is in

place. Research ethics acknowledges the moral risk involved with participation in clinical

research, and the same can be done in cases of profit-derived medical actions. While this quote is

not exactly similar to what has been discussed in profit-motivated patient care, consider the

following quote from David Wendler’s The Ethics of Clinical Research:

“The process of conducting clinical research involves the threat of exploitation of a particular kind. It runs the risk of investigators treating persons as things, devoid of any interests of their own. The worry here is not so much that investigators and subjects enter together into the shared activity of clinical research with different, perhaps even conflicting goals. The concern is rather that, in the process of conducting clinical research, investigators treat subjects as if they had no goals at all or, perhaps, that any goals they might have are normatively irrelevant.”93

We can begin to see increased similarities between what is morally at stake in research ethics and

what is morally at stake in patient care; the “threat of exploitation” is of the same particular kind:

unconditional value commodification. The difference between commodification in these two

areas of clinical activity relates to the shared or distinct “goals” relating to patient involvement.

In clinical research ethics, it is easier to see how shared goals may be reached; profit-motivated

clinicians seek treatment that works (and, will hence, deliver a profit). In profit-motivated

standard patient care, shared goals seem more nebulous of a concept; I have explored the

inherent tension between cost cutting and profit derivation versus quality-of-care in my previous

arguments, and it will be more difficult to remedy that divide. Moreover, this disparity in patient

92 Wendler, David. "The Ethics of Clinical Research." Stanford University. January 30, 2009. Accessed April 04, 2014. http://plato.stanford.edu/entries/clinical-research/. 93 Ibid.

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care can lead to moral travesties on a systemic level. This is not to suggest that it is not possible

for clinical ethics to cause great wrongdoing (i.e. if a risky treatment plan is heavily pursued and

ends up harming a large volume of patients), but wrongdoing is more easily accounted for and

justified in the context of clinical research ethics. The field is premised on some deal of risk and

consent to risk.

This principle is in place to also protect the medical professional from making morally

risky decisions. Physicians may feel inclined to cut costs or seek more expensive treatment plans

in medical care in order to make more money, something that also can prove to be detrimental in

the clinical setting. Both of these situations are unattractive for a moral medical organization. It

may not be the most ideal solution, but to inject practicality into what has been discussed in my

engagement with ideal theory, a way to pursue a more moral medical organization is to reduce

economic conflicts-of-interest. This can be done a number of ways; I have mentioned

accountable care (or quality-of-care/shared savings profit derivation) as a potential model to

reduce economic conflicts-of-interest, but this is not the only solution.

On a general level, if we were to borrow “advice” from principles in place within clinical

research ethics, it has been suggested that moral clinical research can be pursued if patients and

clinicians share similar goals. Accountable care is one approach to addressing this general

principle, but there can be other ways that clinical goals can join together. It would be hard to

imagine that patients could share a goal of profit motivation in the clinical setting, so I support

the notion that patients have the goal of increasing their health or well-being when willingly

engaging with a medical professional. Even if one wanted to claim that physicians and patients

could share the goal of wanting to make or save the most money in a treatment plan, these are

still incongruent goals. Patients would want to save money because of their financial health,

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while physicians (who wanted to save money) would want to save money because of the health

of their institution; physicians do not make more money if they save money for their medical

organization—unless, of course, their medical organization happens to be an Accountable Care

Organization.

The Accountable Care Organization seems to be the most logical way to account for the

immoral nature of profit motivation, something that policy makers have been—and should

continue to be—mindful of. In the ACA, the Accountable Care Organization was introduced as a

prevalent model of health care maintenance for Medicare patients; large medical organizations

are incentivized to uptake this model of health care because of the “shared savings” potential

they can take in (that is, a share of the savings they obtain through caring for their Medicare

patients without sacrificing current standards of patient care). If the ACO model of health care

proves to be successful with lowering costs and improving patient health, it should be

implemented into further areas of health care. Even if the ACO model is not successful, policy

makers must be mindful of the inherent tension between profit and health promotion that exists

in a fee-for-service model of health care.

