Access to Health Care:
A Clinician's Opinion
About al1 Ethical Issue
Joanne C. Cassidy
Key Words: ethics, professional. health
policy. social change. public policy
Is health care a social good, or is it a commodity? A
trend to increase access to health care was initiated
in the 1960s by the Social Security Act. The current
prospective payment system has served to reverse
the impact of the Social Security Act and has caused
a clash between administrative and clinical decision makers. The physician's traditional pledge to
place the patient's welfare first conflicts with the social reality offiscal constraint, which is causing the
rationing ofpatient care without public consensus.
This article raises the issue of distributive justice in
health care and points to the need for increased understanding of the nature of health care as a social
good.
Joanne C. Cassidy, MEd, OTR, is Manager of Occupational
Therapy at the Medical Center Hospital of Vermont, Burlington, Vermont 05401.
f asked what they think are the ethical issues in
health care today, most Americans would list
concerns about abortion, AIDS, or organ transplantation. These issues receive broad media coverage but have direct impact on only a few. A more
encompassing issue is the ethics of health care distribution. Americans appear to fail to understand the
serious ethical issues in recent health care policy
changes. Much of the current confusion stems from
our national ambivalence about health care. Is health
care a social good, something to which we all ought to
have equal access? Or is it a commodity that ought to
be controlled by supply and demand in a competitive
market? As a nation we are at a pOint where the trend
of increasing people's access to health care, which has
been taking place over the past 30 years, is being
reversed. Yet the public seems unaware of the issues.
I
The Problem
In the 1960s, health policy increased access to health
care through expanding reimbursement. Two titles
were added to the Social Security Act of 1965 which
allowed eligible beneficiaries to be reimbursed for
health care by the federal government. The first was
Title XVIII, which established the Medicare program
for people 65 years old or older. The second was Title
XIX, the Medicaid program, which substantially expanded financial assistance to enable states to pay for
medical services for the poor.
In April 1983, in an effort to prevent the
bankrupting of the Medicare Trust Fund, the Soci<ll
Security Amendments Act of 1983 (PL 98-21) was
signed into law. Title VI of this law contained a prospective payment system (PPS) for Medicare patients.
This legislation radically restructured the manner in
which hospitals were paid for inpatient services provided to Medicare beneficiaries. Before PPS, Medicare reimbursed for the costs of care after the care was
proVided. The PPS payment is predetermined by
diagnostic categories known as diagnosis-related
groups (DRGs).
As a result of this and other changes in the health
care field, physicians are increasingly faced with financial concerns, as well as medical concerns, when
managing patients. Some possible implications that
the PPS might have for physicians were outlined by
the American Medical Association (AMA, 1984) in a
handbook for physicians, including the folloWing:
• Hospital administrators, in their efforts to minimize uncompensated care, may take a more
active role in clinical decision making, such as
determining the length of stay and which procedures are performed.
• Hospitals may encourage physicians to treat
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more people as outpatients or, conversely, to
admit patients for procedures that are typically
performed on an outpatient basis, depending
on the dollar amount of the DRG.
• Hospitals may encourage the early discharge of
patients or the transfer of patients to nursing
homes and rehabilitation centers as costs exceed payment.
The Dilemma
All of these actions are based on management's need
to move patients out of the hospital before DRG funds
are expended. Johnson (1986) observed in Modern
Health Care that hospitals and medical staffs were in
adversarial roles under PPS. Hospital management
views the DRG as the maximum stay. Physicians who
are increasingly concerned about their own involvement in malpractice suits may tend to keep patients in
the hospital until the mean number of days is reached.
Thus, the physician who is practicing defensive medicine will view the DRG as a minimum length of stay,
leadlDg to potential conflict between administrative
and clinical decision makers (Johnson, 1986).
The problem at hand is that American physicians
are not accustomed to focusing on the costs of hospital-based health care. "Physicians are to do all they
can for their patients, without taking into account the
kinds of factors . . . that policy makers rightly should
consider" (Beauchamp & Childress, 1979, p. 213)
This ethical view holds that physicians must secure
every benefit that the system offers for their patients,
but that they are not obliged to violate that system's
rules on the patient's behalf. Physicians defend the
patient's interest, while society (or the hospital) defends its own interests. In the context of modern
scarcity, is it possible-or appropriate-for physicians to seek the maximization of the quality of care
they deliver, regardless of cost?
