THEORETICAL REFLECTIONS
3. THE PROBLEM: WHO IS RESPONSIBLE FOR WHAT?
health and a new appreciation for the status of health is a societal responsibility that cannot be delegated in a roundabout way to MCOs.
Society also fell short in reaching an agreement or even starting a discussion on an authoritative standard for defining the scope of entitlements. No authoritative standard has been construed that defines the domain and the quality of health care services and products to which everyone should be entitled. The federal government has floundered by not taking responsibility for assuring universal access to health care and establishing agreement on the distribution of labor between public and private-sector entities in regard to access and quality (Buchanan 1998). A significant portion of public criticism pertains to exactly these issues.
Although putting the blame solely on managed care may not be justified, the concerns about health care are truly legitimate. The uneasiness and frustration about the current practice of managed care, however understandable, can be resolved only by addressing the root causes of the problem rather than by relying on the application of stopgap measures. It appears that the discussion about health care comes to a head on the issue of responsibility.
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Thus, defining the good is a continuing process. With reference to health care, the good is contingent not only on the progress of medical science but also on the affordability of products and services, as well as on other considerations. As a result, what is “affordable” within the context of time and competing interests is a matter of social and political choice, which in turn further defines the quality of that society.
Within such a perspective on ethics and the good, identifying how the role of business in society should be defined is also subject to moral discourse and agreement. Classic libertarian business principles have focused exclusively on the fiduciary responsibilities of organizations and have ignored the fact that business has the ability to bring about consequences in accordance with collective purposes. These consequences produce effects on the very communities that constitute the marketplace in the first place. That phenomenon justifies and validates the idea that business should accept a broader notion of responsibility and that markets, at least to some degree, should be regulated.
Instead of building on qualities such as individual success, short-term returns on investments, and preference for a small role by government in the marketplace, the Rhineland model (Albert 1991) and the social community market model (Jonas 2003) are thriving on societal consensus, a long-term mentality, a participatory role for its social partners, and an active role for national governments. Liberal egalitarianism holds that the concepts of corporate responsibility and the free market are not mutually exclusive. Considering the variety and the magnitude of the interests at stake in health care, the most appropriate economic philosophy appears to be one that more closely resembles the characteristics that uniquely define the
distribution of a (social) good that is important to all members of society. Individual and societal interests deserve to be included within the domain of corporate responsibilities. The role of business in society is one of corporate citizenship with business organizations accepting a broader domain of corporate responsibility that primarily consists of those individuals and groups or social entities that can affect or be affected by the strategic activities of an organization.
3.1 Defining Responsibility
The concept of responsibility plays a crucial role in any attempt to resolve the problems inherent in health care. Unfortunately, a shared understanding of the fundamental quality that constitutes the concept of responsibility is absent. Within the diverse group of stakeholders in health care, at least three levels of responsibility, and thus accountability, can be identified: professional, political, and economic or consumerist (Emanuel and Emanuel 1996). The professional level of responsibility pertains to the physician–patient relationship. The political level represents managed care plans and other integrated health care delivery networks, and the economic or consumerist level deals with the relations between managed care plans and other groups, such as employers, government, and professional organizations. Each level justifies and takes responsibility for specific content areas 160
Rhineland and the social community market models.
The health care industry, and managed care in particular, is concerned with the
that are based on substantive criteria. For example, physicians are responsible for providing appropriate care to their patients. MCOs are responsible not only for carrying out contractual obligations related to the provision of health care services to the population that is insured but also for fulfilling fiduciary obligations to their owners and investors.
Unfortunately, the absence of widespread agreement on the appropriate delineation of the various content areas contributes to controversy about the very practice of managed care. Disagreements about the validity of the substantive criteria only intensify the dispute. At the same time, there is controversy surrounding the prioritization of potentially conflicting interests at the juncture of the three levels of responsibility, which is the point where decisions about the distribution or rationing of health care are ultimately made.
A unifying paradigm of responsibility or, at minimum, a shared understanding of the basic premise underlying the notion of responsibility would allow all parties with a stake in health care to discuss the various options to resolve health care problems in a morally adequate fashion and with sufficient consideration of each stakeholder’s legitimate interests. Emanuel and Emanuel (1996) contended that a unifying paradigm of responsibility is unlikely to be effectively construed. The fact that we are left with a situation involving various groups with differing perspectives on issues, such as how to identify the proper content areas, define accountability criteria, and monitor compliance with these criteria, does not diminish the necessity for agreement on a shared understanding of the fundamental quality that constitutes the concept of responsibility.