To reduce economic conflicts-of-interest in health care is not only desirable because of

the promotion of the value of human health, but because economic conflicts-of-interest may

contribute to a degradation of the trust within the doctor-patient relationship. Take the following

case as an example:

The Conflicted Oncologist. Dr. L is conflicted between satisfying two interest groups in medical decision-making. On one hand, Dr. L wants to prescribe his patients the most effective (cost-effective and for health) pharmaceutical to treat their cancer. On the other hand, Dr. L is receiving money from a large pharmaceutical company to prescribe a different, less effective pharmaceutical.

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This is morally troubling, especially if Dr. L’s patients were aware of this conflict. In one regard,

this economic conflict-of-interest could directly impact patient health, but indirectly, there are

additional ways that patient health could be affected. Consider, now, that a patient was aware of

Dr. L being funded by a large pharmaceutical company. If this were the case, there is a chance

that the patient would lose trust in Dr. L, which could then directly affect the treatment of that

patient; it is difficult for patient well-being to be optimally promoted without patient trust being

intact because compliance with advised treatment and obtaining relevant information to make

informed medical decisions requires patient trust. In both of these ways, pecuniary conflicts-of-

interest are undesirable. Unfortunately, Dr. L is not an anomaly in the medical field, as

evidenced by a database compiled by ProPublica that displays the amount of “industry” dollars

being funneled to physicians for “promotional talks, research, and consulting.”94

III. Goal-Mindedness Towards Patient Outcomes

The third principle—perhaps the most important for health care reform to be mindful

of—is based on the “commodity” at stake in health care: human health and well-being. With all

of the conversation on health care reform relating to economic feasibility and political tension, I

feel as though the moral purpose of medical reform is sometimes lost in the fray. Thus, I have

generated my third principle for health care reform to be mindful of:

Principle 3: Quality-of-care must be our guiding factor; patient health outcomes are what

truly matter.

If a more moral medical organization comes about, it is ultimately because they are able to

promote patient health and well-being to the optimal level. This principle grounds values-

centered health care; the value of patient health and well-being ought to be what invokes

94 This database can be found at: “http://projects.propublica.org/docdollars/”.

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conversation in the forum of health policy, and if a policy detriments this value, policy-makers or

relevant individuals in that sphere ought to consider revision towards a more moral policy. This

principle was derived from my arguments in Chapters I and II, where I have exemplified the

sheer importance of patient health outcomes and championed them in the clinical/administrative

spheres of the medical organization. With this principle, I intend to do the same at the policy

level.

At the policy level, there are a number of ways that quality-of-care can be the “guiding

factor” in how policy is developed and how policy is evaluated. To name a few, quality-of-care

measures can be instituted that provide feedback on how policy decisions are affecting quality-

of-care. To reduce the impersonal nature of this data, the feedback should include some form of

direct patient response or patient testimony. That way, quality-of-care can avoid being

commodified as much as possible. Another way for quality-of-care to remain at the forefront of

consideration in policy formation is for policy makers to develop some “code of conduct” or

statement of ethics that they must swear to upon entering their role as a policy maker, something

that would be analogous to the Hippocratic Oath (but would be relevant for policy making). As a

general rule, if policy can be directed away from making health care into more of a market place

(to avoid health commodification) and closer to respecting the value of patient health and a

proper quality-of-care, that would be morally desirable.

Quality-of-care is not intended to simply mean the quality of individual patient visits; I

am referring to a systemic quality-of-care. In these terms, we can start to think about quality-of-

care in a faux-consequentialist mindset. We would not be able to articulate this principle in pure

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consequentialist terms because it would diminish what is important about moral medical care.95

Let us say that a health care reform is looking to implement one of two policies to aid some

aspect of patient care, A and B. Through pure consequentialism, we would desire to produce the

maximum amount of utils (of patient happiness or even health outcomes) with a given decision,

regardless of how it may be structured. If policy A produces 120 utils as opposed to the 100 utils

produced by policy B, policy A is preferred in this mindset. Now, let us assume that these

policies affect 10 individuals, and while policy B produces 10 utils of health outcomes per

individual, policy A produces 80 utils of health outcomes for one person (and the rest are divided

evenly among the remaining 9 patients). This would be an unjust way to frame optimal health

care reform; we must consider that maximizing health outcomes—in a purely consequentialist

set—is not our mission. I support a baseline of health outcomes for as many individuals as

possible, and after that condition is met, I can understand being concerned with health outcomes.