Hospital administrators are forcing physicians to
face the financial implications of their clinical decisions. Physicians must learn to distingUish between
their traditional allegiance to the patient and the economic realities of the hospital, which they need to
treat their patients. A new relationship between physicians and hospitals must be developed that keeps in
mind both moral and economic ramifications.
Some observers see the physician's duty to the
patient as prima facie: "Physicians' allegiance to their
patients must still assume a primary role in any mar
ally acceptable response to economic contraints"
(Morreim, 1985, p. 34). Others see physicians' duty to
socIety as overriding their duty to the individual patient: "Considerations of justice challenge the traditional, perhaps mythical, view that physicians can act
as the unrestrained agents of their patients" (Daniels,
296
1982, p. 51) The latter view is based on the basic
principles of social justice: "Social justice requires
that the concept of individual freedom always be held
in balance by the concept of the common good"
(Weber, 1984, p. 63).
Clash of Values
At the center of the conflict between hospital administratorS and physicians is a difference in the theoretical
basis for the decision making of each group. Physicians evaluate their actions, including the morality of
their actions, by the consequences that these actions
produce. They weigh the side effects and benefits in
their clinical decision making. They seek to maximize
benefits and minimize harms. Thus, their approach
can be characterized as utilitarian. Codes of practice
for administrators tend toward deontological theory.
Administrators judge their actions to be right or wrong
without consideration of the actions' consequences.
Fidelity to promise, truthfulness, and duty are the
characteristics that determine rightfulness. This difference in thinking sets up a dynamiC tension between the two groups as they struggle for economic
survival in this time of financial constraints.
Medical practitioners have long maintained their
tradition of independent professionalism. They have
had autonomy in both practice decisions and fee setting. The advent of the Medicare program created a
bonanza for physicians, as they gained payment for
services that they had traditionally proVided as a professional obligation. The failure of Medicare to build
in controls or to set limits on fees led to the dramatic
spiraling of costs. The PPS represents a step to control
the costs of services, and thus it is a dramatic step
toward decreasing the autonomy of physicians in the
area of fee setting. Although this requires an adjustment in physicians' professional posture, it should not
necessarily pose a significant moral conflict to physicians or administrators. Physicians must recognize
their obligation to the society in which they function:
"The professional is helping or healing or giving advice or solVing problems within a framework supported by the profession and limited by societal
structures" (Lebacqz, 1985, p. 140). The Congress has
taken a step to limit the autonomy of the medical
profession in order to protect the rights of society.
The Issue of Distribution
The issue of decreasing physician autonomy is overshadowed by a much larger issue, that of justice in
distributing health care. Discussions of justice in
health care focus attention on Americans' ambivalent
view of health care as a commodity or a social good
(Reinhardt, 1985). To examine this and other changes
in medical care, the AMA held a conference on Medi-
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cal Ethics in March 1986 to provide physicians with an
opportunity to analyze and debate the proper balance
between ethical considerations and the competing
societal values, such as autonomy, competition, and
economic efficiency. The conference revealed that
physicians, while steadfastly holding on to their Hippocratic oath, are finding it "increasingly difficult to
know how to apply the old ethic" (Rust, 1985, p. 9).
The Reagan Administration has expressed the
view that concern for the poor is a private virtue, not a
public duty: "It's time to reject the notion that advocating government programs is a form of personal
charity. Generosity is a reflection of what one does
with lone's] resources and not what [one] advocates
the government [should] do with everyone's money"
(Bellah, 1985, p. 263). Although the federal government has cut funding and increasingly has relied on
the private sector to arrive at a marketplace solution,
physicians have been concerned about the implications of health care policies on access to health care
services for the poor. Arnold Reiman, MD, editor of
the New England Journal of Medicine, has warned
that physicians must choose between being physicians and entrepreneurs.
A new word, dumping, has been added to medical terminology; this is "when a hospital refuses to
admit, or qUickly transfers to another hospital, a poor
or uninsured emergency patient to avoid getting stuck
with an unpaid bill" (Day, 1985, p. 1) In this situation, clinical decision making has become secondary
to financial decision making; this raises the question
of who is responsible for treating the poor. The anger
generated by stories of dumping is damaging to hospitals and physicians and gives politicians publiC justification to further legislate control over the health
care industry and the medical profession. Some analysts have concluded that "our country cannot live
much longer with the fantasy that the needs of the
poor can be addressed by a combination of enhanced
private philanthropy and state support" (Kinzer, 1984,
P 5)
Ethics of Health Care
The apparent rationing of health care is not a product
of careful design, but rather a result of America's ambivalence over the ethics of distributing health care.