As reality shows, without such agreement, communication between parties is hampered. For their moral justification, rationing decisions in health care (i.e., deciding which services are appropriate, at what cost, for which patients, and under what circumstances) depend on agreement by the stakeholders on the issue of responsibility. The selection of appropriate rationing principles should not be left to any single entity. Such decisions should only be made collectively and with the knowledge that all parties are operating according to the shared assumption underlying the concept of responsibility. This procedure would ensure that the moral weight of each of the conflicting interests will truly be impartially assessed, discussed, and prioritized within what Emanuel and Emanuel (1996) called “a complex reciprocating matrix of accountability” (p. 231).
3.2 Genuine Responsibility
In essence, genuine responsibility can be understood as a rational denotation of the intuitive notion of obligation. The ontological origin of obligations is unknown.
For the lack of a better explanation, obligations just happen. If we feel obliged, a phrase is obligatory, even when the phrase has no cognitive credentials (Caputo 1993). These feelings are intentional as well as cognitive, and they convey something about the external world. As such, they are social reconstructions, to the degree to which the underlying opinions are social reconstructions, that is, dominant views and norms (van Reijen 1995).
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The assumption that human beings possess an intrinsic capacity to reciprocate in deciding how to distribute social goods denotes the term genuine responsibility. This capacity to reciprocate is understood as the primary constituting factor of morality, and it implicitly disqualifies single choices as an option for moral decision making.
The term genuineness emphasizes the crucial role played by awareness of others as the primary constituent of human morality.
Genuine responsibility is defined as the intrinsic capacity to make moral choices regarding the (re)distribution of social goods in society, that is, choices that can be justified by appealing to the notion of deliberate reciprocity. Social goods are considered to be the components that are essential to the process by which human beings establish themselves as moral agents and constitute a moral community. The idea of interdependence is understood in terms of the need for deliberate responsive reciprocity with the fair distribution of scarce social goods being considered not as a final objective but rather as an instrument for providing human beings with an opportunity to establish themselves as moral agents.
Genuine individuals are fostered by supportive and vibrant communities which, in turn, are the result of the actions and choices of authentic and autonomous individuals.
Good decision making is a subtle balancing of the individual’s good and communal good, of the good of a particular group and the broader public good. (Kegley 1999, p. 205)
The concept of genuine responsibility is operationalized within a democratic perspective on ethics. All parties in health care have an opportunity to introduce their legitimate interests to the discussion and all these interests will be impartially taken into consideration. Decisions on the prioritization of competing interests depend on the outcome of the assessment of the moral weight of each claim, as well as on the strength of the moral arguments supporting each claim. The primary focus of the discussion is to order and arrange the complex structure of social interactions.
The concept of genuine responsibility also creates opportunities for the various parties to discuss health care issues under the assumption of a shared basic understanding of responsibility to which can be assayed the substantive criteria for each group’s domain of responsibility. Emanuel and Emanuel’s (1996) plea for the institution of a reciprocating matrix of accountability in health care appears reasonable only under the assumption of a shared premise preceding a definition of responsibility. On the basis of this shared premise, at each respective level of responsibility (i.e., professional, political, and economic or consumerist), a level- specific model of responsibility can be established that further defines the substantive criteria within the respective models. Without a shared understanding on the basic premise of responsibility, the matrix suffers from incommensurability and is subsequently left without problem-solving attributes.
Intuitively, a unifying paradigm of responsibility in health care appears unlikely because of seemingly incompatible level-specific objectives. But that lack of a unifying paradigm does not equate to an inability to share a basic foundation on which the concept of responsibility at each level or domain can be further defined and operationalized. In fact, a shared understanding of the constituting premise of responsibility is essential in order for the various stakeholders in health care to hold 162
meaningful discussions on the issue of a productive reciprocating matrix of responsibility.
From that perspective, the principle of genuine responsibility offers a bridgehead for all stakeholders to use in overcoming the absence of a single concept of responsibility. The unanimous agreement to accept the premise of deliberate reciprocity as the basic assumption underlying the concept of responsibility thus becomes the unifying component of the paradigm of responsibility in health care.
Applied to the restructuring of health care, genuine responsibility does not raise any new questions. Instead, it merely reformulates the ground rules of the practical discussion by rephrasing the question of just rationing and by redefining the framework within which the stakeholders can undertake the search for morally acceptable answers.