If a reform practice is detrimental to health outcomes, it need not be pursued.96

The patient, similar to the medical professional in Principle 2, must also be a responsible

agent in medical decision-making; a moral medical organization cannot be a practical benchmark

if the effort towards moral medical decision-making is one-sided. It is harder to generalize or

characterize patient responsibility in health care because of the inherent complexity and

subjectivity of the patient experience. Still, patient responsibility must include self-reflection

95 If we were to think about promoting quality-of-care through consequentialist health care policy, it may lead to some conclusions that would disregard the unconditional value of human health. 96 It may seem as though I am forwarding a view of health care through distributive justice rather than through values-centered health care, but that is a misleading interpretation of my analysis. Through the analysis of the pure consequentialist position, I show that it is the wrong way to think about patient quality-of-care. The value of patient health calls for a baseline of health to be promoted, so in a way, I forward a sufficientarian account of health distribution. When considering this, understand that it is informed by a values-centered account of health care; the value of human health is what informs this distributive conclusion.

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about health care utilization and effort towards maintaining quality care (so efforts to remain

steadfast in appropriate treatment plans). Patients must be active participants in their treatment

plans for moral medical reform to be effective. A medical policy may have the proper intentions

and may increase quality-of-care with compliance from patient populations, but it cannot be

criticized if the policy fails because of patient noncompliance.

Here, I am not saying that patient must abide by medical policies or succumb to treatment

plans if they are prescribed by their physicians; I am just trying to relieve some portion of blame

from medical professionals and medical policy makers if they are acting ethically. In some cases,

patients might reject a treatment plan for other motivations (to save money, they do not value

their health, they want to die, etc.). I will not criticize their decision here because I am concerned

by those with heightened agency in medical decision-making taking advantage of weak agents to

pursue something undesirable in medical care. For example, if an elder woman who is afflicted

with terminal cancer decides to discontinue further cancer treatment in order to save money for

her relatives, this is permissible. I think that this woman is mistaken about the value of her own

life by commodifying her health, but (assuming it was free from coercion) it is a decision that

she has made on her own volition—a decision that she is entitled to make. This is not the same

case as a commodification process that is forwarded by a health professional and takes advantage

of a weak agent.

Keep in mind, patient responsibility in medical and health care ethics is minimal for a

reason: the particular vulnerability of the patient in medical decision-making and the fear

towards medical paternalism suggest emphasizing professional responsibility over patient

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responsibility.97 Without at least some component of patient responsibility in health care reform,

however, it would not be fair to attribute all of the moral blame towards a medical organization

striving for more morally sound operation.

IV. “Wal-Mart” or “Southwest” Healthcare

Values-centered medical reform is antithetical to ideas about promoting free-markets in

health care. I support reducing market-mindedness in health care through value attribution and

promotion towards human health, but others have approached this same issue—and have reached

the same conclusion—through different (sometimes related) discussions. Others, still, have not

reached the same conclusion.

Market thinking in health care within the United States is “easy to see…the emergence of

the market frame among elites is having crucial influence on the evolution of contemporary

American health policy;” while it is tempting to pursue for pecuniary purposes, it is

simultaneously “luring health policy voyagers to destruction on the shoals of clashing values.”98

This quote is from Mark Schlesinger’s argument in On Values and Democratic Policy Making:

The Deceptively Fragile Consensus around Market-Oriented Medical Care, where Schlesinger

approaches the market debate in medicine from a political standpoint. Even here, Schlesinger

concedes that pro-market health care reformation introduces morally troubling conflicts-of-

interest. His central claim is that a “divergent [notion] of fairness” is what has led market-based

health care reform to implement questionable or objectionable health care policy. Schlesinger’s

argument is empirical and demonstrates (in conjunction with the apropos title) that market-

97 Kelley, Maureen. "Limits on Patient Responsibility." Journal of Medicine and Philosophy30, no. 2 (2005): 189-206. doi:10.1080/03605310590926858. 98 Schlesinger, M. "On Values and Democratic Policy Making: The Deceptively Fragile Consensus around Market-Oriented Medical Care." Journal of Health Politics, Policy and Law 27, no. 6 (December 2002): 889-926. doi:10.1215/03616878-27-6-889.