Americans have never agreed on the social role of
health care, and several difficult questions must be
asked and answered. Should health care, like jurisprudence and basic education, be considered a social
good and be collectively financed; Or should it be
viewed as a private good to be financed by the recipient; If we could decide whether access to health care
services is a basic right, or a moral obligation of phy.
sicians (and therefore publicly financed), could we
not better meet the needs of our society;
The changes brought about by Medicare and the
DRG system have fueled an old debate as to whether
health care is unique among goods and services.
Some contend that health care is a commodity and
should be sold in the marketplace to those who have
the capacity to buy. After all, other basic necessities of
life like food, clothing, and shelter are treated this
way. To this end, we have witnessed the growth of
private for-profit hospital chains.
The counter argument is that health care is a
moral right, since it is fundamental to survival and
necessary to enjoying life (Grey, 1983). "Access to
decent levels of care is more than a matter of compassion, it is a fundamental precondition for enjoying
life, liberty and the pursuit of happiness. Thus, it is a
basic American right" (Dolenc & Dougherty, 1985, p.
27) The right to health care has been an evolVing
moral concept in the United States. The World Health
Organization (WHO) prefaced its call for health with
the follOWing: "Considering that health is a basic
human right . . . " (Nichols, 1981, p. 523). The report
of the President's Commission for the Study of Ethical
Problems in Medicine and Biomedical and Behavioral
Research stated that the commission chose not to base
its recommendations on a belief in the right to health
care: "No such legal or constitutional right has been
recognized in this country, and it is not necessary to
assert a moral right in order to argue that society has
the obligation to ensure access" (Weber, 1984, p. 63).
Paul Starr, in The Social Transformation ofAmerican Medicine (982), addressed this issue in a social
definition of health care: "Health care is a matter of
right not priVilege: No other single idea so captures
the spirit of the time [1970s]" (p. 389). The laws do
not, in fact, recognize a basic right to health care. The
President'S Commission on Health Care pOinted out
that "society has an ethical obligation to ensure equitable access to health care for all" (Weber, 1980, p.
54) Since there are limited resources for health care
and demand exceeds supply, the issue becomes one
of distributive justice. How will society allocate fairly
the scarce resources of health care?
The distinction between goods as needed social
rights or as commodities is important, especially in
terms of distribution. Once it is determined that
something is a needed good, free exchange is constrained. Needed goods are not commodities, a distinction that Walzer (1983, p. 89) pointed out:
"Needed goods cannot be left to the whim or distributed in the interest of some powerful group of owners
or practitioners." If we clearly defined health care as a
right, then free enterprise would not be appropriate.
Equity in the delivery of health care services is
not given high priority in our country. Walzer wrote
that "so long as communal funds are spent, as they
currently are, to finance research, build hospitals and
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pay the fees of doctors in private practice, the services
that these expenditures underwrite must be equally
available to all citizens" (1983, p. 90) Health care
costs are more of a concern to the population than are
citizens' rights to health care People relate to the
crises of individuals, but are not empassioned by a
discussion of the issues of access to health care and
the concept of health care as a commodity. This has
allowed political leaders to stand up for the rights of a
particular individual to get a heart transplant but also
to vote for health care budget cuts that reduce support
for heart transplant research. Bellah (I 985) theorized
that Americans lack the moral language they need to
think clearly about such complex social problems.
Implications for Occupational Therapy
Occupational therapy, as a part of the health care system, has been tremendously influenced by many recent changes. "Change in the system is not being
done by someone or to someone, but simply exists; it
needs to be gUided when possible, resisted when necessary, and adapted to when it is inevitable" (Brown,
1986, p. 1245). The changes before us are inevitable;
at worst we must adapt to them, and at best we can
gUide them.
At the core of the issue is the image of the occupational therapy profession. The visibility and viability of occupational therapy are essential to its survival
in times of change. To be effective change makers,
occupational therapy personnel must project to the
public a model that is autonomous and essential. The
challenge is to confront our natural reaction to withdraw from the turbulent issues of change in the health
care system and instead to seek to expand our role in
determining the direction of that change.
