Access to healthcare

The question of access occupies a curious position in the complex ethos of healthcare. On the one hand, it would seem to be the most basic of all ethics issues, for if people do not have access to care, all the other problems that providers and ethicists worry about are more or less moot. If there were no patients, it would be impossible to provide healthcare, at least to human beings.

On the other hand, despite all the rights that have been addressed (and, in some cases, created) by modern bioethics— including, but not limited to, the right to refuse treatment, the right to informed consent, the right to protection as a human subject of research, and the right to die on one's own terms—no right of access to care has been formally established. It is not addressed in the Declaration of Independence. Its only association with the U.S. Constitution is the 1976 Supreme Court ruling in Estelle v. Gamble, which held that deliberate indifference to an inmate's serious illness or injury on the part of prison officials violates the Eighth Amendment prohibition against cruel and unusual punishment.

Access is not addressed in the Nuremberg Code or the Universal Declaration of Human Rights. Even the World Health Organization's (WHO) oft-cited definition of health, set out in the preamble to its constitution (1946), as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" does not specifically address the issue of access, although the same preamble states that "the extension to all peoples of the benefits of medical, psychological, and related knowledge is essential to the fullest attainment of health."

Perhaps the closest the United States has come to a formal policy statement is the language in the 1983 report of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. The commission concluded that "society has an ethical obligation to ensure equitable access to healthcare for all" and that "equitable access to care requires that all citizens be able to secure an adequate level of care without excessive burdens" (p. 4). Despite these recommendations, no policy initiatives were undertaken.

Yet, in both charitable tradition and public policy, there is a history of implicit acknowledgement that the sick and injured should be able to obtain the care they need. Most major religions have, to one degree or another, adopted the provision of care as a ministry, usually in the form of hospitals. Most developed nations (and some others) have formally committed themselves to access to care for most or all of their residents. Public funds support hospitals, nursing homes, clinics, and other sources of care, and in some nations (the United States and Australia being prominent examples), these funds are also used to subsidize insurance coverage, which is usually public but sometimes private.

In the United States, federal law requires that any person seeking care in a hospital emergency department must receive an examination and evaluation, and if the person is at grave risk of death or severe debility, or is a pregnant woman in labor, the hospital may not transfer that patient unless it is clinically necessary. Many states have similar laws. There are also civil penalties for providers who are perceived to have refused care if the need was dire (and sometimes, even if it was not). Furthermore, public opinion surveys conducted by a wide range of opinion research organizations have found that most Americans support universal access to needed care, even if definitions of what that means vary considerably.

In the twentieth century, the United States also passed laws providing public funding for many healthcare services for people sixty-five or older (Medicare); for some of the poor, including some pregnant women and young children and the disabled (Medicaid); and for other low-income children (State Children's Health Insurance Program). Many states have also enacted programs subsidizing the care of low-income individuals.

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