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directed medical reform is not supported as strongly by political and authoritative elites as one

would imagine, based on the market-directed medical reforms that have been implemented over

the recent history of American medicine. In his concluding remarks, he takes a weaker position

on the issue by suggesting this:

“Proponents of managed competition and market-oriented medical care therefore need to develop strategies that can both acknowledge the risks of greater disparities and mitigate those risks in a meaningful manner. To date, policy makers have largely ignored these obligations. In my assessment, this reflects the connection that they draw between market reforms and norms of equity, connections that are not shared by all the elites who favor markets, and which are rejected by most of the public.”99

His analysis raises the question: why are market-directed efforts towards health care reform so

vehemently rejected by the public? Keeping this in mind, we will now examine a particular pro-

market argument.

John H. Cochrane introduced a fervent, sometimes abrasive argument towards a free-

market model of medicine in his work After the ACA: Freeing the market for health care; he

believes that a “much less regulated” health care system is “possible, and necessary,” and in

general, he argues for a market-based health care model.100 Cochrane is a professor of finance at

the University of Chicago, someone very qualified to be discussing market principles and ways

to implement strategies that result in more effective marketplaces. Unfortunately, Cochrane is

missing the point of the medical “marketplace”: the idea in itself is immoral, and he—along with

myself or any other non-medical professional—is the last person apt enough to be making

values-based decisions about patient health and well-being. The moral decision is to turn away

99 Schlesinger, M. "On Values and Democratic Policy Making: The Deceptively Fragile Consensus around Market-Oriented Medical Care." Journal of Health Politics, Policy and Law 27, no. 6 (December 2002): 889-926. doi:10.1215/03616878-27-6-889. 100 Cochrane, John H. "After the ACA: Freeing the Market for Health Care." February 6, 2013. Accessed March 21, 2014. http://faculty.chicagobooth.edu/john.cochrane/research/papers/after_aca.pdf.

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from health commodification, something that Cochrane embraces in his analysis. Apart from the

inherently immoral nature of a market-based argument for health care, there are other reasons to

believe that Cochrane is mistaken about the moral facts behind patient care (which will be

depicted in the next section).101

Cochrane initiates his analysis in a beneficial manner, but quickly turns his analysis awry;

he states, “we all agree what we’d like to see: Health care needs to become efficient, innovative,

and provide high quality of care at a reasonable cost,” an idea that anybody could support. Those

factors of ideal medical care are linked to what drives individuals to debate medical ethics in the

first place: we care about providing the best medical care possible because there is something

special—yet ethically fragile—in the scheme of medical decision-making. I will not attempt to

show that Cochrane’s intentions are misguided because I believe that is adverse to his pursuit in

the first place; I will instead demonstrate how Cochrane’s approach, evidence, and conclusions

are all ethically misguided. Even ethically misguided analyses are important because they help us

affirm the moral facts that are essential to promote or uphold.

His paper is structured around fundamental economic principles, so he begins by

discussing the “supply” side of health care. Here, Cochrane is angered by the lack of process

efficiency in health care, something that he suggests could be remedied by looking at other

“complex service-oriented industries” and applying their efficiency principles. After all, “the

Cheesecake Factory delivers a complex service-oriented product with remarkable quality,

efficiency, and cost…why can’t hospitals do the same?” The problem here is that the complex

101 A good portion of Cochrane’s argument is about the way our health insurance is structured in the United States and how that affects the medical marketplace. As much as I am able to (because really, they are intertwined), I attempt to stray away from this argument; I do not discuss the ethics of health insurance in this paper. Thus, I will fail to mention a significant portion of what Cochrane is angered about by our current health care system.

