THE CONCEPT OF GENUINE RESPONSIBILITY
5. KEY PRESUMPTIONS
Critical to the success of such a moral endeavor is that society must acknowledge its preference for economic self-interested individualism as the operative framework in health care. Nonetheless, it must also recognize the need to ground this framework in a more broadly based stakeholder theory characterized by the commonality of the notion of responsibility.
For most parties in health care, the legitimacy of the claim to be recognized as stakeholders depends on whether society adheres to a broader society-oriented foundation of stakeholder theories or still holds fast to the more traditional legal and economic-based theory. Stakeholders can be described as persons, groups, or organizations with a legitimate claim that their rights and interests must be taken into account by the primary moral actor. Within the context of managed care or, for that matter, any kind of health care delivery organization, the legitimacy of the stakeholders’ claim is validated by the fact that the nature of these organizations—
their core business—is managing individual access to medical care. But the very nature of managed care is not the only legitimizing factor. As a general rule, the legitimacy of a claim is also decided by its strength, which, in turn, depends on the validated needs of the claimant. Finally, the legitimacy of a claim depends on the moral weight of the claim itself.
In regard to health care, the moral weight of the claim is derived from the premise that health should be considered a social good. Rawls (1973) argued that social goods are the primary goods that every rational person is presumed to want.
Although Rawls considered the primary goods to be rights and liberties, together with powers, opportunities, income, and wealth, he also recognized that health, vigor, and intelligence should be appreciated as (natural) primary goods as well. One might reasonably presume that if the stakeholders of organizations that manage the
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delivery of health care services do present their claim, then the legitimacy of their claim would be strong (van Luijk and Schilder 1997). If such were the case, then their rights and interests must be taken into account.
An additional argument in favor of a change to a more broadly based stakeholder theory can be made by taking into consideration the technological and sociopolitical developments affecting society. Widening the concept of stakeholder involves expanding the group of interested parties that a business organization must recognize as its stakeholders. Whereas the legal foundation or the economic foundation recognizes only shareholders, suppliers, and employees as stakeholders, the society-oriented foundation adds to the domain the interests of society as a whole and of the individual members of society, under the assumption that they also present a legitimate claim to the primary moral actor.
organization’s obligations. From an ethics point of view, the acknowledgment of a broader domain of stakeholders within a democratized concept of morality implies that reflecting on the rights and interests of all stakeholders is synonymous with acting in a morally responsible manner (van Luijk and Schilder 1997).
5.1 Challenging the Notion of Responsibility in Managed Care
Even in the early part of the twenty-first century, managed care procedures indicated that the industry was still operating in synchronicity with a restricted definition of the term stakeholder and with an operative philosophical framework of unconditional, economic, self-interested individualism. For that matter, managed care functioned within the same economic model as any other industry. In other words, the distribution and the delivery of health care services take place within a market philosophy similar to that of other industries characterized by the prioritization of fiduciary responsibilities. The organization’s success depends largely on its financial performance. The higher the returns on investments, the better the stock market can be expected to respond. Performing well in regard to serving the interests of health plan enrollees is a concept that financial strategists often deem of secondary importance and thus of less relevance to the market value of an MCO.
The notion of moral responsibility in managed care has had a limited connotation that is understood in terms of compliance. In this interpretation, moral responsibility becomes synonymous with the duty to fulfill legal contractual obligations.
Responsibility becomes comparable to the function of natural survival in an environment wherein moral agents must live together, work together, and sometimes necessarily even rely on each other. The process of enhancing one’s self-interest is served by reciprocating, but the duty to reciprocate is limited to what the contractual rights of others require the actor to do.
Narrowly defining moral responsibility in terms of compliance suggests that the notion of responsibility is synonymous with the term grudging reciprocity. The disposition to reciprocate favors and cooperate with others is understood as a function of prudent behavior, which reduces human beings to self-interested rational 114
Indeed, societal considerations are the main determinants of any definition of an
maximizers. Grudging reciprocity does not invite people to be genuinely interested in others (i.e., to include the dispositions of empathy and sympathy) while interacting, because an intrinsic value has been attached to the concept of living in community.
