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Individual Autonomy and State Involvement in Health Care J Med Ethics: first published as 10.1136/jme.27.4.240 on 1 August 2001. Downloaded from Journal of Medical Ethics 2001;27:240–244 Individual autonomy and state involvement in health care Thomas Rice UCLA School of Public Heath, Los Angeles, USA Abstract this have for the role that government does–and This article examines the ethical basis for government should–have in health care? This article considers involvement in health care. It first provides the case for these issues. individual autonomy, focusing on the justifications–particularly ethical ones–for allowing The case for individual autonomy individuals to make their own choices in health care, There are many reasons to believe that individuals and to control more of their own resources in doing so. should be able to make their own choices in health Next, it provides the opposite case–for abridging care. Moreover, there are reasons to think they individual autonomy, and in particular, for should have control over (more of) their resources redistributing resources from those who are well oV to in order to make these choices rather than having those who are not. The overriding reason for favouring them taxed away by government. This section the latter case, which trumps the notion of individual focuses on three major advantages of consumer autonomy, is to ensure that individuals who are at a sovereignty in health care. These advantages are disadvantage have an equal probability of attaining categorised below under the headings of economic good health. eYciency, psychology, and fairness. (Journal of Medical Ethics 2001;27:240–244) Keywords: Distributive justice; ethics; government; health ECONOMIC EFFICIENCY care The central tenet of traditional economic theory is that consumers will be best oV if they are allowed to make their own choices about the goods and serv- Introduction ices they consume. This belief is exemplified by the For many decades and throughout the world, theory of revealed preference–which posits that government has been deeply involved in the organ- allowing people to make their own economic http://jme.bmj.com/ isation, financing, and delivery of health care serv- choices will, in and of itself, make them best oV.As ices. We usually take this strong involvement for developed by Paul Samuelson,1 people are assumed granted, and sometimes even equate a country’s to prefer the bundle of goods that they purchase. If health care system with the role taken by its they choose one bundle over another, they have government. This is unfortunate because the foun- “revealed themselves” to prefer the former bundle. dation and extent of government involvement are The theory is unusually powerful because it does predicated on certain key ethical issues. One’s take not require individuals to reflect on their underly- on the particulars of these issues drive one’s views ing motivations. As Robert Sugden has written: on September 26, 2021 by guest. Protected copyright. of when and how much government should “[The] most significant property of the revealed intervene in the market-place. preference approach ...isthatwedonotneed to Government has the power to influence any enquire into the reasons why one thing is chosen number of aspects of health care strongly. It can, for rather than another. We do not look into the factors instance, control the number of providers as well as that go into the deliberation which leads to a the kinds of services they deliver; set prices and the choice; we look only at the results of that types (and even quality) of services that can be pro- process . ..”2 vided, particularly when public resources are The theory of revealed preferences relies on indi- involved; and have a strong influence on the intro- viduals’ abilities to make utility-maximising duction and diVusion of new products and choices. Going one step further, and assuming that technologies. One of the most important roles of social welfare is simply the sum of all individuals’ government is the collecting of taxes, using the rev- welfare, we can conclude that allowing consumers enues to support further regulation of the sector, as to make their own choices will lead to the highest well as to finance the distribution of services to level of societal welfare. This is the precise those it deems most fit to receive them–most nota- argument made by proponents of competition: bly the poor, the elderly and veterans. markets allow people to choose, resulting, in turn, Having this power and using it ethically are, in the best possible outcome for society. In other however, two diVerent issues. What is the ethical words, a society where all people make their own basis for government intervention? Are there other choices results in the highest level of satisfaction. strong reasons for government to intervene in the A related reason for encouraging choice is that health care market-place? What implications does the use of markets can lead to better value. Choice, www.jmedethics.com J Med Ethics: first published as 10.1136/jme.27.4.240 on 1 August 2001. Downloaded from Rice 241 of course, is a characteristic of a competitive standing, a “veil of ignorance”. His goal is to deter- market. Having a choice leads to a situation where mine what system of justice rational, self-oriented firms strive to operate eYciently to keep prices low. people would choose when placed in the original And to the extent that the goods sold are not position. homogeneous, competition may also take place on Rawls posits that people in the original position the basis of quality. One should not underestimate would accept the proposition that primary goods the significance of this argument in favour of (which he defines as “rights and liberties, powers choice, since better value through lower prices and and opportunities, income and wealth”) “be better quality has the potential to provide over- distributed equally unless an unequal distribution whelming advantages to consumers. of any, or all, of these values is to everyone’s advan- tage. Injustice, then, is simply inequalities that are not to the benefit of everyone”.6 PSYCHOLOGY The upshot is that society is better oV only when The second reason for believing that consumers it makes its least well-oV people better oV. In other should have autonomy–in health care as well as words, society’s resources should be devoted to throughout the economy–is more psychological in increasing the primary goods possessed by the most nature: individuals are likely to get more satisfac- disadvantaged people. The only time that resources tion out of the goods and services they purchase if will go to the group that does not occupy the they choose them. It is plausible that individuals bottom rung is when, by so doing, benefits will would prefer the particular goods that they picked trickle down to the most disadvantaged group. The out of a set of alternatives, rather than having had overriding implication is that society should engage these goods assigned to them by someone else. This in far more redistribution than it does currently. can be clarified by the following thought experi- This is because resource distribution is quite ment. Your employer knows that you need a new skewed and, moreover, because much if not most of car to get to work, knows that you have a certain current redistributive programmes are not targeted budget, and picks out for you a particular make, solely at those who are worst oV in society. model, and colour, withholding its cost from your Why would people who are placed in the original pay-check. Compare that to a situation where you position decide on this particular conception of pick out your own car. Even if it turns out that you justice? Rawls answers: “Since it is not reasonable would have picked exactly the same car, the latter for [a person] to expect more than an equal share in situation would satisfy more people because they the division of social goods, and since it is not know it was their choice. When the particular car is rational for him to agree to less, the sensible thing assigned by an outside agent, you may be for him to do is to acknowledge as the first princi- concerned that you might have picked diVerently if ple of justice one requiring an equal distribution. given the choice. Consequently, your satisfaction Indeed, this principle is so obvious that we would http://jme.bmj.com/ with the decision will be lower. Some might argue expect it to occur to anyone immediately.”7 that this would be even more true in health care, Some analysts believe Rawls overlooked a key where consumer decisions (such as what doctor to primary good–access to good health care. Accord- see) are very personal, individualistic, and can be of ing to Ronald Green: “Access to health care is not considerable import. only a social primary good, but possibly one of the most important such goods [because] disease and ill health interfere with our happiness and under- FAIRNESS mine our self-confidence and self-respect”.8 An argument can be made that it is unfair to tax Although Rawls’s theory is often praised even by on September 26, 2021 by guest. Protected copyright. away an individual’s resources to spend either on those who have criticised it, a number of objections other people, or alternatively, on health care have been raised. One is that people would not resources that the person may not have chosen. choose to redistribute primary goods only to those Perhaps the main proponent of this philosophy is who are worst oV .9 Another is that, when asked, Robert Nozick,3 partly in response to John Rawls.4 people seem to choose to maximise average income subject to some minimum floor rather than Rawls’s solution.10 A third objection is that there is little Rawls’s theory place in Rawls’s theory for rewarding motivation or Briefly, Rawls’s theory provides an alternative to hard work, which has ethical implications in itself utilitarian philosophy.
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