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service-oriented industry that Cochrane is comparing medicine to is not even close to being as

valuable or subjective as medical care is. The author continues his attempt to liken health care to

other industries because of their ability to optimize quality and service, next by positing to the

reader that “the iPhone error rate is a lot lower than the medical error rate.”102 It is one thing to

make claims about how the medical field can benefit from economic industry principles, but I

have an issue with when these suggestions are intentionally misleading. Of course the medical

error rate is higher than the iPhone error rate; the premise of medicine is fixing error in human

well-being. The premise of an iPhone sale is to provide an excellent product, and if that was

associated with a high error rate, the business of the iPhone would diminish. Medical care is

premised on fixing medical ailments, and often, procedures or acute care treatment plans are

complex in nature. Thus, one must expect medical error to be relatively higher—it exists in a

completely different context. I am not saying that high medical error is acceptable; I am saying

that making a claim that likens medical error to technological error is not only cold and

dehumanizing, but incorrectly assessing the moral realities behind the two kinds of error.

Cochrane continues his analysis by focusing on competition in the medical “marketplace”.

He introduces some valid points about not enough competition existing between medical

insurance companies, but when he extends this debate into the medical organization, it is

erroneous. At times, he focuses on the consolidation of the medical organization, something that

is inevitable with future health care reform. This is not where I raise an issue with Cochrane’s

point; the reality is such, and we must be even more mindful of how we separate clinical care

with administrative practice. Instead, Cochrane incorrectly criticizes the “fragmentation” of the

medical organization. He fails to take notice of the specialty and specificity of each medical

102 Cochrane, John H. "After the ACA: Freeing the Market for Health Care." February 6, 2013. Accessed March 21, 2014. http://faculty.chicagobooth.edu/john.cochrane/research/papers/after_aca.pdf.

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branch, and while I agree that some areas in medicine could be theoretically consolidated (to

“streamline” medical care in a pursuit of efficiency without jeopardizing patient well-being),

fragmentation is in place because of medical specificity; to consolidate all medical branches

under one umbrella through a profit motive could be detrimental to patient care.

When discussing health care policy on a broader scale, Cochrane does not feel too

optimistic, suggesting that “government-imposed efficiency” of markets are, “to put it charitably,

a hope without historical precedent.”103 Primarily, let us not forget that health care should not

simply be a marketplace (based on the unconditional value of human health), and even if we

think about health care as a standard marketplace, historical precedent of effectiveness is not the

way we should be framing moral medical reform. Medicine needs some form of regulation

because of what is at stake in medical decision-making. Moral medical reform should be

forward-thinking and should examine the aforementioned “picnic spot”; even if it cannot be fully

realized, the moral medical organization can be pursued, and this is apart from historical

precedent.

Cochrane then examines the “demand” side of the health care market, which further

distorts the application of Cochrane’s analysis (because health care is a desirable commodity,

correct? Ironically, if demand for health care was at an all-time low, that would be an optimal

scenario, something that Cochrane’s analysis could not account for).104 In this examination,

Cochrane raises an interesting and controversial scenario that he recommends as being useful to

think about when examining the economics of medical care. His case is as follows:

103 Cochrane, John H. "After the ACA: Freeing the Market for Health Care." February 6, 2013. Accessed March 21, 2014. http://faculty.chicagobooth.edu/john.cochrane/research/papers/after_aca.pdf. 104 Here is what I mean: according to a market model of health care, the health care market would be “at its best” and thriving with tremendous patient volumes in a sickly society. Clearly, our moral intuitions do not say the same. In a moral model of the health care market, no individual would require medical attention. This is the root of why market-mindedness and health care are ethically counter-intuitive.

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“So what does “need” really mean for services like these? The only sensible economic definition I can think of is that “need” is the bundle of services you would choose if you were paying with your own money at the margin. You “need” that MRI to make sure your back pain won’t just heal after 6 weeks of ibuprofen if you’d be willing to shell out $1,000 of your own money to get it. (I am!) And you “need” it delivered at a convenient hour, tomorrow, rather than next week across town if you’re willing to pay that extra cost…As economists, we are expected to avoid that confusion. A good way to do so is to pose the question in the positive rather than the negative: Suppose we offered each patient the choice, ‘Your doctor prescribed this MRI. You can have the MRI or you can have $1000 in cash.’ The patient “needs” the MRI if he or she foregoes the cash and goes through with the MRI.”105

Cochrane’s thought experiment seems to be—in his frame of reference—proposing an unsettling

reality of what medical “need” truly is, and I have an issue with the structure of this thought

experiment in the first place. His thought experiment qualifies as value-centered coercion, a

theory I forward in Chapter II. An action—according to values-centered coercion—is coercive

when it forces an agent to choose between something of conditional value and something of

unconditional value. Whoever “we” is in this thought experiment, the “we” offers the patient the

choice between a treatment that can have potential health benefit or money, something of

conditional value. If the MRI is not clinically indicated or necessary, I will withdraw my critique,

but if it is, it assumes an unconditional value—it may be necessary to preserve the health and

well-being of the patient. Therefore, it would be coercive for this option to be given to the patient.