5.2 Health Care Distribution in a Free-market Economy
Within the context of the dominant economic ideology of market capitalism in the United States, the prevalence of rights-oriented ethics in society reinforces the idea that self-interested behavior is good and rational. People will therefore always and necessarily first assess their self-interest, which is believed to be the right thing to do (Lantos 1997). According to this view, self-interested behavior does not focus on the interests of others unless the neglect of considering those interests could jeopardize the securement of one’s own self-interests. To be considered a moral actor, there is no need to be genuinely dedicated to the enhancement of the interests of others, although most people do indeed feel bad when confronted with the life situations endured by those who are weaker and worse off in society. As the philosopher Baier (1994) noted, such confrontations intuitively urge action to ease the pain of others. Relationships between persons who are unequal are put aside until they are eventually dealt with but then only with some sort of promotion of the weaker to achieve an appearance of equality.
The prevalence of rights-oriented ethics in health care and the preponderance of the traditional free-market system in U.S. society apparently provide a context for moral practice in which an interpretation of the notion of responsibility in terms of compliance is considered acceptable by society. The emphasis in libertarianism on the appreciation of freedom and individualism, combined with a specific dominant rights-oriented perspective of morality, allows members of the moral community to adopt a limited view of responsibility. In general, liberal theories focus on duties stemming from the legitimate rights of others, whereas the rights-based theory of morality, in which the rights of individuals or groups impose a duty on others, accentuates personal autonomy. The business practice of managed care illustrates that this orientation on rights is commonly considered a legitimate position. The obligation to provide medical services to health plan enrollees stems from a contractual duty. At the same time, the extent of the duty to provide such medical services depends on the range of these rights. No consensus has been reached on a definition of this range, although health care is appreciated as a social good. For example, egalitarians consider health care to be a social good but even they fail to define the domain of what should be considered a person’s legitimate interest.
The confusion about the extent of a person’s legitimate health care interests results in controversial positions regarding the distribution of health care. MCOs benefit economically from limiting or strictly monitoring access to care and from challenging the legitimacy of some claims to care. On the other hand, individual patients argue in favor of defining the domain of their rights without restrictions so that they may feel assured that all of their needs will be met.
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In light of all the controversies about rights and the fact that health plans, often organized as profit-oriented business organizations, must function in a free-market environment, the question arises as to what extent economic considerations produce morally proficient criteria for regulating the social good of health care. The nature of MCOs, which manage and distribute the social good of health care, as well as the nature of those distributed services (e.g., medical services needed by others), may very well require a different or additional decision-making mechanism. Health is one of the things that every rational human being presumably wants. As Walzer (1983) explained, health is a good that is defined, at least in part, as a good that money cannot buy. Thus, what should or should not be for sale is something we always have to decide and often decide in different ways.
In addition to the problem of distribution, MCOs are confronted with quality-of- care issues that add to their responsibility. The identification of health care as a social good emphasizes that these services and products are important. Therefore, these goods should be of the highest quality. MCOs can either define their responsibility in terms of compliance or they can use responsibility in its broader meaning to serve as a criterion for identifying themselves as primary moral actors.
Enrollees in health plans basically purchase the right to access health care in case their health status necessitates medical intervention. Health plans manage utilization levels largely through mechanisms such as service preauthorization and provider contracting. Because of the impact that these management tools have on the well- being of individual plan enrollees, MCOs should accept a notion of responsibility that goes beyond strict compliance with the duty to fulfill contractual obligations.
Medical needs can be assessed and provider contracts can be negotiated in many different ways. Selecting the appropriate protocols and strategies is particularly challenging because, from a business point of view, the economic relevance of service distribution has changed. The economic appreciation of providing health care services within the concept of managed care differs greatly from that of the fee- for-service situation.
Managed care has moved from a revenue-generating activity to an expense- management operation. Within the context of managed care, fewer services offered or provided to consumers (patients) and lower reimbursement fees for providers translate into better net operating results. However, the proper management of access to medical services requires an even greater level of responsibility than in the fee-for-service environment, because unjustified denial of access may prove detrimental to the health of patients.
5.3 Justice as Appropriation
As defined earlier in this chapter, morality requires moral agents to participate in the distribution debate as rational, well-informed, and sympathetic members of the community. This premise implies that all participants in the debate are obligated to accept accountability for all the collective decisions made as a result of the moral viewpoints they brought to the negotiating table. Furthermore, the justification for this moral positioning must be given in public and can be based only on rational 116
arguments. Moral agents legitimize holding a particular moral view on the grounds that they will accept responsibility and accountability for outcomes as well as for compliance with the impartial consideration of the interests of others.
In this sense, the principle of genuine responsibility operates as a prerequisite to the moral debate. The principle of genuine responsibility also assigns an intrinsic rather than an exclusively instrumental value to the concept of living in community.