To do this we must work to increase the autonomy of the profession. We must clarify our theoretical
base to demonstrate our specialized body of knowledge. Practitioners need to actively discuss the application of occupational therapy theory to current clini·
cal practice. We need to examine how our profes·
sion's philosophy and theory are applied in practice,
and we must work qUickly to strengthen the links
between education, practice, and research.
Faculty members and clinicians should engage in
collaborative studies that describe and test our philo·
sophical base. Studies demonstrating that occupa·
tional therapy can make the difference between insti·
tutionalization and home care or between unem·
ployability and employability must be carried out.
The demonstrated efficacy of our work will clarify our
role and convey the importance of what we do to the
public and the patients.
We must make the occupational therapy code of
ethics come alive. Our code states that an ethical
practitioner "seeks information about the major
298
health problems and issues to learn their implications
for occupational therapy" (Welles, 1985, p. 379). Occupational therapy personnel need to understand the
concept of social justice-that is, individual freedom
held in balance with the common good. Educational
efforts should be focllsed on those occupational therapists who, because they are frustrated by these
issues, are leaving the profession instead of seeking to
understand the current dilemmas. Of even greater
concern are those who remain in the profession but
fail to accept the reality of the changing system. Their
failure to adjust to the changing health care system
weakens us all and clearly represents practice outside
the gUidelines of our code
Our code of ethics also states that occupational
therapists have a "beneficent concern for the recipient of services" (Welles, 1985, p. 361). Thus, the decision as to who should be served with limited resources should be based on the occupational thera·
pist's assessment as to who can best benefit from
those services. Those who cannot be served, or those
who would have fewer gains, should be given a lower
priority for services.
The fact that medical care in rehabilitation is unaVOidably
value-laden creates a variety of ethical questions of a kind that
rarely arise when health care proViders and patients agree
about the goals of care. Since patients and prOViders bring
different values to the rehabilitation setting and evaluate out·
comes differently according to their individual norms, dis·
agreements may arise concerning goals or the priority that
ought to be assigned to achieving particular goals. (Caplan,
Callahan, & Haas, 1987, p. 6)
Occupational therapy is a limited resource within
health care for many reasons. One reason is that the
supply of occupational therapists does not meet the
demand. The demand for occupational therapy services has risen due to an increase in the number of
older people and increasing numbers of survivors of
severe trauma. As demand rises, a system for distribution of occupational therapy services must be established. In the current system, occupational therapy is
sometimes perceived as a luxury, not a necessity. Our
focus on function is valued less than the physician's
focus on saving lives (Shannon, 1983). We need to be
advocates for those patients whose lives were saved
by the "miracles of technology" but now are faced
with significant functional barriers and a diminished
quality of life.
Without consensus as to whether occupational
therapy is a luxury or a necessity, it will be difficult to
reach an ethical resolution to these issues. We are part
of the greater health care system and must keep in
mind that "the professional is helping or healing.
within a framework supported by the profession and
limited by societal structures" (Lebacqz, 1985, p.
140). Thus, one of our roles is to increase society's
support for the therapeutic needs of disabled people.
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We must build an ethical framework that supports
occupational therapists 3nd allows them to feel confident that they have done the best for their patients
within the constraints of the health care delivery system. "In 3 society th3t places great value on youth,
vigor, and industriousness, and manifests an ongoing
trust in the power of science and disability, there 3re
powerful stigmas and little prestige associated with
patients who lack both highly valued characteristics
and the capacity for cure" (Caplan, Callahan, & Haas,
1987, p. 3). Our challenge is to change the image of
occupational therapy to that of an essential service.
Conclusion
We must speak clearly about the special role we serve
in the health care system. Each therapist must recognize his or her role and explain to others exactly what
occupational therapy is and what it can accomplish. In
addition, we must work vigorously to remove unessential activities from our clinics Since the essential
service that we provide is constrained by the rules of
supply and demand, it is improper for us to spend our
time in wasteful or unproductive activities. Instead,
we must become active in the political process at
every level. Therapists who work in nontraditional
areas should continue to identify themselves as occupational therapists We all should seek to increase the
public's awareness of the essential services that occupational therapy provides.
Public rights should be ch311enged and debated
by the public. Citizens need to clarify their health care
rights and establish a juSt system to ensure those
rights. To demand those rights, individuals need to
understand the concept of social good. We must come
to a consensus on the meaning of health care before
we discuss (or legislate) levels of access Only
through dialogue can we fairly consider distributive
justice.
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