So, I would not think that a valid conclusion could be drawn from a thought experiment

premised on coercing an agent.

The essence of the disparity between Cochrane’s pro-market position and my position is

realized when Cochrane asserts that “health care is an economic good…health care is not that

different from the services provided by lawyers, auto mechanics, home remodelers, tax

105 Cochrane, John H. "After the ACA: Freeing the Market for Health Care." February 6, 2013. Accessed March 21, 2014. http://faculty.chicagobooth.edu/john.cochrane/research/papers/after_aca.pdf.

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accountants, financial planners, restaurants, airlines or college professors.”106 With the potential

exception of lawyers, I entirely disagree with Cochrane. This disagreement is at the core of

values-centered health care.

V. A Values-Centered Response to the Pro-Market Position

Cochrane’s argument is mistaken about the moral facts of medical care. To begin, he is

so adamant about the idea of the “for-profit” health organization being distinct from the

“nonprofit” medical organization, and it is not when considering the ethical wrongdoings relating

to patient care. As he acknowledges, for-profit medical organizations must answer to

stockholders and pay attention to their position as a publically-traded entity, but just because a

medical organization does not have stockholders does not mean that they do not maintain a profit

motivation; a board of trustees or governing body can just as easily desire profit and jeopardize

patient and well-being. There is still something fundamentally wrong with a medical profit

motivation regardless of the medical organization maintaining it, so health care policy in this

area should be directed towards all medical organizations. I would say that the profit-motive is

more dangerous and alarming in the for-profit setting, but still, effort should be directed towards

all medical profit motivation, regardless of its brand.

In After the ACA, Cochrane tries to justify medical reform on a value-neutral account,

something that I believe is unavoidable in the medical setting. It would seem that Cochrane

avoids a value-based account through a system of economic analysis, but I would disagree. By

arguing for increased competition, less regulation, and the promotion of economic or industrial

ideals in the medical market, Cochrane is making a claim about the value of freedom and

106 Cochrane, John H. "After the ACA: Freeing the Market for Health Care." February 6, 2013. Accessed March 21, 2014. http://faculty.chicagobooth.edu/john.cochrane/research/papers/after_aca.pdf.

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economic sovereignty. If he was not or did not support this position, why should we have to

value his argument? His discussion is premised on the idea that freedom is intrinsically valuable.

I agree that freedom is valuable, but we must consider what other values are at stake in the

“medical market”. Primarily, I am referring to the value of human health; Cochrane avoids

making a claim on the value of health by analyzing health care as a system of commodities that

is subjected to supply and demand curves. This is a mistake, and even with the value of freedom

in mind, there are reasons to believe that the value of health can demand promotion over the

value of freedom (when the two are pitted against one another).107

Cochrane—like others—needs to take a stance on the value of health, because I believe

this is the only method of pursing viable, patient-focused health care reform; the “others” I am

referring to includes policy makers in health care. Being value-neutral about human health is to

deny our humanity. There is no sense in rejecting the fact that human health is too subjective of a

value to allow for an unrestricted medial market place to viably emerge (and be morally in place),

and there is moral danger in treating health like any other commodity. Promoting values-centered

health care is where relevant medical policy needs to be directed towards.

107 This is not an entirely controversial ideal; in other ways, we are able to sacrifice freedom to promote other higher-order values. For example, we can think of having law enforcement agencies as being an example of some member of society forfeiting some degree of autonomy to protect the autonomy and bodily integrity of all of society. Additionally, we can think about providing tax dollars to provide public goods as forfeiting some of our financial autonomy for the ability to educate our society, protect our citizens, and promote other public goods. We can also think about forfeiting some of our financial freedom in terms of Social Security: throughout our lives, we pay into a system that forces us to concede some monetary freedom in order to help promote financial freedom in the future. There are several ways that we forfeit freedom to promote unconditional values, an idea that sounds more controversial than it actually is.