In other words, human coexistence cannot be described adequately in terms of persons who are willfully establishing or maintaining peaceful living conditions solely for the purpose of realizing individual goals. Establishing moral communities involves acting responsibly and compassionately toward the interests of others. Only then are we capable of making accurate assessments of the needs of others.
Genuine responsibility can therefore be described as the ability to reflect on the intrinsic value of the relationship between personal interests and the interests of others. That means that human beings define their status as moral agents within the part of the process within which individuals establish their moral status. A true reciprocal relationship must
be present between the members of the moral community and the societal institutions that they constitute.
Within such a context of morality, and the place of responsibility therein, the appropriate concept of distributive justice requires moral agents to act responsibly toward impartial consideration of the interests of others. Justice demands the distribution to others of what would be appropriate, considering their need to maintain species-typical functioning, and such action is therefore necessary to defining one’s status as a moral agent. Instead of claiming or granting the claim of access to social goods, genuine responsibility demands a distribution system based on the moral requirement to create or maintain optimal conditions for substantiating entry into the distribution system (i.e., conditions of mutual responsiveness and sensitivity to the needs of others). By acting on these conditions, human beings can establish or maintain their status as moral agents. The question of whether only human beings have an obligation to establish themselves as moral agents or whether this concept extends to any party or stakeholder involved in the debate about health care distribution becomes almost trivial in light of the significant interests of the health care industry. Thus, it seems reasonable to apply the procedural rules for arranging and ordering complex social structures to all parties. Societal institutions play an equally important role in defining the good. The business of health care
should therefore conform to the same preamble of justice: the principle of genuine responsibility.
These procedural rules constitute the basis of what I refer to as “justice as appropriation.” The model is not a theory of justice; rather, it simply defines the foundation and thus serves as a preamble to just distribution processes within the larger context of genuine responsibility. The notion of justice cannot be understood only as a theory such as, for example, fairness is in the theory of justice. As within the theory of genuine responsibility, it is appreciated as a commitment. Genuine responsibility asks moral agents to explicitly commit to the appropriation of social goods according to distributive rules that they deliberately consented to and will distribution process. Societal institutions, in the specific definition of complex wholes that guide and sustain the individual’s identity, become an integral
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appreciate as just. As such, justice as appropriation becomes the operationalization of genuine responsibility. The notion of justice as appropriation stands for commitment rather than as a model. Justice as appropriation 1) allows discussion toward social agreement on what entitlement to health care should include within the context of scarcity, 2) facilitates the process of developing concrete institutional arrangements for assuring that everyone has access to a decent minimum of care through the combined operations of the private and public sectors, 3) requires private sector entities to balance priorities appropriately, and 4) demands that individuals accept limited packages of health care services, as consented to in the debate.
Justice as appropriation is consistent with Daniels’ (1985) premise that access to health care is based on the fair equality of opportunity principle. Health care is a social good that contributes to the maintenance or restoration of normal species functioning. However, the extent of the services that must be offered in health care (i.e., the extent of the legitimate entitlement) has been a priori well defined by applying the principle of genuine responsibility and the notion of justice as appropriation. Similarly, the proportionality principle is equally acceptable for the decision-making process at the micro level of distribution, because the entitlement has been capped by the moral discussion at the macro level. Also, the broader definition of rationality presupposes the inclusion of empathy and sympathy in the decision-making process. Different models or theories of justice are thus compatible with the notion of justice as appropriation and can be applied within different contexts and at various decision-making levels. Compliance with the principle of genuine responsibility ensures that the outcome of the decision-making process will be consistent with the notion of justice as appropriation.
The process of deliberate identification implies that individuals recognize the obligation as a personal obligation. In regard to health care distribution, such recognition—within reason—for one’s personal moral obligation is therefore also expected from the recipient of the care. The notion of deliberateness in genuine responsibility legitimizes this premise.
The principle of genuine responsibility imposes specific conditions on formulating distributive decision criteria. On the basis of these stipulations, the notion of appropriation must be understood in terms of a commitment, an attitude of accountability for the domain, and the nature of the responsibility as originating from the moral agent’s deliberate identification with a moral obligation. Thus, the definition of appropriation with the context of genuine responsibility closely resembles the connotation of that term in reflexive philosophy.
The contribution of justice as appropriation to distributive decision making is that it leads to the internalization of the term deliberateness. As a result, fairness in genuine responsibility is not defined in terms of objective criteria in regard to content. Rather, fairness is defined as the outcome of the process of appropriation (i.e., the outcome of a moral decision-making process or moral behavior that acknowledges the legitimacy of the claims on both sides of the issue).
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