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Conclusion

I decided to pursue this project after I was able to reflect upon my personal experiences

with patient care and hospital administration. I plan on pursuing a career in medicine; as a result,

I have attempted to gain as much perspective into medical decision-making as possible. This

journey eventually led me into an internship under an administrator in a large medical

organization. From this experience, I was angered. I was angered by the commodification of

patient health I was witnessing. Patient health and well-being were the values that have

motivated me to pursue a career in medicine, and to see those be degraded by administrative

decision-making was frustrating. I have been fortunate enough to learn about and appreciate the

uniqueness, subjectivity, and importance of human health, realized though discourse with

medical professionals and patients with medical ailments. Even though my experiences with

medical administration have been frustrating, I am also thankful for having them. Otherwise, I

would not have been intrigued by the tension between business considerations and medicine, and

thus, I would not have pursued this defense against profit-motivated health commodification in

health care.

In this thesis, I have championed the unconditional value of human health in all tiers of

health care. I have shown that there are reasons to believe that doctors have concrete obligations

to their patients, and these obligations amount to a physician being accountable for not optimally

promoting patient health and well-being. Early on, I introduced “the medical profit motive” as

the direct antithesis to doctoral obligation. Within the medical profit motive, an agent would in

some way desire monetary profit that would result from patient care. To think about medical

profit in this way is a complete rejection of our humanity and the nature of patient care. Although

profit motivation can be justified when isolated into a doctor-patient relationship, the same does

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not hold true for an administrative medical profit motive. When thinking about leadership and

responsibility in collective wrongdoing, the non-existence of normatively significant force

(coercion) towards decision-making, and the lack of medical expertise that ought to exist in a

role responsible for medical decision-making, it is hard to transpose the justification of a medical

profit motive into the administrative sphere. I maintain that an administrative profit motive ought

to be abolished because of the moral risk involved, and if it cannot be abolished, it must be

accounted for.

This discussion began a larger conversation about values in health care policy. I was

particularly dissatisfied with a pro-market argument for health care reform, and I did not believe

that thought on distributive justice in health care truly captured what was morally at stake in

health care. Thus, I forwarded my own theory of health care: values-centered health care.

Values-centered health care borrowed the moral facts teased out from the first two chapters and

distilled them into three relevant principles for medical policy makers to consider. I believe that

health care reform guided by the value of health is the most desirable model of reform, and the

value of health cannot be lost though extensive policy debate.

With this, I charge the entire health care field to consider what has been introduced here

and in several other places: there is something unique about human health that should invoke

pause and caution when making decisions affecting health. For doctors, profit considerations are

still not desirable (they are pro tanto wrong), but if they are instrumental to providing optimal

patient outcomes, they can exist. Doctors should reflect on the value of patient health when

deciding how to best treat patients, and similarly, administrators should reflect on the value of

human health when deciding how to run medical organizations. If it is not fully possible, it still

should be understood that a medical organization led by medical experts is the most morally

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desirable model of administration. The medical administrator must use the value of patient health

as a bulwark against profit considerations that may be tied to their role in the medical

organization. The medical organization will have a very difficult time approaching a moral ideal

with a fee-for-service incentive structure in place; I have recommended the Accountable Care

model of patient care here, but regardless, there should be a push to reduce pecuniary conflicts-

of-interest in medical decision-making.

Those who develop medical policy ought to act through what has been introduced by

values-centered health care. In our current state of affairs, health care reform is at the forefront of

debate and consideration, so it is a very apt time for a theory of health care to be forwarded. It is

also a very apt time for the value of health to be lost in the maelstrom of policy and debate,

something that must not take place. When considering my future in the maelstrom of health care,

I must also be cautious of profit motivation in patient care. If I do become a medical doctor, I

cannot allow for a profit motivation to be at the forefront of my clinical practice. Like other

aspiring physicians, aspiring medical administrators, and those aspiring for roles that deal with

medical policy, we must recognize that the unconditional value of health is what governs moral

medical care.

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